Colorado
Exhibit #6Dental Fee ScheduleEffective 1/1/2020ProcDescriptionRateD0120PERIODIC ORAL EVALUATION ‐ EST PATIENT$67.25D0140LIMITED ORAL EVALUATION ‐ PROBLEM FOCUSED$113.00D0145ORAL EVAL PT UND 3 YR AGE CNSL W/PRIM CAREGIVER$105.25D0150COMP ORAL EVALUATION ‐ NEW OR EST PATIENT$119.00D0160DTL&EXT ORAL EVALUATION ‐ PROBLEM FOCUSED REPORT$238.00D0170RE‐EVALUATION ‐ LIMITED PROBLEM FOCUSED$79.25D0171RE‐EVALUATION POST‐OPERATIVE OFFICE VISIT$79.25D0180COMP PERIODONTAL EVALUATION ‐ NEW OR EST PATIENT$129.25D0190SCREENING OF A PATIENT$67.25D0191ASSESSMENT OF A PATIENT$47.50D0210INTRAORAL‐COMPLETE SERIES$182.00D0220INTRAORAL ‐ PERIAPICAL FIRST RADIOGRAPHIC IMAGE$36.75D0230INTRAORAL‐PERIAPICAL‐EACH ADDITIONAL FILM$32.75D0240INTRAORAL ‐ OCCLUSAL RADIOGRAPHIC IMAGE$56.50D0250EXTRAORAL 2D PRJECTN RAD IMG BY RAD SRCE/ DTECTR$69.50D0251EXTRAORAL 2D POSTERIOR DENTAL RAD IMAGE$63.75D0270BITEWING ‐ SINGLE RADIOGRAPHIC IMAGE$35.25D0272BITEWINGS ‐ TWO RADIOGRAPHIC IMAGES$56.75D0273BITEWINGS ‐ THREE RADIOGRAPHIC IMAGES$69.00D0274BITEWINGS ‐ FOUR RADIOGRAPHIC IMAGES$79.50D0277VERTICAL BITEWINGS ‐ 7 TO 8 RADIOGRAPHIC IMAGES$120.50D0310SIALOGRAPHY$517.50D0320TEMPOROMANDIBULAR JOINT ARTHROGRAM INCL INJ$915.00D0321OTHER TEMPOROMANDIBULAR JOINT FILMS BY REPORTBRD0322TOMOGRAPHIC SURVEY$742.25D0330PANORAMIC RADIOGRAPHIC IMAGE$160.50D03402D CEPHLOMTRIC RAD IMG ‐ ACQSTN MEASRE& ANALYSIS$181.00D03502D ORAL/FACIAL PHOTOGRAPHIC IMAGES$86.50D03513D PHOTOGRAPHIC IMAGE$86.50D0364CONE BEAM 3$288.25D0365CNE BEAM CAPTR INTERPJ W FLD VIEW 1 ARCH MNDBL$367.50D0366CNE BEAM CAPTR INTERPJ W FLD VIEW 1 ARCH MAXL$367.50D0367CNE BEAM CAPTR INTERPJ W FLD VIEW BTH JAWS$414.50D0368CNE BEAM CAPTR INTERPJ FR TMJ 2 OR MORE$426.00D0369MAXILLOFACIAL MRI CAPTURE AND INTERPRETATION$241.50D0370MAXLFCL US IMAGE CAPTR AND INTRPJ$138.25D0371SIALOENDOSCOPY CAPTURE AND INTERPRETATIONBRD0380CNE BEAM CAPTR LMTD FLD <1 WHL JAW$297.00D0381CNE BEAM CAPTR W FLD VIEW 1 ARCH MNDBL$402.25D0382CNE BEAM CAPTR W FLD VIEW 1 ARCH MAXL$402.25D0383CNE BEAM CAPTR W FLD VIEW BTH JAWS$402.25D0384CNE BEAM CAPTR FR TMJ 2 OR MORE$431.50D0385MAXILLOFACIAL MRI IMAGE CAPTURE$2,649.00D0386MAXILLOFACIAL ULTRASOUND IMAGE CAPTURE$662.75D0391INTERPRETATION OF DIAGNOSTIC IMAGEBRD0393TREATMENT SIMULATION USING 3D IMAGE VOLUMEBRD0394DIGITAL SUBTR OF 2 > IMAGES OF THE SAME MODALITYBRD0395FUSION OF 2/> 3D IMAGE VOLUMES OF 1/> MODALITIESBRD0411HBA1C IN‐OFFICE POINT OF SERVICE TESTINGBRD0412BLOOD GLCSE LVL TST ‐ IN‐OFFICE USING GLCSE MTRBRD0414LAB MICRBAL SPEC CULTRE/SENS/REPORT PREP TRNSMSN$70.75D0415COLLECTION MICROORGANISMS CULTURE & SENSITIVITY$51.25D0416VIRAL CULTURE$76.25D0417CLCT & PREP SALIVA SAMPLE FOR LAB DX TESTING$68.75D0418ANALYSIS OF SALIVA SAMPLE$70.75D0422COLLECT/PREP GENETIC SAMPLE FOR LAB ANALYSIS$51.25D0423GENETIC TEST SUSCEPT TO DSEASE SPECIMEN ANLYSBRD0425CARIES SUSCEPTIBILITY TESTS$44.25D0431ADJUNCTIVE PREDX TST NOT INCL CYTOLOGY/BX PROC$70.75D0460PULP VITALITY TESTS$70.75D0470DIAGNOSTIC CASTS$156.25D0472ACCESSION OF TISSUE GROSS EXAMINATION PREP/REPRT$97.50D0473ACCESS TISSUE GR&MIC EXAMINATION PREP/REPRT$205.75D0474ACCESS TISS GR&MIC EX ASSESS SURG MARG PREP/RPT$230.50D0475DECALCIFICATION PROCEDURE$124.25D0476SPECIAL STAINS FOR MICROORGANISMS$120.75D0477SPECIAL STAINS NOT FOR MICROORGANISMS$165.00D0478IMMUNOHISTOCHEMICAL STAINS$150.75D0479TISSUE INSITU HYBRIDIZATION INCL INTERPRETATION$230.50D0480ACESS EXFOLIATIVE CYTOL SMEAR MIC EXAM PREP/REPT$142.00D0481ELECTRON MICROSCOPY$532.00D0482DIRECT IMMUNOFLUORESCENCE$177.25D0483INDIRECT IMMUNOFLUORESCENCE$177.25D0484CONSULTATION ON SLIDES PREPARED ELSEWHERE$265.75D0485CONSULT INCL PREP SLIDES BX MATL SPL REF SRC$367.25D0486ACCESSION TRANSEPITHELIAL CYTOLOG SAMPL MIC EXAM$170.50D0502OTHER ORAL PATHOLOGY PROCEDURES BY REPORTBRD0600DX PX QUANT/MNITR/RECRD CHNGS ENAML/DENTN/CEMNTMBRD0601CARIES RISK ASSESS DOCU FINDING OF LOW RISK$106.25D0602CARIES RISK AX AND DOCU WITH A FNDNG OF MOD RISK$106.25D0603CARIES RISK AX AND DOCU WITH FNDNG OF HIGH RISK$106.25D0999UNSPECIFIED DIAGNOSTIC PROCEDURE BY REPORTBRD1110PROPHYLAXIS ‐ ADULT$117.25D1120PROPHYLAXIS ‐ CHILD$80.75D1206TOPICAL APPLICATION OF FLUORIDE VARNISH$64.25D1208TOPICAL APPLICATION OF FLUORIDE EXCL VARNISH$43.00D1310NUTRITIONAL COUNSELING CONTROL OF DENTAL DISEASE$62.75D1320TOBACCO CNSL CONTROL&PREVENTION ORAL DISEASE$68.00D1330ORAL HYGIENE INSTRUCTIONS$86.00D1351SEALANT ‐ PER TOOTH$69.75D1352PREV RSN REST MOD HIGH CARIES RISK PT‐PERM TOOTH$89.50D1353SEALANT REPAIR PER TOOTH$89.50D1354INTERIM CARIES ARRESTING MEDICATION APPLICATION$69.75D1510SPACE MAINTAINER ‐ FIXED ‐ UNILATERAL$425.25D1516SPACE MAINTAINER ‐ FIXED ‐ BILATERIAL MAXILLARY$595.25D1517SPACE MAINTAINER ‐ FIXED ‐ BILATERIAL MANDIBULAR$595.25D1520SPACE MAINTAINER ‐ REMOVABLE ‐ UNILATERAL$467.50D1526SPACE MAINTAINER ‐ REMOVABLE ‐ BILATERAL MAXILRY$722.75D1527SPACE MAINTAINER ‐ REMOVABLE ‐ BILATERAL MNDBULR$722.75D1550RECMNT/REBND OF SPACE MAINTAINER$91.75D1555REMOVAL OF FIXED SPACE MAINTAINER$88.50D1575DISTAL SHOE SPACE MAINTANR ‐ FIXED ‐ UNILATERIAL$467.50D1999UNSPECIFIED PREVENTIVE PROCEDURE BY REPORTBRD2140AMALGAM ‐ ONE SURFACE PRIMARY OR PERMANENT$201.25D2150AMALGAM ‐ TWO SURFACES PRIMARY OR PERMANENT$260.50D2160AMALGAM ‐ THREE SURFACES PRIMARY OR PERMANENT$314.75D2161AMALGAM‐FOUR/MORE SURFACES PRIMARY/PERMANENT$383.50D2330RESIN‐BASED COMPOSITE ‐ ONE SURFACE ANTERIOR$204.25D2331RESIN‐BASED COMPOSITE ‐ TWO SURFACES ANTERIOR$260.75D2332RESIN‐BASED COMPOSITE ‐ THREE SURFACES ANTERIOR$319.00D2335RESIN‐BASED COMPOSITE 4/> SURFACES INCISAL ANGLE$377.50D2390RESIN‐BASED COMPOSITE CROWN ANTERIOR$418.25D2391RESIN‐BASED COMPOSITE ‐ ONE SURFACE POSTERIOR$239.25D2392RESIN‐BASED COMPOSITE ‐ TWO SURFACES POSTERIOR$313.00D2393RESIN‐BASED COMPOSITE ‐ THREE SURFACES POSTERIOR$389.00D2394RESIN COMPOS ‐ FOUR OR MORE SURFACES POSTERIOR$476.25D2410GOLD FOIL ‐ ONE SURFACE$352.00D2420GOLD FOIL ‐ TWO SURFACES$586.75D2430GOLD FOIL ‐ THREE SURFACES$1,016.75D2510INLAY ‐ METALLIC ‐ ONE SURFACE$930.50D2520INLAY ‐ METALLIC ‐ TWO SURFACES$1,055.75D2530INLAY ‐ METALLIC ‐ THREE OR MORE SURFACES$1,217.00D2542ONLAY ‐ METALLIC ‐ TWO SURFACES$1,193.50D2543ONLAY ‐ METALLIC ‐ THREE SURFACES$1,248.25D2544ONLAY ‐ METALLIC ‐ FOUR OR MORE SURFACES$1,298.00D2610INLAY ‐ PORCELAIN/CERAMIC ‐ ONE SURFACE$1,095.00D2620INLAY ‐ PORCELAIN/CERAMIC ‐ TWO SURFACES$1,155.75D2630INLAY ‐ PORCELAIN/CERAMIC ‐ THREE/MORE SURFACES$1,231.00D2642ONLAY ‐ PORCELAIN/CERAMIC ‐ TWO SURFACES$1,196.50D2643ONLAY ‐ PORCELAIN/CERAMIC ‐ THREE SURFACES$1,290.50D2644ONLAY ‐ PORCELAIN/CERAMIC ‐ 4 OR MORE SURFACES$1,368.75D2650INLAY ‐ RESIN‐BASED COMPOSITE ‐ ONE SURFACE$719.50D2651INLAY ‐ RESIN‐BASED COMPOSITE ‐ TWO SURFACES$857.00D2652INLAY RESIN BASED COMPOSITE 3 OR MORE SURFACES$901.00D2662ONLAY ‐ RESIN‐BASED COMPOSITE ‐ TWO SURFACES$782.00D2663ONLAY ‐ RESIN‐BASED COMPOSITE ‐ THREE SURFACES$919.75D2664ONLAY RESIN BASED COMPOSIT FOUR OR MORE SURFACES$985.25D2710CROWN ‐ RESIN‐BASED COMPOSITE (INDIRECT)$585.25D2712CROWN 3/4 RESIN‐BASED COMPOSITE (INDIRECT)$585.25D2720CROWN ‐ RESIN WITH HIGH NOBLE METAL$1,442.00D2721CROWN ‐ RESIN WITH PREDOMINANTLY BASE METAL$1,351.50D2722CROWN ‐ RESIN WITH NOBLE METAL$1,381.00D2740CROWN ‐ PORCELAIN/CERAMIC SUBSTRATE$1,480.00D2750CROWN ‐ PORCELAIN FUSED TO HIGH NOBLE METAL$1,460.50D2751CROWN ‐ PORCELAIN FUSED PREDOMINANTLY BASE METAL$1,360.00D2752CROWN ‐ PORCELAIN FUSED TO NOBLE METAL$1,392.75D2780CROWN ‐ 3/4 CAST HIGH NOBLE METAL$1,401.00D2781CROWN ‐ 3/4 CAST PREDOMINANTLY BASE METAL$1,318.50D2782CROWN ‐ 3/4 CAST NOBLE METAL$1,361.50D2783CROWN ‐ 3/4 PORCELAIN/CERAMIC$1,440.50D2790CROWN ‐ FULL CAST HIGH NOBLE METAL$1,409.25D2791CROWN ‐ FULL CAST PREDOMINANTLY BASE METAL$1,335.25D2792CROWN ‐ FULL CAST NOBLE METAL$1,360.00D2794CROWN ‐ TITANIUM$1,442.00D2799PROVISIONAL CROWN$585.25D2910RECMNT/REBND INLAY ONLAY/PART CVRGE RESTORATION$131.75D2915RECMNT/REBND CAST OR PREFABRICATED POST AND CORE$131.75D2920RE‐CEMENT OR RE‐BOND CROWN$133.50D2921REATTACHMENT OF TOOTH FRAG INCISAL EDGE/CUSP$192.25D2929PREFABR STAINLESS PORC CROWN ‐ PRIMARY TOOTH$528.75D2930PREFABR STAINLESS STEEL CROWN ‐ PRIMARY TOOTH$363.75D2931PREFABR STAINLESS STEEL CROWN ‐ PERMANENT TOOTH$411.50D2932PREFABRICATED RESIN CROWN$439.00D2933PREFABR STAINLESS STEEL CROWN W/RESIN WINDOW$503.25D2934PREFAB ESTHETIC COAT STNLESS STEEL CROWN PRIM$503.25D2940PROTECTIVE RESTORATION$138.75D2941INTERIM THERAPEUTIC RESTORATION PRIM DENTITION$138.75D2949RESTOR FOUNDATION N INDIR RESTOR$138.75D2950CORE BUILDUP INCLUDING ANY PINS WHEN REQUIRED$347.50D2951PIN RETENTION ‐ PER TOOTH ADDITION RESTORATION$78.75D2952POST AND CORE ADDITION TO CROWN INDIRECTLY FAB$548.75D2953EACH ADDITIONAL INDIRECTLY FAB POST SAME TOOTH$274.25D2954PREFABRICATED POST AND CORE IN ADDITION TO CROWN$439.00D2955POST REMOVAL$338.50D2957EACH ADDITIONAL PREFABRICATED POST ‐ SAME TOOTH$219.50D2960LABIAL VENEER (RESIN LAMINATE) ‐ CHAIRSIDE$1,060.75D2961LABIAL VENEER (RESIN LAMINATE) ‐ LABORATORY$1,203.75D2962LABIAL VENEER (PORCELAIN LAMINATE) ‐ LABORATORY$1,307.75D2971ADD PROC NEW CRWN UND XSTING PART DENTUR FRMEWRK$210.25D2975COPING$640.00D2980CROWN REPAIR BY REPORT$256.00D2981INLAY REPAIR BY REPORT$256.00D2982ONLAY REPAIR BY REPORT$256.00D2983VENEER REPAIR BY REPORT$256.00D2990RESIN INFILT OF INCIPIENT LESIONS$91.75D2999UNSPECIFIED RESTORATIVE PROCEDURE BY REPORTBRD3110PULP CAP ‐ DIRECT (EXCLUDING FINAL RESTORATION)$125.00D3120PULP CAP ‐ INDIRECT$100.50D3220TX PULP‐REMV PULP CORONAL DENTINOCEMENTL JUNC$257.00D3221PULPAL DEBRIDEMENT PRIMARY AND PERMANENT TEETH$282.00D3222PART PULPOTOMY FOR APEXOGENEIS PERM TOOTH$260.75D3230PULPAL THERAPY ‐ ANTERIOR PRIMARY TOOTH$252.00D3240PULPAL THERAPY ‐ POSTERIOR PRIMARY TOOTH$310.25D3310ENDODONTIC THERAPY ANTERIOR TOOTH$988.00D3320ENDODONTIC THERAPY PREMOLAR TOOTH$1,210.75D3330ENODODONTIC THERAPY MOLAR$1,501.25D3331TREATMENT RC OBSTRUCTION; NON‐SURGICAL ACCESS$387.50D3332INCOMPLETE ENDO TX; INOP UNRESTORABLE/FX TOOTH$736.00D3333INTERNAL ROOT REPAIR OF PERFORATION DEFECTS$339.00D3346RETREATMENT PREVIOUS RC THERAPY ‐ ANTERIOR$1,317.50D3347RETREATMENT PREVIOUS RC THERAPY ‐ PREMOLAR$1,550.00D3348RETREATMENT PREVIOUS ROOT CANAL THERAPY ‐ MOLAR$1,918.00D3351APEXIFICATION/RECALCIFICAT INIT VST$604.00D3352APEXIFICAT/RECALCIFICAT INT MED REPL$270.75D3353APEXIFICATION/RECALCIFICATION ‐ FINAL VISIT$833.00D3355PULPAL REGENERATION ‐ INITIAL VISIT$604.00D3356PULPAL REGEN ‐ INTERIM MED RPLCMNT$270.75D3357PULPAL REGENERATION ‐ COMPLETION OF TREATMENTBRD3410APICOECTOMY ‐ ANTERIOR$1,197.50D3421APICOECTOMY ‐ PREMOLAR (FIRST ROOT)$1,333.25D3425APICOECTOMY ‐ MOLAR (FIRST ROOT)$1,510.25D3426APICOECTOMY (EACH ADDITIONAL ROOT)$510.50D3427PERIRADICULAR SURGERY WITHOUT APICOECTOMY$1,083.25D3428BG IN CONJ PERIRADICULAR SURG/TOOTH SINGLE SITE$1,579.00D3429BG IN CONJ PERIRADICUL SURG EACH CONTIG TH SSS$1,506.00D3430RETROGRADE FILLING ‐ PER ROOT$375.00D3431BIO MAT SFT OSS REGE CONJ PERIR SUR$1,854.00D3432GTR RESORB BRRER PER SITE IN CONJ PERIRAD SURG$1,593.25D3450ROOT AMPUTATION ‐ PER ROOT$781.00D3460ENDODONTIC ENDOSSEOUS IMPLANT$2,916.00D3470INTENTIONAL REIMPLANTATION W/NECESSARY SPLINTING$1,489.25D3910SURGICAL PROCEDURE ISOLATION TOOTH W/RUBBER DAM$208.25D3920HEMISECTION NOT INCLUDING ROOT CANAL THERAPY$593.50D3950CANAL PREPARATION&FITTING PREFORMED DOWEL/POST$270.75D3999UNSPECIFIED ENDODONTIC PROCEDURE BY REPORTBRD4210GINGIVECT/PLSTY 4/>CNTIG/TOOTH BOUND SPACES‐QUAD$1,249.50D4211GINGIVECT/PLSTY 1‐3 CNTIG/TOOTH BOUND SPACE‐QUAD$555.00D4212GINGIVECT/PLSTY 1‐3CNTIG PER TOOTH$444.25D4230ANAT CROWN EXP 4/> CONTIGUOUS TEETH PER QUAD$1,749.00D4231ANATOMICAL CROWN EXPOSURE 1‐3 TEETH PER QUADRANT$833.00D4240GINGL FLP PROC 4/> CONTIG/TOOTH BOUND SPACE‐QUAD$1,582.50D4241GINGL FLP PROC 1‐3 CONTIG/TOOTH BOUND SPACE‐QUAD$916.25D4245APICALLY POSITIONED FLAP$1,166.00D4249CLINICAL CROWN LENGTHENING ‐ HARD TISSUE$1,734.75D4260OSSEOUS SURG 4/> CNTIG TEETH QUAD$2,637.25D4261OSSEOUS SURG 1‐3 CNTIG TEETH QUAD$1,416.00D4263BONE REPLACEMENT GRAFT ‐ FIRST SITE IN QUADRANT$943.75D4264BONE REPLACEMENT GRAFT ‐ EA ADD SITE QUADRANT$805.00D4265BIOLOGIC MATERIALS AID SOFT&OSSEOUS TISSUE REGENBRD4266GUID TISSUE REGEN ‐ RESORBABLE BARRIER PER SITE$971.50D4267GUID TISSUE REGEN ‐ NONRESORB BARRIER PER SITE$1,249.50D4268SURGICAL REVISION PROCEDURE PER TOOTHBRD4270PEDICLE SOFT TISSUE GRAFT PROCEDURE$1,873.75D4273AUTOGNS CONECTIVE TISSUE GRFT 1ST TOOTH/IMPLANT$2,290.25D4274DISTAL OR PROXIMAL WEDGE PROCEDURE$1,299.25D4275NONAUTGNS CONECTV TISSUE GRFT 1ST TOOTH/IMPLANT$1,721.25D4276COMB CNCTIVE TISSUE&DBL PEDICLE GRAFT PER TOOTH$2,567.75D4277FREE SOFT TISSUE GRAFT, 1ST TOOTH/ IMPLANT$1,943.25D4278FREE SOFT TISSUE GRAFT, E/ADNL TOOTH, IMPLNT$638.50D4283AUTO CNNCTV TISSUE GRFT PROC E/A TOOTH, IMPLANT$1,951.50D4285NON‐AUTO CNNCTV TSSUE GRFT PROC E/A TOOTH/IMPLNT$1,468.50D4320PROVISIONAL SPLINTING ‐ INTRACORONAL$612.50D4321PROVISIONAL SPLINTING ‐ EXTRACORONAL$556.75D4341PRDONTAL SCALING&ROOT PLANING 4/MORE TEETH‐QUAD$352.50D4342PRDONTAL SCALING&ROOT PLANING 1‐3 TEETH‐QUAD$204.25D4346SCALNG GNGIVAL INFLAMM FULL MOUTH AFTR ORAL EVAL$204.25D4355FULL MOUTH DEBRID ENABLE COMP EVALUATION&DX$241.25D4381LOC DEL ANTIMICROBL AGTS CREVICULR TISS TOOTH BRBRD4910PERIODONTAL MAINTENANCE$217.25D4920UNSCHEDULED DRESSING CHANGE$157.75D4921GINGIVAL IRRIGATION PER QUADRANTBRD4999UNSPECIFIED PERIODONTAL PROCEDURE BY REPORTBRD5110COMPLETE DENTURE ‐ MAXILLARY$2,383.50D5120COMPLETE DENTURE ‐ MANDIBULAR$2,383.50D5130IMMEDIATE DENTURE ‐ MAXILLARY$2,598.50D5140IMMEDIATE DENTURE ‐ MANDIBULAR$2,598.50D5211MAXILLARY PARTIAL DENTURE ‐ RESIN BASE$2,011.50D5212MANDIBULAR PARTIAL DENTURE ‐ RESIN BASE$2,337.75D5213MAX PART DENTUR‐CAST METL FRMEWRK W/RSN BASE$2,633.50D5214MAND PART DENTUR‐ CAST METL FRMEWRK W/RSN BASE$2,633.50D5221IMMED MAXILLARY PARTIAL DENTURE RESIN BASE$2,194.25D5222IMMED MANDIBULAR PARTIAL DENTURE RESIN BASE$2,548.75D5223IMMED MAXIL PART DENTURE CAST METL FRAME W/RESIN$2,870.50D5224IMMED MAND PART DENTURE CAST METL FRAME W/RESIN$2,870.50D5225MAXILLARY PARTIAL DENTRUE FLEXIBLE BASE$2,011.50D5226MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE$2,337.75D5282RMVBL UNIL PRTL DNTR CST MTL INCL CLSP TTH MXLRY$1,535.25D5283RMVBL UNIL PRTL DNTR CST MTL INCL CLSP TTH MNDBL$1,535.25D5410ADJUST COMPLETE DENTURE ‐ MAXILLARY$130.50D5411ADJUST COMPLETE DENTURE ‐ MANDIBULAR$130.50D5421ADJUST PARTIAL DENTURE ‐ MAXILLARY$130.50D5422ADJUST PARTIAL DENTURE ‐ MANDIBULAR$130.50D5511REPAIR BROKEN COMPLETE DENTURE BASE, MANDIBULAR$261.00D5512REPAIR BROKEN COMPLETE DENTURE BASE, MAXILLARY$261.00D5520REPLACE MISSING/BROKEN TEETH ‐ COMPLETE DENTURE$217.25D5611REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR$282.50D5612REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY$282.50D5621REPAIR CAST FRAMEWORK, MANDIBULAR$304.50D5622REPAIR CAST FRAMEWORK, MAXILLARY$304.50D5630REPAIR OR REPLACE BROKEN CLASP PER TOOTH$369.50D5640REPLACE BROKEN TEETH ‐ PER TOOTH$239.25D5650ADD TOOTH TO EXISTING PARTIAL DENTURE$326.25D5660ADD CLASP TO EXISTING PARTIAL DENTURE PER TOOTH$391.50D5670REPLACE ALL TEETH&ACRYLIC CAST METAL FRMEWRK MAX$956.75D5671REPLACE ALL TEETH&ACRYLIC CAST METL FRMEWRK MAND$956.75D5710REBASE COMPLETE MAXILLARY DENTURE$967.75D5711REBASE COMPLETE MANDIBULAR DENTURE$924.00D5720REBASE MAXILLARY PARTIAL DENTURE$913.75D5721REBASE MANDIBULAR PARTIAL DENTURE$913.75D5730RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)$546.00D5731RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)$546.00D5740RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)$500.25D5741RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)$500.25D5750RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)$728.50D5751RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY)$728.50D5760RELINE MAXILLARY PARTIAL DENTURE (LABORATORY)$717.75D5761RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY)$717.75D5810INTERIM COMPLETE DENTURE (MAXILLARY)$1,152.50D5811INTERIM COMPLETE DENTURE (MANDIBULAR)$1,239.50D5820INTERIM PARTIAL DENTURE (MAXILLARY)$891.50D5821INTERIM PARTIAL DENTURE (MANDIBULAR)$946.00D5850TISSUE CONDITIONING MAXILLARY$228.50D5851TISSUE CONDITIONING MANDIBULAR$228.50D5862PRECISION ATTACHMENT BY REPORTBRD5863OVERDENTURE COMPLETE MAXILLARY$2,522.25D5864OVERDENTURE PARTIAL MAXILLARY$3,327.00D5865OVERDENTURE COMPLETE MIBULAR$2,522.25D5866OVERDENTURE PARTIAL MIBULAR$3,457.50D5867REPLACEMENT REPL PART SEMI‐PRCISN/PRCISN ATTCHBRD5875MODIFICATION REMV PROSTH AFTER IMPLANT SURGERYBRD5876ADD MTL SUBSTRUCTR TO ACRYLIC FULL DNTR PER ARCHBRD5899UNS REMOVABLE PROSTHODONTIC PROCEDURE REPORTBRD5911FACIAL MOULAGE (SECTIONAL)$604.50D5912FACIAL MOULAGE (COMPLETE)$604.50D5913NASAL PROSTHESIS$12,730.25D5914AURICULAR PROSTHESIS$12,730.25D5915ORBITAL PROSTHESIS$17,227.25D5916OCULAR PROSTHESIS$4,595.00D5919FACIAL PROSTHESISBRD5922NASAL SEPTAL PROSTHESISBRD5923OCULAR PROSTHESIS INTERIMBRD5924CRANIAL PROSTHESISBRD5925FACIAL AUGMENTATION IMPLANT PROSTHESISBRD5926NASAL PROSTHESIS REPLACEMENTBRD5927AURICULAR PROSTHESIS REPLACEMENTBRD5928ORBITAL PROSTHESIS REPLACEMENTBRD5929FACIAL PROSTHESIS REPLACEMENTBRD5931OBTURATOR PROSTHESIS SURGICAL$6,854.25D5932OBTURATOR PROSTHESIS DEFINITIVE$12,819.50D5933OBTURATOR PROSTHESIS MODIFICATIONBRD5934MANDIBULAR RESECTION PROSTHESIS W/GUIDE FLANGE$11,684.00D5935MANDIBULAR RESECTION PROSTHESIS W/O GUIDE FLANGE$10,166.50D5936OBTURATOR PROSTHESIS INTERIM$11,419.00D5937TRISMUS APPLIANCE (NOT FOR TMD TREATMENT)$1,435.25D5951FEEDING AID$1,865.75D5952SPEECH AID PROSTHESIS PEDIATRIC$6,058.50D5953SPEECH AID PROSTHESIS ADULT$11,505.75D5954PALATAL AUGMENTATION PROSTHESIS$10,662.25D5955PALATAL LIFT PROSTHESIS DEFINITIVE$9,861.75D5958PALATAL LIFT PROSTHESIS INTERIMBRD5959PALATAL LIFT PROSTHESIS MODIFICATIONBRD5960SPEECH AID PROSTHESIS MODIFICATIONBRD5982SURGICAL STENT$967.75D5983RADIATION CARRIER$2,174.75D5984RADIATION SHIELD$2,174.75D5985RADIATION CONE LOCATOR$2,174.75D5986FLUORIDE GEL CARRIER$217.25D5987COMMISSURE SPLINT$3,262.00D5988SURGICAL SPLINT$652.50D5991VESICULOBULLOUS DISEASE MEDICAMENT CARRIER$250.00D5992ADJUST MAXILLOFACIAL PROSTH APPLIANCE BY REPORTBRD5993MAINT / CLEAN MAXILLOFACIAL PROSTH BY REPORTBRD5994PERIDONL MEDIC CARRIER PERIPH SEAL LAB PRCESSDBRD5999UNSPECIFIED MAXILLOFACIAL PROSTHESIS BY REPORTBRD6010SURG PLACEMENT IMPLANT BODY: ENDOSTEAL IMPLANT$3,981.75D6011SECOND STAGE IMPLANT SURGERYBRD6012SURG PLCMT INTERIM IMPL TRNSITIONL PROS: ENDOS$3,762.25D6013SURGICAL PLACEMENT OF MINI IMPLANT$3,981.75D6040SURGICAL PLACEMENT: EPOSTEAL IMPLANT$13,700.25D6050SURGICAL PLACEMENT: TRANSOSTEAL IMPLANT$10,220.75D6051INTERIM ABUTMENTBRD6052SEMI‐PRECISION ATTACHMENT ABUTMENT$1,687.50D6055CONNECTING BAR IMPLANT OR ABUTMENT SUPPORTED$1,196.00D6056PREFABRICATED ABUTMENT INCLUDES PLACEMENT$826.50D6057CUSTOM FABRICATED ABUTMENT INCLUDES PLACEMENT$1,022.00D6058ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN$2,292.00D6059ABUT SUPP PORCELAIN TO METL CROWN HI NOBLE METL$2,261.50D6060ABUT SUPP PORCELAIN TO MTL CROWN PREDOM BASE MTL$2,137.75D6061ABUT SUPP PORCELAIN TO METAL CROWN NOBLE METAL$2,181.25D6062ABUTMENT SUPP CAST METAL CROWN HIGH NOBLE METAL$2,172.50D6063ABUTMENT SUPP CAST METAL CROWN PREDOM BASE METAL$1,891.75D6064ABUTMENT SUPP CAST METAL CROWN NOBLE METAL$1,979.00D6065IMPL SUPP PORCELAIN/CERAMIC CROWN$2,255.00D6066IMPL SUPP PORCLN FUSED METL CRWN TITNM/HIGH NOBL$2,196.25D6067IMPL SUPP METAL CROWN TITIANM/HIGH NOBLE METL$2,131.25D6068ABUT SUPP RETAINER PORCELAIN/CERAMIC FPD$2,272.50D6069ABUT RETAINR PORCELN TO METL FPD HI NOBL METL$2,261.50D6070ABUT RETN PORCELN TO METL FPD PREDOM BASE METL$2,137.75D6071ABUT SUPP RETN PORCELN FUSD METAL FPD NOBLE METL$2,181.25D6072ABUT SUPP RETN CAST METL FPD HIGH NOBLE METL$2,207.00D6073ABUT RTNR CAST METL FPD PREDOM BASE METL$2,016.00D6074ABUTMENT RTNR CAST METAL FPD NOBLE METAL$2,142.00D6075IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD$2,255.00D6076IMPL SUPP RTNR PORCLN FUSED METL FPD TITNM/HIGH$2,196.25D6077IMPL SUPP RTNR CST METL FPD TITNM/HIGH NOBLE$2,131.25D6080IMPL MAINT PROC REMV CLEAN PROSTH & ABUT REINSRT$187.25D6081SCALNG/DBRDMNT IMPLNT WO FLAP ENTRY/CLOS$95.75D6085PROVISIONAL IMPLANT CROWN$656.75D6090REPAIR IMPLANT SUPPORTED PROSTHESIS BY REPORTBRD6091REPL ATTACHMNT IMPL/ABUT SUPP PROS PER ATTACHMNT$902.50D6092RECEMENT / REBOND IMPLANT/ABUTMENT SUPP CROWN$176.25D6093RECMNT/REBOND IMPL/ABUTMNT SUPP FIX PART DENTURE$276.25D6094ABUTMENT SUPPORTED CROWN TITANIUM$1,793.75D6095REPAIR IMPLANT ABUTMENT BY REPORTBRD6096REMOVE BROKEN IMPLANT RETAINING SCREWBRD6100IMPLANT REMOVAL BY REPORTBRD6101DBRDMNT OF PERI‐IMPLANT DEFECT$645.75D6102DBRDMNT OF PERI‐IMPLANT DEFECT$887.25D6103BONE GRFT RPR PERIIMPLNT DFCT W/O FLAP ENTR/CLSE$739.50D6104BONE GRAFT AT TIME OF IMPLANT PLACEMENT$739.50D6110IMPL/ABUTMENT SUPPORTED RD ‐ MAXILLARY$2,972.75D6111IMPL/ABUTMENT SUPPORTED RD ‐ MANDIBULAR$2,972.75D6112IMPL/ABUTMENT SUPPORTED RPD ‐ MAXILLARY$2,972.75D6113IMPLANT / ABUTMENT SUPPORTED RPD ‐ MANDIBULAR$2,972.75D6114IMPLANT / ABUTMENT SUPPORTED FD ‐ MAXILLARY$5,206.00D6115IMPLANT/ABUTMENT SUPPORTED FD ‐ MANDIBULAR$5,206.00D6116IMPL/ABUTMENT SUPPORTED FD ‐ MAXILLARY ‐ PARTIAL$3,992.50D6117IMPL/ABUT SUPPORTED FD ‐ MANDIBULAR ‐ PARTIAL$3,992.50D6118IMP/ABUT SPRTD INTRM FIXED DENTR EDENTLS MANDBLR$2,707.25D6119IMP/ABUT SPRTD INTRM FIXED DENTR EDENTLS MAXLARY$2,707.25D6190RADIOGRAPHIC/SURGICAL IMPLANT INDEX BY REPORT$402.25D6194ABUTMENT SUPPORTED RETAINER CROWN FOR FPD$1,848.25D6199UNSPECIFIED IMPLANT PROCEDURE BY REPORTBRD6205PONTIC ‐ INDIRECT RESIN BASED COMPOSITE$931.25D6210PONTIC ‐ CAST HIGH NOBLE METAL$1,423.75D6211PONTIC ‐ CAST PREDOMINANTLY BASE METAL$1,334.25D6212PONTIC ‐ CAST NOBLE METAL$1,388.25D6214PONTIC ‐ TITANIUM$1,432.75D6240PONTIC ‐ PORCELAIN FUSED TO HIGH NOBLE METAL$1,406.00D6241PONTIC ‐ PORCELN FUSED PREDOMINANTLY BASE METAL$1,298.50D6242PONTIC ‐ PORCELAIN FUSED TO NOBLE METAL$1,370.00D6245PONTIC ‐ PORCELAIN/CERAMIC$1,450.75D6250PONTIC ‐ RESIN WITH HIGH NOBLE METAL$1,388.25D6251PONTIC ‐ RESIN WITH PREDOMINANTLY BASE METAL$1,280.50D6252PONTIC ‐ RESIN WITH NOBLE METAL$1,321.75D6253PROVISIONAL PONTIC$598.25D6545RETAINER ‐ CAST METAL RESIN BONDED FIX PROSTH$530.25D6548RETAINER ‐ PORCELN/CERAMIC RSN BONDED FIX PROSTH$582.75D6549RESIN RETAINER FOR RESIN BONDED FIXED PROSTHESIS$382.00D6600RETAINER INLAY ‐ PORCELAIN/CERAMIC TWO SURFACES$1,052.25D6601RETAINER INLAY ‐ PORC/CERAMIC 3 OR MORE SURFACES$1,103.25D6602RETAINER INLAY CAST HIGH NOBLE METAL 2 SURFACES$1,124.25D6603RETAINR INLAY ‐ CAST HI NOBLE METAL 3/MORE SURFS$1,237.00D6604RETAINER INLAY ‐ CAST PREDOM BASE METAL 2 SURFS$1,102.00D6605RTAINR INLAY ‐ CAST PREDOM BASE MTL 3/MORE SURFS$1,167.50D6606RETAINER INLAY ‐ CAST NOBLE METAL TWO SURFACES$1,084.25D6607RETNR INLAY CAST NOBLE METAL 3 OR MORE SURFACES$1,202.75D6608RETAINER ONLAY ‐ PORCELAIN/CERAMIC TWO SURFACES$1,143.50D6609RETAINER ONLAY PORCELAIN/CERAMIC 3/MORE SURFACES$1,193.50D6610RETAINER ONLAY ‐ HIGH NOBLE METAL TWO SURFACES$1,212.75D6611RETAINER ONLAY HIGH NOBLE METAL 3/MORE SURFACES$1,326.50D6612RETAINER ONLAY CAST PREDOM BASE METAL 2 SURFACES$1,206.25D6613RETNR ONLAY CAST PREDOM BASE METAL 3/MORE SURFS$1,260.75D6614RETAINER ONLAY ‐ CAST NOBLE METAL TWO SURFACES$1,180.75D6615RETNR ONLAY CAST NOBLE METAL 3 OR MORE SURFACES$1,227.00D6624RETAINER INLAY ‐ TITANIUM$1,124.25D6634RETAINER ONLAY ‐ TITANIUM$1,180.75D6710RETAINER CROWN ‐ INDIRECT RESIN BASED COMPOSITE$1,204.50D6720RETAINER CROWN ‐ RESIN WITH HIGH NOBLE METAL$1,405.25D6721RETAINER CROWN ‐ RESIN WITH PREDOM BASE METAL$1,333.00D6722RETAINER CROWN ‐ RESIN WITH NOBLE METAL$1,357.25D6740RETAINER CROWN ‐ PORCELAIN/CERAMIC$1,477.50D6750RETNR CROWN PORCELAIN FUSED TO HIGH NOBLE METAL$1,439.25D6751RETNR CROWN PORCELAIN FUSED PREDOM BASE METAL$1,342.50D6752RETAINER CROWN ‐ PORCELAIN FUSED TO NOBLE METAL$1,374.75D6780RETAINER CROWN ‐ 3/4 CAST HIGH NOBLE METAL$1,357.25D6781RETAINER CROWN 3/4 CAST PREDOMINANTLY BASE METAL$1,357.25D6782RETAINER CROWN ‐ 3/4 CAST NOBLE METAL$1,260.75D6783RETAINER CROWN ‐ 3/4 PORCELAIN/CERAMIC$1,397.25D6790RETAINER CROWN ‐ FULL CAST HIGH NOBLE METAL$1,389.25D6791RETAINER CROWN FULL CAST PREDOM BASE METAL$1,316.75D6792RETAINER CROWN ‐ FULL CAST NOBLE METAL$1,365.00D6793PROVISIONAL RETAINER CROWN$570.25D6794RETAINER CROWN ‐ TITANIUM$1,365.00D6920CONNECTOR BAR$388.50D6930RECEMENT / REBOND FIXED PARTIAL DENTURE$226.25D6940STRESS BREAKER$513.75D6950PRECISION ATTACHMENT$992.50D6980FIXED PARTIAL DENTURE REPAIR BY REPORTBRD6985PEDIATRIC PARTIAL DENTURE FIXED$863.25D6999UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE REPORTBRD7111EXTRACTION CORONAL REMNANTS ‐ PRIMARY TOOTH$181.50D7140EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT$241.25D7210SURG REMOVAL ERUPTED TOOTH REMV BONE ELEV FLAP$360.50D7220REMOVAL OF IMPACTED TOOTH ‐ SOFT TISSUE$451.75D7230REMOVAL OF IMPACTED TOOTH ‐ PARTIALLY BONY$601.00D7240REMOVAL OF IMPACTED TOOTH ‐ COMPLETELY BONY$705.50D7241REMV IMP TOOTH ‐ CMPL BONY W/UNUSUAL SURG COMPS$886.25D7250SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS$380.75D7251CORONECTOMY INTENTIONAL PARTIAL TOOTH REMOVAL$746.50D7260OROANTRAL FISTULA CLOSURE$3,281.25D7261PRIMARY CLOSURE OF A SINUS PERFORATION$1,367.00D7270TOOTH REIMPL &OR STBL ACC EVULSED/DISPLCD TOOTH$1,025.25D7272TOOTH TRANSPLANTATION$1,367.00D7280SURGICAL ACCESS OF AN UNERUPTED TOOTH$956.75D7282MOBILIZ ERUPTED/MALPOSITIONED TOOTH AID ERUPTION$478.50D7283PLCMT DEVICE FACILITATE ERUPTION IMPACTED TOOTH$410.00D7285BIOPSY OF ORAL TISSUE HARD$1,914.00D7286BIOPSY OF ORAL TISSUE SOFT$820.50D7287EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION$328.00D7288BRUSH BIOPSY ‐ TRANSEPITHELIAL SAMPLE COLLECTION$328.00D7290SURGICAL REPOSITIONING OF TEETH$820.50D7291TRANSSEPTAL FIBEROT/SUPRA CRESTAL FIBEROT BRBRD7292SURG PLCMT: TEMP ANCHORAGE SCREW RET PLATE FLAP$1,312.50D7293SURG PLCMT: TEMP ANCHORAGE DEVICE RQR SURG FLAP$820.50D7294SURG PLCMT: TEMP ANCHORAGE DEVICE W/O SURG FLAP$683.50D7295HARVEST BONE FOR USE AUTOGENOUS GRAFTING PROCBRD7296CORTICOTOMY 1 ‐ 3 TEETH OR TOOTH SPACES PER QUADBRD7297CORTCTMY 4 OR MORE TEETH OR TOOTH SPCES PER QUADBRD7310ALVEOLOPLASTY W/EXTRACTION 4/> TEETH/SPACE QUAD$582.50D7311ALVEOLOPLSTY CONJNC XTRACT 1‐3 TEETH/SPACES QUAD$509.75D7320ALVEOLOPLASTY NOT W/EXTRACTIONS 4/> TEETH/SPACE$947.00D7321ALVEOLOPLSTY NOT CNJNC XTRCT 1‐3 TEETH/SPCE QUAD$801.00D7340VESTIBULOPLASTY RIDGE EXT SEC EPITHELIALIZATION$4,005.25D7350VESTIBULOPLASTY RIDGE EXT W/SOFT TISS GRAFTS$11,652.25D7410EXCISION OF BENIGN LESION UP TO 1.25 CM$1,747.75D7411EXCISION OF BENIGN LESION GREATER THAN 1.25 CM$2,767.50D7412EXCISION OF BENIGN LESION COMPLICATED$3,058.75D7413EXCISION OF MALIGNANT LESION UP TO 1.25 CM$2,039.00D7414EXCISION OF MALIGNANT LESION > 1.25 CM$3,058.75D7415EXCISION OF MALIGNANT LESION COMPLICATED$3,422.50D7440EXC MALIG TUMOR‐LESION DIAMETER UP TO 1.25 CM$2,767.50D7441EXC MALIG TUMOR‐LESION DIAM GREATER THAN 1.25 CM$4,078.25D7450REMOVAL BEN ODONTOGENIC CYST/TUMR‐ UP T0 1.25 CM$1,747.75D7451REMOVAL BENIGN ODONTOGENIC CYST/TUMOR‐ > 1.25 CM$2,388.50D7460REMOVAL BEN NONODONTOGENIC CYST/TUMR‐ UP 1.25 CM$1,747.75D7461REMOVAL BEN NONODONTOGENIC CYST/TUMOR > 1.25 CM$2,388.50D7465DESTRUCTION LESION PHYSICAL/CHEM METHOD BY REPRT$947.00D7471REMOVAL OF LATERAL EXOSTOSIS$2,164.50D7472REMOVAL OF TORUS PALATINUS$2,572.25D7473REMOVAL OF TORUS MANDIBULARIS$2,426.50D7485SURGICAL REDUCTION OF OSSEOUS TUBEROSITY$2,164.50D7490RADICAL RESECTION OF MAXILLA OR MANDIBLE$17,478.25D7510INCISION & DRAINAGE ABSCESS‐INTRAORAL SOFT TISS$626.50D7511I & D ABSCESS INTRAORAL SOFT TISSUE COMPLICATED$947.00D7520INCISION & DRAINAGE ABSCESS‐EXTRAORAL SOFT TISS$2,983.00D7521I & D ABSCESS EXTRAORAL SOFT TISSUE COMPLICATED$3,277.00D7530REMOVAL FB FROM MUCOSA SKIN/SUBCUT ALVEOL TISSUE$1,074.75D7540REMV REACT‐PRODUC FOREIGN BODIES‐MUSCULOSKEL SYS$1,191.25D7550PART OSTEC/SEQUESTRECTOMY REMOVAL NON‐VITAL BONE$742.75D7560MAXILLARY SINUSOTOMY REMOVAL TOOTH FRAGMENT/FB$5,899.00D7610MAXILLA‐OPEN REDUCTION$9,540.00D7620MAXILLA‐CLOSED REDUCTION$7,154.25D7630MANDIBLE‐OPEN REDUCTION$12,403.75D7640MANDIBLE‐CLOSED REDUCTION$7,871.25D7650MALAR AND/OR ZYGOMATIC ARCH ‐ OPEN REDUCTION$5,963.00D7660MALAR AND/OR ZYGOMATIC ARCH ‐ CLOSED REDUCTION$3,516.25D7670ALVEOLUS‐CLOSED REDUCTION W/STABILIZATION TEETH$2,744.00D7671ALVEOLUS‐OPEN REDUCTION W/STABILIZATION TEETH$5,170.50D7680FCE BNS ‐ COMP RDUC W/FIX&MX SURG APPRCHES CPT$17,888.75D7710MAXILLA ‐ OPEN REDUCTION$11,212.00D7720MAXILLA ‐ CLOSED REDUCTION$7,871.25D7730MANDIBLE ‐ OPEN REDUCTION$16,219.75D7740MANDIBLE ‐ CLOSED REDUCTION$8,025.50D7750MALAR AND/OR ZYGOMATIC ARCH ‐ OPEN REDUCTION$10,207.25D7760MALAR AND/OR ZYGOMATIC ARCH ‐ CLOSED REDUCTION$4,095.50D7770ALVEOLUS ‐ OPEN REDUCTION STABILIZATION OF TEETH$5,549.25D7771ALVEOLUS CLOSED REDUCTION STABILIZATION OF TEETH$4,282.00D7780FACIAL BONES‐COMP RDUC FIX & MX SURG APPROACHES$23,852.00D7810OPEN REDUCTION OF DISLOCATION$10,492.75D7820CLOSED REDUCTION OF DISLOCATION$1,718.75D7830MANIPULATION UNDER ANESTHESIA$984.25D7840CONDYLECTOMY$14,303.00D7850SURGICAL DISCECTOMY WITH/WITHOUT IMPLANT$12,351.25D7852DISC REPAIR$14,143.00D7854SYNOVECTOMY$14,594.25D7856MYOTOMY$10,355.75D7858JOINT RECONSTRUCTION$29,518.00D7860ARTHROTOMY$12,581.50D7865ARTHROPLASTY$20,275.00D7870ARTHROCENTESIS$670.00D7871NON‐ARTHROSCOPIC LYSIS AND LAVAGE$1,339.75D7872ARTHROSCOPY ‐ DIAGNOSIS WITH OR WITHOUT BIOPSY$7,151.50D7873ARTHROSCOPY SURGICAL: LAVAGE&LYSIS ADHESIONS$8,611.00D7874ARTHROSCOPY SURGICAL: DISC REPSTN&STABILIZATION$12,351.25D7875ARTHROSCOPY ‐ SURGICAL: SYNOVECTOMY$13,531.00D7876ARTHROSCOPY ‐ SURGICAL: DISCECTOMY$14,588.75D7877ARTHROSCOPY ‐ SURGICAL: DEBRIDEMENT$12,875.75D7880OCCLUSAL ORTHOTIC DEVICE BY REPORT$1,608.00D7881OCCLUSAL ORTHOTIC DEVICE ADJUSTMENT$174.50D7899UNSPECIFIED TMD THERAPY BY REPORTBRD7910SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM$955.50D7911COMPLICATED SUTURE ‐ UP TO 5 CM$2,385.75D7912COMPLICATED SUTURE ‐ GREATER THAN 5 CM$4,293.75D7920SKIN GRAFT$7,035.00D7921COLL APPL AUTOLOGOUS BLD CNCNTRT PRODUCT$649.50D7940OSTEOPLASTY ‐ FOR ORTHOGNATHIC DEFORMITIESBRD7941OSTEOTOMY ‐ MANDIBULAR RAMI$17,915.25D7943OSTEOT‐MANDIB RAMI W/BONE GRFT;INCL OBTAIN GRAFT$16,458.50D7944OSTEOTOMY ‐ SEGMENTED OR SUBAPICAL$14,667.50D7945OSTEOTOMY ‐ BODY OF MANDIBLE$19,517.00D7946LEFORT I (MAXILLA ‐ TOTAL)$24,178.25D7947LEFORT I (MAXILLA ‐ SEGMENTED)$20,333.25D7948LEFORT II/LEFORT III ‐ W/O BONE GRAFT$26,392.00D7949LEFORT II OR LEFORT III ‐ WITH BONE GRAFT$34,374.00D7950OSSEOUS OSTEOPERIOSTEAL/CARTILAGE GRAFT MAND/MAXBRD7951SINUS AUGMENTATION WITH BONE OR BONE SUBSTITUTESBRD7952SINUS AUGMENTATION VIA A VERTICAL APPROACHBRD7953BONE REPLCMT GRAFT RIDGE PRESERVATION PER SITE$990.75D7955REPAIR MAXLOFACIAL SOFT &/ HARD TISSUE DEFECTBRD7960FRENULECTOMY SEP PROC NOT INCIDENTL ANOTHER PROC$801.00D7963FRENULOPLASTY$1,311.00D7970EXCISION OF HYPERPLASTIC TISSUE ‐ PER ARCH$1,165.25D7971EXCISION OF PERICORONAL GINGIVA$437.25D7972SURGICAL REDUCTION OF FIBROUS TUBEROSITY$1,631.50D7979NON‐SURGICAL SIALOLITHOTOMYBRD7980SURGICAL SIALOLITHOTOMY$1,835.25D7981EXCISION OF SALIVARY GLAND BY REPORTBRD7982SIALODOCHOPLASTY$4,340.25D7983CLOSURE OF SALIVARY FISTULA$4,165.75D7990EMERGENCY TRACHEOTOMY$3,583.00D7991CORONOIDECTOMY$8,739.00D7995SYNTHETIC GRAFT‐MANDIBLE/FACIAL BONES BY REPORTBRD7996IMPLANT‐MANDIBLE AUGMENTATION PURPOSES BY REPORTBRD7997APPLIANCE REMOVAL INCLUDES REMOVAL OF ARCHBAR$670.00D7998INTRAORAL PLCMT FIX DEVICE NOT CONJUNCTION W/FX$2,913.00D7999UNSPECIFIED ORAL SURGERY PROCEDURE BY REPORTBRD8010LIMITED ORTHODONTIC TREATMENT PRIMARY DENTITIONBRD8020LTD ORTHODONTIC TREATMENT TRANSITIONAL DENTITIONBRD8030LTD ORTHODONTIC TREATMENT ADOLESCENT DENTITIONBRD8040LIMITED ORTHODONTIC TREATMENT ADULT DENTITIONBRD8050INTERCEPTIVE ORTHODONTIC TX PRIMARY DENTITIONBRD8060INTRCPTV ORTHODONTIC TX TRANSITIONAL DENTITIONBRD8070COMP ORTHODONTIC TX TRANSITIONAL DENTITIONBRD8080COMPREHENSIVE ORTHODONTIC TX ADOLES DENTITIONBRD8090COMPREHENSIVE ORTHODONTIC TX ADULT DENTITIONBRD8210REMOVABLE APPLIANCE THERAPYBRD8220FIXED APPLIANCE THERAPYBRD8660PREORTHODONTIC TREATMENT VISITBRD8670PERIODIC ORTHODONTIC TREATMENT VISITBRD8680ORTHODONTIC RETENTIONBRD8681REMOVABLE ORTHODONTIC RETAINER ADJUSTMENTBRD8690ORTHODONTIC TREATMENTBRD8691REPAIR OF ORTHODONTIC APPLIANCEBRD8692REPLACEMENT OF LOST OR BROKEN RETAINERBRD8693RE‐CEMENT OR RE‐BOND FIXED RETAINERBRD8694REPAIR OF FIXED RETAINERS INCLUDES REATTACHMENTBRD8695REMOVAL OF FIXED ORTHO APPLIANCES TX NOT COMPLTBRD8999UNSPECIFIED ORTHODONTIC PROCEDURE BY REPORTBRD9110PALLIATIVE EMERGENCY TX DENTAL PAIN MINOR PROC$181.00D9120FIXED PARTIAL DENTURE SECTIONING$204.75D9130TMJ JOINT DYSFUNCTION ‐ NON‐INVASIVE PHYSL THERPBRD9210LOCAL ANES‐NOT CONJUNCTION W/OP/SURGICAL PROC$96.75D9211REGIONAL BLOCK ANESTHESIA$107.00D9212TRIGEMINAL DIVISION BLOCK ANESTHESIA$167.00D9215LOCAL ANESTHESIA CONJUCTION OPERATIVE/SURG PROC$80.25D9219EVALUATION FOR DEEP SEDATION / GA$190.25D9222DEEP SEDATION / GENERAL ANESTHESIA FIRST 15 MIN$567.25D9223DEEP SEDATION/ GEN ANESTH EACH 15 MIN INCREMENT$434.00D9230INHALATION OF NITROUS OXIDE/ANXIOLYSIS ANALGESIA$160.00D9239IV MOD (CONSCIOUS) SEDTION/ANALGSIA FIRST 15 MIN$467.00D9243IV MOD (CONSCIOUS) SEDATION EACH 15 MIN INCRMENT$366.75D9248NON‐INTRAVENOUS CONSCIOUS SEDATION$233.75D9310CONSULT DX SERV DENT/PHY NOT REQUESTING DENT/PHY$251.50D9311CONSULT WITH A MEDICAL HEALTHCARE PROFESSIONAL$251.50D9410HOUSE/EXTENDED CARE FACILITY CALL$287.25D9420HOSPITAL OR AMBULATORY SURGICAL CENTER CALL$465.00D9430OFFICE VISIT OBSERVATION NO OTHER SRVC PERFORMEDBRD9440OFFICE VISIT ‐ AFTER REGULARLY SCHEDULED HOURS$157.00D9450CASE PRESENTATION DTL&EXT TREATMENT PLANNING$78.50D9610THERAPEUTIC PARENTERAL DRUG SINGL ADMINISTRATIONBRD9612TX PARENTERAL DRUGS 2/> ADMINISTRATIONS DIFF MEDBRD9613INFLTRN SUSTND RELSE THRPTIC DRG SNGLE MTPL SITE$81.75D9630OTHER DRUGS AND/OR MEDICAMENTS BY REPORTBRD9910APPLICATION OF DESENSITIZING MEDICAMENT$99.00D9911APPLIC DESENZT RSN CERV &OR ROOT SURF‐TOOTH$138.00D9920BEHAVIOR MANAGEMENT BY REPORTBRD9930TX COMPLICATIONS ‐ UNUSUAL CIRCUMSTANCES REPORTBRD9932CLEAN/INSPECT REMOVBL COMPLETE MAXILLARY DENTURE$242.50D9933CLEAN INSPECT REMVBL COMPLETE MANDIBULAR DENTURE$242.50D9934CLEAN/ INSPECT REMVBL PARTIAL MAXILLARY DENTURE$242.50D9935CLEAN INSPECT REMVBL PARTIAL MANDIBULAR DENTURE$242.50D9941FABRICATION OF ATHLETIC MOUTHGUARD$282.25D9942REPAIR AND/OR RELINE OF OCCLUSAL GUARD$338.75D9943OCCLUSAL GUARD ADJUSTMENT$169.25D9944OCCLUSAL GUARD ‐ HARD APPLIANCE, FULL ARCH$818.50D9945OCCLUSAL GUARD ‐ SOFT APPLIANCE, FULL ARCH$818.50D9946OCCLUSAL GUARD HARD APPLIANCE PARTIAL ARCH$818.50D9950OCCLUSION ANALYSIS ‐ MOUNTED CASE$536.00D9951OCCLUSAL ADJUSTMENT ‐ LIMITED$239.75D9952OCCLUSAL ADJUSTMENT ‐ COMPLETE$1,128.75D9961DUPLICATE/COPY PATIENT'S RECORDSBRD9970ENAMEL MICROABRASION$126.75D9971ODONTOPLASTY 1‐2 TEETH; INCL REMOVAL ENAMEL PROJ$163.75D9972EXTERNAL BLEACHING ‐ PER ARCH$564.50D9973EXTERNAL BLEACHING ‐ PER TOOTH$93.25D9974INTERNAL BLEACHING ‐ PER TOOTH$493.75D9975EXTERNAL BLEACHING ‐ PER ARCH$564.50D9985SALES TAXBRD9986MISSED APPOINTMENTBRD9987CANCELLED APPOINTMENTBRD9990CERT TRNSLATION OR SIGN LANGUAGE SRVCS PER VISITBRD9991DENTAL CASE MGMT ADDRESS APPNTMNT COMPL BARRIERS$99.00D9992DENTAL CASE MANAGEMENT ‐ CARE COORDINATION$99.00D9993DENTAL CASE MGMT ‐ MOTIVATIONAL INTERVIEWING$99.00D9994DENTAL CASE MGMT ‐ PATIENT EDU IMPRV ORAL HEALTH$135.25D9995TELEDENTISTRY ‐ SYNCHRONOUS; REAL TIME ENCOUNTER$451.25D9996TELDENTRY ASYNCHRNS INFO FWD DENTIST SBSQNT REVW$338.75D9999UNSPECIFIED ADJUNCTIVE PROC BY REPORT (01/2019)BR ................
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