Confidential and Proprietary - Regence BlueCross BlueShield of Oregon
Participating Dental Reimbursement Rates
Effective July 1, 2015
All published Regence BlueCross BlueShield Administrative Guidelines apply.
Payment shall be per the terms of your Provider Agreement and the Member’s benefit plan.
All services performed must be within the scope of the provider’s license. The absence of a code from this
list does not necessarily mean the service is not paid to the fee schedule. Please notify Regence BlueCross
BlueShield if you have questions concerning any code that may or may not be included on this list. The
inclusion/exclusion of codes/fees from this list does not necessarily indicate coverage or lack thereof.
ADA CODE
DESCRIPTION
CDT 2015
D0120
Periodic oral evaluation - established patient
D0140
Limited oral evaluation - problem focused
Oral evaluation for patient under three years of age and counseling with
D0145
primary caregiver
D0150
Comprehensive oral evaluation - new or established patient
ALLOWABLE
$52
$67
$64
$75
D0160
Detailed and extensive oral evaluation - problem focused, by report
$105
D0170
Re-evaluation - limited, problem focused (established patient; not postoperative visit)
$64
D0180
Comprehensive periodontal evaluation - new or established patient
$109
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
Intraoral - complete series (including bitewings)
Intraoral - periapical first radiographic image
Intraoral - periapical each additional radiographic image
Intraoral - occlusal radiographic image
Extraoral - first radiographic image
Extraoral - each additional radiographic image
Bitewing - single radiographic image
Bitewings - two radiographic images
Bitewings - three radiographic images
Bitewings - four radiographic images
Vertical bitewings - 7 to 8 radiographic images
Posterior - anterior or lateral skull and facial bone survey radiographic
image
Temporomandibular joint arthrogram, including injection
Panoramic radiographic image
Cephalometric radiographic image
$103
$25
$20
$39
$43
$22
$25
$42
$51
$61
$87
D0290
D0320
D0330
D0340
Effective 7/1/2015
Oregon Dental
$85
$40
$94
$100
1
ADA CODE
CDT 2015
D0460
D1110
D1120
D1206
D1208
D1330
D1351
D1352
D1510
D1515
D1520
D1525
D1550
D1555
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
DESCRIPTION
Pulp vitality tests
Prophylaxis – adult
Prophylaxis - child
Topical fluoride varnish
Topical application of fluoride – excluding varnish
Oral hygiene instructions
Sealant - per tooth
Preventive resin restoration in a moderate to high caries risk patient permanent tooth
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
Space maintainer - removable – unilateral
Space maintainer - removable - bilateral
Re-cement or re-bond space maintainer
Removal of fixed space maintainer
Amalgam - one surface, primary or permanent
Amalgam - two surfaces, primary or permanent
Amalgam - three surfaces, primary or permanent
Amalgam - four or more surfaces, primary or permanent
Resin-based composite - one surface, anterior
Resin- based composite - two surfaces, anterior
Resin-based composite - three surfaces, anterior
Resin-based composite - four or more surfaces involving incisal angle
(anterior)
Resin-based composite crown - anterior
Resin-based composite - one surface, posterior
Resin-based composite - two surfaces, posterior
Resin-based composite - three surfaces, posterior
Resin-based composite - four or more surfaces, posterior
Inlay - metallic - one surface
Inlay - metallic - two surfaces
Inlay - metallic - three or more surfaces
Onlay - metallic - two surfaces
Onlay - metallic - three surfaces
Onlay - metallic - four or more surfaces
Inlay - porcelain/ceramic - one surface
Inlay - porcelain/ceramic - two surfaces
Inlay - porcelain/ceramic - three or more surfaces
Onlay - porcelain/ceramic - two surfaces
Onlay - porcelain/ceramic - three surfaces
Onlay - porcelain/ceramic - four or more surfaces
Inlay - resin-based composite - one surface
Inlay - resin based composite - two surfaces
Inlay- resin based composite - three or more surfaces
Onlay - resin based composite - two surfaces
Effective 7/1/2015
Oregon Dental
ALLOWABLE
$50
$87
$61
$37
$35
$57
$46
$75
$285
$415
$400
$275
$64
$76
$145
$179
$225
$255
$130
$163
$200
$240
$275
$150
$190
$235
$270
$600
$700
$800
$775
$850
$875
$625
$675
$800
$775
$850
$875
$425
$475
$525
$700
2
ADA CODE
CDT 2015
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
DESCRIPTION
ALLOWABLE
Onlay - resin based composite - three surfaces
Onlay - resin based composite - four or more surfaces
Crown - resin-based composite (indirect)
Crown - 3/4 resin-based composite (indirect)
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown - porcelain/ceramic substrate
Crown - porcelain fused to high noble metal
Crown - porcelain fused to predominantly base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominately base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly base metal
Crown - full cast noble metal
Crown - titanium
$755
$775
$250
$725
$775
$595
$630
$925
$925
$820
$925
$931
$710
$978
$875
$900
$760
$900
$850
D2910
Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration
$81
D2915
Re-cement or re-bond indirectly fabricated or prefabricated post and core
$120
D2920
D2921
D2930
D2931
D2932
D2933
Re-cement or re-bond crown
Reattachment of tooth fragment, incisal edge or cusp
Prefabricated stainless steel crown - primary tooth
Prefabricated stainless steel crown - permanent tooth
Prefabricated resin crown
Prefab stainless steel crown with resin window
$86
$235
$229
$250
$265
$308
D2934
Prefabricated esthetic coated stainless steel crown - primary tooth
$298
D2940
D2941
D2949
D2950
D2952
D2954
D2955
D2957
D2960
D2961
D2962
Protective Restoration
Interim therapeutic restoration – primary dentition
Restorative foundation for an indirect restoration
Core buildup, including any pins when required
Post and core in addition to crown, indirectly fabricated
Prefabricated post and core in addition to crown
Post removal
Each additional prefabricated post - same tooth
Labial veneer (resin laminate) – chairside
Labial veneer (resin laminate) – laboratory
Labial veneer (porcelain laminate) – laboratory
Additional procedures to construct new crown under existing partial
denture framework
Coping
$82
$79
$195
$203
$325
$256
$250
$100
$639
$867
$850
D2971
D2975
Effective 7/1/2015
Oregon Dental
$100
$350
3
ADA CODE
DESCRIPTION
CDT 2015
D2980
Crown repair necessitated by restorative material failure
D2990
Resin infiltration of incipient smooth surface lesions
D3110
Pulp cap - direct (excluding final restoration)
D3220
D3221
D3222
D3230
D3240
D3310
D3320
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
D3352
Therapeutic pulpotomy (excluding final restoration) - removal of pulp
coronal to the dentinocemental junction and application of medicament
Pulpal debridement, primary and permanent teeth
Partial pulpotomy for apexogenesis - permanent tooth with incomplete
root development
Pulpal therapy (resorbable filling) - anterior, primary tooth
Pulpal therapy (resorbable filling) - posterior, primary tooth
Endodontic therapy, anterior tooth (excluding final restoration)
Endodontic therapy, bicuspid tooth (excluding final restoration)
Endodontic therapy, molar (excluding final restoration)
Treatment of root canal obstruction; non-surgical access
Incomplete endodontic therapy; inoperable, unrestorable or fractured
tooth
Internal root repair of perforation defects
Retreatment of previous root canal therapy - anterior
Retreatment of previous root canal therapy - bicuspid
Retreatment of previous root canal therapy - molar
Apexification/recalcification - initial visit (apical closure/calcific repair of
perforations, root resorption, etc.)
Apexification/recalcification - interim mediation replacement
ALLOWABLE
$176
$96
$69
$171
$182
$152
$233
$227
$606
$714
$938
$225
$339
$250
$854
$949
$1,183
$350
$125
D3353
Apexification/recalcification - final visit (includes completed root canal
therapy - apical closure/calcific repair of perforations, root resorption, etc.)
$350
D3355
D3356
D3357
D3410
D3421
D3425
D3426
D3427
Pulpal regeneration – initial visit
Pulpal regeneration – interim medication replacement
Pulpal regeneration – completion of treatment
Apicoectomy - anterior
Apicoectomy - bicuspid (first root)
Apicoectomy - molar (first root)
Apicoectomy (each additional root)
Periradicular surgery without apicoectomy
$350
$125
$350
$742
$820
$935
$291
$585
D3428
Bone graft in conjunction with periradicular surgery – per tooth, single site
$375
D3429
D3430
D3431
D3432
D3450
Bone graft in conjunction with periradicular surgery – each additional
contiguous tooth in the same surgical site
Retrograde filling - per root
Biologic materials to aid in soft and osseous tissue regeneration in
conjunction with periradicular surgery
Guided tissue regeneration, resorbable barrier, per site, in conjunction
with periradicular surgery
Root amputation - per root
Effective 7/1/2015
Oregon Dental
$325
$330
$372
$275
$646
4
ADA CODE
DESCRIPTION
CDT 2015
D3470
Intentional reimplantation (including necessary splinting)
D3920
D4210
D4211
D4240
D4241
D4245
D4249
Hemisection (including any root removal), not including root canal therapy
Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth
bounded spaces per quadrant
Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth
bounded spaces per quadrant
Gingival flap procedure, including root planning - four or more contiguous
teeth or tooth bounded spaces per quadrant
Gingival flap procedure, including root planning - one to three contiguous
teeth or tooth bounded spaces per quadrant
Apically positioned flap
Clinical crown lengthening - hard tissue
ALLOWABLE
$490
$375
$425
$194
$850
$594
$450
$750
D4260
Osseous surgery (including elevation of full thickness flap and closure) four or more contiguous teeth or tooth bounded spaces per quadrant
$1,040
D4261
Osseous surgery (including elevation of full thickness flap and closure) one to three contiguous teeth or tooth bounded spaces per quadrant
$800
D4263
D4264
D4265
D4266
D4267
D4268
D4270
D4273
D4274
D4275
D4276
D4277
Bone replacement graft - first site in quadrant
Bone replacement graft - each additional site in quadrant
Biologic materials to aid in soft and osseous tissue regeneration
Guided tissue regeneration - resorbable barrier, per site
Guided tissue regeneration - nonresorbable barrier, per site (includes
membrane removal)
Surgical revision procedure, per tooth
Pedicle soft tissue graft procedure
Subepithelial connective tissue graft procedures, per tooth
Distal or proximal wedge procedure (when not performed in conjunction
with surgical procedures in the same anatomical area)
Soft tissue allograft
Combined connective tissue and double pedicle graft, per tooth
Free soft tissue graft procedure (including donor site surgery), first tooth or
edentulous tooth position in graft
$440
$397
$372
$390
$337
$178
$815
$910
$500
$778
$750
$825
D4278
Free soft tissue graft procedure (including donor site surgery), each
additional contiguous tooth or edentulous tooth position in same graft site
$425
D4341
Periodontal scaling and root planning - four or more teeth per quadrant
$242
D4342
Periodontal scaling and root planning - one to three teeth per quadrant
$170
D4355
D4910
Full mouth debridement to enable comprehensive evaluation and
diagnosis
Periodontal maintenance
Effective 7/1/2015
Oregon Dental
$152
$138
5
ADA CODE
CDT 2015
DESCRIPTION
D4920
Unscheduled dressing change (by someone other than treating dentist)
D5110
D5120
D5130
D5140
Complete denture - maxillary
Complete denture - mandibular
Immediate denture - maxillary
Immediate denture - mandibular
Maxillary partial denture - resin base (including any conventional clasps,
rests and teeth)
Mandibular partial denture - resin base (including any conventional clasps,
rests and teeth)
D5211
D5212
ALLOWABLE
$32
$1,100
$1,100
$1,248
$1,200
$925
$925
D5213
Maxillary partial denture - cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth)
$1,270
D5214
Mandibular partial denture - cast metal framework with resin denture
bases (including any conventional clasps, rests and teeth)
$1,270
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
Maxillary partial denture - flexible base (including any clasps, rests and
teeth)
Mandibular partial denture - flexible base (including any clasps, rests and
teeth)
Removable unilateral partial denture - one piece cast metal (including
clasps and teeth)
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
Repair broken complete denture base
Replace missing or broken teeth - complete denture (each tooth)
Repair resin denture base
Repair cast framework
Repair or replace broken clasp
Replace broken teeth - per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture
Replace all teeth and acrylic on cast metal framework (maxillary)
D5671
Replace all teeth and acrylic on cast metal framework (mandibular)
$700
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
Rebase complete maxillary denture
Rebase complete mandibular denture
Rebase maxillary partial denture
Rebase mandibular partial denture
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
$450
$450
$475
$475
$260
$260
$245
$245
D5225
D5226
D5281
Effective 7/1/2015
Oregon Dental
$930
$1,052
$750
$62
$62
$76
$62
$142
$130
$140
$200
$200
$149
$160
$236
$680
6
ADA CODE
CDT 2015
D5750
D5751
D5760
D5761
D5850
D5851
D5863
D5864
D5865
D5866
D6010
D6055
D6056
D6057
D6058
DESCRIPTION
ALLOWABLE
Reline complete maxillary denture (laboratory)
Reline complete mandibular denture (laboratory)
Reline maxillary partial denture (laboratory)
Reline mandibular partial denture (laboratory)
Tissue conditioning, maxillary
Tissue conditioning, mandibular
Overdenture – complete maxillary
Overdenture – partial maxillary
Overdenture – complete mandibular
Overdenture – partial mandibular
Surgical placement of implant body: endosteal implant
Connecting bar – implant supported or abutment supported
Prefabricated abutment – includes modification and placement
Custom fabricated abutment - includes placement
Abutment supported porcelain/ceramic crown
$350
$350
$350
$350
$100
$100
$1,100
$1,100
$1,100
$1,100
$1,900
$610
$519
$601
$1,157
D6059
Abutment supported porcelain fused to metal crown (high noble metal)
$1,168
D6060
Abutment supported porcelain fused to metal crown (predominantly base
metal)
D6061
Abutment supported porcelain fused to metal crown (noble metal)
$1,100
D6062
Abutment supported cast metal crown (high noble metal)
$1,150
D6063
Abutment supported cast metal crown (predominantly base metal)
D6064
D6065
Abutment supported cast metal crown (noble metal)
Implant supported porcelain/ceramic crown
Implant supported porcelain fused to metal crown (titanium, titanium
allow, high noble metal)
$1,150
$1,200
D6067
Implant supported metal crown (titanium, titanium alloy, high noble metal)
$1,200
D6068
Abutment supported retainer for porcelain/ceramic FPD
Abutment supported retainer for porcelain fused to metal FPD (high noble
metal)
Abutment supported retainer for porcelain fused to metal FPD
(predominantly base metal)
Abutment supported retainer for porcelain fused to metal FPD (noble
metal)
$1,000
Abutment supported retainer for cast metal FPD (high noble metal)
$1,000
D6066
D6069
D6070
D6071
D6072
D6073
D6074
D6075
D6076
Abutment supported retainer for cast metal FPD (predominantly base
metal)
Abutment supported retainer for cast metal FPD (noble metal)
Implant supported retainer for ceramic FPD
Implant supported retainer porcelain fused to metal FPD (titanium,
titanium alloy, or high noble metal)
Effective 7/1/2015
Oregon Dental
$900
$890
$1,261
$1,233
$1,220
$1,000
$890
$1,000
$1,000
$925
7
ADA CODE
DESCRIPTION
CDT 2015
D6090
Repair implant supported prosthesis, by report
D6092
Re-cement or re-bond implant/abutment supported crown
ALLOWABLE
$425
$72
D6093
Re-cement or re-bond implant/abutment supported fixed partial denture
$110
D6094
D6095
D6100
Abutment supported crown (titanium)
Repair implant abutment, by report
Implant removal, by report
Implant/abutment supported removable denture for edentulous arch maxillary
Implant/abutment supported removable denture for edentulous arch –
mandibular
Implant/abutment supported removable denture for partially edentulous
arch – maxillary
Implant /abutment supported removable denture for partially edentulous
arch - mandibular
Abutment supported retainer crown for cast metal FPD (titanium)
Pontic - indirect resin based composite
Pontic - cast high noble metal
Pontic - cast predominantly base metal
Pontic - cast noble metal
Pontic - titanium
Pontic - porcelain fused to high noble metal
Pontic - porcelain fused to predominantly base metal
Pontic - porcelain fused to noble metal
Pontic - porcelain/ceramic
Pontic - resin with high noble metal
Pontic - resin with predominantly base metal
Pontic - resin with noble metal
Retainer- cast metal for resin bonded fixed prosthesis
Retainer - porcelain/ceramic for resin bonded fixed prosthesis
Resin retainer-for resin bonded fixed prosthesis
Onlay - porcelain/ceramic, two surfaces
Onlay - porcelain/ceramic, three or more surfaces
Onlay - cast high noble metal, two surfaces
Onlay - cast high noble metal, three or more surfaces
Onlay - cast predominantly base metal, two surfaces
Onlay - cast predominantly base metal, three or more surfaces
Onlay - cast noble metal, two surfaces
Onlay - cast noble metal, three or more surfaces
Inlay - titanium
Onlay - titanium
Crown - indirect resin based composite
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
$900
$250
$150
D6110
D6111
D6112
D6113
D6194
D6205
D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6545
D6548
D6549
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6624
D6634
D6710
D6720
D6721
D6722
Effective 7/1/2015
Oregon Dental
$1,200
$1,200
$1,200
$1,200
$900
$710
$835
$750
$815
$815
$850
$800
$850
$875
$775
$390
$710
$438
$438
$775
$750
$750
$700
$750
$700
$700
$700
$775
$630
$675
$595
$775
$630
$630
8
ADA CODE
CDT 2015
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6794
D6930
DESCRIPTION
ALLOWABLE
Crown - porcelain/ceramic
Crown - porcelain fused to high noble metal
Crown - porcelain fused to predominantly base metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominantly base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly base metal
Crown - full cast noble metal
Crown - titanium
Re-cement or re-bond fixed partial denture
$925
$925
$820
$925
$850
$710
$850
$875
$947
$760
$900
$850
$122
D6980
Fixed partial denture repair necessitated by restorative material failure
$240
D7111
Extraction, coronal remnants - deciduous tooth
Extraction, erupted tooth or exposed root (elevation and/or forceps
removal)
Surgical removal of erupted tooth requiring removal of bone and/or
sectioning of tooth, and including elevation of mucoperiosteal flap if
indicated
Removal of impacted tooth - soft tissue
Removal of impacted tooth - partially bony
Removal of impacted tooth - completely bony
Removal of impact tooth - completely bony, with unusual surgical
complications
Surgical removal of residual tooth roots (cutting procedure)
Coronectomy – intentional partial tooth removal
Oroantral fistula closure
Primary closure of a sinus perforation
Tooth reimplantation and/or stabilization of accidentally evulsed or
displaced tooth
Surgical access of an unerupted tooth
Mobilization of erupted or malpositioned tooth to aid eruption
Incisional biopsy of oral tissue - hard (bone, tooth)
Incisional biopsy of oral tissue - soft
Surgical repositioning of teeth
Transseptal fiberotomy/supra crestal fiberotomy, by report
Alveoloplasty in conjunction with extractions - four or more teeth or tooth
spaces, per quadrant
Alveoloplasty in conjunction with extractions - one to three teeth or tooth
spaces, per quadrant
Alveoloplasty not in conjunction with extractions - four or more teeth or
tooth spaces, per quadrant
$100
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7251
D7260
D7261
D7270
D7280
D7282
D7285
D7286
D7290
D7291
D7310
D7311
D7320
Effective 7/1/2015
Oregon Dental
$137
$234
$281
$360
$418
$486
$256
$388
$450
$50
$417
$473
$200
$360
$322
$287
$90
$250
$130
$291
9
ADA CODE
CDT 2015
D7321
D7340
D7350
D7410
D7411
D7412
D7450
D7451
D7465
D7471
D7472
D7473
D7485
D7510
D7511
D7530
DESCRIPTION
Alveoloplasty not in conjunction with extractions - one to three teeth or
tooth spaces, per quadrant
Vestibuloplasty - ridge extension (secondary epithelialization)
Vestibuloplasty - ridge extension (including soft tissue grafts, muscle
reattachment, revisions of soft tissue attachment and management of
hypertrophied and hyperplastic tissue)
Excision of benign lesion up to 1.25 cm
Excision of benign lesion greater than 1.25 cm
Excision of benign lesion, complicated
Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25
cm
Removal of benign odontogenic cyst or tumor - lesion diameter greater
than 1.25 cm
Destruction of lesion(s) by physical or chemical method, by report
Removal of lateral exostosis (maxilla or mandible)
Removal of torus palatinus
Removal of torus mandibularis
Surgical reduction of osseous tuberosity
Incision and drain of abscess - intraoral soft tissue
Incision and drainage of abscess - intraoral soft tissue - complicated
(includes drainage of multiple fascial spaces)
Removal of foreign body from mucosa, skin, or subcutaneous alveolar
tissue
ALLOWABLE
$247
$650
$675
$267
$275
$272
$500
$700
$210
$450
$450
$600
$400
$180
$200
$157
D7540
Removal of reaction producing foreign bodies, musculoskeletal system
$150
D7550
Partial ostectomy/sequestrectomy for removal of non-vital bone
$350
D7560
Maxillary sinusotomy for removal of tooth fragment or foreign body
$225
D7880
D7910
D7911
D7912
Occlusal orthotic device, by report
Suture of recent small wounds up to 5 cm
Complicated suture - up to 5 cm
Complicated suture - greater than 5 cm
Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla –
autogenous or nonautogenous, by report
Bone replacement graft for ridge preservation - per site
Frenulectomy – also known as frenectomy or frenotomy - separate
procedure not incidental to another
Frenuloplasty
Excision of hyperplastic tissue - per arch
Excision of periocoronal gingiva
Surgical reduction of fibrous tuberosity
Palliative (emergent) treatment of dental pain - minor procedure
Fixed partial denture sectioning
Deep sedation/general anesthesia - first 30 minutes
Deep sedation/general anesthesia - each additional 15 minutes
$475
$170
$243
$305
D7950
D7953
D7960
D7963
D7970
D7971
D7972
D9110
D9120
D9220
D9221
Effective 7/1/2015
Oregon Dental
$1,000
$332
$410
$424
$125
$171
$450
$132
$155
$437
$110
10
ADA CODE
DESCRIPTION
CDT 2015
D9241
IV moderate (conscious) sedation/analgesia - first 30 minutes
ALLOWABLE
$375
D9242
IV moderate (conscious) sedation/analgesia - each additional 15 minutes
$94
D9248
D9410
D9420
Non-intravenous moderate (conscious) sedation
House/extended care facility call
Hospital or ambulatory surgical center call
Office visit for observation (during regularly scheduled hours) - no other
services performed
Office visit - after regularly scheduled hours
Occlusal guard, by report
Repair and/or reline of occlusal guard
$175
$139
$285
D9430
D9440
D9940
D9942
Effective 7/1/2015
Oregon Dental
$58
$105
$411
$90
11