|
|
|
|
|
|
|
Diagnostic & Preventive |
|
|
|
|
|
|
|
|
| 150 |
Comprehensive Oral
Evaluation ( new or established patient ) |
110 |
0 |
110 |
| 120 |
Periodic Oral Evaluation |
60 |
0 |
60 |
| 110 |
Infection Control Fee |
39 |
10 |
29 |
| 140 |
Limited Oral
Exam..Emergency Exam -- Problem Focused -- During Regular Office Hours |
75 |
45 |
30 |
| 180 |
Comprehensive Perio
Evaluation (includes perio probing and charting) |
106 |
53 |
53 |
| 220 |
Intraoral Periapical -
Single First Film |
25 |
14 |
11 |
| 210 |
X-Rays - Complete Series
(IF NOT PANORAMIC EQUIPPED) |
115 |
50 |
65 |
| 330 |
Panoramic X-Ray |
110 |
45 |
65 |
| 1110 |
Adult Prophylaxis This Fee
is for regular cleanings. The first cleaning may be charged under the
Periodontal Section |
120 |
60 |
60 |
| 1120 |
Child Prophylaxis This Fee
is for regular cleanings. The first cleaning may be charged under the
Periodontal Section |
85 |
40 |
45 |
| 1201 |
Topical Application of
Fluoride -- (Including Prophy - Child) |
105 |
53 |
52 |
| 1203 |
Topical Application of
Fluoride -- (Without Prophy - Child) |
42 |
22 |
20 |
| 1351 |
Sealants -- (Fee is per
tooth) |
61 |
31 |
30 |
|
|
|
|
|
|
Radiographs |
|
|
|
|
|
|
|
|
| 230 |
Intraoral Periapical - Each
Additional Film |
23 |
0 |
23 |
| 240 |
Intraoral - Occlusal Film |
42 |
0 |
42 |
| 272 |
Bitewings - Two Films |
47 |
0 |
47 |
| 274 |
Bitewings - Four Films |
66 |
0 |
66 |
|
|
|
|
|
|
Other |
|
|
|
|
|
|
|
|
| 416 |
Viral Culture (a test to
identify viral organisms) |
196 |
98 |
98 |
| 460 |
Pulp Vitality Test |
75 |
38 |
37 |
| 470 |
Diagnostic Casts (Study
Models) |
124 |
62 |
62 |
|
|
|
|
|
|
Special Maintainers |
|
|
|
| 1510 |
Fixed - Unilateral Type
--(To Include Adjustments) |
362 |
181 |
181 |
| 1515 |
Fixed - Bilateral Type
--(To Include Adjustments) |
512 |
256 |
256 |
| 1520 |
Removable - Unilateral Type
--(To Include Adjustments) |
452 |
226 |
226 |
| 1525 |
Removable - Bilateral Type
--(To Include Adjustments) |
565 |
283 |
282 |
|
Restorative Amalgam |
|
|
|
| 2140 |
Amalgam - One Surface --
Primary or Permanent Tooth |
142 |
71 |
71 |
| 2150 |
Amalgam - Two Surfaces --
Primary or Permanent Tooth |
189 |
95 |
94 |
| 2160 |
Amalgam - Three Surfaces --
Primary or Permanent Tooth |
219 |
110 |
109 |
| 2161 |
Amalgam - Four or More
Surfaces -- Primary or Permanent Tooth |
260 |
130 |
130 |
|
|
|
|
|
|
Restorative Composite |
|
|
|
|
|
|
|
|
| 2330 |
Resin - Based Composite -
One Surface Anterior |
235 |
118 |
117 |
| 2331 |
Resin - Based Composite -
Two Surfaces Anterior |
296 |
148 |
148 |
| 2332 |
Resin - Based Composite -
Three Surfaces Anterior |
368 |
184 |
184 |
| 2335 |
Resin - Based Composite -
Four or More Surfaces or Involving Incisal Angle - Anterior |
462 |
231 |
231 |
| 2391 |
Resin - Based Composite -
One Surface Posterior |
261 |
131 |
130 |
| 2392 |
Resin - Based Composite -
Two Surfaces Posterior |
338 |
169 |
169 |
| 2393 |
Resin - Based Composite -
Three Surfaces Posterior |
423 |
212 |
211 |
| 2394 |
Resin - Based Composite -
Four or More Surfaces Posterior |
509 |
255 |
254 |
| 2510 |
Inlay - Metallic - One
Surface |
883 |
442 |
441 |
|
Plus Actual Lab fee |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2520 |
Inlay - Metallic - Two
Surfaces |
972 |
486 |
486 |
|
Plus Actual Lab fee |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2530 |
Inlay - Metallic - Three
Surfaces |
1059 |
530 |
529 |
|
Plus Actual Lab fee |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2542 |
Onlay - Metallic - Two
Surfaces |
1097 |
549 |
548 |
|
Plus Actual Lab fee |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2543 |
Onlay - Metallic - Three
Surfaces |
1138 |
569 |
569 |
|
Plus Actual Lab fee |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2544 |
Onlay - Metallic - Four or
More Surfaces |
1183 |
592 |
591 |
|
Plus Actual Lab fee |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
|
|
|
|
|
|
Other Restorative Services |
|
|
|
|
|
|
|
|
| 2910 |
Recement Inlay |
117 |
59 |
58 |
| 2915 |
Re-cement cast or
prefabricated post and core |
124 |
62 |
62 |
| 2920 |
Re-cement Crowns |
117 |
59 |
58 |
| 2930 |
Prefabricated Stainless
Steel Crown - Primary Tooth |
324 |
162 |
162 |
| 2931 |
Prefabricated Stainless
Steel Crown - Permanent Tooth |
391 |
196 |
195 |
| 2932 |
Prefabricated Resin Crown |
415 |
208 |
207 |
| 2934 |
Prefabricated esthetic
coated stainless steel crown (primary tooth) |
460 |
230 |
230 |
| 2940 |
Sedative Filling -
Temporary Restoration Intended to Relieve Pain |
136 |
68 |
68 |
| 2950 |
Core Build up - Including
any Pins |
313 |
157 |
156 |
| 2951 |
Pin Retention - Per Tooth -
In Addition to Restoration |
83 |
42 |
41 |
| 2952 |
Cast Post and Core - In
Addition to Crown |
501 |
251 |
250 |
| 2954 |
Prefabricated Post and Core
- In Addition to Crown |
407 |
204 |
203 |
|
|
|
|
|
|
Crowns |
|
|
|
|
|
|
|
|
| 2740 |
Crown - Procelain/Ceramic
Substrate |
1526 |
763 |
763 |
|
Plus Actual Lab fee |
|
|
|
| 2750 |
Crown - Porcelain Fused to
High Noble Metal |
1285 |
643 |
642 |
|
Plus Lab Fee Not to Exceed
$100.00 |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2751 |
Crown - Procelain Fused to
Predominantly Base Metal |
1175 |
588 |
587 |
|
Plus Lab Fee Not to Exceed
$100.00 |
|
|
|
| 2752 |
Crown - Porcelain Fused to
Noble Metal |
1228 |
614 |
614 |
|
Plus Lab Fee Not to Exceed
$100.00 |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2780 |
Crown - 3/4 Cast High Noble
Metal |
1252 |
626 |
626 |
|
Plus Lab Fee Not to Exceed
$100.00 |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2790 |
Crown - Full Cast High
Noble Metal |
1322 |
661 |
661 |
|
Plus Lab Fee Not to Exceed
$100.00 |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
| 2792 |
Crown - Full Cast Noble
Metal |
1214 |
607 |
607 |
|
Plus Lab Fee Not to Exceed
$100.00 |
|
|
|
|
Plus Gold or Metal Charges |
|
|
|
|
|
|
|
|
|
Veneers |
|
|
|
|
|
|
|
|
| 2960 |
Labial Veneer - Resin
Laminate - Performed Chairside |
787 |
394 |
393 |
| 2961 |
Labial Veneer - Resin
Laminate - Performed In Laboratory |
1094 |
547 |
547 |
|
Plus Actual Lab fee |
|
|
|
| 2962 |
Labial Veneer - Porcelain
Laminate - Performed In Laboratory |
1362 |
681 |
681 |
|
Plus Actual Lab fee |
|
|
|
|
|
|
|
|
|
Bleaching |
|
|
|
|
|
|
|
|
| 9972 |
External Bleaching - Per
Arch |
546 |
273 |
273 |
| 9973 |
External Bleaching - Per
Tooth |
346 |
173 |
173 |
| 9974 |
Internal Bleaching - Per
Tooth |
449 |
225 |
224 |
|
|
|
|
|
|
Endodontics |
|
|
|
|
|
|
|
|
| 3110 |
Pulp Cap - Direct - Exposed
Pulp - Excluding Final Restoration - Per Tooth |
94 |
47 |
47 |
| 3120 |
Pulp Cap - Indirect -
Nearly Exposed Pulp - Excluding Final Restoration - Per Tooth |
91 |
46 |
45 |
| 3220 |
Therapeutic Pulpotomy -
Excluding Final Restoration |
440 |
219 |
221 |
| 3221 |
Therapeutic Pulpectomy -
Pulpal Debridement - Primary and Permanent Teeth |
241 |
121 |
120 |
| 3310 |
Root Canal - Anterior -
Excluding Final Restoration |
779 |
390 |
389 |
| 3320 |
Root Canal - Bicuspid -
Excluding Final Restoration |
1009 |
505 |
504 |
| 3330 |
Root Canal - Molar - Up to
Three Canals - Excluding Final Restoration |
1235 |
618 |
617 |
| 3920 |
Hemisection - Including any
Root Removal - Not Including Root Canal Therapy |
565 |
283 |
282 |
|
|
|
|
|
|
Periodontics |
|
|
|
|
|
|
|
|
| 4210 |
Gingivectomy or
Gingivoplasty - Four or More Contiguous Teeth or Bounded Teeth Spaces - Per
Quadrant |
803 |
402 |
401 |
| 4211 |
Gingivectomy or
Gingivoplasty - One to Three Teeth or Bounded Teeth Spaces - Per Quadrant |
308 |
154 |
154 |
| 4240 |
Gingival Flap Curettage -
Including Root Planing - Four or More Contiguous Teeth or Bounded Teeth
Spaces - Per Quadrant |
939 |
470 |
469 |
| 4249 |
Clinical Crown Lengthening
- Hard Tissue |
977 |
489 |
488 |
| 4260 |
Osseous Surgery - Including
Flap Entry and Closure |
1354 |
677 |
677 |
| 4263 |
Bone Replacement Graft -
First Site in Quadrant - Does Not Include Flap Entry, Closure or Donor Site |
972 |
486 |
486 |
| 4264 |
Bone Replacement Graft -
Each Additional Site in Quadrant - Does Not Include Flap Entry, Closure or
Donor Site |
667 |
334 |
333 |
| 4270 |
Pedicle Soft Tissue
Procedure |
1055 |
528 |
527 |
| 4271 |
Free Soft Tissue Graft
Procedure - Including Donor Site Surgery |
1119 |
560 |
559 |
| 4341 |
Periodontal Scailing and
Root Planing - Per Quadrant |
316 |
158 |
158 |
| 4355 |
Full Mouth Debridement to
Enable Comprehensive Evaluation and Diagnosis |
290 |
145 |
145 |
| 4910 |
Periodontal Maintenance -
After completion of Active Periodontal Treatment |
211 |
106 |
105 |
|
|
|
|
|
|
Prosthodontics-Removable |
|
|
|
|
|
|
|
|
| 5110 |
Complete
Denture - Maxillary - Including Routine Post - Delivery Care |
1878 |
939 |
939 |
|
Plus actual lab fee |
|
|
|
| 5120 |
Complete Denture -
Mandibular - Including Routine Post - Delivery Care |
1878 |
939 |
939 |
|
Plus actual lab fee |
|
|
|
| 5130 |
Immediate Denture -
Maxillary - ( NOT INCLUDING EXTRACTIONS ) - Includes Limited Follow Up Care
Only |
2020 |
1010 |
1010 |
|
Plus actual lab fee |
|
|
|
| 5140 |
Immediate Denture -
Mandibular - ( NOT INCLUDING EXTRACTIONS ) - Includes Limited Follow Up Care
Only |
2034 |
1017 |
1017 |
|
Plus actual lab fee |
|
|
|
| 5211 |
Partial Denture Maxillary -
Resin Base - ( includes any conventional clasps, rest and teeth) - Includes
acrylic resin base denture with resin or wrought wire clasps |
1557 |
779 |
778 |
|
Plus actual lab fee |
|
|
|
| 5212 |
Partial Denture Mandibular
- Resin Base - ( includes any conventional clasps, rest and teeth) - Includes
acrylic resin base denture with resin or wrought wire clasps |
1584 |
792 |
792 |
|
Plus actual lab fee |
|
|
|
| 5213 |
Partial
Denture - Maxillary - Cast chrome base with acrylic saddles - Including any
conventional Clasps, rests and teeth |
1997 |
975 |
1022 |
|
Plus actual lab fee |
|
|
|
| 5214 |
Partial Denture -
Mandibular - Cast chrome base with acrylic saddles - Including any
conventional Clasps, rests and teeth - Including Routine Post - D |
1994 |
975 |
1019 |
|
Plus actual lab fee |
|
|
|
| 5225 |
Partial Denture Maxillary -
Flexible base - ( includes any clasps, rests and teeth ) |
2088 |
1050 |
1038 |
|
Plus actual lab fee |
|
|
|
| 5226 |
Partial Denture Mandibular
- Flexible base - ( includes any clasps, rests and teeth ) |
2088 |
1050 |
1038 |
|
Plus actual lab fee |
|
|
|
| 5410 |
Adjust complete Denture -
Maxillary |
102 |
51 |
51 |
| 5411 |
Adjust complete Denture -
Mandibular |
102 |
51 |
51 |
| 5421 |
Adjust Partial Denture -
Maxillary |
102 |
51 |
51 |
| 5422 |
Adjust Partial Denture -
Mandibular |
102 |
51 |
51 |
| 5520 |
Replace Missing or Broken
Teeth - Complete Denture - Each Tooth |
219 |
110 |
109 |
|
Plus actual lab fee |
|
|
|
| 5610 |
Repair Resin Base Denture -
Cold Cure |
238 |
119 |
119 |
|
Plus actual lab fee |
|
|
|
| 5630 |
Repair or Replace Broken
Clasp - Partial Denture |
297 |
149 |
148 |
|
Plus actual lab fee |
|
|
|
| 5640 |
Replace broken tooth -
partial denture - per tooth |
207 |
103 |
104 |
|
Plus actual lab fee |
|
|
|
| 5650 |
Add Tooth to Existing
Partial Denture |
252 |
126 |
126 |
|
Plus actual lab fee |
|
|
|
| 5660 |
Add Clasp to Existing
Partial Denture |
313 |
157 |
156 |
|
Plus actual lab fee |
|
|
|
| 5710 |
Rebase Complete Denture -
Maxillary - The Process of Refitting a Denture by Replacing the Base Material |
704 |
352 |
352 |
|
Plus actual lab fee |
|
|
|
| 5711 |
Rebase Complete Denture -
Mandibular - The Process of Refitting a Denture by Replacing the Base
Material |
704 |
352 |
352 |
|
Plus actual lab fee |
|
|
|
| 5720 |
Rebase Partial Denture -
Maxillary - The Process of Refitting a Denture by Replacing the Base Material |
671 |
335 |
336 |
|
Plus actual lab fee |
|
|
|
| 5721 |
Rebase Partial Denture -
Mandibular - The Process of Refitting a Denture by Replacing the Base
Material |
671 |
335 |
336 |
|
Plus actual lab fee |
|
|
|
| 5730 |
Reline Complete Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary -
Done Chariside |
457 |
230 |
227 |
| 5731 |
Reline Complete Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular
- Done Chariside |
457 |
230 |
227 |
| 5740 |
Reline Partial Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary -
Done Chariside |
449 |
230 |
219 |
| 5741 |
Reline Partial Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular
- Done Chariside |
449 |
230 |
219 |
| 5750 |
Reline Complete Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary -
Done in Laboratory |
577 |
287 |
290 |
|
Plus actual lab fee |
|
|
|
| 5751 |
Reline Complete Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular
- Done in Laboratory |
577 |
287 |
290 |
|
Plus actual lab fee |
|
|
|
| 5760 |
Reline Partial Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary -
Done in Laboratory |
570 |
285 |
285 |
|
Plus actual lab fee |
|
|
|
| 5761 |
Reline Partial Denture -
Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular
- Done in Laboratory |
570 |
285 |
285 |
| Plus Actual Lab fee |
| 5820 |
Interim Partial Denture -
Maxillary - Includes any Necessary Clasps and Rests |
781 |
390 |
391 |
| Plus Actual Lab fee |
| 5821 |
Interim Partial Denture -
Mandibular - Includes any Necessary Clasps and Rests |
781 |
390 |
391 |
| Plus Actual Lab fee |
| 5850 |
Tissue Conditioning -
Treatment Reline Using Materials Designed to Heal Unhealthy Ridges Prior to
More Definitive Final Restoration - Maxillary -( Per |
225 |
112 |
113 |
| 5851 |
Tissue Conditioning -
Treatment Reline Using Materials Designed to Heal Unhealthy Ridges Prior to
More Definitive Final Restoration - Mandibular -( Pe |
233 |
112 |
121 |
|
|
|
|
|
|
Prosthodontics-Fixed-Bridges |
|
|
|
|
|
|
|
|
| 6210 |
Bridge Pontic - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Cast High Noble
Metal |
1252 |
626 |
626 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6211 |
Bridge Pontic - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Cast Non Precious
Metal |
1161 |
580 |
581 |
| Plus Lab Fee Not to Exceed $110.00 |
| 6212 |
Bridge Pontic - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Cast Noble Metal |
1207 |
604 |
603 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6214 |
Pontic - Titanium |
1304 |
652 |
652 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6240 |
Bridge Pontic - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to
High Noble Metal |
1285 |
653 |
632 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6241 |
Bridge Pontic - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to
Predominantly Base Metal |
1175 |
588 |
587 |
| Plus Lab Fee Not to Exceed $110.00 |
| 6242 |
Bridge Pontic - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to
Noble Metal |
1236 |
618 |
618 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6545 |
Retainer - Cast Metal for
Resin Bonded Fixed Prosthesis |
862 |
431 |
431 |
| 6750 |
Bridge Abutment - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to
High Noble Metal |
1293 |
647 |
646 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6751 |
Bridge Abutment - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to
Predominantly Base Metal |
1175 |
588 |
587 |
| Plus Lab Fee Not to Exceed $110.00 |
| 6752 |
Bridge Abutment - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to
Noble Metal |
1236 |
618 |
618 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6780 |
Bridge Abutment - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - 3/4 Cast High Noble
Metal |
1252 |
626 |
626 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6790 |
Bridge Abutment - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Full Cast High
Noble Metal |
1315 |
658 |
657 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6791 |
Bridge Abutment - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Full Cast
Predominantly Base Metal |
1169 |
585 |
584 |
| Plus Lab Fee Not to Exceed $110.00 |
| 6792 |
Bridge Abutment - Each
Abutment and Each Pontic Constitutes a Unit in a Bridge - Full Cast Noble
Metal |
1218 |
609 |
609 |
| Plus Lab Fee Not to Exceed $110.00 |
| Plus Gold or Metal Charges |
| 6794 |
Crown - Titanium |
1387 |
694 |
693 |
| Plus Gold or Metal Charges |
| Plus Lab Fee Not to Exceed $110.00 |
| 6930 |
Re-Cement Bridge |
188 |
97 |
91 |
|
|
|
|
|
|
Extractions |
|
|
|
|
|
|
|
|
| 7111 |
Coronal Remnants -
Deciduous Tooth - Includes Soft Tissue Retained Coronal Remnants |
155 |
78 |
77 |
|
|
|
|
|
| 7140 |
Extraction - Erupted Tooth
or Exposed Root - Elevation and/or Forceps Removal |
182 |
91 |
91 |
|
Oral Extractions |
|
|
|
|
|
|
|
|
| 7210 |
Surgical Removal of Erupted
Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or
Section of Tooth |
313 |
157 |
156 |
| 7220 |
Removal of Impacted Tooth -
Soft Tissue |
362 |
181 |
181 |
| 7230 |
Removal of Impacted Tooth -
Partially Bony |
468 |
234 |
234 |
| 7240 |
Removal of Impacted Tooth -
Completely Bony |
565 |
283 |
282 |
| 7241 |
Removal of Impacted Tooth -
Completely Bony with Unusual Surgical Complications |
704 |
352 |
352 |
| 7250 |
Surgical Removal of
Residual Tooth Roots - Cutting Procedure |
347 |
174 |
173 |
|
Orthodontics |
|
|
|
|
|
|
|
|
| 8010 |
Limited Orthodontic
Treatment of the Primary Dentition |
3088 |
1544 |
1544 |
| 8020 |
Limited Orthodontic
Treatment of the Transitional Dentition |
3393 |
1697 |
1696 |
| 8030 |
Limited Orthodontic
Treatment of the Adolescent Dentition |
3837 |
1919 |
1918 |
| 8040 |
Limited Orthodontic
Treatment of the Adult Dentition |
4448 |
2224 |
2224 |
| 8050 |
Interceptive Orthodontic
Treatment of the Primary Dentition |
3912 |
1956 |
1956 |
| 8060 |
Interceptive Orthodontic
Treatment of the Adult Dentition |
4255 |
2128 |
2127 |
| 8070 |
Comprehensive Orthodontic
Treatment of the Transitional Dentition |
7207 |
3604 |
3603 |
| 8080 |
Comprehensive Orthodontic
Treatment of the Adolescent Dentition |
7388 |
3694 |
3694 |
| 8090 |
Comprehensive Orthodontic
Treatment of the Adult Dentition |
8095 |
4048 |
4047 |
| 8210 |
Removable Appliance Therapy
- Removable indicates patient can remove; Includes appliances for thumb
sucking and tongue thrusting |
1252 |
626 |
626 |
| 8220 |
Fixed Appliance Therapy -
Fixed indicates patient cannot remove; Includes appliances for thumb sucking
and tongue thrusting |
1477 |
739 |
738 |
| 8660 |
Pre-Orthodontic Treatment
Visit - Initial Exam including Diagnostic aids and Creation of Records |
471 |
236 |
235 |
| 8670 |
Periodic Orthodontic
Treatment Visit - As part of Contract |
346 |
0 |
346 |
| 8680 |
Orthodontic Retention -
Removal of appliances, construction and placement of retainer(s) |
958 |
479 |
479 |
| 8691 |
Repair of Orthodontic
Appliance - Does not include bracket and standard Orthodontic appliances - It
does include Functional appliances and Palatal Exp |
286 |
143 |
143 |
| 8692 |
Replacement of lost or
broken Retainer |
546 |
273 |
273 |
|
|
|
|
|
|
TMJ |
|
|
|
|
|
|
|
|
| 1 |
TMJ Screening Exam |
117 |
0 |
117 |
| 10 |
Splint Adjustment |
391 |
196 |
195 |
| 2 |
Diagnostic Work Up and
X-Rays |
784 |
392 |
392 |
| 3 |
Tomographic Radiographs |
0 |
0 |
0 |
|
| 4 |
TMJ Treatment - Includes
Oral Appliance and Five (5) Adjustment Visits - Treatment Not to Exceed Five
(5) Months |
5526 |
2763 |
2763 |
| 5 |
Night Orthotic - Includes
Follow Up Adjustment |
1410 |
705 |
705 |
| 6 |
Lost Appliance |
972 |
486 |
486 |
| 7 |
Ultrasound Therapy -
Unilateral - Each |
188 |
94 |
94 |
| 8 |
Ultrasound Therapy -
Bilateral - Each |
207 |
104 |
103 |
| 9 |
Drug Injection Therapy |
784 |
392 |
392 |
|
|
|
|
|
|
Adjunctive General Services |
|
|
|
|
|
|
|
|
| 9110 |
Emergency Palliative
Treatment of Dental Pain - Minor Procedure |
147 |
74 |
73 |
| 9215 |
Local Anesthetic |
86 |
0 |
86 |
| 9220 |
Deep Sedation/General
Anesthesia - First 30 Minutes |
498 |
249 |
249 |
| 9221 |
Deep Sedation/General
Anesthesia - Each additional 15 Minutes |
208 |
104 |
104 |
| 9230 |
Analgesia - Anxiolysis -
Inhalation of Nitrous Oxide |
94 |
47 |
47 |
| 9248 |
Non Intravenous Conscious
Sedation |
412 |
206 |
206 |
| 9440 |
Emergency Office Visit -
After Regularly Scheduled Hours |
290 |
145 |
145 |
| 9920 |
Behavior Management -
Difficult Patient - In addtion to treatment provided - Reported in 15 minute
increments |
158 |
79 |
79 |
|
|
|
|
|
| Any procedure not listed shall be charged at 20% off the
provider's usual fee. |
|
|
|
|
|
| Adjunctive General Services • Bleaching • Crowns • Diagnostic •
Endodontics • Extractions • Fluoride Treatments • Oral Extractions •
Orthodontics • Other • Other Restorative Services • Other Surgical •
Periapical Services • Periodontics • Preventative • Prosthodontics-Fixed-Bridges
• Prosthodontics-Removable • Radiographs • Restorative Amalgam • Restorative
Composite • Specific Codes • Special Maintainers • TMJ • Veneers |
|
| The fees listed on this schedule of benefits are as provided by
a general dentist. |
