AmeriPlan Lime Fee Zip: 78411

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1 AmeriPlan Lime Fee Zip: SPECIALIST FEE SCHEDULE Any AmeriPlan /Dental Plans of America member receiving treatment from a participating specialist provider (advanced degree), shall receive a 15% discount off the participating specialist's usual and customary fee for that procedure. These participating specialists include the following: Orthodontists Periodontists Endodontists Prosthodontists Pedodontists Oral Surgeons ADA Code Dentist Procedures AmeriPlan Fees Periodic Oral Exam $ Periodic Oral Exam $ Periodic Oral Exam $ Limited Oral Exam $ Limited Oral Exam $ Limited Oral Exam $ Initial Oral Exam $ Initial Oral Exam $ Initial Oral Exam $ Comprehensive Periodontal Evaluation Comprehensive Periodontal Evaluation Comprehensive Periodontal Evaluation X-Ray: Intraoral Complete Series $ X-Ray: Intraoral Complete Series $ X-Ray: Intraoral Complete Series $ Intraoral - Periapical - First film $ Intraoral - Periapical - First film $ Intraoral - Periapical - First film $ Intraoral - Periapical - each additional film $ Intraoral - Periapical - each additional film $ Intraoral - Periapical - each additional film $ Intraoral - Occlusal film $ Intraoral - Occlusal film $25

2 00240 Intraoral - Occlusal film $ Extraoral - first film Extraoral - first film Extraoral - first film Extraoral - each additional film Extraoral - each additional film Extraoral - each additional film Bitewing - Single film $ Bitewing - Single film $ Bitewing - Single film $ Bitewings - 2 films $ Bitewings - 2 films $ Bitewings - 2 films $ Bitewings - 3 films Bitewings - 3 films Bitewings - 3 films Bitewings - 4 films $ Bitewings - 4 films $ Bitewings - 4 films $ X-Ray: Panoramic $ X-Ray: Panoramic $ X-Ray: Panoramic $ Cephalometric film Cephalometric film Cephalometric film Pulp Vitality Test Pulp Vitality Test Pulp Vitality Test Diagnostic Casts Diagnostic Casts Diagnostic Casts Diagnostic photographs Diagnostic photographs Diagnostic photographs

3 Infection Control - OSHA requirements to prevent transmission of disease Infection Control - OSHA requirements to prevent transmission of disease Infection Control - OSHA requirements to prevent transmission of disease Regular Teeth Cleaning (Light Scaling & Polishing) Regular Teeth Cleaning (Light Scaling & Polishing) Regular Teeth Cleaning (Light Scaling & Polishing) Prophylaxis - Child (to include light scaling and polishing) Prophylaxis - Child (to include light scaling and polishing) Prophylaxis - Child (to include light scaling and polishing) Topical Application of Fluoride (including prophylaxis - child) Topical Application of Fluoride (including prophylaxis - child) Topical Application of Fluoride (including prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - child) Topical Application of Fluoride (excluding prophylaxis - adult) Topical Application of Fluoride (excluding prophylaxis - adult) Topical Application of Fluoride (excluding prophylaxis - adult) $50 $50 $50 $42 $42 $42 $47 $47 $47 $18 $18 $18 $18 $18 $ Regular Teeth Cleaning (with Fluoride) $ Regular Teeth Cleaning (with Fluoride) $ Regular Teeth Cleaning (with Fluoride) $55

4 01208 Topical Application of Fluoride $ Topical Application of Fluoride $ Topical Application of Fluoride $ Oral Hygiene Instruction $ Oral Hygiene Instruction $ Oral Hygiene Instruction $ Sealant - per tooth $ Sealant - per tooth $ Sealant - per tooth $ Space Maintainer - fixed unilateral type Space Maintainer - fixed unilateral type Space Maintainer - fixed unilateral type Space Maintainer - fixed bilateral type Space Maintainer - fixed bilateral type Space Maintainer - fixed bilateral type Space maintainer - removable unilateral type Space maintainer - removable unilateral type Space maintainer - removable unilateral type Space maintainer - removable bilateral type Space maintainer - removable bilateral type Space maintainer - removable bilateral type Re-cementation of space maintainer Re-cementation of space maintainer Re-cementation of space maintainer Amalgam Filling (Silver Colored) 1 Surface (Anterior) Amalgam Filling (Silver Colored) 1 Surface (Anterior) Amalgam Filling (Silver Colored) 1 Surface (Anterior) Amalgam Filling (Silver Colored) 2 Surface (Anterior) Amalgam Filling (Silver Colored) 2 Surface (Anterior) Amalgam Filling (Silver Colored) 2 Surface

5 (Anterior) Amalgam - 3 surfaces, primary or permanent, per tooth Amalgam - 3 surfaces, primary or permanent, per tooth Amalgam - 3 surfaces, primary or permanent, per tooth Amalgam - 4 or more surfaces, primary or permanent, per tooth Amalgam - 4 or more surfaces, primary or permanent, per tooth Amalgam - 4 or more surfaces, primary or permanent, per tooth Resin Based composite - 1 Surface, Anterior Resin Based composite - 1 Surface, Anterior Resin Based composite - 1 Surface, Anterior Resin Based Composite - 2 Surface Anterior Resin Based Composite - 2 Surface Anterior Resin Based Composite - 2 Surface Anterior Resin based composite - 3 surface, anterior Resin based composite - 3 surface, anterior Resin based composite - 3 surface, anterior Resin based composite - 4 surfaces or more involving incisal angle, anterior Resin based composite - 4 surfaces or more involving incisal angle, anterior Resin based composite - 4 surfaces or more involving incisal angle, anterior Resin based composite - 1 surface, posterior Resin based composite - 1 surface, posterior Resin based composite - 1 surface, posterior Resin based composite - 2 surface, posterior Resin based composite - 2 surface, posterior Resin based composite - 2 surface, posterior Resin based composite - 3 surface, posterior Resin based composite - 3 surface, posterior

6 02393 Resin based composite - 3 surface, posterior Resin based composite - 4 surfaces or more, posterior Resin based composite - 4 surfaces or more, posterior Resin based composite - 4 surfaces or more, posterior Inlay - 1 surface, Metallic Inlay - 1 surface, Metallic Inlay - 1 surface, Metallic Inlay - 2 surfaces, Metallic Inlay - 2 surfaces, Metallic Inlay - 2 surfaces, Metallic Inlay - 3 surfaces, Metallic Inlay - 3 surfaces, Metallic Inlay - 3 surfaces, Metallic Onlay - metallic, per tooth (in addition to inlay) Onlay - metallic, per tooth (in addition to inlay) Onlay - metallic, per tooth (in addition to inlay) Onlay - metallic - 2 surface Onlay - metallic - 2 surface Onlay - metallic - 2 surface Crown - Resin based composite (indirect) Crown - Resin based composite (indirect) Crown - Resin based composite (indirect) Crown - Porcelain/Ceramic Substrate Crown - Porcelain/Ceramic Substrate Crown - Porcelain/Ceramic Substrate Porcelain Crown with High Noble Metal Porcelain Crown with High Noble Metal Porcelain Crown with High Noble Metal Crown - Porcelain fused to predcominantly base metal

7 Crown - Porcelain fused to predcominantly base metal Crown - Porcelain fused to predcominantly base metal Crown - Porcelain fused to noble metal Crown - Porcelain fused to noble metal Crown - Porcelain fused to noble metal Crown - Full cast high noble metal Crown - Full cast high noble metal Crown - Full cast high noble metal Crown - Full cast predominantly base metal Crown - Full cast predominantly base metal Crown - Full cast predominantly base metal Crown - Full cast noble metal Crown - Full cast noble metal Crown - Full cast noble metal Crown - 3/4 cast metallic Crown - 3/4 cast metallic Crown - 3/4 cast metallic Recement Inlay Recement Inlay Recement Inlay Recement Crown Recement Crown Recement Crown Prefabricated Stainless Steel Crown, primary tooth Prefabricated Stainless Steel Crown, primary tooth Prefabricated Stainless Steel Crown, primary tooth Prefabricated Stainless Steel Crown, permanent tooth Prefabricated Stainless Steel Crown, permanent tooth Prefabricated Stainless Steel Crown,

8 permanent tooth Prefabricated Resin Crown Prefabricated Resin Crown Prefabricated Resin Crown Sedative Filling Sedative Filling Sedative Filling Crown build up, including any pins Crown build up, including any pins Crown build up, including any pins Pin retention per tooth in addition to restoration Pin retention per tooth in addition to restoration Pin retention per tooth in addition to restoration Cast post and core in addition to crown Cast post and core in addition to crown Cast post and core in addition to crown Cast post as part of crown Cast post as part of crown Cast post as part of crown Prefabricated post and core in addition to crown Prefabricated post and core in addition to crown Prefabricated post and core in addition to crown Labial veneer (laminate) chairside Labial veneer (laminate) chairside Labial veneer (laminate) chairside Labial veneer (porcelain laminate) laboratory Labial veneer (porcelain laminate) laboratory Labial veneer (porcelain laminate) laboratory Temporary Crown (artificial over damaged tooth)

9 Temporary Crown (artificial over damaged tooth) Temporary Crown (artificial over damaged tooth) Crown repair, by report Crown repair, by report Crown repair, by report Cosmetic, bonding, bleaching and veneers Cosmetic, bonding, bleaching and veneers Cosmetic, bonding, bleaching and veneers Pulp Cap - Direct (excluding final restoration) Pulp Cap - Direct (excluding final restoration) Pulp Cap - Direct (excluding final restoration) Pulp Cap - Indirect (excluding final restoration) Pulp Cap - Indirect (excluding final restoration) Pulp Cap - Indirect (excluding final restoration) Therapeutic Pulpotomy (excluding final restoration) Therapeutic Pulpotomy (excluding final restoration) Therapeutic Pulpotomy (excluding final restoration) Root Canal Anterior Root Canal Anterior Root Canal Anterior Root Canal Bicuspid Root Canal Bicuspid Root Canal Bicuspid Root Canal - Molar (excluding final restoration) Root Canal - Molar (excluding final restoration) Root Canal - Molar (excluding final restoration)

10 03346 Retreatment of prev. root canal, anterior Retreatment of prev. root canal, anterior Retreatment of prev. root canal, anterior Retreatment of prev. root canal, bicuspid Retreatment of prev. root canal, bicuspid Retreatment of prev. root canal, bicuspid Retreatment of prev. root canal, molar Retreatment of prev. root canal, molar Retreatment of prev. root canal, molar Apicoectomy - anterior Apicoectomy - anterior Apicoectomy - anterior Apicoectomy - bicuspid (first root) Apicoectomy - bicuspid (first root) Apicoectomy - bicuspid (first root) Apicoectomy - molar (first root) Apicoectomy - molar (first root) Apicoectomy - molar (first root) Root amputation (per root) Root amputation (per root) Root amputation (per root) Endodontic endosseous implant Endodontic endosseous implant Endodontic endosseous implant Intentional reimplantation (including necessary splinting) Intentional reimplantation (including necessary splinting) Intentional reimplantation (including necessary splinting) Hemisection (including any root removal) not including root canal therapy Hemisection (including any root removal) not including root canal therapy Hemisection (including any root removal) not

11 including root canal therapy Bleaching of discolored tooth Bleaching of discolored tooth Bleaching of discolored tooth Unspecified endodontic procedure Unspecified endodontic procedure Unspecified endodontic procedure Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty - per tooth Gingivectomy or gingivoplasty - per tooth Gingivectomy or gingivoplasty - per tooth Gingival Flap Procedure, including root planing Gingival Flap Procedure, including root planing Gingival Flap Procedure, including root planing Clinical crown lengthening - hard tissue Clinical crown lengthening - hard tissue Clinical crown lengthening - hard tissue Mucogingival surgery - per quadrant Mucogingival surgery - per quadrant Mucogingival surgery - per quadrant Osseous Surgery (including flap entry and closure) Osseous Surgery (including flap entry and closure) Osseous Surgery (including flap entry and closure) Bone replacement graft - first site in quadrant Bone replacement graft - first site in quadrant Bone replacement graft - first site in quadrant Bone replacement graft - each additional site in quadrant

12 Bone replacement graft - each additional site in quadrant Bone replacement graft - each additional site in quadrant Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - nonresorbable barrier Guided tissue regeneration - nonresorbable barrier Guided tissue regeneration - nonresorbable barrier Pedicle Soft Tissue Graft Procedure Pedicle Soft Tissue Graft Procedure Pedicle Soft Tissue Graft Procedure Free Soft Tissue Graft Procedure Free Soft Tissue Graft Procedure Free Soft Tissue Graft Procedure Subepithelial connective tissue graft procedure per tooth Subepithelial connective tissue graft procedure per tooth Subepithelial connective tissue graft procedure per tooth Distal or proximal wedge procedure Distal or proximal wedge procedure Distal or proximal wedge procedure Provisional splinting - intracoronal Provisional splinting - intracoronal Provisional splinting - intracoronal Provisional splinting - extracoronal Provisional splinting - extracoronal Provisional splinting - extracoronal

13 Periodontial Scaling and Root Planing - per quadrant Periodontial Scaling and Root Planing - per quadrant Periodontial Scaling and Root Planing - per quadrant Deep Teeth Cleaning (Full Mouth Debridement / Removal of heavy tartar buildup) Deep Teeth Cleaning (Full Mouth Debridement / Removal of heavy tartar buildup) Deep Teeth Cleaning (Full Mouth Debridement / Removal of heavy tartar buildup) Localized delivery of chemotherapeutic agents via controlled release Localized delivery of chemotherapeutic agents via controlled release Localized delivery of chemotherapeutic agents via controlled release Periodontal maintenance procedures following active therapy Periodontal maintenance procedures following active therapy Periodontal maintenance procedures following active therapy Unspecified periodontic procedure Unspecified periodontic procedure Unspecified periodontic procedure Complete Upper Denture Complete Upper Denture Complete Upper Denture Complete Lower Denture Complete Lower Denture Complete Lower Denture Immediate Upper Denture Immediate Upper Denture

14 05130 Immediate Upper Denture Immediate Lower Denture Immediate Lower Denture Immediate Lower Denture Upper Partial - acrylic base (including any conventional clasps, rests and teeth) Upper Partial - acrylic base (including any conventional clasps, rests and teeth) Upper Partial - acrylic base (including any conventional clasps, rests and teeth) Lower Partial - acrylic base (including any conventional clasps, rests and teeth) Lower Partial - acrylic base (including any conventional clasps, rests and teeth) Lower Partial - acrylic base (including any conventional clasps, rests and teeth) Upper Partial - predominantly base cast base with acrylic saddles (including any conventional clasps, rests and teeth) Upper Partial - predominantly base cast base with acrylic saddles (including any conventional clasps, rests and teeth) Upper Partial - predominantly base cast base with acrylic saddles (including any conventional clasps, rests and teeth) Lower Partial - perdominantly base cast base with acrylic saddles (including any conventional clasps, rest and teeth) Lower Partial - perdominantly base cast base with acrylic saddles (including any conventional clasps, rest and teeth) Lower Partial - perdominantly base cast base with acrylic saddles (including any conventional clasps, rest and teeth) Removable unilateral partial denture - one piece cast metal (including clasps and teeth) Removable unilateral partial denture - one piece cast metal (including clasps and teeth) Removable unilateral partial denture - one

15 piece cast metal (including clasps and teeth) Adjust Complete Denture - upper Adjust Complete Denture - upper Adjust Complete Denture - upper Adjust Complete Denture - lower Adjust Complete Denture - lower Adjust Complete Denture - lower Adjust Partial Denture - upper Adjust Partial Denture - upper Adjust Partial Denture - upper Adjust Partial Denture - lower Adjust Partial Denture - lower Adjust Partial Denture - lower Repair broken complete denture base Repair broken complete denture base Repair broken complete denture base Replace missing or borken teeth complete denture (each tooth) Replace missing or borken teeth complete denture (each tooth) Replace missing or borken teeth complete denture (each tooth) Repair acrylic saddle or base Repair acrylic saddle or base Repair acrylic saddle or base Repair cast framework Repair cast framework Repair cast framework Repair or replace broken clasp Repair or replace broken clasp Repair or replace broken clasp Replace broken teeth (per tooth) Replace broken teeth (per tooth) Replace broken teeth (per tooth)

16 05650 Add tooth to existing partial denture Add tooth to existing partial denture Add tooth to existing partial denture Add clasp to existing partial denture Add clasp to existing partial denture Add clasp to existing partial denture Rebase complete upper denture Rebase complete upper denture Rebase complete upper denture Rebase complete lower denture Rebase complete lower denture Rebase complete lower denture Rebase upper partial denture Rebase upper partial denture Rebase upper partial denture Rebase lower partial denture Rebase lower partial denture Rebase lower partial denture Reline complete upper denture (chairside) Reline complete upper denture (chairside) Reline complete upper denture (chairside) Reline complete lower denture (chairside) Reline complete lower denture (chairside) Reline complete lower denture (chairside) Reline upper partial denture (chairside) Reline upper partial denture (chairside) Reline upper partial denture (chairside) Reline lower partial denture (chairside) Reline lower partial denture (chairside) Reline lower partial denture (chairside) Reline complete upper denture (laboratory) Reline complete upper denture (laboratory) Reline complete upper denture (laboratory) Reline complete lower denture (laboratory)

17 05751 Reline complete lower denture (laboratory) Reline complete lower denture (laboratory) Reline upper partial denture (laboratory) Reline upper partial denture (laboratory) Reline upper partial denture (laboratory) Reline lower partial denture (laboratory) Reline lower partial denture (laboratory) Reline lower partial denture (laboratory) Interim complete denture (upper) Interim complete denture (upper) Interim complete denture (upper) Interim complete denture (lower) Interim complete denture (lower) Interim complete denture (lower) Interim partial denture (upper) Interim partial denture (upper) Interim partial denture (upper) Interim partial denture (lower) Interim partial denture (lower) Interim partial denture (lower) Tissue conditioning (upper) Tissue conditioning (upper) Tissue conditioning (upper) Tissue conditioning (lower) Tissue conditioning (lower) Tissue conditioning (lower) Overdenture - complete Overdenture - complete Overdenture - complete Overdenture - partial Overdenture - partial Overdenture - partial Precision attachment Precision attachment

18 05862 Precision attachment Unspecified removable prosthodontic procedure Unspecified removable prosthodontic procedure Unspecified removable prosthodontic procedure Surgical placement of implant body - endosteal implant Surgical placement of implant body - endosteal implant Surgical placement of implant body - endosteal implant Abutment placement or substitution - endosteal implant Abutment placement or substitution - endosteal implant Abutment placement or substitution - endosteal implant Dental implant supported connecting bar Dental implant supported connecting bar Dental implant supported connecting bar Implant maintenance procedures, including: removal of prosthesis Implant maintenance procedures, including: removal of prosthesis Implant maintenance procedures, including: removal of prosthesis Repair implant abutment Repair implant abutment Repair implant abutment Implant removal Implant removal Implant removal Unspecified implant procedure Unspecified implant procedure Unspecified implant procedure

19 06210 Pontic - cast high noble metal Pontic - cast high noble metal Pontic - cast high noble metal Pontic - cast predominantly base metal Pontic - cast predominantly base metal Pontic - cast predominantly base metal Pontic - cast noble metal Pontic - cast noble metal Pontic - cast noble metal Pontic - porcelain fused to high noble metal Pontic - porcelain fused to high noble metal Pontic - porcelain fused to high noble metal Pontic - porcelain fused to predominantly base met Pontic - porcelain fused to predominantly base met Pontic - porcelain fused to predominantly base met Pontic - porcelain fused to noble metal Pontic - porcelain fused to noble metal Pontic - porcelain fused to noble metal Inlay - 2 surfaces, metallic Inlay - 2 surfaces, metallic Inlay - 2 surfaces, metallic Inlay - 3 or more surfaces, metallic Inlay - 3 or more surfaces, metallic Inlay - 3 or more surfaces, metallic Cast metal retainer for resin bonded fixed prosthe Cast metal retainer for resin bonded fixed prosthe Cast metal retainer for resin bonded fixed prosthe Crown - porcelain fused to high noble metal Crown - porcelain fused to high noble metal

20 06750 Crown - porcelain fused to high noble metal Crown - porcelain fused to predominantly base meta Crown - porcelain fused to predominantly base meta Crown - porcelain fused to predominantly base meta Crown - porcelain fused to noble metal Crown - porcelain fused to noble metal Crown - porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast high noble metal Crown - full cast high noble metal Crown - full cast high noble metal Crown - full cast high noble metal Crown - full cast perdominantly base metal Crown - full cast perdominantly base metal Crown - full cast perdominantly base metal Crown - full cast noble metal Crown - full cast noble metal Crown - full cast noble metal Connector bar Connector bar Connector bar Recement bridge Recement bridge Recement bridge Stress breaker Stress breaker Stress breaker Precision attachment Precision attachment Precision attachment

21 Cast post and core in addition to bridge retainer Cast post and core in addition to bridge retainer Cast post and core in addition to bridge retainer Cast post as part of bridge retainer Cast post as part of bridge retainer Cast post as part of bridge retainer Prefabricated post and core in addition to bridge Prefabricated post and core in addition to bridge Prefabricated post and core in addition to bridge Unspecified fixed prosthodontic procedure Unspecified fixed prosthodontic procedure Unspecified fixed prosthodontic procedure Extraction of coronal remnants - decidous tooth Extraction of coronal remnants - decidous tooth Extraction of coronal remnants - decidous tooth Extraction, erupted tooth or exposed tooth Extraction, erupted tooth or exposed tooth Extraction, erupted tooth or exposed tooth Surgical removal of erupted tooth requiring elevation Surgical removal of erupted tooth requiring elevation Surgical removal of erupted tooth requiring elevation Removal of impacted tooth - soft tissue Removal of impacted tooth - soft tissue Removal of impacted tooth - soft tissue Removal of impacted tooth partially bony

22 07230 Removal of impacted tooth partially bony Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony - with unusual surgical complications Removal of impacted tooth completely bony - with unusual surgical complications Removal of impacted tooth completely bony - with unusual surgical complications Surgical removal of residual tooth roots (cutting procedures) Surgical removal of residual tooth roots (cutting procedures) Surgical removal of residual tooth roots (cutting procedures) Surgical exposure of impacted or unerupted tooth f Surgical exposure of impacted or unerupted tooth f Surgical exposure of impacted or unerupted tooth f Surgical exposure of impacted or unerupted tooth t Surgical exposure of impacted or unerupted tooth t Surgical exposure of impacted or unerupted tooth t Biopsy of oral tissue - hard Biopsy of oral tissue - hard Biopsy of oral tissue - hard Biopsy of oral tissue - soft Biopsy of oral tissue - soft Biopsy of oral tissue - soft Alveoloplasty in conjuction with extractions - per Quadrant

23 Alveoloplasty in conjuction with extractions - per Quadrant Alveoloplasty in conjuction with extractions - per Quadrant Alveoloplasty not in conjuction with extractions - Alveoloplasty not in conjuction with extractions - Alveoloplasty not in conjuction with extractions - Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension (secondary epithelialization) Vestibuloplasty - ridge extension (soft tissue gra Vestibuloplasty - ridge extension (soft tissue gra Vestibuloplasty - ridge extension (soft tissue gra Excision of malignant tumor-lesion diameter up to Excision of malignant tumor-lesion diameter up to Excision of malignant tumor-lesion diameter up to Excision of malignant tumor-lesion diameter greate Excision of malignant tumor-lesion diameter greate Excision of malignant tumor-lesion diameter greate Removal of odontogenic cyst or tumor-lesion diamet Removal of odontogenic cyst or tumor-lesion diamet Removal of odontogenic cyst or tumor-lesion

24 diamet Removal of odontogenic cyst or tumor-lesion diamet Removal of odontogenic cyst or tumor-lesion diamet Removal of odontogenic cyst or tumor-lesion diamet Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Removal of nonodontogenic cyst or tumorlesion dia Destruction of lesion(s) by physical or chemical m Destruction of lesion(s) by physical or chemical m Destruction of lesion(s) by physical or chemical m Removal of exostosis-maxilla or mandible Removal of exostosis-maxilla or mandible Removal of exostosis-maxilla or mandible Incision and drainage of abcess-intraoral soft tis Incision and drainage of abcess-intraoral soft tis Incision and drainage of abcess-intraoral soft tis Incision and drainage of abcess-extraoral soft tis Incision and drainage of abcess-extraoral soft tis

25 07520 Incision and drainage of abcess-extraoral soft tis Suture of recent small wounds up to 5 cm Suture of recent small wounds up to 5 cm Suture of recent small wounds up to 5 cm Complicated suture up to 5 cm Complicated suture up to 5 cm Complicated suture up to 5 cm Complicated suture greater than 5 cm Complicated suture greater than 5 cm Complicated suture greater than 5 cm Frenulectomy (frenectomy or frenotomy) - separate Frenulectomy (frenectomy or frenotomy) - separate Frenulectomy (frenectomy or frenotomy) - separate Excision of hyperplastic tissue - per arch Excision of hyperplastic tissue - per arch Excision of hyperplastic tissue - per arch Excision of pericoronal gingiva Excision of pericoronal gingiva Excision of pericoronal gingiva Unspecified oral surgery procedure Unspecified oral surgery procedure Unspecified oral surgery procedure Limited orthodontic treatment of the primary denti Limited orthodontic treatment of the primary denti Limited orthodontic treatment of the primary denti Limited orthodontic treatment of the transitional Limited orthodontic treatment of the transitional

26 Limited orthodontic treatment of the transitional Limited orthodontic treatment of the adolescent de Limited orthodontic treatment of the adolescent de Limited orthodontic treatment of the adolescent de Limited orthodontic treatment of the adult dentiti Limited orthodontic treatment of the adult dentiti Limited orthodontic treatment of the adult dentiti Interceptive orthodontic treatment of the primary Interceptive orthodontic treatment of the primary Interceptive orthodontic treatment of the primary Interceptive orthodontic treatment of the transiti Interceptive orthodontic treatment of the transiti Interceptive orthodontic treatment of the transiti Comprehensive orthodontic treatment of the transit Comprehensive orthodontic treatment of the transit Comprehensive orthodontic treatment of the transit Orthodontic Braces by General dentist - children under age 19 Orthodontic Braces by General dentist - children under age 19 Orthodontic Braces by General dentist - children under age Orthodontic Braces by General dentist - adult

27 and over Orthodontic Braces by General dentist - adult 19 and over Orthodontic Braces by General dentist - adult 19 and over Retainers (each up to 2 years) Retainers (each up to 2 years) Retainers (each up to 2 years) Maxillary expansion Maxillary expansion Maxillary expansion Diagnostic workup including cephalometric, panoram Diagnostic workup including cephalometric, panoram Diagnostic workup including cephalometric, panoram Periodic orthodontic treatment visit 0% Periodic orthodontic treatment visit 0% Periodic orthodontic treatment visit 0% Orthodontic retention (removal of appliances, cons Orthodontic retention (removal of appliances, cons Orthodontic retention (removal of appliances, cons Unspecified orthodontic procedure by report Unspecified orthodontic procedure by report Unspecified orthodontic procedure by report Failed appointment (without 24 hr. notice) Failed appointment (without 24 hr. notice) Failed appointment (without 24 hr. notice) Palliative (emergency) treatment of dental pain - Palliative (emergency) treatment of dental pain -

28 Palliative (emergency) treatment of dental pain - Local anesthesia not in conjuction with operative Local anesthesia not in conjuction with operative Local anesthesia not in conjuction with operative Local anesthesia Local anesthesia Local anesthesia Analgesia Analgesia Analgesia Intravenous sedation Intravenous sedation Intravenous sedation Consultation - per session (diagnostic service pro Consultation - per session (diagnostic service pro Consultation - per session (diagnostic service pro Office visit for observation (during regularly sch Office visit for observation (during regularly sch Office visit for observation (during regularly sch Office visit - after regularly scheduled hours Office visit - after regularly scheduled hours Office visit - after regularly scheduled hours fabrication of athletic mouthguard fabrication of athletic mouthguard fabrication of athletic mouthguard Occlusion analysis (mounted case)

29 09950 Occlusion analysis (mounted case) Occlusion analysis (mounted case) Occlusal adjustment (limited) Occlusal adjustment (limited) Occlusal adjustment (limited) Occlusal adjustment (complete) Occlusal adjustment (complete) Occlusal adjustment (complete) Invisalign Braces may not be included.

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