120 PERIODIC ORAL EVALUATION ESTABLISHED PATIENT 49.00 59.00 59.00 71.00 140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 71.00 85.00 99.00 119.00 145 ORAL EVAL PT UND 3 YR AGE CNSL W/PRIM CAREGIVER 71.00 85.00 92.00 110.00 150 COMP ORAL EVALUATION - NEW/ESTABLISHED PATIENT 78.00 94.00 104.00 125.00 160 DTL&EXT ORAL EVALUATION - PROBLEM FOCUSED REPORT 183.00 219.60 209.00 251.00 180 COMP PERIODONTAL EVALUATION - NEW/EST PATIENT 80.00 96.00 113.00 136.00 210 INTRAORAL-COMPLETE SERIES 116.00 139.00 132.00 158.00 220 INTRAORAL-PERIAPICAL-FIRST FILM 23.00 28.00 26.00 31.00 230 INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM 18.00 22.00 24.00 29.00 240 INTRAORAL - OCCLUSAL FILM 25.00 35.00 41.00 49.00 270 BITEWING - SINGLE FILM 21.00 25.00 27.00 32.00 272 BITEWINGS - TWO FILMS 37.00 44.00 44.00 53.00 273 BITEWINGS - THREE FILMS 43.00 52.00 54.00 65.00 274 BITEWINGS - FOUR FILMS 50.00 60.00 62.00 74.00 277 VERTICAL BITEWINGS - 7 TO 8 FILMS 77.00 93.00 94.00 113.00 330 PANORAMIC FILM 88.00 106.00 106.00 127.00 340 CEPHALOMETRIC FILM 108.25 129.90 120.00 144.00 460 PULP VITALITY TESTS 35.00 49.00 47.00 56.00 470 DIAGNOSTIC CASTS 63.00 75.00 104.00 125.00 473 ACCESS TISSUE GR&MIC EXAMINATION PREP/REPRT 102.00 122.00 138.00 166.00 1110 PROPHYLAXIS - ADULT 92.00 110.00 106.00 127.00 1120 PROPHYLAXIS - CHILD 61.00 73.00 74.00 89.00 1206 TOP FLUORIDE VARNISH; TX APPL MOD-HI CARIES RISK 43.00 51.00 62.00 74.00 1208 TOPICAL APPLICATION OF FLUORIDE 36.00 43.00 41.00 49.00 1351 SEALANT - PER TOOTH 43.00 52.00 52.00 62.00 1352 PREV RSN REST MOD HIGH CARIES RISK PT-PERM TOOTH 43.00 52.00 66.00 79.00 1510 SPACE MAINTAINER - FIXED-UNILATERAL 285.00 342.00 341.00 409.00 1515 SPACE MAINTAINER - FIXED-BILATERAL 311.00 373.00 477.00 572.00 1520 SPACE MAINTAINER - REMOVABLE-UNILATERAL 342.00 392.00 374.00 449.00 1525 SPACE MAINTAINER - REMOVABLE-BILATERAL 400.00 480.00 579.00 695.00 1550 RECEMENTATION OF SPACE MAINTAINER 79.00 85.00 74.00 89.00
2140 AMALGAM-ONE SURFACE PRIMARY OR PERMANENT 98.00 118.00 128.00 154.00 2150 AMALGAM-TWO SURFACES PRIMARY OR PERMANENT 130.00 156.00 166.00 199.00 2160 AMALGAM-THREE SURFACES PRIMARY OR PERMANENT 158.00 190.00 201.00 241.00 2161 AMALGAM-FOUR/MORE SURFACES PRIMARY/PERMANENT 186.00 223.00 245.00 294.00 2330 RESIN-BASED COMPOSITE ONE SURFACE ANTERIOR 102.00 122.00 116.00 139.00 2331 RESIN-BASED COMPOSITE TWO SURFACES ANTERIOR 128.00 154.00 148.00 178.00 2332 RESIN-BASED COMPOSITE THREE SURFACES ANTERIOR 155.00 186.00 182.00 218.00 2335 RESIN-BASED COMPOSITE 4/> SURFACES INCISAL ANGLE 173.00 208.00 215.00 258.00 2390 RESIN-BASED COMPOSITE CROWN ANTERIOR 195.00 235.00 238.00 286.00 2391 RESIN-BASED COMPOSITE - ONE SURFACE POSTERIOR 116.00 139.00 136.00 163.00 2392 RESIN-BASED COMPOSITE - TWO SURFACES POSTERIOR 148.00 178.00 178.00 214.00 2393 RESIN-BASED COMPOSITE - THREE SURFACES POSTERIOR 192.00 230.00 221.00 265.00 2394 RESIN COMPOS - FOUR OR MORE SURFACES POSTERIOR 207.00 248.00 271.00 325.00 2510 INLAY - METALLIC - ONE SURFACE 439.00 527.00 500.00 600.00 2520 INLAY - METALLIC - TWO SURFACES 404.00 485.00 567.00 680.00 2530 INLAY - METALLIC - THREE OR MORE SURFACES 501.00 601.00 654.00 785.00 2542 ONLAY - METALLIC - TWO SURFACES 534.00 641.00 641.00 769.00 2543 ONLAY METALLIC THREE SURFACES 558.00 670.00 670.00 804.00 2544 ONLAY METALLIC FOUR OR MORE SURFACES 599.00 719.00 697.00 836.00 2610 INLAY - PORCELAIN/CERAMIC - ONE SURFACE 484.00 581.00 588.00 706.00 2620 INLAY - PORCELAIN/CERAMIC - TWO SURFACES 524.00 620.00 621.00 745.00 2630 INLAY - PORCELAIN/CERAMIC - THREE/MORE SURFACES 551.00 652.00 661.00 793.00 2642 ONLAY - PORCELAIN/CERAMIC - TWO SURFACES 535.00 642.00 643.00 772.00 2643 ONLAY - PORCELAIN/CERAMIC - THREE SURFACES 544.00 653.00 693.00 832.00 2644 ONLAY - PORCELAIN/CERAMIC - 4 OR MORE SURFACES 622.00 747.00 735.00 882.00 2710 CROWN RESINBASED COMPOSITE INDIRECT 260.00 312.00 274.00 329.00 2720 CROWN - RESIN WITH HIGH NOBLE METAL 590.00 708.00 674.00 809.00 2721 CROWN - RESIN WITH PREDOMINANTLY BASE METAL 590.00 708.00 632.00 758.00 2722 CROWN - RESIN WITH NOBLE METAL 590.00 708.00 646.00 775.00 2740 CROWN - PORCELAIN/CERAMIC SUBSTRATE 559.00 671.00 692.00 830.00 2750 CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL 559.00 671.00 683.00 820.00
2751 CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL 559.00 671.00 636.00 763.00 2752 CROWN - PORCELAIN FUSED TO NOBLE METAL 559.00 671.00 651.00 781.00 2780 CROWN - 3/4 CAST HIGH NOBLE METAL 545.00 654.00 655.00 786.00 2781 CROWN - 3/4 CAST PREDOMINATELY BASE METAL 545.00 654.00 616.00 739.00 2782 CROWN - 3/4 CAST NOBLE METAL 545.00 654.00 637.00 764.00 2783 CROWN - 3/4 PORCELAIN/CERAMIC 545.00 654.00 673.00 808.00 2790 CROWN - FULL CAST HIGH NOBLE METAL 545.00 654.00 659.00 791.00 2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL 545.00 654.00 624.00 749.00 2792 CROWN - FULL CAST NOBLE METAL 545.00 654.00 636.00 763.00 2910 RECEMENT INLAY ONLAY/PART COVERAGE RESTORATION 55.00 66.00 62.00 74.00 2920 RECEMENT CROWN 55.00 66.00 63.00 76.00 2930 PREFABR STAINLESS STEEL CROWN - PRIMARY TOOTH 140.00 168.00 170.00 204.00 2931 PREFABR STAINLESS STEEL CROWN - PERMANENT TOOTH 140.00 168.00 193.00 232.00 2932 PREFABRICATED RESIN CROWN 224.00 291.00 206.00 247.00 2933 PREFABR STAINLESS STEEL CROWN W/RESIN WINDOW 140.00 168.00 235.00 282.00 2940 PROTECTIVE RESTORATION 67.00 80.00 65.00 78.00 2950 CORE BUILDUP INCLUDING ANY PINS 145.00 174.00 163.00 196.00 2951 PIN RETENTION - PER TOOTH ADDITION RESTORATION 33.00 40.00 37.00 44.00 2952 POST AND CORE ADDITION TO CROWN INDIRECTLY FAB 270.00 351.00 257.00 308.00 2953 EACH ADDITIONAL INDIRECTLY FAB POST SAME TOOTH 135.00 223.00 129.00 155.00 2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN 224.00 291.00 206.00 247.00 2961 LABIAL VENEER - LABORATORY 320.00 402.00 563.00 676.00 2970 TEMPORARY CROWN FRACTURED TOOTH 95.00 114.00 154.00 185.00 2971 ADD PROC NEW CRWN UND XSTING PART DENTUR FRMEWRK 84.00 101.00 99.00 119.00 3110 PULP CAP - DIRECT 48.00 58.00 59.00 71.00 3120 PULP CAP - INDIRECT 41.00 49.00 47.00 56.00 3220 TX PULP-REMV PULP CORONAL DENTINOCEMENTL JUNC 106.00 127.00 121.00 145.00 3221 PULPAL DEBRIDEMENT PRIMARY AND PERMANENT TEETH 110.00 131.00 133.00 160.00 3230 PULPAL THERAPY - ANTERIOR PRIMARY TOOTH 197.00 211.00 154.00 185.00 3240 PULPAL THERAPY - POSTERIOR PRIMARY TOOTH 212.00 227.00 190.00 228.00 3310 ENDODONTIC THERAPY ANTERIOR TOOTH 484.00 581.00 605.00 726.00
3320 ENDODONTIC THERAPY BICUSPID TOOTH 638.00 766.00 742.00 890.00 3330 ENODODONTIC THERAPY MOLAR 834.00 1001.00 920.00 1104.00 3333 INTERNAL ROOT REPAIR OF PERFORATION DEFECTS 189.00 227.00 208.00 250.00 3346 RETREATMENT PREVIOUS RC THERAPY - ANTERIOR 568.00 670.00 807.00 968.00 3347 RETREATMENT PREVIOUS RC THERAPY - BICUSPID 670.00 810.00 949.00 1139.00 3348 RETREATMENT PREVIOUS ROOT CANAL THERAPY - MOLAR 851.00 1001.00 1175.00 1410.00 3351 APEXIFICATION/RECALCIFICAT/PUPAL REGEN INIT VST 211.00 325.00 349.00 419.00 3352 APEXIFICAT/RECALCIFICAT/PUPAL REGEN INT MED REPL 105.00 152.00 157.00 188.00 3353 APEXIFICATION/RECALCIFICATION - FINAL VISIT 325.00 420.00 482.00 578.00 3410 APICOECTOMY/PERIRADICULAR SURGERY - ANTERIOR 613.00 736.00 693.00 832.00 3425 APICOECTOMY/PERIRADICULAR SURGERY - MOLAR 652.00 710.00 874.00 1049.00 3426 APICOECTOMY/PERIRADICULAR SURGERY 212.00 212.00 295.00 354.00 3430 RETROGRADE FILLING - PER ROOT 169.00 203.00 217.00 260.00 3450 ROOT AMPUTATION - PER ROOT 305.00 355.00 452.00 542.00 3950 CANAL PREPARATION&FITTING PREFORMED DOWEL/POST 115.00 138.00 157.00 188.00 4210 GINGIVECT/PLSTY 4/>CNTIG/TOOTH BOUND SPACES-QUAD 869.00 1043.00 637.00 764.00 4211 GINGIVECT/PLSTY 1-3 CNTIG/TOOTH BOUND SPACE-QUAD 194.00 243.00 283.00 340.00 4240 GINGL FLP PROC 4/> CONTIG/TOOTH BOUND SPACE-QUAD 613.00 736.00 808.00 970.00 4241 GINGL FLP PROC 1-3 CONTIG/TOOTH BOUND SPACE-QUAD 529.00 635.00 467.00 560.00 4249 CLINICAL CROWN LENGTHENING - HARD TISSUE 529.00 635.00 661.00 793.00 4260 OSSEOUS SURG 4/> CONTIG/TOOTH BOUND SPACES-QUAD 1117.00 1340.00 1346.00 1615.00 4261 OSSEOUS SURG 1-3 CONTIG/TOOTH BOUND SPACES-QUAD 558.00 670.00 722.00 866.00 4263 BONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANT 402.00 453.00 482.00 578.00 4264 BONE REPLACEMENT GRAFT - EA ADD SITE QUADRANT 157.00 160.00 411.00 493.00 4266 GUID TISSUE REGEN - RESORBABLE BARRIER PER SITE 352.00 388.00 496.00 595.00 4267 GUID TISSUE REGEN - NONRESORB BARRIER PER SITE 360.00 420.00 450.00 540.00 4273 SUBEPITHEL CONECTIVE TISSUE GRAFT PROC PER TOOTH 519.60 622.80 775.00 930.00 4274 DISTAL OR PROXIMAL WEDGE PROCEDURE 904.00 1085.00 663.00 796.00 4275 SOFT TISSUE ALLOGRAFT 797.00 847.26 878.00 1054.00 4276 COMB CNCTIVE TISSUE&DBL PEDICLE GRAFT PER TOOTH 512.00 575.00 773.00 928.00 4277 SOFT TISSUE GRAFT PROCEDURE FIRST TOOTH 444.25 533.10 555.00 666.00
4278 SOFT TISSUE GRAFT PROCEDURE EACH ADD TOOTH 444.25 533.10 326.00 391.00 4341 PRDONTAL SCALING&ROOT PLANING 4/MORE TEETH-QUAD 150.00 180.00 203.00 244.00 4342 PRDONTAL SCALING&ROOT PLANING 1-3 TEETH-QUAD 100.00 119.00 118.00 142.00 4910 PERIODONTAL MAINTENANCE 110.00 132.00 125.00 150.00 5110 COMPLETE DENTURE - MAXILLARY 758.00 910.00 1034.00 1241.00 5120 COMPLETE DENTURE - MANDIBULAR 758.00 910.00 1034.00 1241.00 5130 IMMEDIATE DENTURE - MAXILLARY 843.00 1012.00 1128.00 1354.00 5140 IMMEDIATE DENTURE - MANDIBULAR 843.00 1012.00 1128.00 1354.00 5211 MAXILLARY PARTIAL DENTURE - RESIN BASE 671.00 805.00 873.00 1048.00 5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE 671.00 805.00 839.00 1007.00 5213 MAX PART DENTUR-CAST METL FRMEWRK W/RSN BASE 876.00 1051.00 1143.00 1372.00 5214 MAND PART DENTUR- CAST METL FRMEWRK W/RSN BASE 876.00 1051.00 1143.00 1372.00 5225 MAXILLARY PARTIAL DENTRUE FLEXIBLE BASE 671.00 805.00 873.00 1048.00 5226 MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE 671.00 805.00 839.00 1007.00 5410 ADJUST COMPLETE DENTURE - MAXILLARY 56.00 68.00 57.00 68.00 5411 ADJUST COMPLETE DENTURE - MANDIBULAR 56.00 68.00 57.00 68.00 5421 ADJUST PARTIAL DENTURE - MAXILLARY 56.00 68.00 57.00 68.00 5422 ADJUST PARTIAL DENTURE - MANDIBULAR 56.00 68.00 57.00 68.00 5510 REPAIR BROKEN COMPLETE DENTURE BASE 83.00 100.00 113.00 136.00 5520 REPLACE MISSING/BROKEN TEETH - COMPLETE DENTURE 84.00 101.00 95.00 114.00 5610 REPAIR RESIN DENTURE BASE 83.00 100.00 123.00 148.00 5620 REPAIR CAST FRAMEWORK 83.00 100.00 132.00 158.00 5630 REPAIR OR REPLACE BROKEN CLASP 139.00 167.00 161.00 193.00 5640 REPLACE BROKEN TEETH - PER TOOTH 84.00 101.00 104.00 125.00 5650 ADD TOOTH TO EXISTING PARTIAL DENTURE 125.00 150.00 142.00 170.00 5660 ADD CLASP TO EXISTING PARTIAL DENTURE 147.00 161.00 170.00 204.00 5710 REBASE COMPLETE MAXILLARY DENTURE 401.00 481.00 420.00 504.00 5711 REBASE COMPLETE MANDIBULAR DENTURE 401.00 481.00 401.00 481.00 5720 REBASE MAXILLARY PARTIAL DENTURE 401.00 481.00 396.00 475.00 5721 REBASE MANDIBULAR PARTIAL DENTURE 401.00 481.00 396.00 475.00 5730 RELINE COMPLETE MAXILLARY DENTURE CHAIRSIDE 226.00 271.00 237.00 284.00
5731 RELINE COMPLETE MANDIBULAR DENTURE CHAIRSIDE 226.00 271.00 237.00 284.00 5740 RELINE MAXILLARY PARTIAL DENTURE CHAIRSIDE 226.00 271.00 217.00 260.00 5741 RELINE MANDIBULAR PARTIAL DENTURE CHAIRSIDE 226.00 271.00 217.00 260.00 5750 RELINE COMPLETE MAXILLARY DENTURE LABORATORY 414.00 497.00 316.00 379.00 5751 RELINE COMPLETE MANDIBULAR DENTRUE LABORATORY 414.00 497.00 316.00 379.00 5760 RELINE MAXILLARY PARTIAL DENTURE LABORATORY 414.00 497.00 312.00 374.00 5761 RELINE MANDIBULAR PARTIAL DENTURE LABORATORY 414.00 497.00 312.00 374.00 5810 INTERIM COMPLETE DENTURE MAXILLARY 370.00 444.00 500.00 600.00 5811 INTERIM COMPLETE DENTURE MANDIBULAR 370.00 444.00 463.00 556.00 5820 INTERIM PARTIAL DENTURE MAXILLARY 268.00 321.00 387.00 464.00 5821 INTERIM PARTIAL DENTURE MANDIBULAR 268.00 321.00 411.00 493.00 5850 TISSUE CONDITIONING MAXILLARY 83.00 88.00 99.00 119.00 5851 TISSUE CONDITIONING MANDIBULAR 83.00 88.00 99.00 119.00 6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN 0.00 0.00 850.00 1020.00 6059 ABUT SUPP PORCELAIN TO METL CROWN HI NOBLE METL 0.00 0.00 960.00 1152.00 6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN 0.00 0.00 921.00 1105.00 6066 IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN 0.00 0.00 709.00 851.00 6067 IMPLANT SUPPORTED METAL CROWN 0.00 0.00 997.00 1196.00 6210 PONTIC - CAST HIGH NOBLE METAL 715.00 858.00 665.00 798.00 6211 PONTIC - CAST PREDOMINANTLY BASE METAL 715.00 858.00 624.00 749.00 6212 PONTIC - CAST NOBLE METAL 715.00 858.00 649.00 779.00 6240 PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL 580.00 696.00 657.00 788.00 6241 PONTIC - PORCELN FUSED PREDOMINANTLY BASE METAL 580.00 696.00 607.00 728.00 6242 PONTIC - PORCELAIN FUSED TO NOBLE METAL 580.00 696.00 640.00 768.00 6250 PONTIC - RESIN WITH HIGH NOBLE METAL 697.00 836.00 649.00 779.00 6251 PONTIC - RESIN WITH PREDOMINANTLY BASE METAL 697.00 836.00 598.00 718.00 6252 PONTIC - RESIN WITH NOBLE METAL 697.00 836.00 618.00 742.00 6545 RETAINER - CAST METAL RESIN BONDED FIX PROSTH 253.00 304.00 242.00 290.00 6548 RETAINER - PORCELN/CERAMIC RSN BONDED FIX PROSTH 297.00 356.00 266.00 319.00 6720 CROWN - RESIN WITH HIGH NOBLE METAL 590.00 708.00 641.00 769.00 6721 CROWN RESIN W/PREDOMINANTLY BASE METAL-DENTURE 590.00 708.00 608.00 730.00
6722 CROWN - RESIN WITH NOBLE METAL 590.00 708.00 619.00 743.00 6750 CROWN PORCELAIN FUSED TO HI NOBLE METAL-DENTURE 559.00 671.00 657.00 788.00 6751 CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL 559.00 671.00 613.00 736.00 6752 CROWN - PORCELAIN FUSED TO NOBLE METAL 559.00 671.00 627.00 752.00 6780 CROWN - 3/4 CAST HIGH NOBLE METAL 545.00 654.00 619.00 743.00 6790 CROWN FULL CAST HIGH NOBLE METAL-DENTURE 545.00 654.00 634.00 761.00 6791 CROWN FULL CAST PREDOMINANTLY BASE METAL-DENTURE 545.00 654.00 601.00 721.00 6792 CROWN FULL CAST NOBLE METAL-DENTURE 545.00 654.00 623.00 748.00 6930 RECEMENT FIXED PARTIAL DENTURE 76.00 91.00 95.00 114.00 6940 STRESS BREAKER 152.00 182.00 214.00 257.00 6950 PRECISION ATTACHMENT 236.00 283.00 414.00 497.00 7111 EXTRACTION CORONAL REMNANTS DECIDUOUS TOOTH 59.00 71.00 90.00 108.00 7140 EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT 79.00 95.00 120.00 144.00 7210 SURG REMOVAL ERUPTED TOOTH REMV BONE ELEV FLAP 189.00 227.00 209.00 251.00 7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE 198.00 238.00 262.00 314.00 7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY 266.00 319.00 348.00 418.00 7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY 329.00 395.00 409.00 491.00 7241 REMV IMP TOOTH - CMPL BONY W/UNUSUAL SURG COMPS 413.00 496.00 514.00 617.00 7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS 195.00 234.00 220.00 264.00 7260 OROANTRAL FISTULA CLOSURE 1144.00 1373.00 1371.00 1645.00 7261 PRIMARY CLOSURE OF A SINUS PERFORATION 355.00 425.00 571.00 685.00 7270 TOOTH REIMPL &OR STBL ACC EVULSED/DISPLCD TOOTH 249.00 299.00 428.00 514.00 7272 TOOTH TRANSPLANTATION 550.00 660.00 571.00 685.00 7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH 232.00 278.00 400.00 480.00 7285 BIOPSY OF ORAL TISSUE HARD 414.00 525.00 620.00 744.00 7286 BIOPSY OF ORAL TISSUE SOFT 297.00 325.00 343.00 412.00 7310 ALVEOLOPLASTY W/EXTRACTION 4/> TEETH/SPACE QUAD 172.00 206.00 452.00 542.00 7320 ALVEOLOPLASTY NOT W/EXTRACTIONS 4/> TEETH/SPACE 432.00 518.00 540.00 648.00 7340 VESTIBULOPLASTY RIDGE EXT SEC EPITHELIALIZATION 1778.00 2134.00 2223.00 2668.00 7350 VESTIBULOPLASTY RIDGE EXT W/SOFT TISS GRAFTS 5172.00 6206.00 6465.00 7758.00 7410 EXCISION OF BENIGN LESION UP TO 1.25 CM 700.00 825.00 875.00 1050.00
7440 EXC MALIG TUMOR-LESION DIAMETER UP TO 1.25 CM 1228.00 1474.00 1535.00 1842.00 7441 EXC MALIG TUMOR-LESION DIAM GREATER THAN 1.25 CM 1810.00 2172.00 2263.00 2716.00 7450 REMOVAL BEN ODONTOGENIC CYST/TUMR- UP T0 1.25 CM 700.00 825.00 875.00 1050.00 7451 REMOVAL BENIGN ODONTOGENIC CYST/TUMOR- > 1.25 CM 1060.00 1272.00 1325.00 1590.00 7460 REMOVAL BEN NONODONTOGENIC CYST/TUMR- UP 1.25 CM 700.00 825.00 875.00 1050.00 7473 REMOVAL OF TORUS MANDIBULARIS 1354.00 1625.00 1884.00 2261.00 7510 INCISION & DRAINAGE ABSCESS-INTRAORAL SOFT TISS 155.00 186.00 486.00 583.00 7511 I & D ABSCESS INTRAORAL SOFT TISSUE COMPLICATED 178.00 214.00 735.00 882.00 7520 INCISION & DRAINAGE ABSCESS-EXTRAORAL SOFT TISS 460.00 475.00 575.00 690.00 7521 I & D ABSCESS EXTRAORAL SOFT TISSUE COMPLICATED 480.00 495.00 600.00 720.00 7540 REMV REACT-PRODUC FOREIGN BODIES-MUSCULOSKEL SYS 610.00 732.00 763.00 916.00 7550 PART OSTEC/SEQUESTRECTOMY REMOVAL NON-VITAL BONE 339.00 407.00 424.00 509.00 7953 BONE REPLCMT GRAFT RIDGE PRESERVATION PER SITE 146.00 175.00 385.00 462.00 7960 FRENULECTOMY SEP PROC NOT INCIDENTL ANOTHER PROC 198.00 238.00 256.00 307.00 7970 EXCISION OF HYPERPLASTIC TISSUE-PER ARCH 597.00 716.00 746.00 895.00 7971 EXCISION OF PERICORONAL GINGIVA 222.00 266.00 278.00 334.00 9110 PALLIATIVE EMERGENCY TX DENTAL PAIN MINOR PROC 75.00 90.00 115.00 138.00 9220 DEEP SEDATION/GENERAL ANESTHESIA-1ST 30 MINUTES 320.00 384.00 301.00 361.00 9248 NON-INTRAVENOUS CONSCIOUS SEDATION 55.00 58.00 73.00 88.00 9440 OFFICE VISIT-AFTER REGULARLY SCHEDULED HOURS 75.00 75.00 71.00 85.00 9940 OCCLUSAL GUARD BY REPORT 375.00 450.00 365.00 438.00 9942 REPAIR AND/OR RELINE OF OCCLUSAL GUARD 111.00 133.00 151.00 181.00