2017 Covered California Dental Copay Plan DRAFT Copay Schedule prepared by Milliman

Transcription

1 0120 Periodic oral evaluation - established patient $0 $ Limited oral evaluation - problem focused $0 $ Oral evaluation for a patient under three years of age and counseling with primary caregiver $0 $ Comprehensive oral evaluation - new or established patient $0 $ Detailed and extensive oral evaluation - problem focused, by report $0 $ Re-evaluation - limited, problem focused (established patient; not post-operative visit) $0 $ Re-evaluation - post-operative office visit 0180 Comprehensive periodontal evaluation - new or established patient $0 $ Screening of a patient 0191 Assessment of a patient 0210 Intraoral - complete series of radiographic images $0 $ Intraoral - periapical first radiographic image $0 $ Intraoral - periapical each additional radiographic image $0 $ Intraoral - occlusal radiographic image $0 $ Extraoral - first radiographic image $0 $ Extraoral - each additional radiographic image $0 $ Bitewing - single radiographic image $0 $ Bitewings - two radiographic images $0 $ Bitewings - three radiographic images $0 $ Bitewings - four radiographic images $0 $ Vertical bitewings - 7 to 8 radiographic images $0 $ Posterior-anterior or lateral skull and facial bone survey radiographic image $0 $ Sialography $0 $ Temporomandibular joint arthrogram, including injection $0 $ Other temporomandibular joint radiographic images, by report $0 $ Tomographic survey $0 $ Panoramic radiographic image $0 $ Cephalometric radiographic image $0 $ D oral/facial photographic image obtained intra-orally or extra-orally $0 $ D photographic image 0364 Cone beam CT capture and interpretation with limited field of view - less than one whole jaw $0 $ Cone beam CT capture and interpretation with field of view of one full dental arch - mandible $0 $ Cone beam CT capture and interpretation with field of view of one full dental arch - maxilla, with or without cranium $0 $ Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium $0 $ Cone beam CT capture and interpretation for TMJ series including two or more exposures $0 $ Maxillofacial MRI capture and interpretation $0 $ Maxillofacial ultrasound capture and interpretation $0 $ Sialoendoscopy capture and interpretation $0 $ Cone beam CT image capture with limited field of view - less than one whole jaw $0 $ Cone beam CT image capture with field of view of one full dental arch - mandible $0 $ Cone beam CT image capture with field of view of one full dental arch - maxilla, with or without cranium $0 $ Cone beam CT image capture with field of view of both jaws, with or without cranium $0 $ Cone beam CT image capture for TMJ series including two or more exposures $0 $ Maxillofacial MRI image capture $0 $ Maxillofacial ultrasound image capture $0 $ Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report $0 $ Treatment simulation using 3D image volume $0 $ Digital subtraction of two or more images or image volumes of the same modality $0 $ Fusion of two or more 3D image volumes of one or more modalities $0 $ Collection of microorganisms for culture and sensitivity $0 $ Viral culture $0 $ Collection and preparation of saliva sample for laboratory diagnostic testing $0 $ Analysis of saliva sample $0 $ Genetic test for susceptibility to oral diseases $0 $ Caries susceptibility tests $0 $ Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures $0 $ Pulp vitality tests $0 $ Diagnostic casts $0 $ Caries risk assessment and documentation, with a finding of low risk 0602 Caries risk assessment and documentation, with a finding of moderate risk 0603 Caries risk assessment and documentation, with a finding of high risk 0472 Accession of tissue, gross examination, preparation and transmission of written report 0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report

2 0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report 0475 Decalcification procedure 0476 Special stains for microorganisms 0477 Special stains, not for microorganisms 0478 Immunohistochemical stains 0479 Tissue in-situ hybridization, including interpretation 0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report 0481 Electron microscopy 0482 Direct immunofluorescence 0483 Indirect immunofluorescence 0484 Consultation on slides prepared elsewhere 0485 Consultation, including preparation of slides from biopsy material supplied by referring source 0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report 0502 Other oral pathology procedures, by report 0999 Unspecified diagnostic procedure, by report 1110 Prophylaxis - adult $0 $ Prophylaxis - child $0 $ Topical application of fluoride varnish $0 $ Topical application of fluoride - excluding varnish $0 $ Nutritional counseling for control of dental disease 1320 Tobacco counseling for the control and prevention of oral disease 1330 Oral hygiene instructions 1351 Sealant - per tooth $0 $ Preventive resin restoration in a moderate to high caries risk patient - permanent tooth 1353 Sealant repair - per tooth 1510 Space maintainer - fixed - unilateral $0 $ Space maintainer - fixed - bilateral $0 $ Space maintainer - removable - unilateral $0 $ Space maintainer - removable - bilateral $0 $ Re-cement or re-bond space maintainer $0 $ Removal of fixed space maintainer $0 $ Unspecified preventive procedure, by report 2140 Amalgam - one surface, primary or permanent $25 $ Amalgam - two surfaces, primary or permanent $30 $ Amalgam - three surfaces, primary or permanent $35 $ Amalgam - four or more surfaces, primary or permanent $40 $ Resin-based composite - one surface, anterior $30 $ Resin-based composite - two surfaces, anterior $35 $ Resin-based composite - three surfaces, anterior $45 $ Resin-based composite - four or more surfaces or involving incisal angle (anterior) $50 $ Resin-based composite crown, anterior $60 $ Resin-based composite - one surface, posterior $30 $ Resin-based composite - two surfaces, posterior $40 $ Resin-based composite - three surfaces, posterior $50 $ Resin-based composite - four or more surfaces, posterior $60 $ Gold foil - one surface $300 $ Gold foil - two surfaces $300 $ Gold foil - three surfaces $300 $ Inlay - metallic - one surface $300 $ Inlay - metallic - two surfaces $300 $ Inlay - metallic - three or more surfaces $300 $ Onlay - metallic - two surfaces $300 $ Onlay - metallic - three surfaces $300 $ Onlay - metallic - four or more surfaces $300 $ Inlay - porcelain/ceramic - one surface $300 $ Inlay - porcelain/ceramic - two surfaces $300 $ Inlay - porcelain/ceramic - three or more surfaces $300 $ Onlay - porcelain/ceramic - two surfaces $300 $ Onlay - porcelain/ceramic - three surfaces $300 $ Onlay - porcelain/ceramic - four or more surfaces $300 $ Inlay - resin-based composite - one surface $300 $ Inlay - resin-based composite - two surfaces $300 $ Inlay - resin-based composite - three or more surfaces $300 $ Onlay - resin-based composite - two surfaces $300 $300

3 2663 Onlay - resin-based composite - three surfaces $300 $ Onlay - resin-based composite - four or more surfaces $300 $ Crown - resin-based composite (indirect) $300 $ Crown - 3/4 resin-based composite (indirect) $300 $ Crown - resin with high noble metal $300 $ Crown - resin with predominantly base metal $300 $ Crown - resin with noble metal $300 $ Crown - porcelain/ceramic substrate $300 $ Crown - porcelain fused to high noble metal $300 $ Crown - porcelain fused to predominantly base metal $300 $ Crown - porcelain fused to noble metal $300 $ Crown - 3/4 cast high noble metal $300 $ Crown - 3/4 cast predominantly base metal $300 $ Crown - 3/4 cast noble metal $300 $ Crown - 3/4 porcelain/ceramic $300 $ Crown - full cast high noble metal $300 $ Crown - full cast predominantly base metal $300 $ Crown - full cast noble metal $300 $ Crown - titanium $300 $ Provisional crown - further treatment of completion of diagnosis necessary prior to final impression $0 $ Resin infiltration of incipient smooth surface lesions $20 $ Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $25 $ Re-cement or re-bond indirectly fabricated or prefabricated post and core $25 $ Re-cement or re-bond crown $25 $ Reattachment of tooth fragment, incisal edge or cusp 2929 Prefabricated porcelain/ceramic crown - primary tooth $75 $ Prefabricated stainless steel crown - primary tooth $75 $ Prefabricated stainless steel crown - permanent tooth $75 $ Prefabricated resin crown $75 $ Prefabricated stainless steel crown with resin window $75 $ Prefabricated esthetic coated stainless steel crown - primary tooth $75 $ Protective restoration 2941 Interim therapeutic resotration - primary dentition 2949 Restorative foundation for an indirect restoration 2950 Core buildup, including any pins when required 2951 Pin retention - per tooth, in addition to restoration 2952 Post and core in addition to crown, indirectly fabricated 2953 Each additional indirectly fabricated post - same tooth 2954 Prefabricated post and core in addition to crown 2955 Post removal 2957 Each additional prefabricated post - same tooth 2960 Labial veneer (resin laminate) - chairside 2961 Labial veneer (resin laminate) - laboratory 2962 Labial veneer (porcelain laminate) - laboratory 2970 Temporary crown (fractured tooth) $75 $ Additional procedures to construct new crown under existing partial denture framework $40 $ Coping $75 $ Crown repair necessitated by restorative material failure $40 $ Inlay repair necessitated by restorative material failure $40 $ Onlay repair necessitated by restorative material failure $75 $ Veneer repair necessitated by restorative material failure $40 $ Unspecified restorative procedure, by report 3110 Pulp cap - direct (excluding final restoration) $20 $ Pulp cap - indirect (excluding final restoration) $20 $ Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $50 $ Pulpal debridement, primary and permanent teeth $50 $ Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development $75 $ Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $75 $ Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $75 $ Endodontic therapy, anterior tooth (excluding final restoration) $200 $ Endodontic therapy, bicuspid tooth (excluding final restoration) $250 $ Endodontic therapy, molar (excluding final restoration) $300 $ Treatment of root canal obstruction; non-surgical access $75 $ Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $100 $ Internal root repair of perforation defects $75 $ Retreatment of previous root canal therapy - anterior $250 $250

4 3347 Retreatment of previous root canal therapy - bicuspid $300 $ Retreatment of previous root canal therapy - molar $350 $ Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $75 $ Apexification/recalcification - interim medication replacement $50 $ Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) $125 $ Pulpal regeneration - initial visit 3356 Pulpal regeneration - interim medication replacement 3357 Pulpal regeneration - completion of treatment $125 $ Apicoectomy - anterior $200 $ Apicoectomy - bicuspid (first root) $250 $ Apicoectomy - molar (first root) $250 $ Apicoectomy (each additional root) $75 $ Periradicular surgery without apicoectomy 3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 3430 Retrograde filling - per root $50 $ Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery 3432 Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery 3450 Root amputation - per root $150 $ Endodontic endosseous implant $450 $ Intentional re-implantation (including necessary splinting) $150 $ Surgical procedure for isolation of tooth with rubber dam $40 $ Hemisection (including any root removal), not including root canal therapy $100 $ Canal preparation and fitting of preformed dowel or post $40 $ Unspecified endodontic procedure, by report 4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $125 $ Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $50 $ Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth $50 $ Anatomical crown exposure - four or more contiguous teeth per quadrant $150 $ Anatomical crown exposure - one to three teeth per quadrant $100 $ Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant $150 $ Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant $150 $ Apically positioned flap $150 $ Clinical crown lengthening - hard tissue $150 $ Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $300 $ Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant $200 $ Bone replacement graft - first site in quadrant $100 $ Bone replacement graft - each additional site in quadrant $75 $ Biologic materials to aid in soft and osseous tissue regeneration $75 $ Guided tissue regeneration - resorbable barrier, per site $100 $ Guided tissue regeneration - non-resorbable barrier, per site (includes membrane removal) $100 $ Surgical revision procedure, per tooth $100 $ Pedicle soft tissue graft procedure $200 $ Subepithelial connective tissue graft procedures, per tooth $200 $ Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $100 $ Soft tissue allograft $200 $ Combined connective tissue and double pedicle graft, per tooth $250 $ Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft $250 $ Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site $150 $ Provisional splinting - intracoronal $75 $ Provisional splinting - extracoronal $75 $ Periodontal scaling and root planing - four or more teeth per quadrant $60 $ Periodontal scaling and root planing - one to three teeth per quadrant $40 $ Full mouth debridement to enable comprehensive evaluation and diagnosis $40 $ Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth $15 $ Periodontal maintenance $35 $ Unscheduled dressing change (by someone other than treating dentist or their staff) $0 $ Gingival irrigation - per quadrant

5 4999 Unspecified periodontal procedure, by report 5110 Complete denture - maxillary $400 $ Complete denture - mandibular $400 $ Immediate denture - maxillary $400 $ Immediate denture - mandibular $400 $ Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $400 $ Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $400 $ Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $400 $ Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $400 $ Maxillary partial denture - flexible base (including any clasps, rests and teeth) $400 $ Mandibular partial denture - flexible base (including any clasps, rests and teeth) $400 $ Removable unilateral partial denture - one piece cast metal (including clasps and teeth) $200 $ Adjust complete denture - maxillary $0 $ Adjust complete denture - mandibular $0 $ Adjust partial denture - maxillary $0 $ Adjust partial denture - mandibular $0 $ Repair broken complete denture base $40 $ Replace missing or broken teeth - complete denture (each tooth) $40 $ Repair resin denture base $40 $ Repair cast framework $40 $ Repair or replace broken clasp $40 $ Replace broken teeth - per tooth $40 $ Add tooth to existing partial denture $40 $ Add clasp to existing partial denture $40 $ Replace all teeth and acrylic on cast metal framework (maxillary) $40 $ Replace all teeth and acrylic on cast metal framework (mandibular) $40 $ Rebase complete maxillary denture $40 $ Rebase complete mandibular denture $40 $ Rebase maxillary partial denture $40 $ Rebase mandibular partial denture $40 $ Reline complete maxillary denture (chairside) $40 $ Reline complete mandibular denture (chairside) $40 $ Reline maxillary partial denture (chairside) $40 $ Reline mandibular partial denture (chairside) $40 $ Reline complete maxillary denture (laboratory) $40 $ Reline complete mandibular denture (laboratory) $40 $ Reline maxillary partial denture (laboratory) $40 $ Reline mandibular partial denture (laboratory) $40 $ Interim complete denture (maxillary) $100 $ Interim complete denture (mandibular) $100 $ Interim partial denture (maxillary) $75 $ Interim partial denture (mandibular) $75 $ Tissue conditioning, maxillary $0 $ Tissue conditioning, mandibular $0 $ Precision attachment, by report $0 $ Overdenture - complete maxillary $250 $ Overdenture - partial maxillary $250 $ Overdenture - complete mandibular $250 $ Overdenture - partial mandibular $250 $ Replacement of replaceable part of semi-precision or precision attachment (male or female component) $0 $ Modification of removable prosthesis following implant surgery 6205 Pontic - indirect resin based composite $200 $ Pontic - cast high noble metal $300 $ Pontic - cast predominantly base metal $300 $ Pontic - cast noble metal $300 $ Pontic - titanium $300 $ Pontic - porcelain fused to high noble metal $300 $ Pontic - porcelain fused to predominantly base metal $300 $ Pontic - porcelain fused to noble metal $300 $ Pontic - porcelain/ceramic $300 $ Pontic - resin with high noble metal $300 $ Pontic - resin with predominantly base metal $300 $ Pontic - resin with noble metal $300 $ Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression $75 $ Retainer - cast metal for resin bonded fixed prosthesis

6 6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis 6549 Resin retainer - for resin bonded fixed prosthesis 6600 Inlay - porcelain/ceramic, two surfaces 6601 Inlay - porcelain/ceramic, three or more surfaces $300 $ Inlay - cast high noble metal, two surfaces 6603 Inlay - cast high noble metal, three or more surfaces $300 $ Inlay - cast predominantly base metal, two surfaces $200 $ Inlay - cast predominantly base metal, three or more surfaces $300 $ Inlay - cast noble metal, two surfaces $250 $ Inlay - cast noble metal, three or more surfaces $250 $ Onlay - porcelain/ceramic, two surfaces $300 $ Onlay - porcelain/ceramic, three or more surfaces $300 $ Onlay - cast high noble metal, two surfaces $250 $ Onlay - cast high noble metal, three or more surfaces $300 $ Onlay - cast predominantly base metal, two surfaces $300 $ Onlay - cast predominantly base metal, three or more surfaces $300 $ Onlay - cast noble metal, two surfaces $300 $ Onlay - cast noble metal, three or more surfaces $300 $ Inlay - titanium 6634 Onlay - titanium $1,000 $1, Crown - indirect resin based composite $200 $ Crown - resin with high noble metal $300 $ Crown - resin with predominantly base metal $300 $ Crown - resin with noble metal $300 $ Crown - porcelain/ceramic $300 $ Crown - porcelain fused to high noble metal $300 $ Crown - porcelain fused to predominantly base metal $300 $ Crown - porcelain fused to noble metal $300 $ Crown - 3/4 cast high noble metal $300 $ Crown - 3/4 cast predominantly base metal $300 $ Crown - 3/4 cast noble metal $300 $ Crown - 3/4 porcelain/ceramic $300 $ Crown - full cast high noble metal $300 $ Crown - full cast predominantly base metal $300 $ Crown - full cast noble metal $300 $ Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression $75 $ Crown - titanium $300 $ Connector bar $60 $ Re-cement or re-bond fixed partial denture $40 $ Stress breaker $40 $ Precision attachment $40 $ Fixed partial denture repair, necessitated by restorative material failure $60 $ Pediatric partial denture, fixed $150 $ Unspecified fixed prosthodontic procedure, by report 7111 Extraction, coronal remnants - deciduous tooth $50 $ Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $65 $ Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated $100 $ Removal of impacted tooth - soft tissue 7230 Removal of impacted tooth - partially bony $140 $ Removal of impacted tooth - completely bony $160 $ Removal of impacted tooth - completely bony, with unusual surgical complications $190 $ Surgical removal of residual tooth roots (cutting procedure) $100 $ Coronectomy - intentional partial tooth removal $150 $ Oroantral fistula closure $250 $ Primary closure of a sinus perforation $150 $ Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth $100 $ Tooth transplantation (includes re-implantation from one site to another and splinting and/or stabilization) $100 $ Surgical access of an unerupted tooth $100 $ Mobilization of erupted or malpositioned tooth to aid eruption $75 $ Placement of device to facilitate eruption of impacted tooth $50 $ Incisional biopsy of oral tissue - hard (bone, tooth) $100 $ Incisional biopsy of oral tissue - soft $100 $ Exfoliative cytological sample collection $40 $ Brush biopsy - transepithelial sample collection $40 $40

7 7290 Surgical repositioning of teeth $100 $ Transseptal fiberotomy/supra crestal fiberotomy, by report $50 $ Surgical placement of temporary anchorage device [screw retained plate] requiring flap; includes device removal $150 $ Surgical placement of temporary anchorage device requiring flap; includes device removal $100 $ Surgical placement of temporary anchorage device without flap; includes device removal $100 $ Harvest of bone for use in autogenous grafting procedure $150 $ Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $75 $ Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $50 $ Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $75 $ Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant $75 $ Vestibuloplasty - ridge extension (secondary epithelialization) $250 $ Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $400 $ Excision of benign lesion up to 1.25 cm $100 $ Excision of benign lesion greater than 1.25 cm $100 $ Excision of benign lesion, complicated $200 $ Excision of malignant lesion up to 1.25 cm $150 $ Excision of malignant lesion greater than 1.25 cm $150 $ Excision of malignant lesion, complicated $300 $ Destruction of lesion(s) by physical or chemical method, by report $50 $ Excision of malignant tumor - lesion diameter up to 1.25 cm $100 $ Excision of malignant tumor - lesion diameter greater than 1.25 cm $200 $ Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $150 $ Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $200 $ Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm $150 $ Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm $500 $ Removal of lateral exostosis (maxilla or mandible) $150 $ Removal of torus palatinus $150 $ Removal of torus mandibularis $150 $ Surgical reduction of osseous tuberosity $150 $ Radical resection of maxilla or mandible $500 $ Incision and drainage of abscess - intraoral soft tissue $50 $ Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $75 $ Incision and drainage of abscess - extraoral soft tissue $100 $ Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) $100 $ Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue $50 $ Removal of reaction producing foreign bodies, musculoskeletal system $100 $ Partial ostectomy/sequestrectomy for removal of non-vital bone $75 $ Maxillary sinusotomy for removal of tooth fragment or foreign body $350 $ Maxilla - open reduction (teeth immobilized, if present) $200 $ Maxilla - closed reduction (teeth immobilized, if present) $375 $ Mandible - open reduction (teeth immobilized, if present) $750 $ Mandible - closed reduction (teeth immobilized, if present) $650 $ Malar and/or zygomatic arch - open reduction $1,000 $1, Malar and/or zygomatic arch - closed reduction $850 $ Alveolus - closed reduction, may include stabilization of teeth $250 $ Alveolus - open reduction, may include stabilization of teeth $350 $ Facial bones - complicated reduction with fixation and multiple surgical approaches $1,000 $1, Maxilla - open reduction $150 $ Maxilla - closed reduction $250 $ Mandible - open reduction $650 $ Mandible - closed reduction $400 $ Malar and/or zygomatic arch - open reduction $325 $ Malar and/or zygomatic arch - closed reduction $1,500 $1, Alveolus - open reduction stabilization of teeth $200 $ Alveolus - closed reduction stabilization of teeth $200 $ Facial bones - complicated reduction with fixation and multiple surgical approaches $2,100 $2, Open reduction of dislocation $1,100 $1, Closed reduction of dislocation $100 $ Manipulation under anesthesia $100 $ Condylectomy $1,400 $1, Surgical discectomy, with/without implant $1,400 $1, Disc repair $1,400 $1, Synovectomy 7856 Myotomy

8 7858 Joint reconstruction 7860 Arthrotomy $0 $ Arthroplasty $0 $ Arthrocentesis $125 $ Non-arthroscopic lysis and lavage $225 $ Arthroscopy - diagnosis, with or without biopsy 7873 Arthroscopy - surgical: lavage and lysis of adhesions $0 $ Arthroscopy - surgical: disc repositioning and stabilization $0 $ Arthroscopy - surgical: synovectomy 7876 Arthroscopy - surgical: discectomy 7877 Arthroscopy - surgical: debridement $0 $ Occlusal orthotic device, by report $175 $ Unspecified TMD therapy, by report 7910 Suture of recent small wounds up to 5 cm $50 $ Complicated suture - up to 5 cm $75 $ Complicated suture - greater than 5 cm $200 $ Skin graft (identify defect covered, location and type of graft) $175 $ Collection and application of autologous blood concentrate product $75 $ Osteoplasty - for orthognathic deformities $225 $ Osteotomy - mandibular rami $1,200 $1, Osteotomy - mandibular rami with bone graft; includes obtaining the graft $650 $ Osteotomy - segmented or subapical $400 $ Osteotomy - body of mandible $1,000 $1, LeFort I (maxilla - total) $1,600 $1, LeFort I (maxilla - segmented) $1,300 $1, LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) - without bone graft $2,500 $2, LeFort II or LeFort III - with bone graft $675 $ Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report $275 $ Sinus augmentation with bone or bone substitutes via a lateral open approach $425 $ Sinus augmentation via a vertical approach $250 $ Bone replacement graft for ridge preservation - per site $100 $ Repair of maxillofacial soft and/or hard tissue defect $300 $ Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure $100 $ Frenuloplasty $125 $ Excision of hyperplastic tissue - per arch $75 $ Excision of pericoronal gingiva $50 $ Surgical reduction of fibrous tuberosity $100 $ Sialolithotomy $125 $ Excision of salivary gland, by report $100 $ Sialodochoplasty $200 $ Closure of salivary fistula $125 $ Emergency tracheotomy $375 $ Coronoidectomy $300 $ Synthetic graft - mandible or facial bones, by report $125 $ Implant - mandible for augmentation purposes (excluding alveolar ridge), by report $350 $ Appliance removal (not by dentist who placed appliance), includes removal of archbar $50 $ Intraoral placement of a fixation device not in conjunction with a fracture $200 $ Unspecified oral surgery procedure, by report 8010 Limited orthodontic treatment of the primary dentition 8020 Limited orthodontic treatment of the transitional dentition 8030 Limited orthodontic treatment of the adolescent dentition 8040 Limited orthodontic treatment of the adult dentition 8050 Interceptive orthodontic treatment of the primary dentition 8060 Interceptive orthodontic treatment of the transitional dentition 8070 Comprehensive orthodontic treatment of the transitional dentition 8080 Comprehensive orthodontic treatment of the adolescent dentition 8090 Comprehensive orthodontic treatment of the adult dentition 8210 Removable appliance therapy 8220 Fixed appliance therapy 8660 Pre-orthodontic treatment examination to monitor growth and development 8670 Periodic orthodontic treatment visit 8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 8690 Orthodontic treatment (alternative billing to a contract fee) 8691 Repair of orthodontic appliance $350 per orthodontic course of treatment not covered

9 8692 Replacement of lost or broken retainer 8693 Re-cement or re-bond fixed retainer 8694 Repair of fixed retainers, includes reattachment 8999 Unspecified orthodontic procedure, by report 9110 Palliative (emergency) treatment of dental pain - minor procedure $0 $ Fixed partial denture sectioning 9210 Local anesthesia not in conjunction with operative or surgical procedures 9211 Regional block anesthesia 9212 Trigeminal division block anesthesia 9215 Local anesthesia in conjunction with operative or surgical procedures 9219 Evaluation for deep sedation or general anesthesia 9220 Deep sedation/general anesthesia - first 30 minutes $100 $ Deep sedation/general anesthesia - each additional 15 minutes $40 $ Inhalation of nitrous oxide/analgesia, anxiolysis 9241 Intravenous moderate (conscious) sedation/analgesia - first 30 minutes 9242 Intravenous moderate (conscious) sedation/analgesia - each additional 15 minutes 9248 Non-intravenous moderate (conscious) sedation 9310 Consultation - diagnostic service by dentist or physician other than requesting dentist or physician 9410 House/extended care facility call 9420 Hospital or ambulatory surgical center call 9430 Office visit for observation (during regularly scheduled hours) - no other services performed 9440 Office visit - after regularly scheduled hours 9450 Case presentation, detailed and extensive treatment planning 9610 Therapeutic parenteral drug, single administration 9612 Therapeutic parenteral drugs, two or more administrations, different medications 9630 Other drugs and/or medicaments, by report 9910 Application of desensitizing medicament 9911 Application of desensitizing resin for cervical and/or root surface, per tooth 9920 Behavior management, by report 9930 Treatment of complications (post-surgical) - unusual circumstances, by report 9931 Cleaning and inspection of a removable appliance 9940 Occlusal guard, by report 9941 Fabrication of athletic mouthguard 9942 Repair and/or reline of occlusal guard 9950 Occlusion analysis - mounted case 9951 Occlusal adjustment - limited 9952 Occlusal adjustment - complete 9970 Enamel microabrasion 9971 Odontoplasty 1-2 teeth; includes removal of enamel projections 9972 External bleaching - per arch - performed in an office 9973 External bleaching - per tooth 9974 Internal bleaching - per tooth 9975 External bleaching for home application, per arch; includes materials and fabrication of custom trays 9985 Sales tax 9986 Missed appointment 9987 Cancelled appointment 9999 Unspecified adjunctive procedure, by report