UCR MEANS 75% OF THE PROVIDERS UCR ALL CHARGES INCLUDE LAB FEES,NC MEANS NO CHARGE

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1 NOTE: UCR MEANS 75% OF THE PROVIDERS UCR ALL CHARGES INCLUDE LAB FEES,NC MEANS NO CHARGE LP1 Procedure Category: Diagnostics LP1 Proc code Procedure Description 17 Cancelled Appt (less than 24hr notice) $ Periodic Oral Evaluation NC 140 Limited Oral Evaluation- Problem Focused NC 150 Comprehensive Oral Evaluation NC 160 Detailed and Extensive Oral Evaluation- Problem focused $ Re-Evaluation- Limited, Problem focused NC 180 Comprehensive Periodontal Evaluation NC 210 Intraoral- Complete Series (Including Bitewings) $ Intraoral- Periapical- One Film NC 230 Intraoral- Periapical- Each Additional Film NC 240 Intraoral- Occlusal Film NC 250 Extraoral- First Film NC 260 Extraoral- Each Additional Film NC 270 Bitewing- Single Film NC 272 Bitewing- Two Films NC 273 Bitewing- Three Films NC 274 Bitewing- Four Films NC 277 Vertical Bitewings- Seven to Eight Films $ Posterior, Anterior, Lateral Skull or Facial Bone Surgery UCR 310 Sialography UCR 320 Temporomandiblar Joint Arthrogram UCR 321 Other Temporomandiblar Joint Films UCR 322 Tomographic Survey UCR 330 Panoramic Film $ Cephalometric Film UCR 350 Oral or Facial Images (Including Intraoral and Extraoral) UCR 415 Bacteriologic Studies for Determination of Pathology UCR 425 Caries Susceptibility UCR 460 Pulp Vitality Tests NC 470 Diagnostic Casts (Per Cast) NC 472 Accession of Tissue, Gross Exam, Prep NC 473 Accession of Tissue, Gross and Microscopic Exam UCR 474 Accession of Tissue, Gross or Micro Exam; Surgical NC 480 Processing or Interpretation of Cytologic Smears NC 502 Other Oral Pathology Procedures, by Report UCR 999 Unspecified Diagnostic Procedures, by Report UCR

2 Procedure Category: Preventative 1110 Prophylaxis, Adult NC 1120 Prophylaxis, Children NC 1203 Topical Application of Fluoride w/out Prophylaxis NC 1204 Topical Application of Fluoride w/out Prophylaxis NC 1310 Nutritional Counseling for Control of Dental Disease UCR 1320 Tobacco Counseling for Control and Prevention UCR 1330 Oral Hygiene Instruction UCR 1351 Sealant- Per Tooth $ Space Maintainer- Fixed- Unilateral $ Space Maintainer- Fixed- Bilateral $ Space Maintainer- Removeable- Unilateral $ Space Maintainer- Removeable- Bilateral $ Recementation of Space Maintainer NC 1555 Removal of Fixed Space Maintainer NC Procedure Category: Restorative 2140 Amalgam- One Surface, Permanent or Deciduous $ Amalgam- Two Surfaces, Permanent or Deciduous $ Amalgam- Three Surfaces, Permanent or Deciduous $ Amalgam- Four or More Surfaces, Permanent or Deciduous UCR 2330 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, Anterior $ Resin-Based Composite Crown, Anterior NC 2391 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 $ Gold Foil- One Surface UCR 2420 Gold Foil- Two Surfaces UCR 2430 Gold Foil- Three Surfaces UCR 2510 Inlay- Metallic- One Surface $ Inlay- Metallic- Two Surfaces $ Inlay- Metallic- Three Surfaces $ Onlay- Metallic- Two Surfaces $ Onlay- Metallic- Three Surfaces $ Onlay- Metallic- Four or More Surfaces $ Inlay- Porcelain or Ceramic- One Surface $ Inlay- Porcelain or Ceramic- Two Surfaces $ Inlay- Porcelain or Ceramic- Three Surfaces $ Onlay- Porcelain or Ceramic- Two Surfaces $ Onlay- Porcelain or Ceramic- Three Surfaces $ Onlay- Porcelain or Ceramic- Four or More Surfaces $ Inlay- Resin-Based Composite-One Surface $ Inlay- Resin-Based Composite-Two Surfaces $ Inlay- Resin-Based Composite-Three Surfaces $ Onlay- Resin Based Composite-Two Surfaces $400.00

3 2663 Onlay- Resin Based Composite-Three Surfaces $ Onlay- Resin Based Composite-Four or More Surfaces $ Procedure Category: Crowns Prod Code Procedure Description 2710 Crown- Resin (laboratory) $ Crown- 3/4 Resin- Based Composite(laboratory) $ Crown- Resin with High Noble Metal $ Crown-Resin with Predominantly Base Metal $ Crown- Resin with Noble Metal $ Crown- Porcelain or 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 Predominantly Base Metal $ Crown- 3/4 Cast Noble Metal $ Crown- 3/4 Porcelain or Ceramic $ Crown- Full Cast High Noble Metal $ Crown- Full Cast Predominately Base Metal $ Crown- Full Cast Noble Metal $ Crown- Titanium $ Provisional Crown- Used for a Minimum of Six Months $ Recement Inlays NC 2915 Recement Cast or Prefabricated Post and Core NC 2920 Recement Crowns NC 2930 Prefabricated Stainless Steel Crown- Primary $ Prefabricated Stainless Steel Crown- Permanent U&C 2932 Prefabricated Resin Crown U&C 2933 Prefabricated Stainless Steel Crown with Resin U&C 2940 Sedative Filing U&C 2950 Crown Buildup, Including any Pins $ Pin Retention in Adition ot Restoration- per Tooth NC 2952 Cast Post and Core in Addition to Crown $ Each Additional Cast Post- Same Tooth $ Prefabricated Post and Core in Addition to Crown $ Post Removal (not in conjunction with Endodontic) NC 2957 Each Additional Prefabricated Post- Same Tooth NC 2960 Labial Veneer (Resin Laminate)- Chair side $ Labial Veneer (Resin Laminate)- Laboratory $ Labial Veneer (Procelain Laminate)- Laboratory $ Temporary Crown (Fractured Tooth) NC 2980 Crown Repair, by Report $ Continued Treatment- Crowns NC 2999 Unspecified Restorative Precedure, by Report NC Procedure Category: Endodontics 3110 Pulpal Cap- Direct (Excluding Final Restoration) $ Pulpal Cap- Indirect (Excluding Final Restoration) $ Theraputic Pulpotomy (Excluding Restoration) $ Pulpal Debridement, Primay and Permanent Teeth $100.00

4 3230 Pulpal Therapy(Resorbable Filling)- Anterior, Primary $ Pulpal Therapy(Resorbable Filling)- Posterior, Primary $ One Canal(Excluding Final Restoration) $ Two Canals (Excluding Final Restoration) $ Three Canals(Excluding Final Restoration) $ Treatment of Root Canal Obstruction, Non- Surgical $ Incomplete Endodonitc Therapy; Inoperable $ Internal Root Repair or Perforation Defects $ Four or More Canals(Excluding Final Restoration) $ Retreatment-Anterior (Excluding Specialists) $ Retreatment- Bicuspid(Excluding Specialists) $ Retreatment- Molar(Excluding Specialists) $ Apexification/Recalcification- Initial visit $ Apexification/Recalcification- Interim Meds Replacement $ Apexification/Recalcification- Final Visit $ Apicoectomy/Periradicular Surgery- Anterior $ Apicoectomy/Periradicular Surgery- Bicuspid $ Apicoectomy/Periradicular Surgery- Molar $ Apicoectomy/Periradicular Surgery- (Each Additional) $ Retrograde Filling- Per Root $ Root Amputation- Per Root $ Endodontic Endosseous Implant UCR 3470 Intentional Re-Implantation(Including Necessary) UCR 3910 Tooth Isolation- Surgical $ Hemisection Including Root Removal not Root Canal $ Canal Preparation and Fitting- Dowel or Post NC 3970 Continued Treatment- Endodontics NC 3999 Unspecified Endodontic Procedure, by Report NC Procedure Category: Periodontics 4210 Gingivectomy or Gingivoplasty(4+ Contiguous Teeth) $ Gingivectomy or Gingivoplasty(1-3 Contiguous Teeth) $ Anatomical Grown Exposure(Four or More Teeth) $ Anatomical Grown Exposure(Three Teeth) $ Gingival Flap Procedure w/ Root Plan(4+ Contiguous) $ Gingival Flap Procedure w/ Root Plan(1-3 contiguous) $ Apically Positioning Flap $ Clinical Crown Lengthening- Hard tissue $ Osseous Surgery(Per Quadrant) $ Osseous Surgery- With Flap (1-3 teeth per quadrant) $ Bone Replacement Graft- Single Site(per quadrant) UCR 4264 Bone Replacement Graft- Multiple Sites (per quadrant) UCR 4265 Biologic Materials to Aid in Soft and Osseous Regeneration UCR 4266 Guided Tissue Reganeration- Resorbable Barrier UCR 4267 Guided Tissue Regenertation- Nonresorbable Barrier UCR 4268 Surgical Revision Procedure- Per Tooth UCR 4270 Pedicle Soft Tissue Graft Procedure UCR 4271 Free Soft Tissure Graft Procedure UCR 4273 Subephitelial Connective Tissue Graft Procedures UCR 4274 Distal or Proximal Wedge Procedure w/out same UCR 4275 Soft Tissue Allograft UCR

5 4276 Combined Connective Tissue and Double Pedicle UCR 4320 Provisional Splinting- Intracoronal(Per Tooth) $ Provisional Splinting- Extracoronal(Per Tooth) $ Root Planning(4+ Contiguous Teeth per Quadrant) $ Periodontal Scaling or Root Planning(1-3 contiguous) $ Full mouth Debriedment to Enable a full evalutation NC 4381 Localized Delivery of Chemotherapeutic Agents $ Periodontal Maintenance- Active Therapy NC 4920 Unscheduled Dressing Change (not the treating) $ Unspecified Periodontal Procedure, by report NC Procedure Category: Prosthodontics 5110 Complete Upper Denture $ Complete Lower Denture $ Immediate Upper Denture $ Immediate Lower Denture $ Upper Partial Denture- Resin Base $ Lower Partial Denture- Resin Base $ Upper Partial Denture- Cast Chrome $ Lower Partial Denture- Cast Chrome $ Maxillary with Flexible Base $ Mandidula with Flexible Base $ Unilateral Partial Denture- Chrome $ Adjust complete denture- Upper NC 5411 Adjust complete denture- Lower NC 5421 Adjust partial denture- Upper NC 5422 Adjust partial denture- Lower NC 5510 Repair Broken complete Denture Base $ Replace Missing or Broken Teeth (complete denture) $ 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- Acrylic on Cast Metal Framework $ Replace All Teeth- Acrylic on Cast Metal Framework $ Rebase Complete Upper Denture $ Rebase Complete Lower Denture $ Rebase Upper partial Denture $ Rebase Lower Partial Denture $ Reline complete Upper Denture(office) $ Reline complete Lower Denture(office) $ Reline Upper Partial Denture(office) $ Reline Lower Partial Denture(Office) $ Reline Complete Upper Denture (lab) $ Reline Complete Lower Denture (lab) $ Reline Upper Partial Denture (lab) $ Reline Lower Partial Denture (lab) $ Interim Complete Denture (Upper) $ Interim Complete Denture (Lower) $400.00

6 5820 Interim Partial Denture (Upper) $ Interim Partial Denture (Lower) $ Tissue Conditioning- Upper NC 5851 Tissue Conditioning- Lower NC 5860 Overdenture- Complete, by Report $ Overdenture- Partial, by report $ Precision Attachment, by report $ Replacement of Replaceable Part(Semi or Full) $ Modification of Removable Prothesis after Implant $ Unspecified Removable Prosthodontic Procedure NC 5980 Continued Treatment- Prosthodontics NC 5999 Unspecified Maxillofacial Prothesis, by Report NC Procedure Category: Bridge Pont. And Crown Abut Pontic- Indirect Resin.. $ Pontic- Cast High Noble Medal $ Pontic- Cast Predominately Base Metal $ Pontic- Cast Noble Medal $ Pontic- Titanium $ Pontic- Porcelain Fused to High Noble Metal $ Pontic- Porcelain Fused to Base Metal $ Pontic- Porcelain Fused to Noble Metal $ Pontic- Porcelain/ Ceramic $ Pontic- Resin with High Noble Metal $ Pontic- Resin with Base Metal $ Pontic- Resin with Noble Metal $ Provisional Pontic NC 6545 Cast Medal Retainer with Acid Etched Arm $ Porcelain/Ceramic Retainer with Acid Etched Arm $ Inlay- Porcelain/Ceramic- Two surfaces $ Inlay- Porcelain/Ceramic- Three or more surfaces $ Inlay- Cast High Noble Metal- Two surfaces $ Inlay- Cast High Noble Metal- Three or more surfaces $ Inlay- Cast Predominately Base Metal- Two surfaces $ Inlay-Cast Predominately Base Metal-Three or more surfaces $ Inlay- Cast Noble Metal- Two surfaces $ Inlay- Cast Noble Metal- Three or more surfaces $ 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 Predominately Base Metal- Two surfaces $ Onlay- Cast Predominately 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- Resin based composite $ Crown- Resin with High Noble metal $ Crown- Resin with Base metal $ Crown- Resin with Noble metal $300.00

7 6740 Crown- Porcelain/ Ceramic $ Crown- Porcelain fused to high noble metal $ Crown- Porcelain fused to base metal $ Crown- Porcelain fused to noble metal $ Crown- Three Quarter Cast to High Noble Metal $ Crown- Three Quarter Cast to Predominately Base Metal $ Crown- Three Quarter Cast Noble Metal $ Crown- Three Quarter Porcelain/ Ceramic $ Crown- Full cast High Noble Metal $ Crown- Full Cast Base Metal $ Crown- Full Cast Noble Metal $ Provisional Retainer Crown NC 6794 Crown- Titanium $ Connector Bar $ Recement Bridge NC 6940 Stress Breaker $ Precision Attachment $ Cast Post and Core in addition ot Fixed Partial denture $ Prefabricated Post and core- Add to Bridge NC 6973 Core Build up for Retainer, Including any Pins $ Coping- Metal NC 6976 Each additional Cast Post- Same tooth $ Each Additional Prefabricated Post- Same tooth NC 6980 Bridge Repair, Per crown $ Pediatric Partial Denture, Fixed UCR 6990 Continued Treatment- Bridges NC 6999 Unspecified Fixed Prosthodontic Procedure, by report NC Procedure Category: Oral Surgery 7111 Coronal Remnants- Deciduous Tooth $ Extraction, Erupted Tooth/ Exposed Root (elevation) $ Surgical Removal of Erupted tooth $ Surgical Removal of Impacted tooth- soft tissue $ Surgical Removal of Impacted tooth- Partially $ Surgical Removal of Impacted tooth- Completely $ Surgical Removal of Impacted tooth- Completely $ Root Recovery, Surgical Removal $ Oroantral Fistula closure UCR 7261 Primary Closure of a Sinus Perforation UCR 7270 Tooth Reimplantation UCR 7272 Tooth Transplatation UCR 7280 Surgical Exposure Impaction/ Unerupted tooth UCR 7281 Surgical Exposure Impaction/ Unerupted tooth UCR 7282 Mobilization of Erupted or Malpositioned Tooth UCR 7283 Deuce to Facilitate Eruption UCR 7285 Biopsy of Oral Tissue- Hard UCR 7286 Biopsy of Oral Tissue- Soft UCR 7287 Cytology Sample Collection $ Surgical repositioning Teeth UCR 7291 Transseptal Fiberotomy/ Supra Crestal Fiberotomy $ Alveoloplasty Per Quadrant in Conjunction $125.00

8 7311 Alveoloplasty in Conjunction with $ Alveoloplasty Per Quadrant Not in conjuction UCR 7321 Alveoloplasty in Conjunction with UCR 7340 Vestibuloplasty- Ridge Ext-Second UCR 7350 Vestibuloplasty- Complicated UCR 7410 Excision of Benign Lesion up to 1.25cm UCR 7411 Excision of Benign Lesion greater than 1.25cm UCR 7412 Excision of benign lesion, complicated UCR 7413 Excision of Malignant lesion up to 1.25cm UCR 7414 Excision of Malignant lesion greater than 1.25cm UCR 7415 Excision of Malignant lesion, complicated UCR 7440 Excision of Malignant tumor- lesion up to 1.25cm UCR 7441 Excision of Malignant tumor- lesion over 1.25cm UCR 7450 Remove Odontogen Cyst or Tumor up to 1.25cm UCR 7451 Remove Odontogen Cyst or Tumor over 1.25cm UCR 7460 Remove Benign Non-Odontogen Cyst or Tumor up to 1.25cm UCR 7461 Remove Benign Non-Odontogen Cyst or Tumor over 1.25cm UCR 7465 Destruction of Lesion(s) by Physical/ Chemical UCR 7471 Remove lateral Exostosis (Maxilla or Mandible) UCR 7472 Remove Torus Palatinus UCR 7473 Remove Torus Mandibularis UCR 7485 Surgical Reduction of Osseous Tuberosity UCR 7490 Radical Resection of Mandible with Bone Graft UCR 7510 Incision and Drainage of Abscess- Intraoral Soft $ Incision and Drainage of Abscess- Intraoral Soft $ Incision and Drainage of Abscess- Extraoral Soft $ Incision and Drainage of Abscess- Extraoral Soft $ Remove Foreign Body from Mucosa/skin/Alveola UCR 7540 Remove Reaction Producing Foreign bodies UCR 7550 Partial Ostectomy/Sequestrectomy- Non-vital UCR 7560 Maxillary Sinusotomy to Remove tooth Fragment UCR 7610 Maxilla- Open Reduction (teeth immobilized) UCR 7620 Maxilla- Closed Reduction (teeth immobilized) UCR 7630 Mandible- Open Reduction (teeth Immobilized) UCR 7640 Mandible- closed reducation (teeth Immobilized) UCR 7650 Malar and/or Zygomatic Arch- Open Reduction UCR 7660 Malar and/or Zygomatic Arch- closed reduction UCR 7670 Alveolus- closed reduction, teeth stabilization UCR 7671 Alveolus- open reduction, teeth stabilization UCR 7680 Facial Bones- complicated Reduction w/ Fixatior UCR 7710 Maxilla- Open Reduction UCR 7720 Maxilla- Closed Reduction UCR 7730 Mandible- Open Reduction UCR 7740 Mandible- Closed Reduction UCR 7750 Malar and/or Zygomatic Arch- Open Reduction UCR 7760 Malar and/or Zygomatic Arch- closed reduction UCR 7770 Alveolus- Open Reduction Stabilization of Teeth UCR 7771 Alveolus- Closed Reduction Stabilization of Teeth UCR 7780 Facial Bones- complicated Reduction w/ Fixatior UCR 7960 Frenectomy $ Surgical Reduction of Fiberous Tuberosity $ Continued Treatment- Oral Surgery NC

9 7999 Unspecified Oral Surgery Procedure by Report NC Procedure Category: Orthodontia 8010 Limited Orthodontic Treatment- Primary UCR 8020 Limited Orthodontic Treatment- Transitional UCR 8030 Limited Orthodontic Treatment- Adolescent UCR 8040 Limited Orthodontic Treatment- Adult UCR 8050 Interceptive Orthodontic Treatment of Primary UCR 8060 Interceptive Orthodontic Treatment of Transitional UCR 8070 Comprehensive Orthodontic Treatment- Transitional $3, Comprehensive Orthodontic Treatment- Adolescent $3, Comprehensive Orthodontic Treatment- Adult $3, Removable Appliance Therapy/ Habit $ Fixed Appliance Therapy/ Habit $ Pre- Orthodontic Treatment Visit NC 8670 Periodic Orthodontic Treatment Visit NC 8680 Orthodontic Retention (Removal of Appliances) $ Orthodontic Treatment UCR 8691 Repair of Orthodontic Appliance $ Replacement of Lost or Broken Retainer UCR 8693 Rebonding or Recementing Fixed Retainers NC Procedure Category: Other Services 9110 Palliative Emergency Treatment $ Local Anesthesia w/out Operative/Surgical NC 9211 Regional Block Anethesia NC 9212 Trigeminal Division Block Anesthesia NC 9215 Local Anesthesia NC 9220 Anesthesia- General(Per Quadrant) $ Inhilation- Nitrous Oxide $ IV Sedation (Per Quadrant) $ Consultation- Per Session(Excluding Specialists) NC 9430 Office Visit for Observation- No other services NC 9440 Office Visit after Regularly Scheduled Hours $ Theraputic Drug Injection, by report UCR 9630 Other drugs and/or medicaments, by report UCR 9910 Application of Desensitizing Medicine NC 9930 Treatment of Complications (Post- Surgical) NC 9940 Occlusal Guards $ Fabrication of Athletic Mouth Guard $ Occlusion Analysis- Mounted Case $ Occlusal Adjustment- Limited $ Occlusal Adjustment- Completed UCR NOTE: ANY PROCEDURES NOT LISTED HERE SHALL BE CHARGED AT 75% OF THE PROVIDERS UCR

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