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D2110 D2120 D2130 D2131 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2380 D2381 D2382 D2385 D2386 D2387 D2388 D2391 D2392 D2393 D2394 D2410 D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2720 D2721 D2722 D2740 D2750 AMALGAM ONE SURFACE PRIMARY AMALGAM TWO SURFACES PRIMARY AMALGAM THREE SURFACES PRIMARY AMALGAM FOUR/MORE SURFACES PRIMARY AMALGAM-ONE SURFACE PRIMARY OR PERMANENT AMALGAM-TWO SURFACES PRIMARY OR PERMANEN AMALGAM-THREE SURFACES PRIMARY OR PERMAN AMALGAM-FOUR/MORE SURFACES PRIMARY/PERMA RESIN-BASED COMPOSITE - ONE SURFACE ANTE RESIN-BASED COMPOSITE - TWO SURFACES ANT RESIN-BASED COMPOSITE - THREE SURFACES A RESIN COMPOS - 4/MORE SURFACES/INVLV INC RESIN ONE SURFACE POSTERIOR PRIMARY RESIN TWO SURFACE POSTERIOR PRIMARY RESIN 3/MORE SURFACE POST PRIM RESIN 1 SURFACE POST PERM RESIN 2 SURFACE POST PERM RESIN 3/MORE SURFACE POST PERM RESIN-BASED COMPOS-4/MORE SURFACES RESIN-BASED COMPOSITE - ONE SURFACE POST RESIN-BASED COMPOSITE - TWO SURFACES POS RESIN-BASED COMPOSITE - THREE SURFACES P RESIN COMPOS - FOUR OR MORE SURFACES POS GOLD FOIL - ONE SURFACE GOLD FOIL - TWO SURFACES GOLD FOIL - THREE SURFACES INLAY - METALLIC - ONE SURFACE INLAY - METALLIC - TWO SURFACES INLAY - METALLIC - THREE OR MORE SURFACE 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/MORE S ONLAY - PORCELAIN/CERAMIC - TWO SURFACES ONLAY - PORCELAIN/CERAMIC - THREE SURFAC ONLAY - PORCELAIN/CERAMIC - 4 OR MORE SU INLAY - RESIN COMPOS COMPOSITE/RESIN - 1 INLAY - RESIN COMPOS COMPOS/RESIN - 2 SU INLAY - RSN COMPOS COMPOS/RSN - 3/MORE S ONLAY - RESIN COMPOS COMPOS/RESIN - 2 SU ONLAY - RESIN COMPOS COMPOS/RESIN - 3 SU ONLAY - RSN COMPOS COMPOS/RSN - 4/MORE S CROWN RESINBASED COMPOSITE INDIRECT CROWN - RESIN WITH HIGH NOBLE METAL CROWN - RESIN WITH PREDOMINANTLY BASE ME CROWN - RESIN WITH NOBLE METAL CROWN - PORCELAIN/CERAMIC SUBSTRATE CROWN - PORCELAIN FUSED TO HIGH NOBLE ME

Rate

$38.35 $56.87 $70.09 $70.09 $38.35 $56.87 $70.09 $70.09 $52.90 $82.00 $138.86 $97.87 $70.09 $82.00 $138.86 $70.09 $82.00 $138.86 $165.31 $70.09 $82.00 $138.86 $138.86 $138.86 $206.31 $249.95 $235.41 $304.18 $346.50 $285.66 $331.95 $294.48 $206.31 $249.95 $416.59 $128.28 $283.02 $316.08 $133.57 $195.73 $317.40 $163.99 $293.60 $376.91 $374.27 $443.04 $443.04 $443.04 $416.59 $517.10

D2751 D2752 D2780 D2782 D2790 D2791 D2792 D2910 D2920 D2930 D2931 D2932 D2940 D2950 D2951 D2952 D2954 D2955 D2960 D2961 D2962 D2980 D3110 D3120 D3220 D3221 D3230 D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3351 D3410 D3421 D3425 D3426 D3430 D3450 D3910 D3920 D3950 D4210 D4211 D4220 D4240 D4241 D4249 D4260

CROWN - PORCELAIN FUSED PREDOMINANTLY BA CROWN - PORCELAIN FUSED TO NOBLE METAL CROWN - 3/4 CAST HIGH NOBLE METAL CROWN - 3/4 CAST NOBLE METAL CROWN - FULL CAST HIGH NOBLE METAL CROWN - FULL CAST PREDOMINANTLY BASE MET CROWN - FULL CAST NOBLE METAL RECEMENT INLAY ONLAY/PART COVERAGE RESTO RECEMENT CROWN PREFABR STAINLESS STEEL CROWN - PRIMARY PREFABR STAINLESS STEEL CROWN - PERMANEN PREFABRICATED RESIN CROWN SEDATIVE FILLING CORE BUILDUP INCLUDING ANY PINS PIN RETENTION - PER TOOTH ADDITION RESTO CAST POST AND CORE IN ADDITION TO CROWN PREFABRICATED POST AND CORE IN ADDITION POST REMOVAL LABIAL VENEER - CHAIRSIDE LABIAL VENEER - LABORATORY LABIAL VENEER - LABORATORY CROWN REPAIR BY REPORT PULP CAP - DIRECT PULP CAP - INDIRECT TX PULP-REMV PULP CORONAL DENTINOCEMENTL PULPAL DEBRIDEMENT PRIMARY AND PERMANENT PULPAL THERAPY - ANTERIOR PRIMARY TOOTH PULPAL THERAPY - POSTERIOR PRIMARY TOOTH ANTERIOR BICUSPID MOLAR RETREATMENT PREVIOUS RC THERAPY - ANTERI RETREATMENT PREVIOUS RC THERAPY - BICUSP RETREATMENT PREVIOUS ROOT CANAL THERAPY APEXIFICATION/RECALCIFICATION - INITIAL APICOECTOMY/PERIRADICULAR SURGERY - ANTE APICOECTOMY/PERIRADICULAR SURGERY - BICU APICOECTOMY/PERIRADICULAR SURGERY - MOLA APICOECTOMY/PERIRADICULAR SURGERY RETROGRADE FILLING - PER ROOT ROOT AMPUTATION - PER ROOT SURGICAL PROCEDURE ISOLATION TOOTH W/RUB HEMISECTION NOT INCLUDING ROOT CANAL THE CANAL PREPARATION&FITTING PREFORMED DOWE GINGIVECT/PLSTY 4/>CNTIG/BOUND TEETH SPA GINGIVECT/PLSTY 1-3 CNTIG/BOUND TEETH SP GING CURET SURG/QUAD BR GINGL FLP PROC 4/> CONTIG/BOUND TEETH SP GINGL FLP PROC 1-3 CONTIG/BOUND TEETH SP CLINICAL CROWN LENGTHENING - HARD TISSUE OSSEOUS SURG 4/> CONTIG/BOUND TEETH SPAC

$517.10 $517.10 $440.13 $440.13 $411.30 $346.50 $374.27 $27.77 $27.77 $97.87 $97.87 $129.61 $23.81 $138.86 $13.23 $138.86 $138.86 $133.57 $193.09 $193.09 $193.09 $111.09 $19.64 $15.02 $40.43 $36.75 $58.91 $72.77 $257.57 $280.67 $351.12 $263.34 $337.26 $389.24 $200.97 $140.91 $236.78 $219.45 $107.42 $70.46 $140.91 $40.43 $140.91 $19.64 $177.87 $118.97 $57.75 $177.87 $95.63 $218.30 $347.66

D4261 D4263 D4264 D4265 D4266 D4267 D4268 D4270 D4271 D4273 D4341 D4342 D4355 D4381 D4910 D4920 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5850 D5851

OSSEOUS SURG 1-3 CONTIG/BOUND TEETH SPAC BONE REPLACEMENT GRAFT - FIRST SITE IN Q BONE REPLACEMENT GRAFT - EA ADD SITE QUA BIOLOGIC MATERIALS AID SOFT&OSSEOUS TISS GUID TISSUE REGEN - RESORBABLE BARRIER P GUID TISSUE REGEN - NONRESORB BARRIER PE SURGICAL REVISION PROCEDURE PER TOOTH PEDICLE SOFT TISSUE GRAFT PROCEDURE FREE SOFT TISSUE GRAFT PROCEDURE SUBEPITHEL CONECTIVE TISSUE GRAFT PROC P PRDONTAL SCALING&ROOT PLANING 4/MORE TEE PRDONTAL SCALING&ROOT PLANING 1-3 TEETHFULL MOUTH DEBRID ENABLE COMP EVALUATION LOC DEL ANTIMICROBL AGTS CREVICULR TISS PERIODONTAL MAINTENANCE UNSCHEDULED DRESSING CHANGE COMPLETE DENTURE - MAXILLARY COMPLETE DENTURE - MANDIBULAR IMMEDIATE DENTURE - MAXILLARY IMMEDIATE DENTURE - MANDIBULAR MAXILLARY PARTIAL DENTURE - RESIN BASE MANDIBULAR PARTIAL DENTURE - RESIN BASE MAX PART DENTUR-CAST METL FRMEWRK W/RSN MAND PART DENTUR- CAST METL FRMEWRK W/RS REMV UNILAT PART DENTUR - 1 PIECE CAST M ADJUST COMPLETE DENTURE - MAXILLARY ADJUST COMPLETE DENTURE - MANDIBULAR ADJUST PARTIAL DENTURE - MAXILLARY ADJUST PARTIAL DENTURE - MANDIBULAR REPAIR BROKEN COMPLETE DENTURE BASE REPLACE MISSING/BROKEN TEETH - COMPLETE 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 REBASE COMPLETE MAXILLARY DENTURE REBASE COMPLETE MANDIBULAR DENTURE REBASE MAXILLARY PARTIAL DENTURE REBASE MANDIBULAR PARTIAL DENTURE RELINE COMPLETE MAXILLARY DENTURE RELINE COMPLETE MANDIBULAR DENTURE RELINE MAXILLARY PARTIAL DENTURE RELINE MANDIBULAR PARTIAL DENTURE RELINE COMPLETE MAXILLARY DENTURE RELINE COMPLETE MANDIBULAR DENTURE RELINE MAXILLARY PARTIAL DENTURE RELINE MANDIBULAR PARTIAL DENTURE TISSUE CONDITIONING MAXILLARY TISSUE CONDITIONING MANDIBULAR

$177.66 $198.66 $176.72 $31.75 $138.60 $123.59 $123.59 $137.45 $165.17 $207.90 $62.37 $35.49 $40.43 $35.49 $57.75 $18.48 $395.01 $395.01 $494.34 $494.34 $366.14 $366.14 $465.47 $465.47 $183.65 $46.20 $46.20 $17.33 $17.33 $36.96 $36.96 $36.96 $54.29 $64.68 $36.96 $72.77 $54.29 $183.65 $183.65 $128.21 $128.21 $82.01 $82.01 $64.68 $64.68 $128.21 $128.21 $100.49 $100.49 $64.68 $64.68

D5860 D5861 D5931 D5932 D5982 D6010 D6056 D6057 D6058 D6059 D6060 D6066 D6068 D6095 D6100 D6210 D6211 D6212 D6240 D6241 D6242 D6250 D6251 D6252 D6520 D6530 D6545 D6720 D6721 D6722 D6750 D6751 D6752 D6780 D6790 D6791 D6792 D6930 D6940 D6950 D6970 D6971 D6972 D6973 D6980 D7110 D7111 D7120 D7130 D7140 D7210

OVERDENTURE - COMPLETE BY REPORT OVERDENTURE - PARTIAL BY REPORT OBTURATOR PROSTHESIS SURGICAL OBTURATOR PROSTHESIS DEFINITIVE SURGICAL STENT SURG PLACEMENT IMPLANT BODY: ENDOSTEAL I PREFABRICATED ABUTMENT INCLUDES PLACEMEN CUSTOM ABUTMENT INCLUDES PLACEMENT ABUTMENT SUPPORTED PORCELAIN/CERAMIC CRO ABUT SUPP PORCELAIN TO METL CROWN HI NOB ABUT SUPP PORCELAIN TO MTL CROWN PREDOM IMPLANT SUPPORTED PORCELAIN FUSED TO MET ABUT SUPPORTED RETAINER PORCELAIN/CERAMI REPAIR IMPLANT ABUTMENT BY REPORT IMPLANT REMOVAL BY REPORT SEE ALSO CODE PONTIC - CAST HIGH NOBLE METAL PONTIC - CAST PREDOMINANTLY BASE METAL PONTIC - CAST NOBLE METAL PONTIC - PORCELAIN FUSED TO HIGH NOBLE M PONTIC - PORCELN FUSED PREDOMINANTLY BAS PONTIC - PORCELAIN FUSED TO NOBLE METAL PONTIC - RESIN WITH HIGH NOBLE METAL PONTIC - RESIN WITH PREDOMINANTLY BASE M PONTIC - RESIN WITH NOBLE METAL INLAY METALLIC TWO SURFACES INLAY METALLIC THREE/MORE SURFACES RETAINER - CAST METAL RESIN BONDED FIX P CROWN - RESIN WITH HIGH NOBLE METAL CROWN RESIN W/PREDOMINANTLY BASE METAL-D CROWN - RESIN WITH NOBLE METAL CROWN PORCELAIN FUSED TO HI NOBLE METALCROWN - PORCELAIN FUSED PREDOMINANTLY BA CROWN - PORCELAIN FUSED TO NOBLE METAL CROWN - 3/4 CAST HIGH NOBLE METAL CROWN FULL CAST HIGH NOBLE METAL-DENTURE CROWN FULL CAST PREDOMINANTLY BASE METAL CROWN FULL CAST NOBLE METAL-DENTURE RECEMENT FIXED PARTIAL DENTURE STRESS BREAKER PRECISION ATTACHMENT CAST POST&CORE ADDITION FIX PART DENTUR CAST POST AS PART FIXED PARTIAL DENTURE PREFAB POST&CORE ADD FIX PART DENTUR RET CORE BUILD UP FOR RETAINER INCLUDING ANY FIXED PARTIAL DENTURE REPAIR BY REPORT SINGLE TOOTH EXTRACTION CORONAL REMNANTS DECIDUOUS TO EACH ADDITIONAL TOOTH ROOT REMOVAL EXPOSED ROOTS EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT SURG REMV ERUPTED TOOTH RQR ELEV FLP&REM

$493.19 $457.38 $457.38 $457.38 $103.95 $606.38 $485.10 $485.10 $485.10 $485.10 $485.10 $485.10 $485.10 $111.09 $485.10 $255.26 $207.90 $224.07 $303.77 $303.77 $303.77 $266.81 $266.81 $266.81 $182.49 $211.37 $159.39 $284.13 $284.13 $284.13 $317.63 $317.63 $317.63 $248.33 $255.26 $207.90 $224.07 $33.50 $32.34 $99.33 $83.16 $83.16 $83.16 $41.58 $33.50 $27.72 $27.72 $27.72 $36.96 $27.72 $42.74

D7220 D7230 D7240 D7241 D7250 D7260 D7270 D7280 D7281 D7285 D7286 D7290 D7310 D7320 D7340 D7350 D7410 D7420 D7430 D7431 D7440 D7441 D7450 D7451 D7460 D7461 D7471 D7480 D7490 D7510 D7520 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7780

REMOVAL OF IMPACTED TOOTH - SOFT TISSUE REMOVAL OF IMPACTED TOOTH - PARTIALLY BO REMOVAL OF IMPACTED TOOTH - COMPLETELY B REMV IMP TOOTH - CMPL BONY W/UNUSUAL SUR SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS OROLANTRAL FISTULA CLOSURE TOOTH REIMPL &OR STBL ACC EVULSED/DISPLC SURGICAL ACCESS OF AN UNERUPTED TOOTH SURG EXPOS IMPACT/UNERUPTED TOOTH AID ER BIOPSY OF ORAL TISSUE HARD BIOPSY OF ORAL TISSUE SOFT SURGICAL REPOSITIONING OF TEETH ALVEOLPLASTY CONJUNC W/EXTRACTIONS- PER ALVEOLOPLASTY NOT IN CONJUNC W/EXTRACTIO VESTIBULOPLASTY-RIDGE EXT 2ND EPITHELIAL VESTIBULOPLASTY-RIDGE EXT W/SOFT TISS GR EXCISION OF BENIGN LESION UP TO 1.25 CM RADCL EXC LES >1.25CM EXC BEN TUMOR/LES TO 1.25CM EXC BEN TUMOR/LES > 1.25CM EXC MALIG TUMOR-LESION DIAMETER UP TO 1. EXC MALIG TUMOR-LESION DIAM GREATER THAN REMOVAL BEN ODONTOGENIC CYST/TUMR- UP T0 REMOVAL BENIGN ODONTOGENIC CYST/TUMOR- > REMOVAL BEN NONODONTOGENIC CYST/TUMR- UP REMOVAL BEN NONODONTOGENIC CYST/TUMOR- > REMOVAL OF LATERAL EXOSTOSIS PART OSTEC (GUTTERING/SAUCER) RADICAL RESECTION OF MAXILLA OR MANDIBLE INCISION & DRAINAGE ABSCESS-INTRAORAL SO INCISION & DRAINAGE ABSCESS-EXTRAORAL SO REMOVAL FB FROM MUCOSA SKIN/SUBCUT ALVEO REMV REACT-PRODUC FOREIGN BODIES-MUSCULO PART OSTEC/SEQUESTRECTOMY REMOVAL NON-VI MAXILLARY SINUSOTOMY REMOVAL TOOTH FRAGM MAXILLA-OPEN REDUCTION MAXILLA-CLOSED REDUCTION MANDIBLE-OPEN REDUCTION MANDIBLE-CLOSED REDUCTION MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTI MALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUC ALVEOLUS-CLOSED REDUCTION W/STABILIZATIO FCE BNS - COMP RDUC W/FIX&MX SURG APPRCH MAXILLA-OPEN REDUCTION MAXILLA-CLOSED REDUCTION MANDIBLE-OPEN REDUCTION MANDIBLE-CLOSED REDUCTION MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTI MALAR AND/OR ZYGOMATIC ARCH CLOSED REDUC ALVEOLUS - OPEN REDUCTION STABILIZATION FACIAL BONES-COMP RDUC FIX & MX SURG APP

$66.99 $107.42 $143.22 $167.48 $64.68 $214.83 $68.15 $106.26 $106.26 $72.77 $46.20 $106.26 $42.74 $64.68 $75.08 $643.34 $106.26 $214.83 $106.26 $214.83 $321.09 $440.06 $86.63 $170.94 $106.26 $214.83 $273.64 $1,070.69 $2,140.22 $42.74 $42.74 $42.74 $106.26 $150.15 $214.83 $1,070.69 $643.34 $1,070.69 $643.34 $643.34 $106.26 $321.09 $855.86 $1,070.69 $643.34 $1,070.69 $643.34 $643.34 $106.26 $428.51 $1,070.69

D7810 D7820 D7830 D7840 D7850 D7860 D7870 D7880 D7910 D7911 D7912 D7920 D7940 D7950 D7951 D7955 D7960 D7970 D7971 D7980 D7981 D7982 D7983 D7990 D8080 D8210 D8220 D8670 D8999 D9212 D9220 D9221 D9241 D9242 D9610 D9630 D9910 D9930 D9940 D9950 D9951 D9952

OPEN REDUCTION OF DISLOCATION CLOSED REDUCTION OF DISLOCATION MANIPULATION UNDER ANESTHESIA CONDYLECTOMY SURGICAL DISCECTOMY; WITH/WITHOUT IMPLAN ARTHROTOMY ARTHROCENTESIS OCCLUSAL ORTHOTIC APPLIANCE SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM COMPLICATED SUTURE-UP TO 5 CM COMPLICATED SUTURE-GREATER THAN 5 CM SKIN GRAFT OSTEOPLASTY - FOR ORTHOGNATHIC DEFORMITI OSSEOUS OSTEOPERIOSTL/CART GFT MAND/FCE SINUS AUGMENTATION REPAIR MAXLOFACIAL SOFT &/ HARD TISSUE D FRENULECTOMY SEPARATE PROCEDURE EXCISION OF HYPERPLASTIC TISSUE-PER ARCH EXCISION OF PERICORONAL GINGIVA SIALOLITHOTOMY EXCISION OF SALIVARY GLAND BY REPORT SIALODOCHOPLASTY CLOSURE OF SALIVARY FISTULA EMERGENCY TRACHEOTOMY COMPREHENSIVE ORTHODONTIC TX ADOLES DENT REMOVABLE APPLIANCE THERAPY FIXED APPLIANCE THERAPY PERIODIC ORTHODONTIC TREATMENT VISIT UNSPECIFIED ORTHODONTIC PROCEDURE BY REP TRIGEMINAL DIVISION BLOCK ANESTHESIA DEEP SEDATION/GENERAL ANESTHESIA-1ST 30 DEEP SEDATION/GENERAL ANESTHESIA-EA ADD IV CONSCIOUS SEDATION/ANALG - 1ST 30 MIN IV CONSCIOUS SEDATION/ANALG - EA ADD 15 THERAPEUTIC DRUG INJECTION BY REPORT OTHER DRUGS AND/OR MEDICAMENTS BY REPORT APPLICATION OF DESENSITIZING MEDICAMENT TX COMPLICATIONS - UNUSUAL CIRCUMSTANCES OCCLUSAL GUARD BY REPORT OCCLUSION ANALYSIS - MOUNTED CASE OCCLUSAL ADJUSTMENT - LIMITED OCCLUSAL ADJUSTMENT - COMPLETE

$855.86 $106.26 $86.63 $1,070.69 $1,605.45 $1,070.69 $42.74 $504.74 $66.99 $299.15 $643.34 $214.83 $2,140.22 $963.27 $250.00 $1,070.69 $64.68 $106.26 $53.13 $64.68 $428.51 $749.60 $855.86 $428.51 $531.30 $202.13 $202.13 $58.91 $531.30 $160.55 $54.29 $27.72 $42.74 $16.17 $18.48 $18.48 $18.48 $27.72 $20.24 $293.37 $69.30 $274.89

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