Recommended Professional Fee
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1 Fee Guide Development & Negotiation Committee 2018 Recommended Professional Fee and Laboratory Fee Guide Abbreviations T: Time Units / 1 Unit = 15 Minutes G: Gold L: Lab Disbursement E: Extra Expense B.R.: Best Rate Laboratory Disbursements When completing dental insurance claim forms, this code correlates to either commercial (third party) or in house lab fees that are not otherwise listed in the Fee Guide. Laboratory Procedures: (DAC Code) (Fees submitted using this code are required to be Lab Fee only. There is not a Professional Fee component to this code) PROSTHODONTIC EXAMINATIONS AND DIAGNOSTIC CASTS USC CODE DAC CODE DESCRIPTION OF SERVICE Professional Fee Lab Fee Total Fee EXAMINATIONS All Examinations Require Appropriate Charting Of Findings GENERAL PROSTHETIC EXAMINATION Extended examination of the pre prosthetic, edentulous, or partially edentulous mouth, including detailed Medical, Dental and Prosthetic history, visual, digital and mirror examination of the oral structures, and head and neck, to include the TMJ, oral mucosa, lips, tongue, oral pharynx, salivary glands, lymph nodes, musculature, and other associated stomatognathic structures SPECIFIC EXAMINATION Examination and evaluation of a specific situation in a localized area NEW PATIENT LIMITED EXAMINATION Examination with mirror of hard and soft tissues including checking of occlusion and appliances PREVIOUS PATIENT LIMITED EXAMINATION Recall examination with mirror of hard and soft tissues, including checking of occlusion and appliances NONSPECIFIED DIAGNOSIS AND TREATMENT (including VELSCOPE) E E Diagnostic Casts DIAGNOSTIC CAST DIAGNOSTIC CAST DUPLICATE Professional Consultation N/A PROFESSIONAL CONSULTATION (Per Unit of Time) Consultation without oral examination. RADIOGRAPHS USC CODE DAC CODE DESCRIPTION OF SERVICE Professional Fee Lab Fee Total Fee
2 Interpretation One unit of time E E Two Units of Time E E Each Additional Unit over Two E E INTRAORAL Periapical Single Films B.R. B.R Two Films B.R. B.R Three Films B.R. B.R Four Films B.R. B.R Five Films B.R. B.R Six Films B.R. B.R. Bitewing Single Film B.R. B.R Two Films B.R. B.R. Panoramic Single Film B.R. B.R. RADIOGRAPHIC GUIDE Includes diagnostic wax up, with radio opaque markers for pre surgical assessment of alveolar bone and vital structures for potential osseointegrated implant site(s) Maxillary Guide E B.R E+BR Mandibular Guide E B.R E+BR SURGICAL STENT Includes diagnostic wax up. Also used to locate and orient osseointegrated implant(s) Maxillary Surgical Stent E B.R E+BR Mandibular Surgical Stent E B.R E+BR DENTURE DUPLICATION COMPLETE DENTURE Maxillary Mandibular PARTIAL DENTURE Maxillary Mandibular COMPLETE DENTURES Complete Denture Services include impressions, occlusal registration, try in evaluation (where applicable, secondary impressions, facebow transfer), insertion and adjustment including three months post insertion care. STANDARD Maxillary , Mandibular , Resilient Liner, Addition to Above COMPLEX Complex dentures require use of a facebow transfer and post insertion remount on a semi adjustable articulator and equilibration of occlusion Maxillary 1, , Mandibular 1, , Resilient Liner, Addition to Above OVERDENTURE Maxillary , Mandibular , OVERDENTURE COMPLEX Complex dentures require use of a facebow transfer and post insertion remount on a semi adjustable articulator and equilibration of occlusion Maxillary 1, , Mandibular 1, , GNATHOLOGICAL CAST BASE AND METAL OCCLUSAL SURFACES
3 Maxillary B.R. B.R. B.R Mandibular B.R. B.R. B.R. SURGICAL COMPLETE DENTURES Post insertion care does not include tissue conditioners or permanent relines/rebases. STANDARD SURGICAL Complete Maxillary 1, , Complete Mandibular 1, , COMPLEX SURGICAL Complex dentures require use of a facebow transfer and post insertion remount on a semi adjustable articulator and equilibration of occlusion Complete Maxillary 1, , , Complete Mandibular 1, , , OVERDENTURE SURGICAL Maxillary 1, , Mandibular 1, , COMPLEX OVERDENTURE SURGICAL Complex dentures require use of a facebow transfer and post insertion remount on a semi adjustable articulator and equilibration of occlusion. N/A Maxillary 1, , , N/A Mandibular 1, , , TRANSITIONAL TEMPORARY Complete Maxillary B.R. B.R. B.R Complete Mandibular B.R. B.R. B.R. COMPLETE DENTURES ATTACHED TO IMPLANTS REMOVABLE TISSUE BORNE IMPLANT RETAINED WITH INDEPENDENT ATTACHMENTS (Examples: O Rings, Locators, ERA) Maxillary B.R. B.R. B.R Mandibular B.R. B.R. B.R. REMOVABLE IMPLANT BORNE WITH SCREW RETAINED BAR ATTACHED TO IMPLANTS (Examples: Hayder clips and housing, Ackerman clips, Dolder bar clips) Maxillary B.R. B.R. B.R Mandibular B.R. B.R. B.R. FRAMEWORK ATTACHED WITH SCREWS AND INCORPORATING DENTURE TEETH AND ACYRLIC (Practitioner removable Includes All on 4's) Maxillary B.R. B.R. B.R Mandibular B.R. B.R. B.R. FRAMEWORK ATTACHED WITH SCREWS AND INCORPORATING PORCELAIN TEETH BONDED TO FRAMEWORK (Practitioner removable Includes All on 4's) Maxillary B.R. B.R. B.R Mandibular B.R. B.R. B.R. REMOVAL OF SCREW RETAINED PROSTHESIS FOR PROPHYLAXIS Based on units of time: One Unit of Time = 15minutes Maxillary Mandibular REINSERTION OF SCREW RETAINED PROSTHESIS Based on units of time: One Unit of Time = 15minutes Maxillary E Mandibular E IMPLANT ATTACHMENTS Parts and Components N/A Independent Ball Attachments (Per Arch) B.R. B.R. B.R. N/A Bar Attachment (Per Attachment) B.R. B.R. B.R.
4 ACYRLIC PARTIAL DENTURES WITHOUT CLASPS STANDARD N/A Maxillary N/A Mandibular RESILIENT RETAINER N/A Elastic/Resilient Gasket (per retainer) B.R. B.R. WITH WROUGHT/CAST CLASPS AND/OR RESTS Maxillary , Mandibular , Cast Clasps and/or rests (Invoices need to be included) B.R. B.R. WITH WROUGHT PALATAL/LINGUAL BAR, CLASPS AND/OR RESTS N/A Palatal/Lingual Bar (per bar) B.R. B.R. B.R. OVERDENTURE WITH WROUGHT/CAST CLASPS AND/OR RESTS Maxillary , Mandibular , Cast Clasps and/or rests (Invoices need to be included) B.R. B.R. OVERDENTURE WITHOUT CLASPS N/A Maxillary , N/A Mandibular , PARTIAL DENTURE NON ACRYLIC N/A Maxillary B.R. B.R. B.R. N/A Mandibular B.R. B.R. B.R. SURGICAL ACRYLIC PARTIAL DENTURES WITHOUT CLASPS STANDARD Maxillary Mandibular RESILIENT RETAINER N/A Elastic/resilient Gasket (per retainer) B.R. B.R. WITH WROUGHT/CAST CLASPS AND/OR RESTS STANDARD Maxillary , Mandibular , Cast Clasps and/or rests (Invoices need to be included) B.R. B.R. WITH WROUGHT LINGUAL/PALATAL BAR, CLASPS AND/OR RESTS N/A Palatal/Lingual Bar (per bar) B.R. B.R. OVERDENTURE WITHOUT CLASPS N/A Maxillary , N/A Mandibular , OVERDENTURE WITH WROUGHT/CAST CLASPS AND/OR RESTS Maxillary , Mandibular , Cast Clasps and/or rests (Invoices need to be included) B.R. B.R. CAST PARTIAL Framework costs can be billed in addition to lab fee using Code FREE END WITH CLASPS AND RESTS Maxillary , Mandibular , Altered cast impression technique addition to above
5 Framework Costs (invoices need to be included) B.R. B.R. FREE END WITH CLASPS AND RESTS COMPLEX Maxillary 1, , , Mandibular 1, , , Altered cast impression technique addition to above Framework Costs (invoices need to be included) B.R B.R. TOOTH BORNE WITH CLASPS AND RESTS Maxillary , Mandibular , Framework Costs (invoices need to be included) B.R. B.R. TOOTH BORNE WITH CLASPS AND RESTS COMPLEX Maxillary 1, , , Mandibular 1, , , Framework Costs (invoices need to be included) B.R. B.R. PRECISION ATTACHMENTS Maxillary B.R. B.R. B.R Mandibular B.R. B.R. B.R Implant/Abutments New Denture per B.R. B.R. B.R. SEMI PRECISION ATTACHMENTS Maxillary B.R. B.R Mandibular B.R. B.R Altered Cast Impression Technique addition to above B.R. B.R. STRESS BREAKER ATHMENTS (MAXILLARY OR MANDIBULAR) N/A Resilient B.R. B.R. N/A One Hinge B.R. B.R. N/A Two Hinges B.R. B.R. FREE END SWING LOCK CONNECTOR N/A Per Arch B.R. B.R. OVERDENTURE Maxillary , Mandibular , Altered cast impression technique addition to above OVER IMPLANTS N/A Maxillary B.R. B.R. B.R. N/A Mandibular B.R. B.R. B.R. SURGICAL CAST PARTIAL DENTURE FRAMEWORK COSTS CAN BE BILLED IN ADDITION TO LAB FEE USING CODE FREE END WITH CLASPS AND RESTS Maxillary 1, , Mandibular 1, , FREE END WITH CLASPS AND RESTS COMPLEX dentures require use of a facebow transfer and post insertion remount on a semi adjustable articulator and equilibrationof occlusion. N/A Maxillary 1, , , N/A Mandibular 1, , ,421.00
6 TOOTH BORNE WITH CLASPS AND RESTS Maxillary 1, , Mandibular 1, , TOOTH BORNE WITH CLASPS AND RESTS COMPLEX Complex dentures require use of a facebow transfer and post insertion remount on a semi adjustable articulator and equilibration of occlusion. N/A Maxillary 1, , , N/A Mandibular 1, , , OVERDENTURE Maxillary 1, , Mandibular 1, , ADJUSTMENTS AND REMOUNT WITH EQUILIBRATION COMPLETE OR PARTIAL DENTURE MINOR One unit of time Two units of time Each additional unit of time IMPLANT ATTACHMENTS N/A Changing Attachment Component (Examples: Nylon Insert, O Ring, ERA's). B.R. B.R. B.R. COMPLETE DENTURE REMOUNT AND EQUILIBRATION N/A Maxillary N/A Mandibular PARTIAL DENTURE REMOUNT AND EQUILIBRATION N/A Maxillary N/A Mandibular DENTURE DUPLICATION COMPLETE DENTURE Maxillary Mandibular PARTIAL DENTURE LAB PROCESSED/FUNCTION IMPRESSION REPRODUCTION OF EXISTING REPAIRS AND ADDITIONS COMPLETE DENTURE NO IMPRESSION REQUIRED Maxillary Mandibular COMPLETE DENTURE IMPRESSION REQUIRED Maxillary Mandibular PARTIAL DENTURE NO IMPRESSION REQUIRED Maxillary Mandibular PARTIAL DENTURE IMPRESSION REQUIRED Maxillary Mandibular PROSTHESIS PROPHYLAXIS AND POLISHING One unit of time Each additional unit of time
7 DENTURE OCCLUSAL SURFACE REBUILD USING TOOTH COLOURED MATERIALS DIRECT CHAIRSIDE One unit of time Each additional unit of time CUSTOM PIGMENTED/STAINED DENTURE BASE DIRECT CHAIRSIDE One unit of time Each additional unit of time OCCLUSAL TREATMENT SPLINT ON DENTURE N/A Per Arch B.R. B.R B.R. GINGIVAL TONING N/A Per Arch B.R. B.R. ADDITIONAL FEES FOR REPAIRS AND ADDITIONS Cast Clasp per clasp Wrought clasp per clasp Model without impression Opposing Model Impression Required N/A Retentive Post New denture tooth per tooth Multiple Fractures Per denture N/A Addition Flange Per Denture Strengthening wire/mesh Per arch N/A Reinforcement Wire Bar DENTURE RELINES COMPLETE DENTURE DIRECT CHAIRSIDE Maxillary Mandibular COMPLETE DENTURE PROCESSED ACYRLIC Maxillary Mandibular COMPLETE DENTURE PROCESSED WITH FUNCTIONAL IMPRESSION Maxillary Mandibular COMPLETE DENTURE ON IMPLANTS BALL/INDEPENDENT ATTACHMENTS N/A Maxillary BR BR BR N/A Mandibular BR BR BR COMPLETE DENTURE ON IMPLANTS BAR ATTACHMENT N/A Maxillary BR BR BR N/A Mandibular BR BR BR PARTIAL DENTURE DIRECT CHAIRSIDE Maxillary Mandibular PARTIAL DENTURE PROCESSED ACRYLIC Maxillary Mandibular PARTIAL DENTURE PROCESSED WITH FUNCTIONAL IMPRESSION Maxillary Mandibular PARTIAL DENTURE ON IMPLANTS BALL/INDEPENDENT N/A Maxillary BR BR BR N/A Mandibular BR BR BR
8 DENTURE REBASES COMPLETE DENTURE Maxillary Mandibular COMPLETE DENTURE WITH FUNCTIONAL IMPRESSION Maxillary Mandibular COMPLETE DENTURE ON IMPLANTS BALL/INDEPENDENT ATTACHMENTS N/A Maxillary BR BR BR N/A Mandibular BR BR BR COMPLETE DENTURE ON IMPLANTS BAR ATTACHMENT N/A Maxillary BR BR BR N/A Mandibular BR BR BR PARTIAL DENTURE Maxillary Mandibular PARTIAL DENTURE WITH FUNCTIONAL IMPRESSION Maxillary Mandibular PARTIAL DENTURE ON IMPLANTS BALL/INDEPENDENT ATTACHEMENTS N/A Maxillary BR BR BR N/A Mandibular BR BR BR PARTIAL DENTURE ON IMPLANTS BAR ATTACHMENT N/A Maxillary BR BR BR N/A Mandibular BR BR BR ADDITIONS TO RELINES AND REBASES RESILIENT LINER N/A (reline) N/A (rebase) IMPLANT ATTACHMENTS N/A Independent Attachment B.R. B.R. B.R. N/A Bar Attachment B.R. B.R. B.R. RESET N/A Complete Maxillary N/A Complete Mandibular N/A Partial Maxillary N/A Partial Mandibular DENTURE REMAKE PARTIAL DENTURE USING EXISTING FRAMEWORK Maxillary E Mandibular E TISSUE CONDITIONING COMPLETE DENTURE NOTE T.C NOT INCLUDED IN 3 MONTH POST INSERTION CARE Maxillary Mandibular PARTIAL DENTURE Maxillary Mandibular VITAL BLEACHING
9 HOME VITAL BLEACHING Maxillary E Mandibular E IN OFFICE VITAL BLEACHING One Unit of Time B.R. B.R. B.R Two Units of Time B.R. B.R. B.R Three Units of Time B.R. B.R. B.R Each Additional Unit of Time B.R. B.R. B.R. PROTECTIVE MOUTH GUARDS N/A Vacuum Formed (per arch) N/A Processed (per arch) B.R. B.R. B.R. NIGHT GUARD Night Guard AIRWAYS DILATOR Upper Airway Dilator B.R. B.R. B.R. IMPLANT SUPPORTED FIXED PROSTHODONTICS The Denturist Regulation indicates in Section 14, that Regulated Members may perform any or all of the following restricted activities in the practice of denturism: (a) prescribe and fit (i) a removable partial or complete denture; and (ii) a fixed or removable implant supported prosthesis that replaces two or more teeth. Implant supported fixed bridges (each abutment, each retainer and each pontic, constitutes a separate unit in the bridge, with a separate code number). PONTICS: BRIDGE PONTICS: CAST METAL Cast Metal B.R. B.R. + L B.R. + L Cast Metal Framework with separate Porcelain/ Ceramic/Polymer B.R. B.R. + L B.R. + L Glass Jacket Pontic Prefabricated Attachable Facing B.R. B.R. + L Retentive Bar Prefabricated or Custom B.R. B.R. + L B.R. + L Attached to Retainer Retentive Bar: Prefabricated or Custom, Attached to Implant Supported Retainer to Retain Removable Prosthesis B.R. B.R. + L B.R. + L PONTICS: PORCELAIN/CERAMIC/POLYMER GLASS Porcelain/Ceramic/Polymer Glass Fused to Metal B.R. B.R. + L B.R. + L Porcelain/Ceramic/Polymer Glass Aluminous B.R. B.R. + L B.R. + L PONTICS: ACRYLIC/COMPOSITE/COMPOMER Acrylic/Composite/Compomer B.R. B.R. + L B.R. + L Processed to Metal Acrylic/Composite/Compomer Indirect B.R. B.R. + L B.R. + L RECONTOURING OF RETAINERS/PONTICS EXISTING BRIDGEWORK One unit of time Each additional unit of time IMPLANT SUPPORTED FIXED PROSTHODONTICS REPAIRS REPLACEMENT Replace Broken Prefabricated Attachable Facings One unit of time B.R. + L L Two units of time B.R. + L L Three units of time B.R. + L L Four units of time B.R. + L L Each additional unit of time over four B.R. + L L REMOVAL OF EXISTING FIXED PROSTHESIS
10 Removal of Fixed Prosthesis to be reinserted One unit of time B.R. + L L Two units of time B.R. + L L Three units of time B.R. + L L Four units of time B.R. + L L Each additional unit of time over four B.R. + L L REMOVAL OF FIXED PROSTHESIS TO BE REPLACED BY NEW PROSTHESIS One unit of time B.R. + L L Two units of time B.R. + L L Three units of time B.R. + L L Four units of time B.R. + L L Each additional unit of time over four B.R. + L L REINSERTION One unit of time B.R. + L L Two units of time B.R. + L L Three units of time B.R. + L L Four units of time B.R. + L L Each additional unit of time over four B.R. + L L IMPLANT SUPPORTED REATINERS ACRYLIC/COMPOSITE/COMPOMER WITH OR WITHOUT CAST OR PREFABRICATED METAL BASE Indirect Acrylic/Composite/Compomer Provisional B.R. + L L Acrylic/Composite/Compomer B.R. + L L Direct Acrylic/Composite/Compomer B.R. + L L Cast Metal Base, Indirect Acrylic/Composite/Compomer B.R. + L L PORCELAIN/CERAMIC/POLYMER GLASS FULL COVERAGE Porcelain/Ceramic/Polymer Glass Implant Supported B.R. + L L PORCELAIN/CERAMIC/POLYMER GLASS FUSED TO METAL Porcelain/Ceramic/Polymer Glass Implant Supported B.R. + L L FULLCAST METAL RETAINERS Full Cast metal Retainers Implant Supported B.R. + L L OVERDENTURE CUSTOM CAST OR PREFABRICATED WITH NO OCCLUSAL COMPONENT Metal Retainer, Prefabricated or Custom Cast, Implant Supported, with or without mesostructure, no occlusal component B.R. B.R. + L B.R. + L FIXED PROSTHODONTIC FRAMEWORK OSSEO INTEGRATED IMPLANT SUPPORTED Framework Attached with Screws and Incorporating Teeth Denture Teeth and Acrylic Maxillary B.R. B.R. B.R Mandibular B.R. B.R. B.R. Framework Attached with Screws and Incorporating Teeth Porcelain Teeth Bonded to Frame Maxillary B.R. B.R Mandibular B.R. B.R. MISCELLANEOUS SERVICES N/A Custom Tray (per arch) B.R. B.R. N/A Intraoral Pin Tracing B.R. B.R. B.R. N/A Facebow Transfer B.R. B.R. B.R Cast Occlusal Onlay (Surface) B.R. B.R. N/A Resetting of Teeth Complete Maxillary
11 N/A Resetting of Teeth Complete Mandibular N/A Resetting of Teeth Partial Maxillary N/A Resetting of Teeth Partial Mandibular N/A Resilient Liner Per Arch in Conjunction with New Denture Surgical Template Maxillary Surgical Template Mandibular Cast Mesh/or Cast Full Palate B.R. B.R Cast Mandibular Base B.R. B.R. N/A Denture Identification Per Denture Electro Myography Initial Exam Electro Myography Subsequent Examination per electrode B.R. B.R. B.R Transcutaneous Electrical Neurostimulation (TENS) B.R. B.R. B.R Mandibular Kinesiograph per photo B.R. B.R. B.R Mandibular Kinesiograph complete (photos #1 8) B.R. B.R. B.R Nonspecified Diagnosis and Treatment (Includes Velscope ) E E N/A Out of Office Call Cancelled or Missed Appointment (per unit of time) N/A Written Report N/A Gold Inlay B.R. B.R. N/A Amalgam Inlay B.R. B.R.
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