Guide for Dental Fees for

General Dentists

January 2023

Copyright © 2022 by the Alberta Dental Association

 ALBERTA DENTAL ASSOCIATION

Preamble
The fees listed herein are published to serve merely as a guide. No dentist receiving this list is
under any obligation to accept the fees itemized. Any dentist who does not use all or any of
these fees will in no way suffer in their relations with the Alberta Dental Association or any
other body, group or committee affiliated with or under the control of the Alberta Dental
Association.
A genuine suggested fee guide is one which is issued merely for professional information
purposes without raising any intention or expectation whatsoever that the membership will
adopt the guide for their practices.
Dentists have the right and freedom to use any dental codes that are included in the Alberta
Uniform System of Coding and List of Services.
Dentists may use these fees to assist them in determining their own professional fees. A
suggested protocol to follow in order to eliminate the possibility of patient misunderstandings
regarding the fees for dental treatment is:

a. Perform a thorough oral examination for the patient.

b. Explain, carefully, the particular problems encountered in this patient's mouth.
Describe your treatment plan and prognosis, in a manner, which the patient can
fully understand. Assure yourself that the patient has understood the presentation.
c. Present your fee for treatment, before the commencement of treatment.
d. Arrange financial commitments in such a manner that the patient understands their
obligation.
e. If there is any question as to why this fee must be charged ... explain at this time.
f. Describe, explain and note any conditions, which may require an additional fee.
g. For the patient who requires a removable prosthetic service, two pertinent points
must be emphasized:
1. The length of time that adjustments will be provided, at no additional fee; and
2. Whether or not the initial fee includes the cost of necessary relines.
h. In all areas of treatment, the fee you charge should be based on the skill, judgment
and experience, which you have attained, and on the degree to which these are
applied in the treatment of your patient.

ii
Message from the Canadian Dental Association

Your fee guide uses codes from the Uniform System of Coding and List of Services (USC&LS)
which is published annually by the Canadian Dental Association. The USC&LS is a terminological
standard that provides descriptions and codes to represent oral health services. Its two main
uses are the production of fee guides and the exchange of information with insurance
companies. The USC&LS is intended to remove, to the greatest extent possible, any ambiguity in
the description of services. This can only be accomplished if the codes are used in a consistent
fashion—by all users, at all times.

As dentists, you will mainly use the USC&LS to describe the services provided on claims you
prepare for your insured patients. When you do so, it is important to remember that
The therapeutic value of a service is not a factor in the decision to include a description of
a service in the USC&LS. Further, the description of a service in the USC&LS is not an
endorsement or a certification of therapeutic value of that service by the Canadian Dental
Association.
The descriptor of a service provided in the USC&LS is not intended to determine the standard
at which the service should be delivered.
The descriptors of service provided in the USC&LS are not detailed enough to meet the
record keeping requirements of provincial dental regulators.

Structure
The Uniform System of Coding and List of Services (USC&LS) is a terminological standard that
provides descriptions and codes to represent oral health services. Its two main purposes are to
support the production of fee guides and the processing of dental claims. It is intended to be
used by dentists in Alberta and its service descriptors should be clear and unambiguous for this
audience.
The USC&LS is a classification organized around 10 categories, each of which is subdivided into
classes, sub-classes and general service titles to facilitate the identification of the appropriate code
to represent a service.
The categories used for the organization of the classification are:

00000 Diagnostic
10000 Prevention
20000 Restoration
30000 Endodontics
40000 Periodontics
50000 Prosthodontics - removable
60000 Prosthodontics - fixed
70000 Oral maxillofacial surgery
80000 Orthodontics
90000 General Services

The fully specified descriptor of a code is made up of the descriptor of the service code plus

iii
those of the general services title, sub-class and class the service is found under. The category of
a code is not part of its fully specified descriptor. It is solely intended to guide the search for
codes to represent specific services. This means that categories do not constrain the services a
code can describe.

Also, the category does not limit the use of codes to certain specialties. For example, if the fully
specified descriptor of a code in category 70000 Oral and Maxillofacial surgery matches the
service to be described, that code can be used to describe a periodontal or an endodontic
service. That code can equally be used by a general dentist, an oral surgeon, a periodontist, an
endodontist or any other specialist. Except if specified otherwise all codes may be used by all
dentists.

Units of time
Units of time referenced in certain descriptors are periods of 15 minutes or less. A half-unit of
time, which is a period of 7 ½ minutes, is the smallest unit of time described by the USC&LS. Half
units of time are not available for all services.

+L, +E and +PS

The mentions +L, +E and +PS are added to the descriptors of services whose cost involve an
expense component that is too variable to allow for the determination of a usual and
customary fee that includes them.

• The mention "+L” in the descriptor of a code means that associated lab costs are to
be coded separately from the service itself.
• The mention "+E" in the descriptor of a code means that material expenses not already
factored in the fee for that service are to be coded separately from the service itself
• The mention "+PS" in the descriptor of a code means that the professional fees
charged to the dentist for the professional services of an additional provider(s) are to
be coded separately from the service itself.
Codes for lab costs, material expenses and professional services are found in the 99000 class of
codes.

I.C.

The letters “I.C.” following a procedure code indicates a designation “Independent

Consideration” and is utilized when the procedure involves complexities which are too
variable to designate a specific fee.

iv
 Standards

Where the description of a service requires the designation of the tooth or teeth involved, the
use of ISO 3950 is mandatory.

Oral Cavity 00
Maxillary Area 01
Quadrant 10 20
Sextant 03 04 05
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Designation of 55 54 53 52 51 61 62 63 64 65
teeth* 85 84 83 82 81 71 72 73 74 75

48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
Sextant 08 07 06
Quadrant 40 30
Mandibular Area 02
* Designation of teeth
First digit: Digits 1 to 4 represent the quadrants of the permanent dentition and digits 5 to 8
represent the quadrants of the deciduous dentition, clockwise from the upper right side.
Second digit: Teeth in the same quadrant are represented by the second digit from 1 to 8

Coding Instructions
The USC&LS is intended to remove, to the greatest extent possible, any ambiguity in the
description of services. This can only be accomplished if the codes are used in a consistent
fashion-by all users, at all times.

Inclusions and exclusions

Codes provided by the USC&LS represent services. When a service is normally comprised of a
set of distinct procedures, these procedures are included in the service code and should not be
coded separately. For example, consider the use of anesthesia:
• Local anaesthesia is generally required for the provision of a restoration. It is a normal
component of a restorative service and when administered to support the delivery of a
restoration, it must not be coded separately.
• General anaesthesia is not generally required for the provision of restorative services. It
is not a normal component of a restorative service and to give a full description of the
services provided, it must be coded separately.
• Local anaesthesia delivered on its own, not in support of another service, must be
represented using the appropriate code from sub-classification 92100 anaesthesia, local.

v
Selecting the appropriate service code

The codes in the USC&LS are sequences of five digits that indicate the placement of a service
within its classification system
• Codes that end with a sequence of four zeros (X0000) are header codes used for the
identification of a category of services
• Codes that end with a sequence of three zeros (XX000) are header codes used for the
identification of a class within a category of services
• Codes that end with a sequence of two zeros (XXXO0) are header codes used for the
identification of a sub-class of a class of services
• Codes that end with one zero (XXXX0) are header codes used for the identification of
a general service title within a sub-class of services.
• Codes that end with a numeral other than 0 are service codes.

Codes ending in 0 are used for classification purposes only. They cannot be used for the
representation of a service. Only codes ending in a digit other than 0 are service codes that can
be used for the representation of services.
The fully specified descriptor of a service code includes the descriptor of the code, plus the
descriptors of the general service title, sub-classification and classification the code falls under.
For example, the fully specified descriptor of service code 04221 is
04000 Test/analysis/laboratory procedures/interpretation and/or report; 04200
Test/analysis, caries susceptibility/diagnosis; 04220 Non-ionizing scanning procedure to
detect caries and capable of quantifying, monitoring and recording changes in enamel,
dentin, and cementum, which includes diagnosis and interpretation of findings; 04221 One
unit of time
The most important criteria for the identification of which code to use for the representation of
a service is factual accuracy. Any misalignment between the service provided and the fully
specified descriptor of a code means that the code cannot be used.
In cases where more than one code descriptor that accurately matches a service can be
identified, the one that provides the best match must be used.
Even when there isn't a code that accurately represents a service, it is not acceptable to use a
code where the full descriptor is not a match to the service. Conversely, the absence of a code
that accurately describes a service doesn't prevent the billing of that service to the patient or
the submission of a claim for its reimbursement by a dental plan. Claims for services that cannot
be coded through the USC&LS cannot be sent with CDAnet™. However, they can be submitted
on paper, ideally on the Standard Dental Claim Form, using the box labeled " FOR DENTIST USE
ONLY - FOR ADDITIONAL INFORMATION, DIAGNOSIS, PROCEDURES, OR SPECIAL
CONSIDERATION" to provide a text description of the service.
Any combination of codes is allowable providing it accurately describes the services being coded.
The requirement is to use the smallest possible number of combined codes that provides an
accurate description of a service.

vi
Coding of restorations

Services that use direct restorative materials or single unit indirect restorations for the improvement
of the form, function and aesthetics of teeth, without consideration for the cause of the need for
improvement are coded in section 20000. The use of direct restorative materials or single unit
indirect restorations for purposes other than those above cannot be represented by codes in
Category 20000. For example, the addition of composite to a tooth to facilitate an orthodontic
treatment is part of the description of the orthodontic treatment and must not be represented by
codes in classification 23000.
The coding for many restorative services is done on a tooth by tooth basis and depends on the
number of surfaces restored, with one material, at one appointment, not the number of discrete
restorations placed on that tooth.

Units of time
Units of time referenced in the USC&LS are periods of 15 minutes or less. For services where half
units of time are coded, a half unit of time is a period of 7 ½ minutes or less.
For services coded in terms of “units of times", the time spent on the provision of a service
begins when the practitioner begins preparing themselves and the patient for its delivery and
ends either when another service is initiated or when the patient is discharged from the
operatory. Treatment time does not include the time spent setting up or breaking down the
operatory nor does it include the time spent on administrative tasks such as billing and
scheduling the next appointment. Total time units do not equal time on tooth with an
instrument as services directly related to the provision of the main service are included.
A unit of time, either half or full as appropriate, is added to the total number of units used as
soon as the delivery of the service extends into the next unit of time. For example, a service
where a code for half­ units of time is not available that takes between 1 and 15 minutes to
deliver should be recorded as one unit of time. One that takes between 16 and 30 minutes as
two units of time. Services for which a code representing a half-unit of time is available should
be recorded as the number of full units used plus one half-unit if the overage is up to 7 ½
minutes or the number of full units used if the overage is more than 7 ½ minutes. For example,
if a service, for which for which a code representing a half-unit of time is available, took 17
minutes to deliver, it should be coded as one full unit and one half-unit. If the same service
took 24 minutes, it would be coded as two full units.
It is important to recognize that "appointment time" is not the same as "treatment time ".”
Appointment time" maybe less than the time represented by the total of the units of time
reported for that appointment.
+L, +E and +PS
Services whose descriptor involve the mentions +L, +E or +PS separate the dentist fee from an
expense component that is passed through to the patient. The representation of these
services requires the use of two codes, one for the service itself and one for the expense that
is passed through to the patient.

vii
 ALBERTA DENTAL ASSOCIATION

2023 Uniform System of Coding and List of Services

Changed from 2022

Code Change Type Code Description Change Made

32240 New Pulpotomy, Permanent Teeth,

concurrent with restoration
(but excluding final
restoration)
32241 New Anterior and bicuspid teeth

32242 New Molar Teeth

42410 Edit Flap Approach, with Changed to: Flap Approach with
Osteoplasty/Ostectomy Osteoplasty and/or Ostectomy
42430 Edit Flap Approach, with Curettage Changed to: Flap Approach, with
of Osseous Defect and Curettage of Osseous Defect with
Osteoplasty Osteoplasty and/or Ostectomy
91200 Edit UNCLASSIFIED TREATMENT, Changed to: UNCLASSIFIED
UNUSUAL TIME AND TREATMENTS, UNUSUAL TIME AND
RESPONSIBILITIES (Note: If RESPONSIBILITIES (Note: If the
the service affected is service affected is anaesthesia,
anaesthesia, code series Service Class 92000, and the unusual
92000, and the unusual time time and responsibility is the result of
and responsibility is the a patient BMI of 35 or above, refer to
result of a patient BMI of 35 Service Sub-class 92900.)
or above, refer to code series
92900.)
92210 Edit General Anaesthesia Addition of “+ PS”

92300 Edit ANAESTHESIA, DEEP SEDATION Addition of “+ PS”

92400 Edit ANAESTHESIA, CONSCIOUS Addition of “+ PS”

SEDATION
94302 Edit Office or institutional visit, Changed to: Office (of another
after regular scheduled office professional) or institutional visit,
hours (in addition to services outside regular scheduled office
performed). hours (in addition to services
performed).
96104 New Prescription, vaccine

96500 New Vaccine administration

viii
 2023 Uniform System of Coding and List of Services
Changed from 2022
96501 New Vaccine injection +E

96502 New Vaccine, administered by

other routes (e.g. nasal/oral)
+E

98300 New Vaccine/Vaccination

Consultation, with patient
(includes analysis of medical
status, indications and
contraindications, and the
risks and benefits)
98301 New One unit of time

98302 New Two units of time

98309 New Each additional unit of time

ix
0 00000 0 Alberta Dental Association 0
Guide for Dental Fees for General Dentists
January 2023
0 00000 0 0 0 0
0 00000 0 0 0 0.00
00000 00000 0 DIAGNOSTIC 0 0
0 00000 0 0 0 0
01000 00000 0 EXAMINATION AND DIAGNOSIS, CLINICAL ORAL 0 0
0 00000 0 0 0 0
01010 00 FIRST DENTAL VISIT/ORIENTATION 0 0
0 00 00000 0 0
- 00000 01011 Oral assessment for patients up to the age of 3 years inclusive. Assessment to include: Medical history, 0 81.82
familial dental history; dietary/feeding practices; oral habits; oral hygiene; fluoride exposure.
Anticipatory guidance with parent/guardian
0 00000 0 0 0
01100 00 EXAMINATIONS, AND DIAGNOSIS COMPLETE ORAL, to include: 0
0 00000 0 0 0
(a) 0 History, Medical and Dental. 0.00
0 (b) 0 Clinical Examination and Diagnosis of Hard and Soft tissues, including the following as necessary: 0.00
Carious lesions, missing teeth, determination of sulcular depth, gingival contours, mobility of teeth,
interproximal tooth contact relationships, occlusion of teeth, TMJ, pulp vitality test/analysis, where
necessary and any other pertinent factors;

0 (c) 0 Radiographs extra, as required. 0.00

0 00000 0 0 0
0 00000 01101 Examination and Diagnosis, Complete, Primary Dentition, to include: 0 81.82
0 00000 (a) Extended examination and diagnosis on primary dentition, recording history, charting, treatment 0
planning and case presentation, including above description as per 01100.

0 00000 0 0 0
0 00000 01102 Examination and Diagnosis, Complete, Mixed Dentition, to include: 0 111.51
0 00000 (a) Extended examination and diagnosis on mixed dentition, recording history, charting, treatment 0
planning and case presentation, including above description as per 01100.

0 00000 (b) Eruption sequence, tooth size - jaw size assessment. 0

0 00000 0 0 0
0 00000 01103 Examination and Diagnosis, Complete, Permanent Dentition, to include: 0 116.66
0 00000 (a) Extended examination on permanent dentition, recording history, charting, treatment planning and 0
case presentation, including above description as per 01100.

0 00000 0 0 0
01200 00000 0 EXAMINATIONS AND DIAGNOSIS, LIMITED ORAL 0
0 00000 0 0 0
0 00000 01201 Examination and Diagnosis, Limited, Oral, New Patient. Examination and diagnosis of hard and soft 0 86.63
tissues, including checking of occlusion and appliances, but not including specific test/ analysis as for
01100. (May include PSR)
0 00000 0 0 0
0 00000 01202 Examination and diagnosis, Limited oral, Previous Patient (recall). Examination of hard and soft tissues, 0 73.85
including checking of occlusion and appliances, but not including specific tests, as for 01100.

0 00000 0 0 0
0 00000 01204 Examination and Diagnosis, Specific Examination and evaluation of a specific situation in a localized 0 73.85
area. Not to be used as a substitute for limited exam codes (01201, 01202)

0 00000 0 0 0
0 00000 01205 Examination and Diagnosis, Emergency. Examination and Diagnosis for the investigation of discomfort 0 73.85
and/or infection in a localized area. Not to be used as a substitute for limited exam codes (01201,
01202).
0 00000 0 0 0
0 00000 01206 Analysis, Mixed Dentition 0 92.69
0 00000 0 0 0
01300 00000 0 EXAMINATIONS AND DIAGNOSIS, STOMATOGNATHIC, DYSFUNCTIONAL 0
0 00000 0 0 0
0 00000 01301 Examination and Diagnosis, Stomatognathic Dysfunctional, Comprehensive, to include: 0 310.60

1
0 00000 (a) History, Medical , Dental, Pain/Dysfunction 0
0 00000 (b) Clinical examination to include, general appraisal, examination of head and neck, musculoskeletal 0
system (static and functional); intraoral examination of hard and soft tissues, including occlusal
analysis; consultation with other health care professionals, review of previous records, including
radiographs, ordering of appropriate test/analysis and consultations.

0 00000 0 0 0
0 00000 01302 Examination and Diagnosis, Stomatognathic Dysfunctional, Limited 0 94.36
0 00000 0 0 0
01400 00000 0 EXAMINATIONS AND DIAGNOSIS, ORAL PATHOLOGY 0
0 00000 0 0 0
0 00000 01401 Examination and Diagnosis, Oral Pathology, General, to include: 0 188.71
0 00000 (a) Initial consultation with referring dentist or physician, 0
0 00000 (b) History, Medical and Dental, 0
0 00000 (c) Clinical examination including in-depth analysis of medical status, 0
0 00000 (d) Diagnosis, prognosis and formulation of a treatment plan. 0
0 00000 0 0 0
0 00000 01402 Examination and Diagnosis, Oral Pathology, Specific (or repeat examination within 90 days for the 0 94.36
same illness).
0 00000 0 0 0
01500 00000 0 EXAMINATION AND DIAGNOSIS, PERIODONTAL 0
0 00000 0 0 0
0 00000 01501 Examination and Diagnosis, Periodontal, General Recording History, Charting, Treatment Planning and 0 236.91
Case Presentation:
0 00000 (a) History, Medical and Dental 0
0 00000 (b) Clinical Examination includes evaluation of topography of the gingiva and related structures; degree of 0
gingival inflammation; location, extent, sulcular depth; furcation involvement, mobility of teeth; tooth
contact relationships; evaluation of occlusion; TMJ; examination of oral soft tissue pathosis; evaluation
of the existing restorative and/or prosthetic appliances; caries and pulpal vitality.

0 00000 0 0 0
0 00000 01502 Examination and Diagnosis, Periodontal, Limited (previous patient) 0 171.59
0 00000 01503 Examination and Diagnosis, Periodontal, Specific 0 171.59
0 00000 0 0 0
01600 00000 0 EXAMINATIONS AND DIAGNOSIS, SURGICAL 0
0 00000 0 0 0
0 00000 01601 Examination and Diagnosis, Surgical, General 0 188.72
0 00000 (a) History, Medical and Dental 0
0 00000 (b) Clinical Examination as above, may include in-depth analysis of medical status, medication, anaesthetic 0
and surgical risk, initial consultation with referring dentist or physician, parent or guardian, evaluation
of source of chief complaint, evaluation of pulpal vitality, mobility of teeth, occlusal factors, TMJ, or
where the patient is to be admitted to hospital for dental procedures.

0 00000 0 0 0
0 00000 01602 Examination and Diagnosis, Surgical, Specific 0 113.12
0 00000 0 0 0
01700 00000 0 EXAMINATIONS AND DIAGNOSIS, PROSTHODONTIC 0
0 00000 0 0 0
0 00000 01701 Examination and Diagnosis, Prosthodontic, Edentulous 0 128.69
0 00000 (a) Extended Examination of the Edentulous Mouth, including detailed Medical and Dental History (incl. 0
prosthetic history), visual and digital examination of the oral structures, head and neck (incl. TMJ), lips,
oral mucosa, tongue, oral pharynx, salivary glands and lymph nodes, and including evaluation for
implant-supported or retained prosthesis.

0 00000 0 0 0
0 00000 01702 Examination and Diagnosis, Prosthodontic, Specific 0 86.94
0 00000 0 0 0
0 00000 01703 Examination and Diagnosis, Prosthodontic, Fixed Oral Rehabilitation, to include: 0 353.56
0 00000 (a) History, Medical and Dental 0
0 00000 (b) Clinical Examination of Hard and Soft Tissues, including carious lesions, missing teeth, determination 0
of sulcular depth, gingival contours, mobility of teeth, interproximal tooth contact relationships,
occlusion of teeth, TMJ, pulp vitality test/analysis, where necessary and any other pertinent factors.

0 00000 (c) Evaluation of specific sites for implant-supported or retained prosthesis; 0

0 00000 (d) Radiographs extra, as required 0
0 00000 0 0 0
01800 00000 0 EXAMINATION AND DIAGNOSIS, ENDODONTIC 0
0 00000 0 0 0

2
0 00000 01801 Examination and Diagnosis, Endodontic, Complete Endodontic examination and/or complicated 0 189.86
diagnosis. Recording history, charting treatment planning and case history. Includes the following:

0 00000 (a) History, Medical and Dental 0

0 00000 (b) Clinical Examination and Diagnosis may include vitality test/analysis, thermal test/analysis, cracked 0
tooth test/analysis, occlusal exams, percussion, palpation, transillumination, anaesthetic test/analysis
and mobility test/analysis.
0 00000 0 0 0
0 00000 01802 Examination and Diagnosis, Endodontic, Specific Endodontic examination and evaluation of a specific 0 118.50
situation in a localized area and vitality tests/analysis.
0 00000 0 0 0
01900 00000 0 EXAMINATION AND DIAGNOSIS, ORTHODONTIC 0
0 00000 0 0 0
0 00000 01901 Examination and Diagnosis, Orthodontic, General. To include: 487.54
0 00000 (a) Diagnostic models, complete intraoral radiograph series, or panoramic film, cephalograms, facial and +L
intraoral photographs, consultation and case presentation.

0 00000 0 0 0
0 00000 01902 Examination and Diagnosis, Orthodontic, Specific 0 97.81
0 00000 0 0 0
02000 00000 0 RADIOGRAPHS (including radiographic examination and diagnosis and interpretation) 0
0 00000 0 0 0
02100 00000 0 RADIOGRAPHS, REGIONAL/LOCALIZED 0
0 00000 0 0 0
0 00000 02101 Radiographs, Complete Series (minimum of 12 images incl. bitewings) 0 228.54
0 00000 0 0 0
0 00000 02102 Radiographs, Complete Series (minimum of 16 images incl. bitewings) 0 228.54
0 00000 0 0 0
0 02110 0 Radiographs, Periapical 0
0 00000 0 0 0
0 00000 02111 Single image 0 34.26
0 00000 02112 Two images 0 54.60
0 00000 02113 Three images 0 77.48
0 00000 02114 Four images 0 100.36
0 00000 02115 Five images 0 115.38
0 00000 02116 Six images 0 138.16
0 00000 02117 Seven images 0 162.64
0 00000 02118 Eight images 0 184.66
0 00000 02119 Nine images 0 206.68
0 00000 02120 Ten images - The assignment to this service of a code ending in 0 is not aligned to the coding rules for 0 217.77
the USC&LS. 02120 is nonetheless the appropriate code for the representation of this service

0 00000 0 0 0
0 02130 0 Radiographs, Occlusal 0
0 00000 0 0 0
0 00000 02131 Single image 0 57.04
0 00000 02132 Two images 0 79.92
0 00000 02133 Three images 0 102.80
0 00000 02134 Four images 0 125.67
0 00000 0 0 0
0 02140 0 Radiographs, Bitewing 0
0 00000 0 0 0
0 00000 02141 Single image 0 34.26
0 00000 02142 Two images 0 54.60
0 00000 02143 Three images 0 77.48
0 00000 02144 Four images 0 100.36
0 00000 02145 Five images 0 115.38
0 00000 02146 Six images 0 138.16
0 00000 0 0 0
02300 00000 0 RADIOGRAPHS, POSTERO-ANTERIOR AND LATERAL SKULL AND FACIAL BONE 0
0 00000 0 0 0
0 00000 02301 Single image 0 85.64
0 00000 02302 Two images 0 142.79
0 00000 02303 Three images 0 199.97
0 00000 02304 Sinus Examination and Diagnosis - Minimum four images identified as: 1) Waters 2) Caldwell 3) Lateral 0 257.11
Skull 4) Basal

0 00000 02309 Each additional image over four 0 56.59

3
0 00000 0 0 0
02400 00000 0 RADIOGRAPHS, SIALOGRAPHY 0
0 00000 0 0 0
0 00000 02401 Single image 0 85.66
0 00000 02402 Two images 0 142.79
0 00000 02409 Each additional image over two 0 56.59
0 00000 0 0 0
0 02410 0 Radiopaque Dyes, Use of, To Demonstrate Lesions 0
0 00000 0 0 0
0 00000 02411 One unit of time 0 I.C.
0 00000 02412 Two units of time 0 I.C.
0 00000 02419 Each additional unit over two 0 I.C.
0 00000 0 0 0
02500 00000 0 RADIOGRAPHS, TEMPOROMANDIBULAR JOINT 0
0 00000 0 0 0
0 00000 02501 Single image 0 85.64
0 00000 02502 Two images 0 142.79
0 00000 02503 Three images 0 199.97
0 00000 02504 Four images (minimum examination and diagnosis closed and open each side) 0 257.11
0 00000 02509 Each additional image over four 0 56.59
0 00000 0 0 0
0 02510 0 Arthrography of Temporo-mandibular joint 0
0 00000 0 0 0
0 00000 02511 Performing the Arthrographic Procedure 0 283.08
0 00000 0 0 0
0 02520 0 Interpretation of the Arthrogram 0
0 00000 0 0 0
0 00000 02521 One unit of time 0 85.79
0 00000 02529 Each additional unit of time 0 85.79
0 00000 0 0 0
02600 00000 0 RADIOGRAPHS, PANORAMIC
0 00000 0 0 0
0 00000 02601 Single image 0 101.53
0 00000 0 0 0
02700 00000 0 RADIOGRAPHS, CEPHALOMETRIC 0
0 00000 0 0 0
0 00000 02701 Single image 0 136.65
0 00000 02702 Two images 0 214.26
0 00000 0 0 0
0 02750 0 Radiographs, Cephalometric, Tracing and Interpretation 0
0 00000 0 0 0
0 00000 02751 One unit of time 0 94.36
0 00000 02752 Two units 0 188.72
0 00000 02759 Each additional unit over two 0 94.36
0 00000 0 0 0
02800 00000 0 RADIOGRAPHS, COMPUTERIZED AXIAL TOMOGRAMS (CT), POSITRON EMISSION TOMOGRAPHY 0
(P.E.T), MAGNETIC RESONANCE IMAGES (M.R.I) INTERPRETATION (either the radiographs, CT scans,
PET scans, MRI scans, or the interpretation must be received from another source)

0 00000 0 0 0
0 00000 02801 One unit of time +PS 105.01
0 00000 02802 Two units +PS 210.02
0 00000 02809 Each additional unit over two +PS 105.01
0 00000 0 0 0
02900 00000 0 RADIOGRAPHS, OTHER 0
0 00000 0 0 0
0 02910 0 Radiographs, Duplications 0
0 00000 0 0 0
0 00000 02911 Single image 0 6.51
0 00000 02912 Two images 0 12.93
0 00000 02913 Three images 0 19.39
0 00000 02914 Four images 0 25.86
0 00000 02915 Five images 0 32.32
0 00000 02916 Six images 0 38.78
0 00000 02917 Seven images 0 45.27
0 00000 02918 Eight images 0 50.11
0 00000 02919 Each additional image over eight 0 6.51

4
0 00000 0 0 0
0 02930 0 Radiographs, Tomography 0
0 00000 0 0 0
0 00000 02931 Single view 0 136.65
0 00000 02932 Two views 0 214.33
0 00000 02933 Three views 0 288.12
0 00000 02934 Four views 0 357.07
0 00000 02939 Each additional view over four 0 56.59
0 00000 0 0 0
0 02940 0 Radiographs, Hand and Wrist 0
0 00000 0 0 0
0 00000 02941 Radiographs, Hand and Wrist (as a diagnostic aid for dental treatment) per case 0 136.65
0 00000 0 0 0
0 02950 0 Radiographic Guide, 0
0 00000 0 (includes diagnostic wax-up, with radio-opaque markers for pre-surgical assessment of alveolar bone 0
and vital structures as potential osseo-integrated implant site(s))

0 00000 02951 Maxillary Guide +L +E I.C.

0 00000 02952 Mandibular +L +E I.C.
0 00000 0 0 0
03000 00000 0 TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to locate and orient osseo-integrated 0
implants)
0 00000 0 0 0
0 00000 03001 Maxillary Template +L +E 85.79
0 00000 03002 Mandibular Template +L +E 85.79
0 00000 0 0 0
04000 00 TEST/ANALYSIS/LABORATORY PROCEDURES/INTERPRETATION AND/OR REPORTS 0
0 00000 0 0 0
0 04100 0 Test/Analysis, Microbiological (technical procedure only) 0
0 00000 0 0 0
0 00000 04101 Microbiological Test/Analysis for the Determination of Pathological Agents +L 81.50
0 00000 0 0 0
0 04200 0 Test/Analysis, Caries Susceptibility/Diagnosis 0
0 00000 0 0 0
0 00000 04201 Bacteriological Test/Analysis for the Determination of Dental Caries Susceptibility (technical procedure +L 81.50
only)
0 00 0 0
0 04220 0 Non-ionizing scanning procedure to detect caries and capable of quantifying, monitoring and recording 0
changes in enamel, dentin, and cementum, which includes diagnosis and interpretation of findings.

0 00000 0 0 0
0 00000 04221 One unit of time 0 34.26
0 00000 04227 One half unit of time 0 17.13
0 00000 0 0 0
04300 00 TEST/ANALYSIS, HISTOPATHOLOGICAL (technical procedure only) 0
0 00000 0 0 0
0 04310 0 Test/Analysis, Histopathological, Soft Tissue 0
0 00000 0 0 0
0 00000 04311 Biopsy, Soft Oral Tissue - by Puncture +L 94.36
0 00000 04312 Biopsy, Soft Oral Tissue - by Incision +L 94.36
0 00000 04313 Biopsy, Soft Oral Tissue - by Aspiration +L 94.36
0 00000 0 0 0
0 04320 0 Test/Analysis, Histopathological, Hard Tissue 0.00
0 00000 0 0 0
0 00000 04321 Biopsy, Hard Oral Tissue - by Puncture +L I.C.
0 00000 04322 Biopsy, Hard Oral Tissue - by Incision +L I.C.
0 00000 04323 Biopsy, Hard Oral Tissue - by Aspiration +L I.C.
0 00000 0 0 0
04400 00 TEST/ANALYSIS, CYTOLOGICAL (technical procedure only) 0
0 00000 0 0 0
0 00000 04401 Cytological Smear from the Oral Cavity +L+E 81.50
0 00000 04402 Vital Staining of Oral Mucosal Tissues +E 81.50
0 00000 0 0 0
04500 00 TESTS/ANALYSIS, PULP VITALITY AND INTERPRETATION 0
0 00000 0 0 0
0 00000 04501 One unit of time 0 81.50
0 00000 04509 Each additional unit 0 81.50
0 00000 0 0 0

5
04600 00 INTERPRETATION AND/OR REPORTS, LABORATORY 0
0 00000 0 0 0
0 00000 04601 Interpretation and/or Report, Microbiological by Oral Microbiologist +L 81.49
0 00000 0 0 to 244.54
0 00000 04602 Interpretation and/or Report, Histopathological by Oral Pathologist or Microbiologist +L 94.36

0 00000 0 0 to 283.08
0 00000 04603 Interpretation and/or Report, Cytological by Oral Pathologist +L 81.50
0 00000 04604 Reports, Other 0 I.C.
0 00000 0 0 0
04700 00 SUPPLEMENTARY DIAGNOSTIC PROCEDURES (INTERPRETATION ONLY) 0
0 00000 0 0 0
0 04710 0 Equilibration, Casts Diagnostic (Pilot Equilibration) For Extensive Or Complicated Restorative 0
Dentistry
0 00000 0 0 0
0 00000 04711 One unit of time +L 85.80
0 00000 04712 Two units +L 171.60
0 00000 04713 Three units +L 257.40
0 00000 04714 Four units +L 343.20
0 00000 04719 Each additional unit over four +L 85.80
0 00000 0 0 0
0 04720 0 Wax-up, Diagnostic (To Evaluate Cosmetic And/Or Preparation Design And/Or Occlusal 0
Considerations) (Gnathological Wax-up)
0 00000 0 0 0
0 00000 04721 One unit of time +L 85.80
0 00000 04722 Two units +L 171.60
0 00000 04723 Three units +L 257.40
0 00000 04724 Four units +L 343.20
0 00000 04729 Each additional unit over four +L 85.80
0 00000 0 0 0
0 04730 0 Split Cast Mounting, Diagnostic 0
0 00000 0 0 0
0 00000 04731 One unit of time +L 85.80
0 00000 04732 Two units +L 171.60
0 00000 04733 Three units +L 257.40
0 00000 04734 Four units +L 343.20
0 00000 04739 Each additional unit over four +L 85.80
0 00000 0 0 0
0 04740 0 Interpretation of Diagnostic Casts 0
0 00000 0 0 0
0 00000 04741 One unit of time 0 82.64
0 00000 04749 Each additional unit 0 82.64
0 00000 0 0 0
04800 00000 0 VISUAL IMAGING, DIAGNOSTIC 0

0 04810 0 Photographs, diagnotic (technical procedure only) 0

0 00000 0 0 0
0 00000 04811 Single photograph 19.55
0 00000 04812 Two photos 37.05
0 00000 04813 Three photos 55.58
0 00000 04819 Each additional photo over three 19.55
0 00000 0 0 0
04900 00000 0 CASTS, DIAGNOSTIC (technical procedure only) 0
0 00000 0 0 0
0 04910 0 Cast, Diagnostic, Unmounted 0
0 00000 0 0 0
0 00000 04911 Cast, Diagnostic, Unmounted +L 91.84
0 00000 04912 Cast, Diagnostic, Unmounted, Duplicate +L 40.75
0 00000 04913 Casts, Diagnostic, Unmounted, Upper and Lower Combined +L 192.91
0 00000 0 0 0
0 04920 0 Casts, Diagnostic, Mounted 0
0 00000 0 0 0
0 00000 04921 Casts, Diagnostic, Mounted +L 144.11
0 00000 04922 Casts, Diagnostic, Mounted, using face bow transfer +L 191.76
0 00000 04923 Casts, Diagnostic, Mounted, using face bow and occlusal records +L 378.69
0 00000 04924 Casts, Diagnostic, Mounted using fully adjustable articulator (used with 04941 and 04942) +L I.C.

0 00000 0 0 0

6
0 04930 0 Casts, Diagnostic, Orthodontic 0
0 00000 0 0 0
0 00000 04931 Casts, Diagnostic, Orthodontic (unmounted, angle trimmed and soaped) +L 163.02
0 00000 0 0 0
0 04940 0 Casts, Diagnostic, Miscellaneous Procedures 0
0 00000 0 0 0
0 00000 04941 Transverse Axis Location and Transfer, used in conjunction with 04922, 04923, and 04924 +L I.C.

0 00000 04942 Three Dimensional Recordings of Patient's Dynamic Movements for Programming of Fully Adjustable +L I.C.
Articulators
0 00000 04943 Custom Incisal Guide Table +L I.C.
0 00000 0 0 0
05000 00000 0 CASE PRESENTATION/TREATMENT PLANNING 0
0 00000 0 0 0
05100 00000 0 TREATMENT PLANNING 0
0 00000 0 (This service is only for extra time spent on unusually complicated cases or where the patient demands 0
unusual time in explanation or where diagnostic material is received from another source. Usual case
presentation time and usual treatment planning time are implicit in the examination fee and diagnosis
fee in the radiographic interpretation fee.)

0 00000 0 0 0
0 00000 05101 One unit of time 0 85.80
0 00000 05102 Two units 0 171.60
0 00000 05103 Three units 0 257.40
0 00000 05104 Four units 0 343.20
0 00000 05109 Each additional unit over four 0 85.80
0 00000 0 0 0
05200 00000 0 CONSULTATION, with patient 0
0 00000 0 0 0
0 00000 05201 One unit of time 0 89.24
0 00000 05202 Two units 0 178.48
0 00000 05209 Each additional unit over two 0 89.24
0 00000 0 0 0
07000 00000 0 RADIOGRAPHS, CONE BEAM COMPUTERIZED TOMOGRAPHY (CBCT) 0
0 00000 0 0 0
0 07010 0 Radiographs, CBCT, Acquisition 0
0 00000 0 0 0
0 00000 07011 Small field of view (e.g. sextant or part of; isolated temporomandibular joint) 0 114.20
0 00000 07012 Large field of view (1 arch) 0 136.65
0 00000 07013 Large field of view (2 arches) 0 214.33
0 00000 00000 0 0
0 07020 0 Radiographs, CBCT, Image Processing 0
0 00000 00000 0 0
0 00000 07021 One unit of time 0 I.C.
0 00000 07022 Two units 0 I.C.
0 00000 07027 One half unit of time 0 I.C.
0 00000 07029 Each additional unit over two 0 I.C.
0 00000 00000 0 0
0 07030 0 Radiographs, CBCT, Interpretation 0
0 00000 00000 0 0
0 00000 07031 One unit of time 0 94.36
0 00000 07032 Two units of time 0 188.72
0 00000 07037 One half unit of time 0 47.18
0 00000 07039 Each additional unit over two 0 94.36
0 00000 00000 0 0
0 07040 0 Radiographs, CBCT, Acquisition, Processing and Interpretation 0
0 00000 00000 0 0
0 00000 07041 Small field of view (sextant or part of; isolated temporomandibular joint) 0 208.56
0 00000 07042 Large field of view (1 arch) 0 231.00
0 00000 07043 Large field of view (2 arches) 0 308.68
0 00000 0 0 0
08000 00000 0 REMOTE ASSESSMENT 0

7
0 00000 0 • Codes in the 08010 series: May be used for consultations with patients exceeding 7.5 minutes, 0
utilizing a remote dentistry platform. The code includes verifying patient identity, informed consent,
review of medical and clinical history, assessment of the clinical situation, interim diagnosis, remote
management (e.g.: calling in a prescription, appropriate referral etc.), appropriate documentation and
subsequent follow up calls.
• Use of this code series will only be authorized for the use of remote dentistry during the Covid-19
Pandemic and State of Public Health Emergency in Alberta, and its use will not be authorized in any
other setting or circumstances

0 00000 0 0 0
0 08010 0 Of chief complaint 0
0 00000 0 0 0
0 00000 08011 One unit of time                  0 89.24
0 00000 08012 Two units of time 0 178.48
0 00000 08019 Each additional unit over two 0 89.24
0 00000 0 0 0
10000 00000 0 PREVENTION 0
0 00000 0 0 0
11100 00000 0 POLISHING 0
0 00000 0 0 0
0 00000 11101 One unit of time 0 68.79
0 00000 11102 Two units 0 137.58
0 00000 11107 One half unit 0 34.40
0 00000 0 0 0
11110 00000 0 SCALING 0
00000 00000 00 0
0 00000 11111 One unit of time 0 77.21
0 00000 11112 Two units 0 154.42
0 00000 11113 Three units 0 231.63
0 00000 11114 Four units 0 308.84
0 00000 11115 Five units 0 386.05
0 00000 11116 Six units 0 463.26
0 00000 11117 One half unit 0 38.61
0 00000 11119 Each Additional unit over six 0 77.21
0 00000 0 0 0
12100 00000 0 FLUORIDE TREATMENTS (whole mouth) 0
0 00000 0 0 0
0 12110 0 Topical, Whole Mouth, in office 0
0 00000 0 0 0
0 00000 12111 Rinse 0 33.33
0 00000 12112 Gel or Foam 0 33.33
0 00000 12113 Varnish 0 33.33
0 00000 12114 Self-Administered Brush-In, supervised 0 33.33
0 00000 0 0 0
12600 00000 0 FLUORIDE, CUSTOM APPLIANCES, (home application) 0
0 00000 0 0 0
0 00000 12601 Fluoride, Custom Appliance - Maxillary Arch +L 81.50
0 00000 12602 Fluoride, Custom Appliance - Mandibular Arch +L 81.50
0 00000 0 0 0
12700 00000 0 MEDICATION, CUSTOM APPLIANCE 0
0 00000 0 0 0
0 00000 12701 Medication, Custom Appliance - Maxillary Arch +L 81.50
0 00000 12702 Medication, Custom Appliance - Mandibular Arch +L 81.50
0 00000 0 0 0
13000 00000 0 PREVENTIVE SERVICES, OTHER 0
0 00000 0 0 0
13100 00000 0 NUTRITIONAL COUNSELLING 0
0 00000 0 Including: recording and analysis of up to seven-day dietary intake and consultation 0

0 00000 0 0 0
0 00000 13101 One unit of time 0 81.50
0 00000 13102 Two units 0 163.00
0 00000 13103 Three units 0 244.50
0 00000 13104 Four units 0 326.00
0 00000 13109 Each additional unit over four 0 81.50
0 00000 0 0 0
13200 00000 0 ORAL HYGIENE INSTRUCTION/PLAQUE CONTROL 0

8
0 00000 0 To include: brushing and/or flossing and/or embrasure cleaning. 0
0 00000 0 0 0
0 13210 0 Individual Instruction (One Instructor To One Patient) - Excluding Audio-Visual Time 0
0 00000 0 0 0
0 00000 13211 One unit of time 0 81.50
0 00000 13212 Two units 0 163.00
0 00000 13213 Three units 0 244.50
0 00000 13214 Four units 0 326.00
0 00000 13217 One half of unit 0 40.75
0 00000 13219 Each additional unit over four 0 81.50
0 00000 0 0 0
0 13220 0 Group Instruction - Excluding Audio-Visual Time 0
0 00000 0 0 0
0 00000 13221 One unit of time 0 81.50
0 00000 13222 Two units 0 163.00
0 00000 13223 Three units 0 244.50
0 00000 13224 Four units 0 326.00
0 00000 13229 Each additional unit over four 0 81.50
0 00000 0 0 0
0 13230 0 Re-Instruction (Within 6 Months) - Excluding Audio-Visual Time 0
0 00000 0 0 0
0 00000 13231 One unit of time 0 81.50
0 00000 13232 Two units 0 163.00
0 00000 13239 Each additional unit over two 0 81.50
0 00000 0 0 0
0 13240 0 Oral Hygiene Instruction - Audio-Visual 0
0 00000 0 0 0
0 00000 13241 One unit of time 0 81.50
0 00000 13242 Two units 0 163.00
0 00000 13249 Each additional unit over two 0 81.50
0 00000 0 0 0
13400 00 SEALANTS, PIT AND FISSURE (Mechanical and/or chemical preparation included) 0
0 00000 0 0 0
0 00000 13401 First tooth 0 37.51
0 00000 13409 Each additional tooth same quadrant 0 18.76
0 00000 0 0 0
0 13410 0 Preventive Restorative Resin (procedure that involves some preparation of the pits and/or fissures in
tooth enamel and may extend into dentin in limited areas)
0 00000 13411 First tooth 0 83.41
0 00000 13419 Each additional tooth same quadrant 0 78.81
0 00000 0 0 0
13600 0 0 TOPICAL APPLICATION TO HARD TISSUE LESION(S) OF AN ANTIMICROBIAL OR REMINERALIZATION 0
AGENT
0 00000 0 0 0
0 00000 13601 One unit of time +E 81.50
0 00000 13602 Two units +E 163.00
0 00000 13609 Each additional unit over two 0 81.50
0 00000 0 0 0
14000 0 0 APPLIANCES 0
0 00000 0 0 0
14100 0 0 APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS 0
0 00000 0 0 0
0 00000 14101 Appliance, Maxillary +L 601.79
0 00000 14102 Appliance, Mandibular +L 601.79
0 00000 0 0 0
14200 0 0 APPLIANCES, FIXED/CEMENTED, CONTROL OF ORAL HABITS 0
0 00000 0 0 0
0 00000 14201 Appliance, Maxillary +L 660.51
0 00000 14202 Appliance, Mandibular +L 660.51
0 00000 0 0 0
14300 0 0 CONTROL OF ORAL HABITS, MISCELLANEOUS 0
0 00000 0 0 0
0 00000 14301 Motivation of Patient - Psychological Approach (e.g. thumb sucking, lip biting, etc.) - per visit +L 94.36

0 00000 0 0 0
0 14310 0 Myofunctional Therapy 0
0 00000 0 (e.g. to correct mouth breathing, abnormal swallowing, tongue thrust, etc.)
0 00000 0 0 0

9
0 00000 14311 First unit of time per visit +L 94.36
0 00000 14312 Two units +L 188.72
0 00000 14319 Each additional unit over two +L 94.36
0 00000 0 0 0
14400 00 APPLIANCES, CONTROL OF ORAL HABITS ADJUSTMENTS, REPAIRS, MAINTENANCE 0
0 00000 0 0 0
0 00000 14401 One unit of time +L 94.36
0 00000 14402 Two units of time +L 188.72
0 00000 14403 Three units of time +L 283.08
0 00000 14409 Each additional unit over three +L 94.36
0 00000 0 0 0
14500 00 APPLIANCES, PROTECTIVE MOUTH GUARDS 0
0 00000 0 0 0
0 00000 14501 Appliance, Protected Mouth Guards, Preformed 0 97.59
0 00000 14502 Appliance, Protective Mouth Guards, Processed +L 106.78
0 00000 0 0 0
14600 00 APPLIANCES, PERIODONTAL 0
0 00000 0 (see separate code for control of Oral Habits 14000, Protective Mouth Guards 14500, TMJ 14700 and 0
TMJ appliances 78700)
0 00000 0 0 0
0 14610 0 Appliances, Periodontal (including bruxism appliance); Includes Impression, Insertion and Insertion 0
Adjustment (no post-insertion adjustments)
0 00000 0 0 0
0 00000 14611 Maxillary Appliance +L 481.22
0 00000 14612 Mandibular Appliance +L 481.23
0 00000 0 0 0
0 14620 0 Appliances, Adjustment, Repair 0
0 00000 0 0 0
0 00000 14621 One unit of time +L 87.50
0 00000 14622 Two units +L 175.00
0 00000 14623 Three units +L 262.50
0 00000 14629 Each additional unit over three +L 87.50
0 00000 0 0 0
0 14630 0 Appliances, Reline 0
0 00000 0 0 0
0 00000 14631 Reline, Direct 0 262.53
0 00000 14632 Reline, Processed +L 262.53
0 00000 0 0 0
14700 00 APPLIANCES, TEMPOROMANDIBULAR JOINT 0
0 00000 0 0 0
0 14710 0 Appliance, TMJ, Diagnostic and/or Therapeutic, includes impression, insertion and insertion 0
adjustment (no post-insertion adjustments)
0 00000 0 0 0
0 00000 14711 Maxillary Appliance +L 708.45
0 00000 14712 Mandibular Appliance +L 708.45
0 00000 0 0 0
0 14720 0 Appliance, TMJ Intraoral Repositioning; includes impression, insertion and insertion adjustment (no 0
post-insertion adjustments)
0 00000 0 0 0
0 00000 14721 Maxillary Appliance +L 708.45
0 00000 14722 Mandibular Appliance +L 708.45
0 00000 0 0 0
0 14730 0 Appliance, TMJ, Periodic Maintenance, Adjustments, Repairs 0
0 00000 0 0 0
0 00000 14731 One unit of time +L 91.87
0 00000 14732 Two units +L 183.74
0 00000 14733 Three units +L 275.61
0 00000 14739 Each additional unit over three +L 91.87
0 00000 0 0 0
0 14740 0 Appliance, TMJ, Reline 0
0 00000 0 0 0
0 00000 14741 Reline, Direct 0 262.53
0 00000 14742 Reline, Indirect +L 262.53
0 00000 0 0 0
14800 00 APPLIANCES, MYOFASCIAL PAIN DYSFUNCTION SYNDROME 0
0 00000 0 (conditions that originate outside the temporomandibular joint) 0
0 00000 0 0 0

10
0 14810 0 Appliance, Myofascial Pain Dysfunction Syndrome, (to include: models, gnathological determinants) 0
Appliance Construction only, and insertion adjustment (no post-insertion adjustments)

0 00000 0 0 0
0 00000 14811 Maxillary Appliance +L 799.53
0 00000 14812 Mandibular Appliance +L 799.53
0 00000 0 0 0
0 14820 0 Appliance, Myofascial Pain Dysfunction Syndrome, Periodic Maintenance, Adjustment and Repairs 0

0 00000 0 0 0
0 00000 14821 One unit of time +L 91.87
0 00000 14822 Two units +L 183.74
0 00000 14823 Three units +L 275.61
0 00000 14829 Each additional unit over three +L 91.87
0 00000 0 0 0
14900 0 0 APPLIANCES, INTRAORAL, TO TREAT MEDICALLY DIAGNOSED OBSTRUCTIVE SLEEP APNEA, SNORING, 0
UPPER AIRWAY RESISTANCE SYNDROM (UARS) WITH OR WITHOUT APNEA (Includes models,
gnathological determinants, appliance construction and insertion adjustment [no post-insertion
adjustments])
0 00000 0 0 0
0 00000 14901 Appliance, Intraoral, For the Treatment of Obstructive Airway Disorders, Ridge or Tooth Supported +L 849.26

0 00000 14902 Appliance, Tongue Retaining Device, for the Treatment of Obstructive Airway Disorders +E 481.22

0 00000 0 0 0
0 14910 0 Appliance, Intraoral, For the Treatment of Obstructive Airway Disorders, Periodic Maintenance, 0
Adjustment and Repairs
0 00000 0 0 0
0 00000 14911 One unit of time +L 94.36
0 00000 14912 Two units +L 188.72
0 00000 14919 Each additional unit over two +L 94.36
0 00000 0 0 0
0 14920 0 Appliance, Intraoral, For the Treatment of Obstructive Airway Disorders, Monitoring To include 0
patient to ensure proper use of appliances and evaluation for referrals to other health care
professionals for appropriate medical management.
0 00000 0 0 0
0 00000 14921 One unit of time 0 85.80
0 00000 14922 Two units 0 171.60
0 00000 14929 Each additional unit over two 0 85.80
0 00000 0 0 0
15000 00 SPACE MAINTAINERS 0
0 00000 0 (Includes the design, separation, fabrication, insertion, and where applicable initial cementation and 0
removal)
0 00000 0 0 0
15100 00 SPACE MAINTAINERS, BAND TYPE 0
0 00000 0 0 0
0 00000 15101 Space Maintainer, Band Type, Fixed, Unilateral +L 283.08
0 00000 15102 Space Maintainer, Band Type, Fixed, Unilateral with Intra-alveolar attachment +L 283.08
0 00000 15103 Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch) +L 377.44
0 00000 15104 Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch), with Teeth Attached +L 377.44

0 00000 15105 Space Maintainer, Band Type, Fixed, Bilateral Tubes and Locking Wire +L 377.44
0 00000 0 0 0
15200 00 SPACE MAINTAINERS, STAINLESS STEEL CROWN TYPE 0
0 00000 0 0 0
0 00000 15201 Space Maintainer, Stainless Steel Crown Type, Fixed +L 299.17
0 00000 15202 Space Maintainer, Stainless Steel Crown Type, Fixed, with Intra Alveolar Attachment +L 283.08
0 00000 0 0 0
15300 00 SPACE MAINTAINERS, CAST TYPE 0
0 00000 0 0 0
0 00000 15301 Space Maintainer, Cast Type, Fixed +L I.C.
0 00000 15302 Space Maintainer, Cast Type, Fixed, with Intra Alveolar Attachment +L I.C.
0 00000 0 0 0
15400 00 SPACE MAINTAINERS, ACRYLIC, REMOVABLE 0
0 00000 0 0 0
0 00000 15401 Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining Wires +L 283.07
0 00000 15402 Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining Wires with Teeth +L 283.08
0 00000 15403 Space Maintainer, Acrylic Removable, No Clasps +L 283.08
0 00000 0 0 0

11
15500 00 SPACE MAINTAINERS, BONDED, PONTIC TYPE 0
0 00000 0 0 0
0 00000 15501 Space Maintainer, Bonded, Pontic Type +L 283.08
0 00000 0 0 0
15600 00 SPACE MAINTAINERS, MAINTENANCE OF 0
0 00000 0 0 0
0 00000 15601 Maintenance, Space Maintainer Appliances, to include: adjustment and/or recementation after 30 0 94.36
days from insertion
0 00000 15602 Maintenance, Space Maintainer Appliances, addition of clasps and/or activating wires +L 188.72

0 00000 15603 Repairs, Space Maintainer Appliances (including recementation) +L 188.72

0 00000 15604 Removal of Fixed Space Maintainer Appliances by Second Dentist 0 90.07
0 00000 0 0 0
16100 00 FINISHING RESTORATIONS 0
0 00000 0 To include: polishing, removal of overhangs, refining marginal ridges and occlusal surfaces, etc. (when 0
restorations were performed by another dentist or restorations are over two years old)

0 00000 0 0 0
0 00000 16101 One unit of time 0 85.80
0 00000 16102 Two units 0 171.60
0 00000 16103 Three units 0 257.40
0 00000 16104 Four units 0 343.20
0 00000 16109 Each additional unit over four 0 85.80
0 00000 0 0 0
16200 0 0 DISKING OF TEETH, Interproximal 0
0 00000 0 0 0
0 00000 16201 One unit of time 0 81.49
0 00000 16202 Two units 0 162.98
0 00000 16203 Three units 0 244.47
0 00000 16209 Each additional unit over three 0 81.49
0 00000 0 0 0
16300 0 0 RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS 0
0 00000 0 0 0
0 00000 16301 One unit of time 0 90.07
0 00000 16309 Each additional unit of time 0 90.07
0 00000 0 0 0
16400 0 0 RECONTOURING OF TEETH FOR FUNCTIONAL REASONS 0
0 00000 0 (Not associated with delivery of a single or multiple prosthesis) 0
0 00000 0 0 0
0 00000 16401 One unit of time 0 90.07
0 00000 16409 Each additional unit of time 0 90.07
0 00000 0 0 0
16500 0 0 OCCLUSION 0
0 00000 0 0 0
0 16510 0 Occlusal Adjustment/Equilibration: 0
0 00000 0 (a) May require several sessions 0
0 00000 0 (b) May be used in conjunction with basic restorative treatment only when occlusal 0
adjustment/equilibration is not required as a result of that restoration.
0 00000 0 (c) Not to be used in conjunction with the delivery and post-insertion care of: fixed or removable 0
prosthesis (50000 & 60000 code series) by the same dentist for period of three months.

0 00000 0 0 0
0 00000 16511 One unit of time 0 100.59
0 00000 16512 Two units 0 201.18
0 00000 16513 Three units 0 301.77
0 00000 16514 Four units 0 402.36
0 00000 16519 Each additional unit over four 0 100.59
0 00000 0 0 0
20000 00000 0 RESTORATION 0
0 00000 0 0 0
0 Note 1: 0 Treatment of dental caries includes pulp protection and local anaesthesia. 0.00
0 Note 2: 0 Where, at the same appointment, in order to conserve tooth structure, two separate restorations are 0.00
performed on the same tooth involving a common surface, when one restoration might have been
done; this should be considered as one restoration in assessing the fee.

0 Note 3: 0 Finishing restorations is a separate procedure done at a separate appointment (See 16100) 0.00

0 00000 0 0 0.00

12
20100 00 CARIES, TRAUMA AND PAIN CONTROL 0
0 00000 0 0 0
0 20110 0 Caries/Trauma/Pain Control 0
0 00000 0 (removal of carious lesions or existing restorations or gingivally attached tooth fragment and 0
placement of sedative/protective dressings, includes pulp caps when necessary, as a separate
procedure).
0 00000 0 0 0
0 00000 20111 First tooth 0 91.87
0 00000 0 0 to 183.75
0 00000 20119 Each additional tooth same quadrant 0 91.87
0 00000 0 0 to 183.75
0 00000 0 0 0
0 20120 0 Caries/Trauma/Pain Control 0
0 00000 0 (removal of carious lesions or existing restorations or gingivally attached tooth fragment and 0
placement of sedative/protective dressings, includes pulp caps when necessary and the use of a band
for retention and support, as a separate procedure)

0 00000 0 0 0
0 00000 20121 First tooth 0 137.82
0 00000 0 0 to 229.69
0 00000 20129 Each additional tooth same quadrant 0 137.82
0 00000 0 0 to 229.69
0 00000 0 0 0
0 20130 0 Trauma Control, Smoothing of Fractured Surfaces Per Tooth 0
0 00000 0 0 0
0 00000 20131 First tooth 0 49.50
0 00000 20139 Each additional tooth same quadrant 0 44.90
0 00000 0 0 0
21000 00 RESTORATIONS, AMALGAM 0
0 00000 0 0 0
21100 00 RESTORATION, AMALGAM, PRIMARY TEETH 0
0 00000 0 0 0
0 21110 0 Restorations, Amalgam, Non-Bonded, Primary Teeth 0
0 00000 21111 One surface 0 111.84
0 00000 21112 Two surfaces 0 148.07
0 00000 21113 Three surfaces 0 202.66
0 00000 21114 Four surfaces 0 247.71
0 00000 21115 Five surfaces or maximum surfaces per tooth 0 289.79
0 00000 0 0 0
0 21120 0 Restorations, Amalgam, Bonded, Primary Teeth 0
0 00000 21121 One surface 0 147.09
0 00000 21122 Two surfaces 0 195.09
0 00000 21123 Three surfaces 0 234.39
0 00000 21124 Four surfaces 0 275.99
0 00000 21125 Five surfaces or maximum surfaces per tooth 0 320.34
0 00000 0 0 0
21200 00 RESTORATIONS, AMALGAM, PERMANENT TEETH 0
0 00000 0 0 0
0 21210 0 Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors 0
0 00000 0 0 0
0 00000 21211 One surface 0 123.34
0 00000 21212 Two surfaces 0 154.17
0 00000 21213 Three surfaces 0 216.45
0 00000 21214 Four surfaces 0 266.10
0 00000 21215 Five surfaces or maximum surfaces per tooth 0 289.79
0 00000 0 0 0
0 21220 0 Restorations, Amalgam, Non-Bonded, Permanent Molars 0
0 00000 0 0 0
0 00000 21221 One surface 0 130.24
0 00000 21222 Two surfaces 0 161.81
0 00000 21223 Three surfaces 0 221.05
0 00000 21224 Four surfaces 0 278.75
0 00000 21225 Five surfaces or maximum surfaces per tooth 0 311.63
0 00000 0 0 0
0 21230 0 Restorations, Amalgam, Bonded, Permanent Bicuspids and Anteriors 0
0 00000 0 0 0
0 00000 21231 One surface 0 156.29
0 00000 21232 Two surfaces 0 193.95

13
0 00000 21233 Three surfaces 0 241.29
0 00000 21234 Four surfaces 0 288.64
0 00000 21235 Five surfaces or maximum surfaces per tooth 0 323.79
0 00000 0 0 0
0 21240 0 Restorations, Amalgam, Bonded, Permanent Molars 0
0 00000 0 0 0
0 00000 21241 One surface 0 168.93
0 00000 21242 Two surfaces 0 208.89
00000 21243 Three surfaces 0 249.33
0 00000 21244 Four surfaces 0 296.68
0 00000 21245 Five surfaces or maximum surfaces per tooth 0 358.28
0 00000 0 0 0
21300 00 Restorations, Amalgam Cores 0
0 00000 0 0 0
0 00000 21301 Restorations, Amalgam Core, Non-Bonded, in Conjunction with Crown or Fixed Bridge Retainer 0 227.49

0 00000 21302 Restorations, Amalgam Core, Bonded, in Conjunction with Crown or Fixed Bridge Retainer 0 254.61

0 00000 0 0 0
21400 00 PINS, RETENTIVE per restoration (for amalgams and tooth coloured restorations) 0
0 00000 0 0 0
0 00000 21401 One pin 0 37.84
0 00000 21402 Two pins 0 54.48
0 00000 21403 Three pins 0 71.11
0 00000 21404 Four pins 0 88.90
0 00000 21405 Five pins or more 0 99.76
0 00000 0 0 0
21500 0 0 RESTORATIONS MADE TO A TOOTH SUPPORTING AN EXISTING PARTIAL DENTURE CLASP 0
(ADDITIONAL TO RESTORATION)
0 00000 0 0 0
0 00000 21501 Per restoration 0 85.45
0 00000 0 0 0
22000 0 0 RESTORATIONS, PREFABRICATED, FULL COVERAGE 0
0 00000 0 0 0
22200 0 0 RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH 0
0 00000 0 0 0
0 00000 22201 Primary Anterior 0 238.30
0 00000 22202 Primary Anterior - open face/acrylic veneer +L 293.69
0 00000 22211 Primary Posterior 0 233.36
0 00000 22212 Primary Posterior - open face 0 315.26
0 00000 0 0 0
22300 0 0 RESTORATIONS PREFABRICATED, METAL, PERMANENT TEETH 0
0 00000 0 0 0
0 00000 22301 Permanent Anterior 0 270.24
0 00000 22302 Permanent Anterior - open face 0 345.15
0 00000 22311 Permanent Posterior 0 270.24
0 00000 22312 Permanent Posterior - open face 0 315.26
0 00000 0 0 0
22400 0 0 RESTORATIONS PREFABRICATED, PLASTIC, PRIMARY TEETH 0
0 00000 0 0 0
0 00000 22401 Primary Anterior 0 200.99
0 00000 22411 Primary Posterior 0 200.99
0 00000 0 0 0
22500 0 0 RESTORATIONS PREFABRICATED, PLASTIC, PERMANENT TEETH 0
0 00000 0 0 0
0 00000 22501 Permanent Anterior 0 267.94
0 00000 22511 Permanent Posterior 0 267.94
0 00000 0 0 0
22600 0 0 RESTORATIONS, PREFABRICATED, PORCELAIN/CERAMIC/POLYMER GLASS, PRIMARY TEETH 0
0 00000 0 0 0
0 00000 22601 Primary Anterior 0 279.97
0 00000 22611 Primary Posterior 0 279.97
0 00000 0 0 0
23000 0 0 RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS 0
0 00000 0 0 0
23100 0 0 RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS, NON BONDED TECHNIQUE 0
0 00000 0 0 0
0 00000 23101 One surface 0 129.78

14
0 00000 23102 Two surfaces 0 147.02
0 00000 23103 Three surfaces 0 206.76
0 00000 23104 Four surfaces 0 225.12
0 00000 23105 Five surfaces (maximum surfaces per tooth) 0 268.75
0 00000 0 0 0
0 23110 0 Restorations, Permanent Anteriors, Bonded Technique 0
0 00000 0 (not to be used for Veneer Applications or Diastema Closures) 0
0 00000 0 0 0
0 00000 23111 One surface 0 156.93
0 00000 23112 Two surfaces 0 187.84
0 00000 23113 Three surfaces 0 215.63
0 00000 23114 Four surfaces 0 282.20
0 00000 23115 Five surfaces (maximum surfaces per tooth) 0 346.78
0 00000 0 0 0
0 23120 0 Restorations, Tooth Coloured, Veneer Applications 0
0 00000 0 0 0
0 00000 23122 Tooth Colored Veneer Application - Non Prefabricated Direct Buildup - Bonded 0 382.84
0 00000 23123 Tooth Colored Veneer Application - Diastema Closure, Interproximal only, Bonded 0 306.55
0 00000 0 0 0
23200 0 0 RESTORATIONS, TOOTH COLOURED/ PLASTIC WITH/WITHOUT SILVER FILINGS, PERMANENT 0
POSTERIORS NON BONDED
0 00000 0 0 0
0 23210 0 Permanent Bicuspids 0
0 00000 0 0 0
0 00000 23211 One surface 0 126.33
0 00000 23212 Two surfaces 0 160.78
0 00000 23213 Three surfaces 0 202.14
0 00000 23214 Four surfaces 0 243.52
0 00000 23215 Five surfaces or maximum surface per tooth 0 256.14
0 00000 0 0 0
0 23220 0 Permanent Molars 0
0 00000 0 0 0
0 00000 23221 One surface 0 137.82
0 00000 23222 Two surfaces 0 180.32
0 00000 23223 Three surfaces 0 211.34
0 00000 23224 Four surfaces 0 245.81
0 00000 23225 Five surfaces or maximum surface per tooth 0 309.02
0 00000 0 0 0
23300 00 RESTORATIONS, TOOTH COLORED, PERMANENT POSTERIORS - BONDED 0
0 00000 0 0 0
0 23310 0 Permanent Bicuspids 0
0 00000 0 0 0
0 00000 23311 One surface 0 164.53
0 00000 23312 Two surfaces 0 229.20
0 00000 23313 Three surfaces 0 268.43
0 00000 23314 Four surfaces 0 331.35
0 00000 23315 Five surfaces or maximum surface per tooth 0 376.40
0 00000 0 0 0
0 23320 0 Permanent Molars 0
0 00000 0 0 0
0 00000 23321 One surface 0 171.98
0 00000 23322 Two surfaces 0 242.45
0 00000 23323 Three surfaces 0 287.04
0 00000 23324 Four surfaces 0 352.05
0 00000 23325 Five surfaces or maximum surface per tooth 0 407.43
0 00000 0 0 0
23400 00 RESTORATIONS, TOOTH COLORED, PRIMARY, ANTERIOR, NON BONDED 0
0 00000 0 0 0
0 00000 23401 One surface 0 124.03
0 00000 23402 Two surfaces 0 152.77
0 00000 23403 Three surfaces 0 179.17
0 00000 23404 Four surfaces 0 226.27
0 00000 23405 Five surfaces (or maximum surfaces per tooth) 0 275.65
0 00000 0 0 0
0 23410 0 Restorations, Tooth Colored, Primary, Anterior, Bonded Technique 0
0 00000 0 0 0
0 00000 23411 One surface 0 157.62

15
0 00000 23412 Two surfaces 0 184.75
0 00000 23413 Three surfaces 0 202.66
0 00000 23414 Four surfaces 0 247.71
0 00000 23415 Five surfaces (or maximum surfaces per tooth) 0 323.79
0 00000 0 0 0
23500 0 0 RESTORATIONS, TOOTH COLOURED/ PLASTIC WITH/WITHOUT SILVER FILINGS, PRIMARY, 0
POSTERIOR, NON BONDED
0 00000 0 0 0
0 00000 23501 One surface 0 126.33
0 00000 23502 Two surfaces 0 165.38
0 00000 23503 Three surfaces 0 190.65
0 00000 23504 Four surfaces 0 205.58
0 00000 23505 Five surfaces or maximum surface per tooth 0 251.54
0 00000 0 0 0
0 23510 0 Restorations, Tooth Colored, Primary, Posterior, Bonded Technique 0
0 00000 0 0 0
0 00000 23511 One surface 0 165.67
0 00000 23512 Two surfaces 0 209.41
0 00000 23513 Three surfaces 0 270.24
0 00000 23514 Four surfaces 0 315.26
0 00000 23515 Five surfaces or maximum surface per tooth 0 360.30
0 00000 0 0 0
23600 0 0 RESTORATIONS, TOOTH COLOURED/ PLASTIC WITH/WITHOUT SILVER FILINGS, CORES 0
0 00000 0 0 0
0 00000 23601 Restoration, Tooth Colored, Non-Bonded Core, in Conjunction with Crown or Fixed Bridge Retainer 0 241.29

0 00000 23602 Restoration, Tooth Colored, Bonded Core, in Conjunction with Crown or Fixed Bridge Retainer 0 278.29

0 00000 0 0 0
23700 0 0 RESIN INFILTRATION (Placement of an infiltrating resin restoration for the purpose of filling the sub- 0
surface porosity of an incipient, non-cavitated lesion for the purpose of strengthening, stabilizing
and/or limiting the progression of the lesion.)
0 00000 0 0 0
0 00000 23701 One surface 0 I.C.
0 00000 23709 Each additional surface over one 0 I.C.
0 00000 0 0 0
24000 0 0 RESTORATIONS, FOIL, GOLD 0
0 00000 0 0 0
24100 0 0 RESTORATIONS, FOIL, GOLD, ANTERIORS 0
0 00000 0 0 0
0 00000 24101 Class l 0 601.86
0 00000 24102 Class lll 0 802.88
0 00000 24103 Class V 0 551.28
0 00000 24104 Class lV 0 946.70
0 00000 0 0 0
24200 0 0 RESTORATIONS, FOIL, GOLD, POSTERIORS 0
0 00000 0 0 0
0 00000 24201 Class l 0 601.86
0 00000 24202 Class ll 0 802.88
0 00000 24203 Class V 0 601.70
0 00000 0 0 0
25000 0 0 RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS 0
0 00000 0 0 0
25100 0 0 RESTORATIONS INLAYS 0
0 00000 0 0 0
0 25110 0 Inlays, Metal 0
0 00000 0 0 0
0 00000 25111 One surface +L 523.78
0 00000 25112 Two surfaces +L 696.00
0 00000 25113 Three surfaces +L 748.86
0 00000 25114 Three surfaces, modified +L 904.64
0 00000 0 0 0
0 25120 0 Inlays, Composite/Compomer, Indirect (Bonded) 0
0 00000 0 0 0
0 00000 25121 One surface +L 541.42
0 00000 25122 Two surfaces +L 631.51
0 00000 25123 Three surfaces +L 737.66
0 00000 25124 Three surfaces, modified +L 948.91

16
0 00000 0 0 0
0 25130 0 Inlays, Porcelain/Ceramic/Polymer Glass 0
0 00000 0 0 0
0 00000 25131 One surface +L 501.94
0 00000 25132 Two surfaces +L 562.78
0 00000 25133 Three surfaces +L 760.41
0 00000 25134 Three surfaces, modified +L 795.43
0 00000 0 0 0
0 25140 0 Inlays, Porcelain/Ceramic/Polymer Glass (Bonded) 0
0 00000 0 0 0
0 00000 25141 One surface +L 536.82
0 00000 25142 Two surfaces +L 753.36
0 00000 25143 Three surfaces +L 879.06
0 00000 25144 Three surfaces, modified +L 948.91
0 00000 0 0 0
25500 00 RESTORATIONS, ONLAYS (where one or more cusps are restored) 0
0 00000 0 0 0
0 25510 0 Onlays, Cast Metal, Indirect 0
0 00000 0 0 0
0 00000 25511 Onlay, Cast Metal, Indirect +L 748.86
0 00000 25512 Onlays, Cast Metal, Indirect (Bonded external retention type) +L 783.35
0 00000 0 0 0
0 25520 0 Onlays, Composite/Compomer, Processed (Bonded) 0
0 00000 0 0 0
0 00000 25521 Onlays, Composite/Compomer, Indirect (Bonded) +L 948.91
0 00000 0 0 0
0 25530 0 Onlays, Porcelain/Ceramic/Polymer glass (Bonded) 0
0 00000 0 0 0
0 00000 25531 Onlays, Porcelain/Ceramic/Polymer Glass (Bonded) +L 948.91
0 00000 0 0 0
25600 00 PINS, RETENTIVE (for inlays, onlays and crowns per tooth) 0
0 00000 0 0 0
0 00000 25601 One pin/tooth +L 51.27
0 00000 25602 Two pins/tooth +L 97.96
0 00000 25603 Three pins/tooth +L 155.18
0 00000 25604 Four pins/tooth +L 190.07
0 00000 25605 Five or more pins/tooth +L 223.82
0 00000 0 0 0
25700 00 POSTS 0
0 00000 0 0 0
0 25710 0 Posts, Cast Metal, (including core) As a Separate Procedure 0
0 00000 0 0 0
0 00000 25711 Single section +L 382.46
0 00000 25712 Two sections +L 459.41
0 00000 25713 Three sections +L 603.01
0 00000 0 0 0
0 25720 0 Posts, Cast Metal (including core) Concurrent with Impression for Crown 0
0 00000 0 0 0
0 00000 25721 Single section +L 218.24
0 00000 25722 Two sections +L 294.04
0 00000 25723 Three sections +L 367.51
0 00000 0 0 0
0 25730 0 Post, Prefabricated Retentive 0
0 00000 0 0 0
0 00000 25731 One post +E 182.66
0 00000 25732 Two posts same tooth +E 303.24
0 00000 25733 Three posts same tooth +E 413.46
0 00000 0 0 0
0 25740 0 Posts, Prefabricated, Retentive and Cast Core 0
0 00000 0 0 0
0 00000 25741 One post and cast core +L +E 318.18
0 00000 25742 Two posts (same tooth) and cast core +L +E 402.01
0 00000 25743 Three posts (same tooth) and cast core +L +E 501.94
0 00000 0 0 0
0 25770 0 Posts, Provisional 0
0 00000 0 0 0

17
0 00000 25771 Per post +L and/or 99.92
+E
0 00000 0 0 0
0 25780 0 Post Removal 0
0 00000 0 0 0
0 00000 25781 One unit of time 0 122.90
0 00000 25782 Two units of time 0 245.80
0 00000 25783 Three units of time 0 368.70
0 00000 25784 Four units of time 0 491.60
0 00000 25789 Each additional unit over four 0 122.90
0 00000 0 0 0
26000 00 MESOSTRUCTURES 0
0 00000 0 (a separate component positioned between the head of an implant and the final restoration, retained 0
by either a cemented post or screw)
0 00000 0 0 0
0 26100 0 Mesostructures, Osseo-integrated Implant - Supported 0
0 00000 0 0 0
0 00000 26101 Indirect, Angulated or transmucosal pre-fabricated abutment, per implant +L +E I.C.
0 00000 26102 Indirect, Custom laboratory fabricated, per implant +L +E I.C.
0 00000 26103 Direct, (with intra-oral preparation), per implant site +E I.C.
0 00000 0 0 0
27000 00 CROWNS, SINGLE UNITS ONLY 0
0 00000 0 (includes temporary protection and local anaesthetic, caries removal, and uncomplicated restoration 0
prior to crown preparation). Extensive restoration requiring pins or dowels extra.

0 00000 0 0 0
27100 00 CROWNS, ACRYLIC/COMPOSITE/COMPOMER, 0
0 00000 0 (with or without Cast or Prefabricated Metal Bases) 0
0 00000 0 0 0
0 27110 0 Crowns, Acrylic/Composite/Compomer, Indirect 0
0 00000 0 0 0
0 00000 27111 Crown, Acrylic/Composite/Compomer, Indirect +L 752.30
0 00000 27112 Crown, Acrylic/Composite/Compomer, Indirect, Complicated (restorative, positional and/or esthetic) +L 1,005.04

0 00000 27113 Crown, Acrylic/Composite/Compomer, Provisional [Long Term], Indirect (lab fabricated/relined intra- +L 294.04
orally)
0 00000 0 0 0
0 27120 0 Crowns, Acrylic/Composite/Compomer, Direct 0
0 00000 0 0 0
0 00000 27121 Crowns, Acrylic/Composite/Compomer, Direct, Provisional (chairside) +E 227.49
0 00000 27125 Crowns, Acrylic/Composite/Compomer, Direct, Provisional Implant-supported +E 227.49
0 00000 0 0 0
0 27130 0 Crown, Acrylic/Composite/Compomer/Cast Metal Base, Indirect 0
0 00000 0 0 0
0 00000 27131 Crown, Acrylic/Composite/Compomer/Cast Metal Base, Indirect +L 801.73
0 00000 27135 Crown, Acrylic/Composite/Compomer Cast Metal Base, Implant-supported +L +E 801.73
0 00000 27136 Crown, Acrylic/Composite/Compomer/Cast Metal Base with Cast Post Retention +L 1,005.04
0 00000 0 0 0
0 27140 0 Crown, Acrylic/Composite/Compomer/ Prefabricated Metal Base, Provisional, Direct 0
0 00000 0 0 0
0 00000 27145 Crown, Acrylic/Composite/Compomer/ Pre-fabricated Metal Base, Provisional, Implant-supported, +E 227.49
Direct
0 00000 0 0 0
0 27150 0 Crown, Acrylic/Composite/Compomer/ Pre-Fabricated Metal Base, Provisional, Indirect 0
0 00000 0 0 0
0 00000 27155 Crown, Acrylic/ Composite/Compomer/Pre-fabricated Metal Base, Provisional, Implant-supported, +L +E 227.49
Indirect
0 00000 0 0 0
27200 00 CROWNS, PORCELAIN/CERAMIC/POLYMER GLASS 0
0 00000 0 0 0
0 00000 27201 Crown, Porcelain/Ceramic/Polymer Glass +L 948.91
0 00000 27202 Crown, Porcelain/Ceramic/Polymer Glass, Complicated +L 1,259.57
0 00000 27205 Crown, Porcelain/Ceramic/Polymer Glass, Implant-supported +L +E 948.91
0 00000 27206 Crown, Porcelain/Ceramic/Polymer Glass, with Cast Ceramic Post Retention +L 1,259.57
0 00000 0 0 0
0 27210 0 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base 0
0 00000 0 0 0
0 00000 27211 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base +L 948.91

18
0 00000 27212 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, Complicated (restorative, positional +L 1,259.57
and/or aesthetic)
0 00000 27215 Crown, Porcelain/Ceramic Fused to Metal Base, Implant-supported +L +E 948.91
0 00000 27216 Crown, Porcelain/Ceramic Fused to Metal Base with Cast Metal Post Retention +L 1,259.57
0 00000 0 0 0
0 27220 0 Crown, ¾, Porcelain/Ceramic/Polymer Glass 0
0 00000 0 0 0
0 00000 27221 Crown, ¾, Porcelain/Ceramic/Polymer Glass +L 948.91
0 00000 27222 Crown, ¾, Porcelain/Ceramic/Polymer Glass, Complicated +L 1,259.57
0 00000 0 0 0
27300 00 CROWNS, CAST METAL 0
0 00000 0 0 0
0 00000 27301 Crown, Cast Metal +L 948.91
0 00000 27302 Crown, Cast Metal, Complicated (restorative, positional) +L 1,259.57
0 00000 27305 Crown, Cast Metal, Implant-supported +L +E 948.91
0 00000 27306 Crown, Cast Metal, with Cast Metal Post Retention +L 1,259.57
0 00000 27307 Semi-precision Rest (Interlock) (in addition to Cast Metal Crown) +L +E 212.29
0 00000 27308 Semi-precision or Precision Attachment RPD Retainer (in addition to Cast Metal Crown) +L +E 524.89

0 00000 0 0 0
0 27310 0 Crowns, ¾, Cast Metal 0
0 00000 0 0 0
0 00000 27311 Crowns, ¾, Cast Metal +L 948.91
0 00000 27312 Crowns, Metal ¾ Cast Metal, Complicated +L 1,259.57
0 00000 27313 Crowns, ¾, Cast Metal, with Direct Tooth Colored Corner +L 948.91
0 00000 0 0 0
27400 0 0 CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP (additional to crown) 0
0 00000 0 0 0
0 00000 27401 One crown +L 137.18
0 00000 27409 Each additional crown +L 90.05
0 00000 0 0 0
27500 0 0 COPINGS, METAL/PLASTIC, TRANSFER (thimble type) 0
0 00000 0 0 0
0 27510 0 Coping, Metal/Acrylic, Transfer (thimble), as a Separate Procedure 0
0 00000 0 0 0
0 00000 27511 Coping, Metal/Acrylic, Transfer (thimble) as a Separate Procedure +L 400.86
0 00000 0 0 0
0 27520 0 Coping, Metal/Acrylic, Transfer (thimble) Concurrent with Impression for Crown 0
0 00000 0 0 0
0 00000 27521 Coping, Metal/Acrylic, Transfer (thimble) Concurrent with Impression for Crown +L 99.92
0 00000 0 0 0
27600 0 0 VENEERS, LABORATORY PROCESSED 0
0 00000 0 0 0
0 00000 27601 Veneers, Acrylic/Composite/Compomer, Bonded +L 829.32
0 00000 27602 Veneers, Porcelain/Ceramic/Polymer Glass, Bonded +L 948.91
0 00000 0 0 0
27700 0 0 REPAIRS, (SINGLE UNIT ONLY, DOES NOT INCLUDE AND RECEMENTATION) 0
0 00000 0 0 0
0 27710 0 Repairs, Inlays, Onlays or Crowns, Acrylic/Composite/Compomer (single units) 0
0 00000 0 0 0
0 00000 27711 Repairs, Acrylic/Composite/Compomer, Direct 0 91.87
0 00000 0 0 to 275.64
0 00000 0 0 0
0 27720 0 Repairs, Inlays, Onlays or Crowns, Porcelain/Ceramic/Polymer Glass, Porcelain/Ceramic/Polymer 0
Glass/Fused to Metal base (single units)
0 00000 0 0 0
0 00000 27721 Repairs, Inlays, Onlays or Crowns, Porcelain/Ceramic/Polymer Glass, 0 91.87
Porcelain/Ceramic/Polymer Glass/Fused to Metal base, Direct
0 00000 0 0 to 275.64
0 00000 27722 Repairs, Inlays, Onlays or Crowns, Porcelain/Ceramic/Polymer Glass, Porcelain/Ceramic/Polymer +L 180.39
Glass/Fused to Metal base, Indirect
0 00000 0 0 0
27800 00 RECONTOURING OF EXISTING CROWNS per tooth 0
0 00000 0 0 0
0 00000 27801 One unit of time 0 97.62
0 00000 27809 Each additional unit of time 0 97.62
0 00000 0 0 0
28000 00 RESTORATIVE PROCEDURES, OVERDENTURES 0

19
0 00000 0 0 0
28100 00 RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT 0
0 00000 0 0 0
0 00000 28101 Natural Tooth Preparation, Placement of Pulp Chamber Restoration 0 251.54
0 00000 0 (amalgam or composite) and Fluoride Application Endodontically Treated Tooth 0
0 00000 28102 Natural Tooth Preparation and Fluoride Application, Vital Tooth 0 300.94
0 00000 28103 Pre-fabricated Attachment, as an Internal/External Overdenture Retentive Device, Direct to a Natural +L +E 300.94
Tooth (used with the appropriate denture code) per tooth
0 00000 28105 Implant-supported Prefabricated Attachment as an Overdenture Retentive Device, Direct +E 150.47

0 00000 0 0 0
28200 00 RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT 0
0 00000 0 0 0
0 28210 0 Coping Crowns, Cast Metal, No Attachments, Indirect 0
0 00000 0 0 0
0 00000 28211 Coping Crown, Cast Metal, No Attachments, Indirect +L 402.01
0 00000 28215 Coping Crown, Cast Metal, No Attachments, Implant-supported, Indirect +L +E 402.01
0 00000 28216 Coping Crown, Cast Metal with Cast Metal Retentive Post, No Attachments +L +E 603.01
0 00000 0 00
0 28220 0 Coping Crown, Cast Metal, with Attachments, Indirect 0
0 00000 0 0 0
0 00000 28221 Coping Crown, Metal Cast, with Attachment, Indirect +L +E 501.94
0 00000 28225 Coping Crown, Cast Metal, Implant-supported with Attachment +L +E 501.94
0 00000 28226 Coping Crown, Cast Metal with Cast Metal Retentive Post, with Attachment +L +E 738.81
0 00000 0 0 0
29000 00 RESTORATIVE SERVICES, OTHER 0
0 00000 0 0 0
29100 0 0 RECEMENTATION/REBONDING, INLAYS/ONLAYS/CROWNS/VENEERS/POSTS/ NATURAL TOOTH 0
FRAGMENTS (single units only) (+ L and/or +E where laboratory charges or expenses are incurred
during repair of the unit)
0 00000 0 0 0
0 00000 29101 One unit of time +L +E 98.77
0 00000 29102 Two units +L +E 197.54
0 00000 29103 Three units +L +E 296.31
0 00000 29104 Four units +L +E 395.08
0 00000 0 0 0
29300 00 REMOVAL, INLAYS/ONLAYS/ CROWNS/ VENEERS (single units only) 0
0 00000 0 0 0
0 00000 29301 One unit of time 0 97.63
0 00000 29302 Two units 0 195.26
0 00000 29303 Three units 0 292.89
0 00000 29304 Four units 0 390.52
0 00000 0 0 0
30000 00000 0 ENDODONTICS 0
0 00000 0 0 0
0 00 General Endodontic Procedures 0
0 00000 0 There are certain Endodontic cases, which, as a result of a previous treatment, tooth position, 0
anatomy and/or stage of development, require additional time and care. Such situations could merit
an additional fee. Conservative root canal therapy includes treatment plan, clinical procedures with
appropriate follow up care. Excludes final restoration.

0 00000 0 Note: If Endodontic therapy is not completed it would be deemed reasonable to charge a portion of 0
the suggested fee in relation to time expended in the procedure.

0 00000 0 0 0
31100 00 PULP CAPPING (refer to code 20100) 0
0 00000 0 0 0
32000 00 PULP CHAMBER, TREATMENT OF, (excluding final restoration) 0
0 00000 0 0 0
32200 00 PULPOTOMY 0
0 00000 0 0 0
0 32220 0 Pulpotomy, Permanent Teeth (as a separate Emergency Procedure) 0
0 00000 0 0 0
0 00000 32221 Anterior and Bicuspid Teeth 0 183.75
0 00000 32222 Molar Teeth 0 183.75
0 00000 0 0 0
0 32230 0 Pulpotomy, Primary Teeth 0
0 00000 0 0 0

20
0 00000 32231 Primary Tooth, as a Separate Procedure 0 175.02
0 00000 32232 Primary Tooth, Concurrent with Restorations (but excluding final restoration) 0 90.64
0 00000 0 0 0
0 32240 0 Pulpotomy, Permanent Teeth, concurrent with restoration (but excluding final restoration) 0

0 00000 0 0 0
0 00000 32241 Anterior and bicuspid teeth 0 95.55
0 00000 32242 Molar Teeth 0 95.55

32300 00 PULPECTOMY (An emergency procedure and/or as a pre-emptive phase to the preparation of the 0
root canal system for obturation)
0 00000 0 0 0
0 32310 0 Pulpectomy, Permanent Teeth/Retained Primary Teeth 0
0 00000 0 0 0
0 00000 32311 One Canal 0 166.56
0 00000 32312 Two Canals 0 213.64
0 00000 32313 Three Canals 0 288.33
0 00000 32314 Four Canals or more 0 315.88
0 00000 0 0 0
0 32320 0 Pulpectomy, Primary Teeth 0
0 00000 0 0 0
0 00000 32321 Anterior Tooth 0 141.27
0 00000 32322 Posterior Tooth 0 254.99
0 00000 0 0 0
33000 00 ROOT CANAL THERAPY 0
0 00000 0 To include: treatment plan, clinical procedures (ie. pulpectomy, biomechanical preparation, 0
chemotherapeutic treatment and obturation), with appropriate radiographs, excluding final
restoration.
0 00000 0 0 0
33100 00 ROOT CANALS, PERMANENT TEETH/RETAINED PRIMARY TEETH (Includes: Clinical procedures with 0
appropriate radiographs, excluding final restoration.)
0 00000 0 0 0
0 00 Definitions: 0
0 00000 0 Uncomplicated - Virtually straight canal penetrated by size #15 file 0
0 00000 0 Difficult Access - Limited jaw opening, unfavourable tooth inclination, through complex restorations 0
eg. Post/core buildups.
0 0 Exceptional Anatomy - Canal size same as uncomplicated, but made complicated by dens-in-dente or 0
partially developed roots, internal/external resorption.
0 00000 0 Calcified Canals - Unable to penetrate with size #10 file and not clearly dicernable on a radiograph 0

0 00000 0 Re-treatment - Re-treatment of previously completed therapy 0

0 00000 0 0 0
0 33110 0 Root Canals, Permanent Teeth/Retained Primary Teeth, One Canal 0
0 00000 0 0 0
0 00000 33111 One canal 0 761.19
0 00000 33112 Difficult Access 0 1,010.60
0 00000 33113 Exceptional Anatomy 0 1,033.60
0 00000 33114 Calcified Canal 0 1,062.34
0 00000 33115 Re-treatment of Previously Completed Therapy 0 1,028.59
0 00000 0 0 0
0 33120 0 Root Canals, Permanent Teeth/Retained Primary Teeth, Two Canals 0
0 00000 0 0 0
0 00000 33121 Two canals 0 1,108.48
0 00000 33122 Difficult Access 0 1,419.66
0 00000 33123 Exceptional Anatomy 0 1,419.66
0 00000 33124 Calcified Canal 0 1,419.66
0 00000 33125 Retreatment of Previously Completed Therapy 0 1,458.75
0 00000 0 0 0
0 33130 0 Root Canals, Permanent Teeth/Retained Primary Teeth, Three Canals 0
0 00000 0 0 0
0 00000 33131 Three canals 0 1,296.32
0 00000 33132 Difficult Access 0 1,608.71
0 00000 33133 Exceptional Anatomy 0 1,684.65
0 00000 33134 Calcified Canal 0 1,598.43
0 00000 33135 Retreatment of Previously Completed Therapy 0 1,586.94
0 00000 0 0 0
0 33140 0 Root Canals, Permanent Teeth/Retained Primary Teeth, Four or More Canals 0
0 00000 0 0 0

21
0 00000 33141 Four or more canals 0 1,636.20
0 00000 33142 Difficult Access 0 1,876.83
0 00000 33143 Exceptional Anatomy 0 1,876.83
0 00000 33144 Calcified Canal 0 1,876.83
0 00000 33145 Retreatment of Previously Completed Therapy 0 1,964.20
0 00000 0 0 0
33500 0 0 PULPAL REVASCULARIZATION 0
0 00000 0 0 0
0 00000 33501 One canal 0 288.73
0 00000 33502 Two canals 0 433.10
0 00000 33503 Three canals or more 0 577.48
0 00000 0 0 0
33600 0 0 APEXIFICATION/APEXOGENESIS/INDUCTION OF HARD TISSUE REPAIR 0
0 00000 0 (to include biomechanical preparation and placement of dentogenic media) 0
0 00000 0 0 0
0 00000 33601 One canal 0 300.22
0 00000 33602 Two canals 0 433.10
0 00000 33603 Three canals 0 577.48
0 00000 33604 Four canals or more 0 769.97
0 00000 0 0 0
0 33610 0 Re-Insertion of Dentogenic Media Per Visit 0
0 00000 0 0 0
0 00000 33611 One canal 0 144.35
0 00000 33612 Two canals 0 195.95
0 00000 33613 Three canals 0 293.66
0 00000 33614 Four canals or more 0 393.03
0 00000 0 0 0
34000 0 0 PERIAPICAL SERVICES 0
0 00000 0 0 0
34100 0 0 APICOECTOMY/APICAL CURETTAGE 0
0 00000 0 0 0
0 34110 0 Maxillary Anterior 0
0 00000 0 0 0
0 00000 34111 One root 0 607.67
0 00000 34112 Two roots 0 749.79
0 00000 0 0 0
0 34120 0 Maxillary Bicuspid 0
0 00000 0 0 0
0 00000 34121 One root 0 749.42
0 00000 34122 Two roots 0 872.02
0 00000 34123 Three roots 0 1,071.61
0 00000 0 0 0
0 34130 0 Maxillary Molar 0
0 00000 0 0 0
0 00000 34131 One root 0 728.73
0 00000 34132 Two roots 0 853.63
0 00000 34133 Three roots 0 1,287.32
0 00000 0 0 0
0 34140 0 Mandibular Anterior 0
0 00000 0 0 0
0 00000 34141 One root 0 631.27
0 00000 34142 Two or more roots 0 857.08
0 00000 0 0 0
0 34150 0 Mandibular Bicuspid 0
0 00000 0 0 0
0 00000 34151 One root 0 930.27
0 00000 34152 Two roots 0 965.51
0 00000 34153 Three or more roots 0 1,178.89
0 00000 0 0 0
0 34160 0 Mandibular Molar 0
0 00000 0 0 0
0 00000 34161 One root 0 747.49
0 00000 34162 Two roots 0 944.81
0 00000 34163 Three roots 0 1,287.32
0 00000 0 0 0
34200 0 0 RETROFILLING 0
0 00000 0 0 0

22
0 34210 0 Maxillary Anterior 0
0 00000 0 0 0
0 00000 34211 One canal 0 114.39
0 00000 34212 Two or more canals 0 203.52
0 00000 0 0 0
0 34220 0 Maxillary Bicuspid 0
0 00000 0 0 0
0 00000 34221 One canal 0 114.39
0 00000 34222 Two canals 0 203.52
0 00000 34223 Three canals 0 307.58
0 00000 34224 Four or more canals 0 409.33
0 00000 0 0 0
0 34230 0 Maxillary Molar 0
0 00000 0 0 0
0 00000 34231 One canal 0 127.04
0 00000 34232 Two canals 0 203.52
0 00000 34233 Three canals 0 307.58
0 00000 34234 Four or more canals 0 409.33
0 00000 0 0 0
0 34240 0 Mandibular Anterior 0
0 00000 0 0 0
0 00000 34241 One canal 0 129.34
0 00000 34242 Two or more canals 0 203.52
0 00000 0 0 0
0 34250 0 Mandibular Bicuspid 0
0 00000 0 0 0
0 00000 34251 One canal 0 101.75
0 00000 34252 Two canals 0 203.52
0 00000 34253 Three canals 0 307.58
0 00000 34254 Four or more canals 0 409.33
0 00000 0 0 0
0 34260 0 Mandibular Molar 0
0 00000 0 0 0
0 00000 34261 One canal 0 101.75
0 00000 34262 Two canals 0 203.52
0 00000 34263 Three canals 0 307.58
0 00000 34264 Four or more canals 0 409.33
0 00000 0 0 0
34300 00 RE-TREATMENT, APICOECTOMY/APICAL CURETTAGE 0
0 00000 0 0 0
0 34310 0 Maxillary Anterior 0
0 00000 34311 One root 0 615.17
0 00000 34312 Two roots 0 857.08
0 00000 0 0 0
0 34320 0 Maxillary Bicuspid 0
0 00000 34321 One root 0 749.79
0 00000 34322 Two roots 0 1,017.99
0 00000 34323 Three roots 0 1,287.32
0 00000 0 0 0
0 34330 0 Maxillary Molar 0
0 00000 34331 One root 0 749.79
0 00000 34332 Two roots 0 1,017.99
0 00000 34333 Three roots 0 1,500.74
0 00000 0 0 0
0 34340 0 Mandibular Anterior 0
0 00000 34341 One root 0 770.70
0 00000 34342 Two or more roots 0 1,071.61
0 00000 0 0 0
0 34350 0 Mandibular Bicuspid 0
0 00000 34351 One root 0 857.08
0 00000 34352 Two roots 0 1,178.89
0 00000 34353 Three roots 0 1,393.45
0 00000 0 0 0
0 34360 0 Mandibular Molar 0
0 00000 34361 One root 0 857.08
0 00000 34362 Two roots 0 1,126.08
0 00000 34363 Three roots 0 1,500.74

23
0 00000 0 0 0
34400 00 SURGICAL SERVICES, MISCELLANEOUS 0
0 00000 0 0 0
0 34410 0 Amputations, Root (includes recontouring tooth and furca) 0
0 00000 0 0 0
0 00000 34411 One root 0 421.39
0 00000 34412 Two roots 0 513.40
0 00000 0 0 0
0 34420 0 Hemisection 0
0 00000 0 0 0
0 00000 34421 Maxillary Bicuspid 0 307.58
0 00000 34422 Maxillary Molar 0 300.68
0 00000 34423 Mandibular Molar 0 300.68
0 00000 0 0 0
0 34430 0 Decompression, Perio-Radicular Lesion 0
0 00000 0 0 0
0 00000 34431 First visit 0 409.33
0 00000 34432 Each Additional visit 0 203.52
0 00000 0 0 0
0 34440 0 Surgery, Endodontic, Exploratory 0
0 00000 0 0 0
0 00000 34441 Maxillary Anterior 0 307.58
0 00000 34442 Maxillary Bicuspid 0 409.33
0 00000 34443 Maxillary Molar 0 513.40
0 00000 34444 Mandibular Anterior 0 307.58
0 00000 34445 Mandibular Bicuspid 0 409.33
0 00000 34446 Mandibular Molar 0 513.40
0 00000 0 0 0
0 34450 0 Removal, Intentional, of Tooth, Apical Filling and Replantation (splinting additional) 0
0 00000 0 0 0
0 00000 34451 Single rooted tooth 0 427.95
0 00000 34452 Two rooted tooth 0 643.66
0 00000 34453 Three rooted tooth or more 0 857.08
0 00000 0 0 0
34500 00 PERFORATIONS 0
0 00000 0 0 0
0 34510 0 Perforation/Resorptive Defect(s), Pulp Chamber Repair, or Root Repair, Non-Surgical 0
0 00000 0 0 0
0 00000 34511 per tooth 0 93.02
0 00000 0 0 0
0 34520 0 Perforation/Resorptive Defect(s), Pulp Chamber Repair, or Root Repair, Surgical 0
0 00000 0 0 0
0 00000 34521 Anterior Tooth 0 101.75
0 00000 34522 Bicuspid Tooth 0 204.06
0 00000 34523 Molar Tooth 0 305.28
0 00000 0 0 0
34600 00 ENLARGEMENT, CANAL AND/OR PULP CHAMBER (Preparation of Post Space) 0
0 00000 0 0 0
0 00000 34601 In Previously Filled Tooth when Root Canal Treatment Done by Another Practitioner 0 97.38
0 00000 34602 In Calcified Canals 0 293.33
0 00000 0 0 0
39000 00 ENDODONTIC, PROCEDURES, MISCELLANEOUS 0
0 00000 0 0 0
39100 00 ISOLATION OF ENDODONTIC TOOTH/TEETH FOR ASEPSIS 0
0 00000 0 0 0
0 00000 39101 Banding and/or Coronal Buildup of Tooth/Teeth and/or Contouring of Tissue Surrounding Tooth/Teeth 0 183.75
to Maintain Aseptic Operating Field (per tooth)
0 00000 0 0 0
39200 00 OPEN AND DRAIN (Separate Emergency Procedures) 0
0 00000 0 0 0
0 00000 39201 Anteriors and Bicuspids 0 87.53
0 00000 39202 Molars 0 87.53
0 00000 0 0 0
0 39210 0 Opening Through Artificial Crown (In addition to Procedures) 0
0 00000 0 0 0
0 00000 39211 Anteriors and Bicuspids 0 96.71
0 00000 39212 Molars 0 96.71

24
0 00000 0 0 0
39300 00 BLEACHING, NON VITAL 0
0 00000 0 0 0
0 39310 0 Bleaching Endodontically Treated Tooth/Teeth 0
0 00000 0 0 0
0 00000 39311 One unit of time 0 93.03
0 00000 39312 Two units 0 186.06
0 00000 39313 Three units 0 279.09
0 00000 39319 Each additional unit over three 0 93.03
0 00000 0 0 0
39400 0 0 EXPLORATORY ACCESS THROUGH CLINICAL CROWN OF PREVIOUSLY TREATED TOOTH 0
0 00000 0 0 0
0 39410 0 Exploratory Access 0
0 00000 0 0 0
0 00000 39411 Anterior 0 83.15
0 00000 39412 Bicuspid 0 83.15
0 00000 39413 Molar 0 174.64
0 00000 0 0 0
40000 00000 0 PERIODONTICS 0
0 00000 0 0 0
0 00000 0 In the treatment of periodontal diseases, variables such as the severity of the patient's periodontal 0
condition and the distribution (i.e. extent) of the condition may require a relatively wide selection of
therapeutic procedures and involve considerable variation in time and expense. In most instances the
time required to perform a certain procedure could, and usually does, vary from one quadrant to
another and therefore the amounts of time as outlined in the following guide could vary in the
management of a particular case.

0 00000 0 0 0
41000 00 PERIODONTAL SERVICES, NON SURGICAL 0
0 00000 0 0 0
41200 00 ORAL DISEASE, Management of 0
0 00000 0 0 0
0 41210 0 Oral Manifestations, Oral Mucosal Disorders, Mucocutaneous disorders and diseases of localized 0
mucosal conditions, e.g. lichen planus, aphthous stomatitis, benign mucous membrane pemphigoid,
pemphigus, salivary gland tumours, leukoplakia with and without dysphasia, neoplasms, hairy
leukoplakia, polyps, verrucae, fibroma etc.

0 00000 0 0 0
0 00000 41211 One unit of time 0 91.87
0 00000 41212 Two units 0 183.74
0 00000 41213 Three units 0 275.61
0 00000 41214 Four units 0 367.48
0 00000 41219 Each additional unit over four 0 91.87
0 00000 0 0 0
0 41220 0 Nervous and Muscular Disorders, Disorders of facial sensation and motor dysfunction at the jaw, e.g. 0
trigeminal neuralgia, atypical facial pain, atypical odontologia, burning mouth syndrome, dyskenesia,
post injection trismus, muscular and joint pain syndrome

0 00000 0 0 0
0 00000 41221 One unit of time 0 91.87
0 00000 41222 Two units 0 183.74
0 00000 41223 Three units 0 275.61
0 00000 41224 Four units 0 367.48
0 00000 41229 Each additional unit over four 0 91.87
0 00000 0 0 0
0 41230 0 Oral Manifestations of Systemic Disease or complications of medical therapy e.g. complications of 0
chemotherapy, radiation therapy, post operative neuropathics, post surgical or radiation therapy,
dysfunction, oral manifestations of lupus erythematosis and systemic disease including leukemia,
diabetes and bleeding disorders (e.g. haemophilia)

0 00000 0 0 0
0 00000 41231 One unit of time 0 91.87
0 00000 41232 Two units 0 183.74
0 00000 41233 Three units 0 275.61
0 00000 41234 Four units 0 367.48
0 00000 41239 Each additional unit over four 0 91.87
0 00000 0 0 0
41300 00 DESENSITIZATION 0

25
0 00000 0 (This may involve application and burnishing of medicinal aids on the root or the use of a variety of 0
therapeutic procedures. More than one appointment may be necessary.)

0 00000 0 0 0
0 00000 41301 One unit of time 0 91.87
0 00000 41302 Two units 0 183.74
0 00000 41309 Each additional unit over two 0 91.87
0 00000 0 0 0
42000 00 PERIODONTAL SERVICES, SURGICAL 0
0 00000 0 (Includes local anaesthetic, suturing and the placement and removal of initial surgical dressing. A 0
surgical site is an area that lends itself to one or more procedures. It is considered to include a full
quadrant, sextant or group of teeth or in some cases a single tooth.)

0 00000 0 0 0
42100 00 PERIODONTAL SURGERY, GINGIVAL CURETTAGE 0
0 00000 0 0 0
0 42110 0 Surgical Curettage, To Include Definitive Root Planing 0
0 00000 0 0 0
0 00000 42111 Per sextant 0 240.61
0 00000 0 0 0
42200 0 0 PERIODONTAL SURGERY, GINGIVOPLASTY (Does not include limited re-contouring to facilitate 0
restorative services)
0 00000 0 0 0
0 00000 42201 Per sextant 0 288.73
0 00000 0 0 0
42300 00 PERIODONTAL SURGERY, GINGIVECTOMY 0
0 00000 0 (The procedure by which gingival deformities are reshaped and reduced to create normal and 0
functional form, when the pocket is uncomplicated by extension into the underlying bone; does not
include limited re-contouring to facilitate restorative services).

0 00000 0 0 0
0 42310 0 Gingivectomy, Uncomplicated 0
0 00000 0 0 0
0 00000 42311 Per sextant 0 328.03
0 00000 0 0 0
0 42320 0 Gingivectomy, Complicated 0
0 00000 0 0 0
0 00000 42321 Per sextant 0 484.51
0 00000 0 0 0
0 42330 0 Gingival Fiber Incision (supra crestal fibrotomy) 0
0 00000 0 0 0
0 00000 42331 First tooth 0 93.50
0 00000 42339 Each additional tooth 0 83.15
0 00000 0 0 0
42400 00 PERIODONTAL SURGERY, FLAP APPROACH 0
0 00000 0 0 0
0 42410 0 Flap Approach, With Osteoplasty and/or Ostectomy 0
0 00000 0 0 0
0 00000 42411 Per sextant 0 1,181.58
0 00000 0 0 0
0 42420 0 Flap Approach, With Curettage of Osseous Defect 0
0 00000 0 0 0
0 00000 42421 Per sextant 0 782.01
0 00000 0 0 0
0 42430 0 Flap Approach, With Curettage of Osseous Defect with Osteoplasty and/or Ostectomy 0
0 00000 0 0 0
0 00000 42431 Per sextant 0 1,114.13
0 00000 0 0 0
0 42440 0 Flap Approach, Exploratory (for diagnosis) 0
0 00000 0 0 0
0 00000 42441 Per site 0 601.39
0 00000 0 0 0
42500 00 PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE 0
0 00000 0 0 0
0 42510 0 Grafts, Soft Tissue, Pedicle (including apically or lateral sliding and rotated flaps.) 0
0 00000 0 0 0
0 00000 42511 Per site 0 734.65
0 00000 42512 Periosteal stimulation in addition to 42511 0 87.51

26
0 00000 0 0 0
0 42520 0 Grafts, Soft Tissue, Pedicle (Coronally Positioned) 0
0 00000 0 0 0
0 00000 42521 Per site 0 734.65
0 00000 42522 Periosteal stimulation in addition to 42521 0 87.51
0 00000 0 0 0
0 42530 0 Grafts Free Soft Tissue 0
0 00000 0 0 0
0 00000 42531 Adjacent to teeth or edentulous area, per site. 0 1,109.41
0 00000 0 0 0
0 42540 0 Grafts, Soft Tissue, Pedicle, With Free Graft Placed In Pedicle Donor Site 0
0 00000 0 0 0
0 00000 42541 Per site 0 1,341.05
0 00000 0 0 0
0 42550 0 Grafts, For Root or Implant Coverage 0
0 00000 0 0 0
0 00000 42551 Autograft (subepithelial connective tissue or epithelialized gingival graft), for root 0 1,053.66
coverage, includes harvesting from donor site - Per site
0 00000 42552 Allograft, for root coverage – per site +E I.C.
0 00000 42556 Autograft (subepithelial connective tissue or epithelialized gingival graft), adjacent to an implant, 0 I.C.
includes harvesting from donor site – per site
0 00000 42557 Allograft, adjacent to an implant – per site +E I.C.
0 00000 0 0 0
0 42560 0 Grafts, For Ridge Augmentation 0
0 00000 0 0 0
0 00000 42561 Autograft (free connective tissue), includes harvesting from donor site – per site. 0 1,299.39
0 00000 42562 Allograft – per site +E I.C.
0 00000 0 0 0
0 42570 0 Grafts, Connective Tissue, Pedicle with Free Graft for Root Coverage 0
0 00000 0 0 0
0 00000 42571 Per site 0 1,005.97
0 00000 0 0 0
0 42580 0 Grafts, Gingival Onlay (for ridge augmentation) 0
0 00000 0 0 0
0 00000 42581 Per site 0 1,040.73
0 00000 0 0 0
0 42590 0 Grafts, Dermal, Onlay, for Ridge Augmentation 0
0 00000 0 0 0
0 0 42591 Autograft – per site 0 1,040.73
0 0 42592 Allograft – per site +E 1,040.74
0 00000 0 0 0
42600 0 0 PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE 0
0 00000 0 0 0
0 42610 0 Grafts, Osseous, Autograft (Including Flap Entry, Closure and Donor Site) 0
0 00000 0 0 0
0 00000 42611 Per site 0 1,224.41
0 00000 0 0 0
0 42620 0 Grafts, Osseous, Allograft (Including Flap Entry and Closure) 0
0 00000 0 0 0
0 00000 42621 Per site +E 1,224.41
0 00000 0 0 0
0 42630 0 Grafts, Osseous, Xenograft (Including Flap Entry and Closure) 0
0 00000 0 0 0
0 00000 42631 Per Site +E 1,224.41
0 00000 0 0 0
42700 0 0 GUIDED TISSUE REGENERATION 0
0 00000 0 0 0
0 0 42701 Guided Tissue Regeneration – Non-resorbable Membrane – per site +E 1,858.84
0 00000 42702 Guided Tissue Regeneration – Resorbable Membrane +E 1,858.84
0 00000 42703 Guided Tissue Regeneration – Non-resorbable Membrane, Surgical Re-entry for Removal +E 1,858.84

0 00000 0 0 0
0 42720 0 Biological Materials to Aid in Soft and Osseous Tissue Regeneration (not including surgical entry and 0
closure)
0 0 0 0 0
0 00000 42721 Per site +E I.C.
0 00000 0 0 0
42800 00 PERIODONTAL SURGERY, MISCELLANEOUS PROCEDURES 0

27
0 00000 0 0 0
0 42810 0 Proximal Wedge Procedure (as a separate procedure) 0
0 00000 0 0 0
0 00000 42811 With Flap Curettage, per site 0 557.67
0 00000 42819 With Flap Curettage and Ostectomy/Osteoplasty, per site 0 673.42
0 00000 0 0 0
0 42820 0 Post Surgical Periodontal Treatment Visit Per Dressing Change 0
0 00000 0 (by dentist other than operating dentist) 0
0 00000 0 0 0
0 00000 42821 One unit of time 0 87.51
0 00000 42822 Two units 0 175.02
0 00000 42823 Three units 0 262.53
0 00000 42829 Each additional unit over three 0 87.51
0 00000 0 0 0
0 42830 0 Periodontal Abscess or Pericoronitis, May Include Any of The Following Procedures: Lancing, Scaling, 0
Curettage, Surgery or Medication
0 00000 0 0 0
0 00000 42831 One unit of time 0 91.87
0 00000 42832 Two units 0 183.74
0 00000 42833 Three units 0 275.61
0 00000 42834 Four units 0 367.48
0 00000 42839 Each additional unit over four 0 91.87
0 00000 0 0 0
0 42840 0 Flap Approach for Creation of Interdental Papillae 0
0 00000 0 0 0
0 00000 42841 Per Site 0 I.C.
0 00000 0 0 0
0 42850 0 Flapless Approach, with Osteoplasty/Ostectomy for Crown Lengthening 0
0 00000 0 0 0
0 00000 42851 Per site 0 183.75
0 00000 0 0 0
43000 00 PERIODONTAL PROCEDURES, ADJUNCTIVE 0
0 00000 0 (when per joint is designated, the corresponding tooth code is represented by the mesial of the tooth 0
involved, except at the midline, where the tooth to the right of the joint is utilized)

0 00000 0 0 0
43100 00 PERIODONTAL SPLINTING OR LIGATION, INTRA CORONAL Note: This procedure is in addition to the 0
usual code for the tooth preparation on either side
0 00000 0 0 0
0 43110 0 "A" Splint (restorative material plus wire, fibre ribbon or rope) 0
0 00000 0 0 0
0 00000 43111 Per joint +E 177.32
0 00000 0 0 0
43200 00 PERIODONTAL SPLINTING OR LIGATION, EXTRA CORONAL 0
0 00000 0 0 0
0 43220 0 Bonded, Interproximal Enamel Splint 0
0 00000 0 0 0
0 00000 43221 Per joint 0 87.51
0 00000 0 0 0
0 43230 0 Wire Ligation 0
0 00000 0 0 0
0 00000 43231 Per joint 0 87.51
0 00000 0 0 0
0 43240 0 Wire Ligation, Restorative Material Covered 0
0 00000 0 0 0
0 00000 43241 Per joint 0 87.51
0 00000 0 0 0
0 43260 0 Orthodontic Band Splint 0
0 00000 0 0 0
0 00000 43261 Per band +E 87.51
0 00000 0 0 0
0 43270 0 Cast/Soldered/Ceramic/Polymer Glass/Wire/Fibre Ribbon, Splint Bonded 0
0 00000 0 0 0
0 00000 43271 Indirect, Per abutment +L 87.51
0 00000 43272 Direct, Per abutment +E 87.51
0 00000 0 0 0
0 43280 0 Removal of Fixed Periodontal Splints 0
0 00000 0 0 0

28
0 00000 43281 One unit of time 0 87.51
0 00000 43289 Each additional unit of time 0 87.51
0 00000 0 0 0
43400 0 0 ROOT PLANING, PERIODONTAL 0
0 00000 0 0 0
0 43420 0 Root Planing 0
0 00000 0 0 0
0 00000 43421 One unit of time 0 83.55
0 00000 43422 Two units of time 0 167.10
0 00000 43423 Three units of time 0 250.65
0 00000 43424 Four units of time 0 334.20
0 00000 43425 Five units of time 0 417.75
0 00000 43426 Six units of time 0 501.30
0 00000 43427 1/2 unit of time 0 41.78
0 00000 43429 Each additional unit over six 0 83.55
0 00000 0 0 0
43500 0 0 CHEMOTHERAPEUTIC and/or ANTIMICROBIAL AGENTS 0
0 00000 0 0 0
0 43510 0 Chemotherapeutic and/or Antimicrobial Agents, Topical Application 0
0 00000 0 0 0
0 00000 43511 One unit of time 0 87.51
0 00000 43519 Each additional unit of time 0 87.51
0 00000 0 0 0
0 43520 0 Chemotherapeutic and/or Antimicrobial Therapy, Intra-Sulcular Application 0
0 00000 0 0 0
0 00000 43521 One unit of time +E 91.87
0 00000 43529 Each additional unit of time +E 91.87
0 00000 0 0 0
0 00000 0 0 0
49000 0 0 PERIODONTAL SERVICES, MISCELLANEOUS 0
0 00000 0 0 0
49100 0 0 PERIODONTAL RE-EVALUATION/EVALUATION 0
0 00000 0 Note: This follow-up service applies to the evaluation of ongoing periodontal treatment or to a post- 0
surgical re-evaluation performed more than one (1) month after surgery, or if performed by another
practitioner
0 00000 0 0 0
0 00000 49101 One unit of time 0 87.51
0 00000 49102 Two units 0 175.02
0 00000 49109 Each additional unit over two 0 87.51
0 00000 0 0 0
49300 00 SOFT TISSUE PROSTHESIS 0
0 0 0 0 0
0 0 49301 Gingival Mask +L I.C.
(Removable appliance to mask unaesthetic embrasures Note: For extensive gingival prostheses
required after maxillofacial surgery see sub-classification 57300 Prosthesis Maxillofacial, other, code
57372 Gingival Prosthesis)

0 00000 0 0 0
50000 00000 0 PROSTHODONTICS - REMOVABLE 0
0 00000 0 0 0
0 00000 0 Special Aesthetic and anatomical considerations involving additional chair time and/or responsibility 0
may require an increase over the basic fee.
0 00000 0 0 0
0 00000 0 Special aesthetic and functional laboratory costs beyond normal laboratory charges will require an 0
increase over the basic fee.
0 00000 0 0 0
0 00000 0 EXAMINATION, DIAGNOSIS AND TREATMENT PLAN - Refer to Diagnostic Services, separate fee. 0

0 00000 0 0 0
0 00000 0 0 0
51000 00 DENTURE COMPLETE 0
0 00000 0 (includes: impressions, initial and final jaw relation records, try-in evaluation and check records, 0
insertion and adjustments, including three month post insertion care)

0 00000 0 0 0
51100 00 DENTURE COMPLETE, STANDARD 0
0 00000 0 0 0
0 00000 51101 Maxillary +L 931.16

29
0 00000 51102 Mandibular +L 931.16
0 00000 51104 Liners, Processed, Resilient, in addition to above 0 LAB
0 00000 0 0 0
51200 0 0 DENTURES, COMPLETE, COMPLEX 0
0 00000 0 0 0
0 00000 51201 Maxillary +L 1,924.96
0 00000 51202 Mandibular +L 1,924.96
0 00000 51204 Liners, Processed, Resilient in addition to above 0 LAB
0 00000 0 0 0
51300 0 0 DENTURES, SURGICAL, STANDARD, (IMMEDIATE) 0
0 00000 0 (includes first tissue conditioner, but not a processed reline) 0
0 00000 0 0 0
0 00000 51301 Maxillary +L 931.16
0 00000 51302 Mandibular +L 931.16
0 00000 0 0 0
51400 0 0 DENTURES, SURGICAL, COMPLEX (IMMEDIATE) 0
0 00000 0 (includes first tissue conditioner, but not a processed reline) 0
0 00000 0 0 0
0 00000 51401 Maxillary +L 1,317.07
0 00000 51402 Mandibular +L 1,317.07
0 00000 0 0 0
51500 0 0 DENTURES, COMPLETE, GNATHOLOGICAL (CAST BASE AND METAL OCCLUSALS) 0
0 00000 0 0 0
0 00000 51501 Maxillary 0 I.C.
0 00000 51502 Mandibular 0 I.C.
0 00000 0 0 0
51600 0 0 DENTURES, COMPLETE, PROVISIONAL 0
0 00000 0 0 0
0 00000 51601 Maxillary +L 643.22
0 00000 51602 Mandibular +L 643.22
0 00000 0 0 0
51700 0 0 DENTURES, COMPLETE, OVERDENTURES, TISSUE BORNE, SUPPORTED BY NATURAL TEETH OR 0
IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS
0 00000 0 0 0
0 51710 0 Dentures, Complete, Overdentures, Tissue Borne, Supported by Natural Teeth with or without Coping 0
Crowns, no Attachments
0 00000 0 0 0
0 00000 51711 Maxillary +L 1,215.77
0 00000 51712 Mandibular +L 1,215.77
0 00000 0 0 0
0 51720 0 Dentures, Complete, Overdentures, Tissue Borne, Supported by Implants with or without Coping 0
Crowns, no Attachments
0 00000 0 0 0
0 00000 51721 Maxillary +L 1,215.77
0 00000 51722 Mandibular +L 1,215.77
0 00000 0 0 0
0 51730 0 Dentures, Complete, Overdentures Tissue Borne, Supported by a Combination of Natural Teeth and 0
Implants with or without Coping Crowns, no Attachments
0 00000 0 0 0
0 00000 51731 Maxillary +L 1,215.77
0 00000 51732 Mandibular +L 1,215.77
0 00000 0 0 0
51800 0 0 DENTURES, COMPLETE, OVERDENTURES, (IMMEDIATE), TISSUE BORNE, SUPPORTED BY NATURAL 0
TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS
0 00000 0 0 0
0 51810 0 Dentures, Complete, Overdentures (Immediate), Tissue Borne, Supported by Natural Teeth with or 0
without Implants with or without Coping Crowns, no Attachments (includes first tissue conditioner,
but not a processed reline)
0 00000 0 0 0
0 00000 51811 Maxillary +L 1,102.59
0 00000 51812 Mandibular +L 1,102.59
0 00000 0 0 0
51900 0 0 DENTURES, COMPLETE, OVERDENTURES, TISSUE BORNE, SECURED BY ATTACHMENTS TO NATURAL 0
TEETH OR IMPLANTS
0 00000 0 0 0
0 51910 0 Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to Natural 0
Teeth with or without Coping Crowns
0 00000 0 0 0

30
0 00000 51911 Maxillary +L 1,102.59
0 00000 51912 Mandibular +L 1,102.59
0 00000 0 0 0
0 51920 0 Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to 0
Implants with or without Coping Crowns
0 00000 0 0 0
0 00000 51921 Maxillary +L I.C.
0 00000 51922 Mandibular +L I.C.
0 00000 0 0 0
0 51930 0 Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to a 0
Combination of Natural Teeth and Implants with or without Coping Crowns
0 00000 0 0 0
0 00000 51931 Maxillary +L I.C.
0 00000 51932 Mandibular +L I.C.
0 00000 0 0 0
0 51950 0 Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to 0
Coping Crowns Supported by Implants
0 00000 0 0 0
0 00000 51951 Maxillary +L I.C.
0 00000 51952 Mandibular +L I.C.
0 00000 0 0 0
0 51960 0 Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to 0
Coping Crowns Supported by a Combination of a Natural Teeth and Implants (see 62105 for Retentive
Bar)
0 00000 0 0 0
0 00000 51961 Maxillary +L I.C.
0 00000 51962 Mandibular +L I.C.
0 00000 0 0 0
52000 00 DENTURES, PARTIAL, ACRYLIC 0
0 00000 0 0 0
0 52100 0 Dentures, Partial, Acrylic Base (Provisional) (With or Without Clasps) 0
0 00000 0 0 0
0 00000 52101 Maxillary +L 268.07
0 00000 52102 Mandibular +L 268.07
0 00000 0 0 0
0 00000 0 0 0
0 52110 0 Dentures, Partial, Acrylic Base (Immediate) 0
0 00000 0 (includes first tissue conditioner, but not a processed reline) 0
0 00000 0 0 0
0 00000 52111 Maxillary +L 268.07
0 00000 52112 Mandibular +L 268.07
0 00000 0 0 0
52200 00 DENTURES, PARTIAL, POLYMER, RESILIENT RETAINER 0
0 00000 0 0 0
0 00000 52201 Maxillary +L 268.07
0 00000 52202 Mandibular +L 268.07
0 00000 0 0 0
0 52210 0 Dentures, Partial, Polymer, Resilient Retainer, (Immediate) 0
0 00000 0 (includes first tissue conditioner, but not a processed reline) 0
0 00000 0 0 0
0 00000 52211 Maxillary +L 268.07
0 00000 52212 Mandibular +L 268.07
0 00000 0 0 0
52300 0 0 DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS 0
0 00000 0 0 0
0 00000 52301 Maxillary +L 901.40
0 00000 52302 Mandibular +L 901.40
0 00000 0 0 0
0 52310 0 Dentures, Partial, Acrylic, with Metal Wrought/Cast Clasps and/or Rests, 0
0 00000 0 (Immediate) (includes first tissue conditioner, but not a processed reline) 0
0 00000 0 0 0
0 00000 52311 Maxillary +L 901.40
0 00000 52312 Mandibular +L 901.40
0 00000 0 0 0
52400 0 0 DENTURES, PARTIAL, ACRYLIC, WITH METAL/WROUGHT PALATAL/LINGUAL BAR AND CLASPS 0
AND/OR RESTS
0 00000 0 0 0
0 00000 52401 Maxillary +L 901.40

31
0 00000 52402 Mandibular +L 901.40
0 00000 0 0 0
0 52410 0 Dentures, Partial, Acrylic, with Metal Wrought Palatal/Lingual Bar and Clasps and/or Rests, 0
(Immediate) (includes first tissue conditioner, but not a processed reline)
0 00000 0 0 0
0 00000 52411 Maxillary +L 901.40
0 00000 52412 Mandibular +L 901.40
0 00000 0 0 0
0 52510 0 Dentures, Partial (Flexible, Non Metal, Non Acrylic) 0
0 00000 0 0 0
0 00000 52511 Maxillary +L 661.19
0 00000 52512 Mandibular +L 661.19
0 00000 0 0 0
52700 0 0 DENTURES, PARTIAL, OVERDENTURES, ACRYLIC, WITH CAST/WROUGHT CLASPS AND/OR RESTS 0
SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING CROWNS, NO
ATTACHMENTS
0 00000 0 0 0
0 52710 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests supported by 0.00
Natural Teeth with or without Coping Crowns, no attachments
0 00000 0 0 0.00
0 00000 52711 Maxillary +L 1,105.48
0 00000 52712 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52720 0 Dentures, Partial, Overdentures, Acrylic, with Cast/ Wrought Clasps and/or Rests, Supported by 0.00
Implants with or without Coping Crowns, no attachments
0 00000 0 0 0.00
0 00000 52721 Maxillary +L 1,105.48
0 00000 52722 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52730 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests Supported by a 0.00
Combination of Natural Teeth and Implants with or without Coping Crowns, no attachments

0 00000 0 0 0.00
0 00000 52731 Maxillary +L 1,105.48
0 00000 52732 Mandibular +L 1,105.48
0 00000 0 0 0.00
52800 0 0 DENTURES, PARTIAL, OVERDENTURES (IMMEDIATE), ACRYLIC, WITH CAST/WROUGHT CLASPS 0
AND/OR RESTS SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH OR WITHOUT COPING
CROWNS, NO ATTACHMENTS
0 00000 0 0 0.00
0 52810 0 Dentures, Partial, Overdentures (Immediate), Acrylic, with Cast/Wrought Clasps and/or Rests 0.00
Supported by Natural Teeth with or without Coping Crowns, no Attachments (includes first tissue
conditioner, but not a processed reline)
0 00000 0 0 0.00
0 00000 52811 Maxillary +L 1,105.48
0 00000 52812 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52820 0 Dentures, Partial, Overdentures (Immediate), Acrylic, with Cast/Wrought Clasps and/or Rests 0.00
Supported by Implants with or without Coping Crowns, no Attachments (includes first tissue
conditioner, but not a processed reline)
0 00000 0 0 0.00
0 00000 52821 Maxillary +L 1,105.48
0 00000 52822 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52830 0 Dentures, Partial, Overdentures (Immediate), Acrylic with Cast/Wrought Clasps and/or Rests Secured 0.00
by a Combination of Natural Teeth and Implants with or without Coping Crowns, no Attachments
(includes first tissue conditioner, but not a processed reline)
0 00000 0 0 0.00
0 00000 52831 Maxillary +L 1,105.48
0 00000 52832 Mandibular +L 1,105.48
0 00000 0 0 0.00
52900 0 0 DENTURES, PARTIAL, OVERDENTURES, ACRYLIC, WITH CAST/WROUGHT CLASPS AND/OR RESTS 0
SECURED BY NATURAL TEETH OR IMPLANTS
0 00000 0 0 0.00
0 52910 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests with Independent 0.00
Attachments Secured by Attachments to Natural Teeth with or without Coping Crowns

0 00000 0 0 0.00
0 00000 52911 Maxillary +L 1,105.48

32
0 00000 52912 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52920 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with Independent 0.00
Attachments Secured to Implants with or without Coping Crowns
0 00000 0 0 0.00
0 00000 52921 Maxillary +L 1,105.48
0 00000 52922 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52930 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with Independent 0.00
Attachments Secured to a Combination of Natural Teeth and Implants with or without Coping
Crowns [used with 26101, 26103 (Mesostructures); or 28221, 28225, 28226 (Cast Metal Coping
Crowns) with or without Attachments]
0 00000 0 0 0.00
0 00000 52931 Maxillary +L 1,105.48
0 00000 52932 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52940 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with Retention 0.00
from a Retentive Bar, Secured to Coping Crowns Supported by Natural Teeth (see 62104 for Retentive
Bar)
0 00000 0 0 0.00
0 00000 52941 Maxillary +L 1,105.48
0 00000 52942 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52950 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with Retention 0.00
from a Retentive Bar, Secured to Coping Crowns Supported by Implants (see 62105 for Retentive Bar)

0 00000 0 0 0.00
0 00000 52951 Maxillary +L 1,105.48
0 00000 52952 Mandibular +L 1,105.48
0 00000 0 0 0.00
0 52960 0 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with Retention 0.00
from a Retentive Bar, Secured to Coping Crowns Supported by a combination of Natural Teeth and
Implants (see 62105 for Retentive Bar)
0 00000 0 0 0.00
0 00000 52961 Maxillary +L 1,105.48
0 00000 52962 Mandibular +L 1,105.48
0 00000 0 0 0
53000 00 DENTURES, PARTIAL, CAST WITH ACRYLIC BASE 0
0 00000 0 0 0
53100 00 DENTURES, PARTIAL, FREE END, CAST FRAME/CONNECTOR, CLASPS AND RESTS 0
0 00000 0 0 0
0 00000 53101 Maxillary +L 930.12
0 00000 53102 Mandibular +L 930.12
0 00000 53104 Altered Cast Impression technique in conjunction with 53101 and 53102 +L 98.77
0 00000 0 0 0
0 53110 0 Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests, (Immediate) (includes first 0
tissue conditioner, but not a processed reline)
0 00000 0 0 0
0 00000 53111 Maxillary +L 1,102.59
0 00000 53112 Mandibular +L 1,102.60
0 00000 0 0 0
0 53120 0 Dentures, Partial Free End, Swing Lock/Connector 0
0 00000 0 0 0
0 00000 53121 Maxillary +L 1,154.98
0 00000 53122 Mandibular +L 1,154.98
0 00000 0 0 0
0 53130 0 Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests (Equilibrated) 0
0 00000 0 0 0
0 00000 53131 Maxillary +L 2,213.70
0 00000 53132 Mandibular +L 2,213.70
0 00000 0 0 0
53200 0 0 DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR, CLASPS AND RESTS 0
0 0 0 0 0
0 00000 53201 Maxillary +L 1,102.59
0 00000 53202 Mandibular +L 1,102.59
0 00000 53205 Unilateral, one piece casting, clasps and pontics +L 643.16
0 00000 0 0 0

33
0 53210 0 Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and Rests, (Immediate) (includes first 0
tissue conditioner, but not a processed reline)
0 00000 0 0 0
0 00000 53211 Maxillary +L 1,102.59
0 00000 53212 Mandibular +L 1,102.59
0 00000 53215 Unilateral, one piece casting, clasps and pontics +L 643.15
0 00000 0 0 0
0 53220 0 Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and Rests (Equilibrated) 0
0 00000 0 0 0
0 00000 53221 Maxillary +L 2,213.70
0 00000 53222 Mandibular +L 2,213.70
0 00000 0 0 0
53400 00 DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS 0
0 00000 0 0 0
0 00000 53401 Maxillary +L I.C.
0 00000 53402 Mandibular +L I.C.
0 00000 53404 Altered Cast Impression Technique done in conjunction with the above mentioned codes +L I.C.

0 00000 0 0 0
53500 00 DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS 0
0 00000 0 0 0
0 00000 53501 Maxillary +L I.C.
0 00000 53502 Mandibular +L I.C.
0 00000 53504 Altered Cast Impression Technique done in conjunction with the above mentioned codes 0 I.C.

0 00000 0 0 0
53600 00 DENTURES, PARTIAL, CAST, STRESS BREAKER ATTACHMENTS 0
0 00000 0 0 0
0 53610 0 Denture, Cast Partial, Maxillary, Stress Breaker Attachments 0
0 00000 0 0 0
0 00000 53611 Maxillary (resilient) +L 1,102.59
0 00000 53612 Maxillary (one hinge) +L 1,102.59
0 00000 53613 Maxillary (two hinges) +L 1,102.59
0 00000 53614 Altered Cast Impression Technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53620 0 Dentures, Cast Partial, Mandibular, Stress Breaker Attachments 0
0 00000 0 0 0
0 00000 53621 Mandibular (resilient) +L 1,102.59
0 00000 53622 Mandibular (one hinge) +L 1,102.59
0 00000 53623 Mandibular (two hinges) +L 1,102.59
0 00000 53624 Altered Cast Impression Technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
53700 0 0 DENTURES, PARTIAL, CAST, OVERDENTURES, SUPPORTED BY NATURAL TEETH OR IMPLANTS WITH 0
OR WITHOUT COPING CROWNS, NO ATTACHMENTS
0 00000 0 0 0
0 53710 0 Dentures, Partial, Cast, Overdentures, Supported by Natural Teeth with or without Coping Crowns, 0
no Attachments
0 00000 0 0 0
0 00000 53711 Maxillary +L 1,102.59
0 00000 53712 Mandibular +L 1,102.59
0 00000 53714 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53720 0 Dentures, Partial, Casts, Overdentures, Supported by Implants with or without Coping Crowns, No 0
Attachments
0 00000 0 0 0
0 00000 53721 Maxillary +L 1,102.60
0 00000 53722 Mandibular +L 1,102.60
0 00000 53724 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53730 0 Dentures, Partial, Casts, Overdentures, Supported by a Combination of Natural Teeth and Implants 0
with or without Coping Crowns, No Attachments
0 00000 0 0 0
0 00000 53731 Maxillary +L 1,102.60
0 00000 53732 Mandibular +L 1,102.60

34
0 00000 53734 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
53800 0 0 DENTURES, PARTIAL, CAST, OVERDENTURES (IMMEDIATE), SUPPORTED BY NATURAL TEETH OR 0
IMPLANTS WITH OR WITHOUT COPING CROWNS, NO ATTACHMENTS
0 00000 0 0 0
0 53810 0 Dentures, Partial, Cast, Overdentures (Immediate), Supported by Natural Teeth with or without 0
Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline)

0 00000 0 0 0
0 00000 53811 Maxillary +L 1,102.60
0 00000 53812 Mandibular +L 1,102.60
0 00000 53814 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53820 0 Dentures, Partial, Cast, Overdentures (Immediate), Supported by Implants with or without Coping 0
Crowns, No Attachments (includes first tissue conditioner, but not a processed reline)
0 00000 0 0 0
0 00000 53821 Maxillary +L 1,102.60
0 00000 53822 Mandibular +L 1,102.60
0 00000 53824 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53830 0 Dentures, Partial, Cast, Overdentures (Immediate), Supported by a Combination of Natural Teeth and 0
Implants with or without Coping Crowns, No Attachments (includes first tissue conditioner, but not a
processed reline)
0 00000 0 0 0
0 00000 53831 Maxillary +L 1,102.60
0 00000 53832 Mandibular +L 1,102.60
0 00000 53834 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
53900 0 0 DENTURES, PARTIAL, CAST, OVERDENTURES, SECURED BY ATTACHMENTS TO NATURAL TEETH OR 0
IMPLANTS
0 00000 0 0 0
0 53910 0 Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to Natural Teeth, with 0
or without Coping Crowns
0 00000 0 0 0
0 00000 53911 Maxillary +L 1,194.56
0 00000 53912 Mandibular +L 1,194.56
0 00000 53914 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53920 0 Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to Implants, with or 0
without Coping Crowns
0 00000 0 0 0
0 00000 53921 Maxillary +L 1,194.56
0 00000 53922 Mandibular +L 1,194.56
0 00000 53924 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53930 0 Dentures, Partial, Cast, Overdentures, with Independent Attachments Secured to a Combination of 0
Natural Teeth and Implants, with or without Coping Crowns
0 00000 0 0 0
0 00000 53931 Maxillary +L 1,194.56
0 00000 53932 Mandibular +L 1,194.56
0 00000 53934 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53940 0 Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping 0
Crowns Supported by Natural Teeth (see 62104 for Retentive Bar)
0 00000 0 0 0
0 00000 53941 Maxillary +L 1,194.56
0 00000 53942 Mandibular +L 1,194.56
0 00000 0 0 0
0 53950 0 Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping 0
Crowns Supported by Implants (see 62105 for Retentive Bar)
0 00000 0 0 0
0 00000 53951 Maxillary +L 1,194.56

35
0 00000 53952 Mandibular +L 1,194.56
0 00000 53954 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
0 53960 0 Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping 0
Crowns Supported by a Combination of Natural Teeth and Implants (see 62105 for Retentive Bar)

0 00000 0 0 0
0 00000 53961 Maxillary +L 1,194.56
0 00000 53962 Mandibular +L 1,194.56
0 00000 53964 Altered Cast Impression technique done in conjunction with the above mentioned codes 0 98.77

0 00000 0 0 0
54000 0 0 DENTURES, ADJUSTMENTS 0
0 00000 0 (after three months insertion or by other than the dentist providing prosthesis) 0
0 00000 0 0 0
54200 00 DENTURE ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE, MINOR 0
0 00000 0 0 0
0 00000 54201 One unit of time +L 80.24
0 00000 54202 Two units +L 160.48
0 00000 54209 Each additional unit over two 0 80.24
0 00000 0 0 0
54300 0 0 DENTURE ADJUSTMENTS, PARTIAL, OR COMPLETE DENTURE, REMOUNT AND OCCLUSAL 0
EQUILIBRATION
0 00000 0 0 0
0 00000 54301 Maxillary +L 795.98
0 00000 54302 Mandibular +L 795.98
0 00000 0 0 0
54400 0 0 DENTURE ADJUSTMENTS, COMPLETE DENTURE, WITH CAST METAL OCCLUSAL SURFACES, REMOUNT 0
AND OCCLUSAL EQUILIBRATION
0 00000 0 0 0
0 00000 54401 Maxillary +L 795.98
0 00000 54402 Mandibular +L 795.98
0 00000 0 0 0
54500 0 0 DENTURE, ADJUSTMENTS, PARTIAL DENTURE, WITH CAST METAL OCCLUSAL SURFACES, REMOUNT 0
AND OCCLUSAL EQUILIBRATION
0 00000 0 0 0
0 00000 54501 Maxillary +L 795.98
0 00000 54502 Mandibular +L 795.98
0 00000 0 0 0
55000 0 0 DENTURES, REPAIRS/ADDITIONS 0
0 00000 0 0 0
55100 0 0 DENTURE, REPAIRS, COMPLETE DENTURE, NO IMPRESSION REQUIRED 0
0 00000 0 0 0
0 00000 55101 Maxillary +L 88.66
0 00000 55102 Mandibular +L 88.66
0 00000 0 0 0
55200 0 0 DENTURE, REPAIRS, COMPLETE DENTURE, IMPRESSION REQUIRED 0
0 00000 0 0 0
0 00000 55201 Maxillary +L 162.16
0 00000 55202 Mandibular +L 162.16
0 00000 0 0 0
55300 0 0 DENTURE, REPAIRS/ADDITIONS, PARTIAL DENTURE, NO IMPRESSION REQUIRED 0
0 00000 0 0 0
0 00000 55301 Maxillary +L 90.95
0 00000 55302 Mandibular +L 90.95
0 00000 0 0 0
55400 0 0 DENTURES, REPAIRS/ADDITIONS, PARTIAL DENTURE, IMPRESSION REQUIRED 0
0 00000 0 0 0
0 00000 55401 Maxillary +L 179.62
0 00000 55402 Mandibular +L 179.62
0 00000 0 0 0
55500 0 0 DENTURES/IMPLANT RETAINED PROSTHESIS PROPHYLAXIS AND POLISHING 0
0 00000 0 0 0
0 00000 55501 One unit of time +L 90.05
0 00000 55509 Each additional unit of time 0 90.05
0 00000 0 0 0

36
55600 0 0 DENTURES, REBUILDING WORN ACRYLIC DENTURE TEETH (DIRECT CHAIRSIDE) WITH TOOTH 0
COLOURED MATERIALS
0 00000 0 0 0
0 00000 55601 One unit of time 0 91.87
0 00000 55609 Each addition unit of time 0 91.87
0 00000 0 0 0
55700 0 0 DENTURES, CUSTOM STAINED (PIGMENTED) DENTURE BASES (DIRECT CHAIRSIDE) 0
0 00000 0 0 0
0 00000 55701 One unit of time 0 98.77
0 00000 55709 Each addition unit of time 0 98.77
0 00000 0 0 0
56000 0 0 DENTURES, REPLICATION, RELINING AND REBASING 0
0 00000 0 0 0
56100 0 0 DENTURES, REPLICATION, PROVISIONAL 0
0 00000 0 0 0
0 56110 0 Dentures, Replication, Complete Denture, Provisional (No Intra-oral Impression Required) 0
0 00000 0 0 0
0 00000 56111 Maxillary +L 188.82
0 00000 56112 Mandibular +L 188.82
0 00000 0 0 0
0 56120 0 Dentures, Replication, Partial Denture (Provisional) (No Intra-oral Impression Required) 0
0 00000 0 0 0
0 00000 56121 Maxillary +L 188.82
0 00000 56122 Mandibular +L 188.82
0 00000 0 0 0
56200 0 0 DENTURES, RELINING (Does not include Remount - see 54000 series) 0
0 00000 0 0 0
0 56210 0 Denture, Reline, Direct Complete Denture 0
0 00000 0 0 0
0 00000 56211 Maxillary 0 242.19
0 00000 56212 Mandibular 0 242.19
0 00000 0 0 0
0 56220 0 Denture, Reline, Direct, Partial Denture 0
0 00000 0 0 0
0 00000 56221 Maxillary 0 262.53
0 00000 56222 Mandibular 0 262.53
0 00000 0 0 0
0 56230 0 Denture, Reline, Processed, Complete Denture 0
0 00000 0 0 0
0 00000 56231 Maxillary +L 262.53
0 00000 56232 Mandibular +L 262.53
0 00000 0 0 0
0 56240 0 Denture, Reline, Processed, Partial Denture 0
0 00000 0 0 0
0 00000 56241 Maxillary +L 262.53
0 00000 56242 Mandibular +L 262.53
0 00000 0 0 0
0 56250 0 Denture, Reline, Processed, Functional Impression Requiring Three Appointments, Complete Denture 0

0 00000 0 0 0
0 00000 56251 Maxillary +L 437.58
0 00000 56252 Mandibular +L 437.58
0 00000 0 0 0
0 56260 0 Denture, Reline, Processed, Functional Impression Requiring Three Appointments, Partial Denture 0

0 00000 0 0 0
0 00000 56261 Maxillary +L 437.58
0 00000 56262 Mandibular +L 437.58
0 00000 0 0 0
56300 00 DENTURES, REBASING (Where the vestibular tissue-contacting surfaces are modified) 0
0 00000 0 0 0
0 56310 0 Denture, Rebase Complete Denture 0
0 00000 0 0 0
0 00000 56311 Maxillary +L 262.53
0 00000 56312 Mandibular +L 262.53
0 00000 0 0 0
0 56320 0 Denture, Rebase Partial Denture 0
0 00000 0 0 0

37
0 00000 56321 Maxillary +L 262.53
0 00000 56322 Mandibular +L 262.53
0 00000 0 0 0
0 56330 0 Denture, Rebase, Complete Denture, Processed, Functional Impression Requiring Three 0
Appointments
0 00000 0 0 0
0 00000 56331 Maxillary +L 437.58
0 00000 56332 Mandibular +L 437.58
0 00000 0 0 0
0 56340 0 Denture, Rebase, Partial Denture, Processed, Functional Impression, Requiring Three Appointments 0

0 00000 0 0 0
0 00000 56341 Maxillary +L 437.58
0 00000 56342 Mandibular +L 437.58
0 00000 0 0 0
56400 00 DENTURES, REMAKE 0
0 00000 0 0 0
0 56410 0 Dentures, Remake, Using Existing Framework, Partial Denture (equilibration) 0
0 00000 0 0 0
0 00000 56411 Maxillary +L 350.07
0 00000 0 0 to 569.47
0 00000 56412 Mandibular +L 350.07
0 00000 0 0 to 569.47
56500 00 DENTURES, THERAPEUTIC TISSUE CONDITIONING 0
0 00000 0 0 0
0 56510 0 Denture, Therapeutic Tissue Conditioning, per appointment, Complete Denture 0
0 00000 0 0 0
0 00000 56511 Maxillary 0 175.02
0 00000 56512 Mandibular 0 175.02
0 00000 0 0 0
0 56520 0 Denture, Therapeutic Tissue Conditioning, per appointment, Partial Denture 0
0 00000 0 0 0
0 00000 56521 Maxillary 0 175.02
0 00000 56522 Mandibular 0 175.02
0 00000 0 0 0
0 56530 0 Dentures, Tissue Conditioning, per appointment, Complete Overdenture, Supported by Natural Teeth 0

0 00000 0 0 0
0 00000 56531 Maxillary 0 188.82
0 00000 56532 Mandibular 0 188.82
0 00000 0 0 0
0 56540 0 Dentures, Tissue Conditioning, per appointment, Complete Overdenture, Implant Supported 0
0 00000 0 0 0
0 00000 56541 Maxillary 0 188.82
0 00000 56542 Mandibular 0 188.82
0 00000 0 0 0
0 56550 0 Dentures, Tissue Conditioning, per appointment, Partial Overdenture, Supported by Natural Teeth 0

0 00000 0 0 0
0 00000 56551 Maxillary 0 188.82
0 00000 56552 Mandibular 0 188.82
0 00000 0 0 0
0 56560 0 Dentures, Tissue Conditioning, per appointment, Partial Overdenture, Implant Supported 0
0 00000 0 0 0
0 00000 56561 Maxillary 0 188.82
0 00000 56562 Mandibular 0 188.82
0 00000 0 0 0
56600 00 DENTURES, MISCELLANEOUS SERVICES 0
0 00000 0 0 0
0 00000 56601 Resilient Liner, in Relined or Rebased Denture (in addition to reline or rebase of denture) +L LAB

0 00000 56602 Resetting of Teeth (not including reline or rebase of denture) +L 367.51
0 00000 56603 Cast occlusal surfaces (includes remount and equilibration) +L 773.74
0 00000 0 0 0
57000 00 PROSTHESIS, MAXILLOFACIAL 0
0 00000 0 0 0
57100 00 PROSTHESIS, FACIAL 0
0 00000 0 0 0

38
0 00000 57101 Orbital +L 2,715.74
0 00000 0 0 to 6,398.11
0 00000 57102 Nose +L 2,125.35
0 00000 0 0 to 4,350.25
0 00000 57103 Ear +L 2,125.35
0 00000 0 0 to 4,350.25
0 00000 57104 Patch +L 638.65
0 00000 57105 Facial, Complex +L 2,715.74
0 00000 0 0 to 5,245.75
0 00000 57106 Facial Moulage Impression, Complete 0 417.17
0 00000 57107 Facial Moulage Impression, Sectional 0 312.87
0 00000 57108 Ocular Conformer Prosthesis (temporary post-surgical) +L 638.65
0 00000 57109 Ocular Prosthesis +L 826.52
0 00000 0 0 to 3,453.59
0 00000 0 0 0
57200 00 PROSTHESIS, MAXILLOFACIAL, OBTURATORS 0
0 00000 0 0 0
0 00000 57201 Obturator, Cleft Palate (prosthesis extra) +L 118.07
0 00000 0 0 to 511.38
0 00000 57202 Obturator, Palatal (prosthesis extra) +L 118.07
0 00000 0 0 to 511.38
0 00000 57203 Obturator, Post-Maxillectomy (prosthesis extra) +L 118.07
0 00000 0 0 to 1,278.46
0 00000 57204 Obturator, Temporary Palatal (prosthesis extra) +L 118.07
0 00000 0 0 to 1,278.46
0 00000 57205 Obturator, Resilient (prosthesis extra) +L 118.07
0 00000 0 0 to 1,278.46
0 00000 57206 Obturator, Hollow Bulb (prosthesis extra) +L 118.07
0 00000 0 0 to 1,278.46
0 00000 57207 Obturator, Inflatable (prosthesis extra) +L 472.29
0 00000 0 0 to 1,535.31
0 00000 57208 Obturator Prosthesis, Modification (relines or repairs) +L 472.29
0 00000 0 0 to 895.50
0 00000 57209 Speech Aid Prosthesis +L 826.52
0 00000 0 0 to 1,662.58
0 00000 0 0 0
57300 00 PROSTHESIS, MAXILLOFACIAL, OTHER 0
0 00000 0 0 0
0 00000 57301 Velar Bulb (prosthesis and obturator extra) +L 118.07
0 00000 0 0 to 1,278.46
0 00000 57302 Velar Lift Button, Mechanical (prosthesis and obturator extra) +L 118.07
0 00000 0 0 to 1,278.46
0 00000 57303 Retention, Spiral Spring (prosthesis extra) +L 767.08
0 00000 57304 Retention, Magnetic (prosthesis extra) +L 381.82
0 00000 57305 Guide Plane, Condylar (prosthesis extra) +L 118.07
0 00000 0 0 to 768.27
0 00000 57306 Implant, Silastic Chin +L I.C.
0 00000 57307 Mesh Prosthesis, Chrome Cobalt Mandibular Mesh +L I.C.
0 00000 57308 Skull Plate, Customized +L I.C.
0 00000 57309 Akerman, Pseudotemporomandibular Joint (prosthesis extra) +L I.C.
0 00000 57311 Feeding Appliance (for infants with cleft palate) +L 590.36
0 00000 0 0 to 1,278.46
0 00000 57321 Lingual Prosthesis +L 1,889.20
0 00000 0 0 to 3,838.85
0 00000 57341 Mandibular Resection Prosthesis with Guide Flange +L 1,180.74
0 00000 0 0 to 2,047.84
0 00000 57342 Mandibular Resection Prosthesis without Guide Flange +L 708.45
0 00000 0 0 to 1,534.16
0 00000 57351 Prosthesis, Maxillofacial, Fixed +L I.C.
0 00000 57361 Palatal Augmentation Prosthesis +L 826.52
0 00000 0 0 to 1,919.43
0 00000 57371 Palatal Life Prosthesis, Modification (relines or repairs) +L 236.14
0 00000 0 0 to 895.50
0 00000 57372 Gingival Prosthesis +L 417.17
Note: For removable appliance used to mask unaesthetic embrasures see sub-classification 49300 soft
tissue prosthesis, code 49301 Gingival Mask

39
0 00000 0 0 0
57400 00 PROSTHESIS, TEMPOROMANDIBULAR JOINT 0
0 00000 0 0 0
0 00000 57401 Exercisers, Trismus, Therapy +L 944.59
0 00000 0 0 to 1,534.16
0 00000 57402 Splints, Permanent Cast Occlusal +L 2,361.51
0 00000 0 0 to 3,838.85
0 00000 0 0 0
57500 00 PROSTHESIS, SPLINTS 0
0 00000 0 0 0
0 00000 57501 Stout +L 1,137.14
0 00000 57502 Cast Capped +L 1,592.71
0 00000 57503 Gunning (upper and lower) +L 1,592.71
0 00000 57504 Bar Splint, Cast, Labial and Lingual +L 1,592.71
0 00000 57505 Scaffolding, Rhinoplastic +L 1,592.71
0 00000 57506 Cast, Adjustable +L 1,592.71
0 00000 57508 Commissure Splint +L 354.23
0 00000 0 0 to 1,663.73
0 00000 0 0 0
57600 00 PROSTHESIS, STENTS 0
0 00000 0 0 0
0 00000 57601 Ridge Extension +L 1,137.14
0 00000 57602 Palatal +L 1,137.14
0 00000 57603 Skin Grafts +L 1,137.14
0 00000 57604 Mucous Membrane Grafts +L 1,137.14
0 00000 0 0 0
0 57650 0 Prosthesis, Radiation Appliances 0
0 00000 0 0 0
0 00000 57651 Radiation Vehicle Carrier +L 1,049.77
0 00000 0 0 to 3,413.77
0 00000 57652 Radiation Protection Shield (extra-oral) +L 1,137.14
0 00000 57653 Radiation Protection Shield (intra-oral) +L 1,137.14
0 00000 57654 Radiation Cone Locator +L 354.23
0 00000 0 0 to 2,047.84
0 00000 0 0 0
0 57660 0 Prosthesis, Stents, Decompression 0
0 00000 0 0 0
0 00000 57661 Decompression Stent, Localized +L 1,137.14
0 00000 57662 Decompression Stent, (prosthesis extra) +L 682.75
0 00000 0 0 0
57700 00 PROSTHESIS, ORTHOPEDIC 0
0 00000 0 0 0
0 00000 57701 Orthopedic Prosthesis (extraoral) +L 590.36
0 00000 0 0 to 1,278.46
0 00000 57702 Orthopedic Prosthesis (intraoral) +L 708.45
0 00000 0 0 to 1,534.16
0 00000 0 0 0
60000 00000 0 PROSTHODONTICS - FIXED 0
0 00000 0 0 0
0 00000 0 Initial description: 0
0 00000 0 Fixed prosthodontic therapy requires the use of a variety of technical and therapeutic procedures 0
depending on the nature of the problems presented in each individual case. The range of these
procedures extends into many areas of treatment in order to provide comprehensive therapy for the
patient. Many of the procedures used vary considerably in their difficulty, time, involvement and
expense. The amount of time involved in a procedure may vary considerably from those outlined in
the following guide. The individual components (abutment, retianer and pontic) of a multi-unit fixed
prosthesis each constitute seperate units of that restoration and must be coded individually.

0 00000 0 0 0
62000 00 PONTICS, BRIDGE 0
0 00000 0 0 0
62100 00 PONTICS, CAST METAL 0
0 00000 0 0 0
0 00000 62101 Pontics, Cast Metal +L 503.45
0 00000 62102 Pontics, Cast Metal Framework with Separate Porcelain/Ceramic/Polymer Glass Jacket Pontic +L 503.45

0 00000 62103 Pontics, Prefabricated Attachable Facing +L 391.57

40
0 00000 62104 Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) Bar, Attached to Retainer +L +E 503.45

0 00000 62105 Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) Bar, Attached to Implant-supported +L +E I.C.
Retainer to Retain Removable Prosthesis, Each Bar
0 00000 0 0 0
62500 00 PONTICS, PORCELAIN/CERAMIC/POLYMER GLASS 0
0 00000 0 0 0
0 00000 62501 Pontics, Porcelain/Ceramic/Polymer Glass, Fused to Metal +L 504.55
0 00000 62502 Pontics, Porcelain/Ceramic/Polymer Glass, Aluminous +L 504.55
0 00000 0 0 0
62700 00 PONTICS, ACRYLIC/COMPOSITE /COMPOMER 0
0 00000 0 0 0
0 00000 62701 Pontics, Acrylic/Composite/Compomer, Processed to Metal +L 392.72
0 00000 62702 Pontics, Acrylic/Composite/Compomer, Indirect (Provisional) +L 115.54
0 00000 62703 Pontics, Acrylic/Composite/Compomer, Bonded to adjacent Teeth Direct (Provisional) +E 115.54

0 00000 62704 Pontics, Acrylic/Composite/Compomer +L 115.54

0 00000 0 0 0
62800 0 0 PONTICS, NATURAL TOOTH 0
0 00000 0 0 0
0 00000 62801 Pontics, Natural Tooth Crown, Direct, Bonded to Adjacent Teeth (Provisional) 0 195.24
0 00000 0 0 0
63000 0 0 RECONTOURING OF RETAINER/PONTICS, (of existing bridgework) 0
0 00000 0 0 0
0 00000 63001 One unit of time 0 91.87
0 00000 63009 Each additional unit of time 0 91.87
0 00000 0 0 0
64000 0 0 MASTER CAST TECHNIQUES 0
0 00000 0 0 0
64100 0 0 MASTER CAST, TECHNIQUES, MAXILLO-MANDIBULAR REGISTRATIONS 0
0 00000 0 0 0
0 64120 0 Master Cast Techniques, True Hinge Axis Registration and Transfer 0
0 00000 0 0 0
0 00000 64121 One unit of time +L 87.75
0 00000 64129 Each additional unit of time +L 87.75
0 00000 0 0 0
0 64130 0 Master Cast Techniques, Centric Registration Recording 0
0 00000 0 0 0
0 00000 64131 One unit of time +L 87.75
0 00000 64139 Each additional unit of time +L 87.75
0 00000 0 0 0
0 64140 0 Master Cast Techniques, Three Dimensional Recordings of Mandibular Movement (Pantograph or 0
Stereograph)
0 00000 0 0 0
0 00000 64141 One unit of time +L I.C.
0 00000 64149 Each additional unit of time +L I.C.
0 00000 0 0 0
64200 0 0 MASTER CAST MOUNTING TECHNIQUES 0
0 00000 0 0 0
0 64220 0 Master Cast Mounting with Arbitrary Facebow Transfer 0
0 00000 0 0 0
0 00000 64221 One unit of time +L 87.75
0 00000 64229 Each additional unit of time +L 87.75
0 00000 0 0 0
0 64230 0 Master Cast Mounting with Kinematic Facebow Transfer 0
0 00000 0 0 0
0 00000 64231 One unit of time +L I.C.
0 00000 64239 Each additional unit of time +L I.C.
0 00000 0 0 0
64300 0 0 MASTER CAST GNATHOLOGICAL WAX-UP 0
0 00000 0 0 0
0 00000 64301 One unit of time +L I.C.
0 00000 64309 Each additional unit of time +L I.C.
0 00000 0 0 0
66000 0 0 REPAIRS 0
0 00000 0 0 0
66100 0 0 REPAIRS, REPLACEMENT 0
0 00000 0 0 0

41
0 66110 0 Replace Broken Prefabricated Attachable Facings 0
0 00000 0 0 0
0 00000 66111 One unit of time +L 91.87
0 00000 66112 Two units +L 183.74
0 00000 66113 Three units +L 275.61
0 00000 66114 Four units +L 367.48
0 00000 66119 Each additional unit over four 0 91.87
0 00000 0 0 0
66200 00 REPAIRS, REMOVAL OF EXISTING FIXED BRIDGE/PROSTHESIS 0
0 00000 0 0 0
0 66210 0 Repairs, Removal, Fixed Bridge/Prosthesis - To be re-cemented 0
0 00000 0 0 0
0 00000 66211 One unit of time +L 101.75
0 00000 66212 Two units +L 203.50
0 00000 66213 Three units +L 305.25
0 00000 66214 Four units +L 407.00
0 00000 66219 Each additional unit over four +L 101.75
0 00000 0 0 0
0 66220 0 Repairs, Removal Fixed Bridge/Prosthesis- To Be Replaced by a new Prosthesis 0
0 00000 0 0 0
0 00000 66221 One unit of time 0 94.17
0 00000 66222 Two units 0 188.34
0 00000 66223 Three units 0 282.51
0 00000 66224 Four units 0 376.68
0 00000 66229 Each additional unit over four 0 94.17
0 00000 0 0 0
66300 00 REPAIRS, REINSERTION/RECEMENTATION 0
0 00000 0 (+L where laboratory charges are incurred during repair of bridge) 0
0 00000 0 0 0
0 00000 66301 One unit of time +L 94.17
0 00000 66302 Two units +L 188.34
0 00000 66303 Three units +L 282.51
0 00000 66304 Four units +L 376.68
0 00000 66309 Each additional unit over four +L 94.17
0 00000 0 0 0
66700 00 REPAIRS, FIXED BRIDGE/PROSTHESIS 0
0 00000 0 0 0
0 66710 0 Repairs, Fixed Bridge/Prosthesis, Porcelain/Ceramic/Polymer Glass/Acrylic/Composite/Compomer, 0
Direct
0 00000 0 0 0
0 00000 66711 First tooth 0 192.49
0 00000 66719 Each additional tooth 0 192.49
0 00000 0 0 0
0 66720 0 Repairs, Solder Indexing to Repair Broken Solder Joint 0
0 00000 0 0 0
0 00000 66721 One unit of time +L 97.62
0 00000 66729 Each additional unit of time 0 97.62
0 00000 0 0 0
0 66730 0 Repair Fractured Porcelain/Metal Pontic With Telescoping Type Crown (pontic prepared, impression 0
made and processed crown seated over metal)
0 00000 0 0 0
0 00000 66731 First pontic +L 514.94
0 00000 66739 Each additional pontic 0 503.45
0 00000 0 0 0
67000 00 FIXED BRIDGE RETAINERS 0
0 00000 0 It is appropriate to use Fixed Bridge Retainer codes, rather than codes for single tooth restorations, 0
where two, or more single tooth inlays/onlays or crowns are joined (Splinted) together and do not
support a pontic
0 00000 0 0 0
67100 0 0 RETAINERS, ACRYLIC/COMPOSITE/ COMPOMER WITH, OR WITHOUT CAST OR PREFABRICATED 0
METAL BASES
0 00000 0 0 0
0 67110 0 Retainers, Acrylic, Composite/Compomer, Indirect 0
0 00000 0 0 0
0 00000 67111 Retainers, Acrylic, Composite/Compomer, Indirect +L 751.43
0 00000 67112 Retainers, Acrylic, Composite/Compomer, Complicated, Indirect +L 966.45
0 00000 67113 Retainers, Acrylic, Composite/Compomer, Provisional, Indirect (lab fabricated/relined intra-orally) +L 321.39

42
0 00000 67115 Retainers, Acrylic, Composite/Compomer, Implant-supported Indirect +L 751.43
0 00000 0 0 0
0 67120 0 Retainers, Acrylic, Composite/Compomer, Direct (provisional during healing, done at chair-side) 0

0 00000 0 0 0
0 00000 67121 Retainers, Acrylic, Composite/Compomer, Direct (provisional during healing, done at chair-side ) +E 211.57

0 00000 67125 Retainers, Acrylic, Composite/Compomer, (provisional during healing, done at chair-side), Implant- +E 212.72
supported, Direct
0 00000 0 0 0
0 67130 0 Retainers, Acrylic, Composite/Compomer, Cast Metal Base, Indirect 0
0 00000 0 0 0
0 00000 67131 Retainer, Compomer/Composite Resin/Acrylic, Processed to Cast Metal, Indirect +L 734.86
0 00000 67135 Retainer, Compomer/Composite Resin/Acrylic, Processed to Metal, Indirect, Implant-supported +L +E 783.14

0 00000 0 0 0
0 67160 0 Retainers, Acrylic/Composite/Compomer, Two surface Inlay, Indirect Bonded 0
0 00000 0 0 0
0 00000 67161 Retainers, Acrylic/Composite/Compomer, Two surface Inlay, Bonded, Indirect +L 672.41
0 00000 0 0 0
0 67170 0 Retainers, Acrylic/Composite/Compomer, Three surface Inlay, Bonded, Indirect 0
0 00000 0 0 0
0 00000 67171 Retainers, Acrylic/Composite/Compomer, Three surface Inlay, Bonded, Indirect +L 828.79
0 00000 0 0 0
0 67180 0 Retainers, Acrylic/Composite/Compomer, Onlay, Bonded, Indirect 0
0 00000 0 0 0
0 00000 67181 Retainers, Acrylic/Composite/Compomer, Onlay, Bonded, Indirect +L 986.20
0 00000 0 0 0
67200 00 RETAINER, PORCELAIN/CERAMIC/POLYMER GLASS 0
0 00000 0 0 0
0 00000 67201 Retainer, Porcelain/Ceramic/Polymer Glass +L 1,135.65
0 00000 67202 Retainer, Porcelain/Ceramic/Polymer Glass, Complicated +L 1,154.77
0 00000 67205 Retainer, Porcelain/Ceramic/Polymer Glass, Implant-supported +L +E 1,135.65
0 00000 0 0 0
0 67210 0 Retainers, Porcelain/Ceramic/Polymer Glass, Fused To Metal Base
0 00000 0 0 0
0 00000 67211 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base +L 1,037.49
0 00000 67212 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, Complicated +L 1,154.77
0 00000 67215 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, Implant-supported +L +E 1,037.49

0 00000 0 0 0
0 67220 0 Retainers, Porcelain/Ceramic/Polymer Glass, Partial Coverage, Bonded (External Retention- e.g. 0
“Maryland Bridge”)
0 00000 0 0 0
0 00000 67221 Retainer, Porcelain/Ceramic/Polymer Glass, Partial Coverage, Bonded (External Retention- e.g. +L 629.88
“Maryland Bridge”)
0 00000 0 0 0
0 67230 0 Retainers, Porcelain/Ceramic/Polymer Glass, Two surface Inlay, Bonded 0
0 00000 0 0 0
0 00000 67231 Retainers, Porcelain/Ceramic/Polymer Glass, Two surface Inlay, Bonded +L 727.20
0 00000 0 0 0
0 67240 0 Retainers, Porcelain/Ceramic/Polymer Glass, Three surface Inlay, Bonded 0
0 00000 0 0 0
0 00000 67241 Retainers, Porcelain/Ceramic/Polymer Glass, Three surface Inlay, Bonded +L 896.17
0 00000 0 0 0
0 67250 0 Retainers, Porcelain/Ceramic/Polymer Glass, Onlay, Bonded 0
0 00000 0 (where one or more cusps are restored) 0
0 00000 0 0 0
0 00000 67251 Retainers, Porcelain/Ceramic/Polymer Glass, Onlay, Bonded +L 1,063.98
0 00000 0 0 0
67300 00 RETAINERS, CAST METAL 0
0 00000 0 0 0
0 00000 67301 Retainers, Cast Metal +L 1,082.90
0 00000 67302 Retainers, Cast Metal, Complicated +L 1,154.77
0 00000 67305 Retainers, Cast Metal, Implant-Supported +L +E 1,082.90
0 00000 0 0 0
0 67310 0 Retainer, ¾ Cast Metal 0
0 00000 0 0 0

43
0 00000 67311 Retainers, ¾, Cast Metal +L 1,082.90
0 00000 67312 Retainers, ¾, Cast Metal, Complicated +L 1,154.77
0 00000 0 0 0
0 67320 0 Retainers, Cast Metal Inlay (used with broken stress technique) 0
0 00000 0 0 0
0 00000 67321 Retainer,Cast Metal Inlay, Two Surfaces +L 782.76
0 00000 67322 Retainer, Cast Metal Inlay, Three or More Surfaces +L 1,035.63
0 00000 0 0 0
0 67330 0 Retainers, Cast Metal Onlay (internal retention type) 0
0 00000 0 0 0
0 00000 67331 Retainers, Cast Metal, Onlay +L 1,082.90
0 00000 0 0 0
0 67340 0 Retainers, Cast Metal, Onlay (bonded external retention/partial coverage - e.g. Maryland Bridge) 0

0 00000 0 0 0
0 00000 67341 Retainer, Cast Metal, Onlay, with or without Perforations, Bonded to Abutment Tooth, (Pontic extra) +L 524.90

0 00000 0 0 0
67400 0 0 RETAINERS, OVERDENTURES, CUSTOM CAST OR PRE-FABRICATED WITH NO OCCLUSAL COMPONENT 0

0 00000 0 0 0
0 00000 67415 Retainer, Metal, Pre-fabricated or Custom Cast, Implant-supported, with or without Mesostructure +L +E I.C.
with no Occlusal Component (see 62105 for retentive bar)
0 00000 0 0 0
67500 0 0 FIXED PROSTHETICS, ABUTMENTS/RETAINERS, MISCELLANEOUS SERVICES 0
0 00000 0 0 0
0 00000 67501 Retainer Made to an Existing Partial Denture Clasp (additional to retainer, per retainer) +L 87.75

0 00000 67502 Telescoping Crown Unit +L 391.66

0 00000 0 0 0
69000 00 FIXED PROSTHETICS, OTHER SERVICES 0
0 00000 0 0 0
69100 00 FIXED PROSTHETICS, MISCELLANEOUS SERVICES 0
0 00000 0 0 0
0 00000 69101 Fixed Prosthesis, Porcelain, to Replace a Substantial Portion of the Alveolar Process (in addition to +L 1,119.23
retainer and pontics)
0 00000 0 0 0
69200 00 FIXED PROSTHETICS, SPLINTING 0
0 00000 0 0 0
0 00000 69201 Splinting, for Extensive or Complicated Restorative Dentistry (per tooth) 0 I.C.
0 00000 0 0 0
69300 00 FIXED PROSTHETICS, RETENTIVE PINS 0
0 00000 0 (for retainers in addition to restoration) 0
0 00000 0 0 0
0 00000 69301 One pin/restoration +L 51.27
0 00000 69302 Two pins/restoration +L 97.96
0 00000 69303 Three pins/restoration +L 155.18
0 00000 69304 Four pins/restoration +L 190.07
0 00000 69305 Five pins or more/restoration +L 223.82
0 00000 0 0 0
69600 00000 0 FIXED PROSTHODONTICS, WHERE AN ENTIRE ARCH IS RECONSTRUCTED (used in extensive or 0
complicated fixed restorative dentistry)
0 00000 0 0 0
0 69610 0 Provisional, immediate, implant-supported, screw retained, polymer base with denture teeth, 0
without a reinforcing framework.
0 00000 0 0 0
0 00000 69611 Maxillary +L I.C.
0 00000 69612 Mandibular +L I.C.
0 00000 0 0 0
0 69620 0 Final prosthesis, full arch, denture teeth and acrylic (also known as "hybrid prosthesis"), with 0
reinforcing framework, implant-supported, screw retained.
0 0 0 0 0
0 00000 69621 Maxillary +L I.C.
0 00000 69622 Mandibular +L I.C.
0 00000 0 0 0
69700 00 FIXED PROSTHETICS, PROVISIONAL COVERAGE (in extensive or complicated restorative dentistry) 0

0 00000 0 0 0

44
0 00000 69701 Abutment Tooth +L 321.38
0 00000 69702 Pontic +L 106.35
0 00000 0 0 0
69800 00 FIXED PROSTHODONTIC FRAMEWORKS, OSSEO-INTEGRATED IMPLANT-SUPPORTED 0
0 00000 0 0 0
0 69820 0 Fixed Prosthodontic Framework, Osseo-Integrated, Attached with Screws Or Cement and 0
Incorporating Teeth (Porcelain/Ceramic/Polymer Glass Bonded to Metal,
Acrylic/Composite/Compomer Processed to Metal or Full Metal Crowns)
0 00000 0 0 0
0 00000 69821 Maxillary +L I.C.
0 00000 69822 Mandibular +L I.C.
0 00000 0 0 0
70000 00000 0 ORAL MAXILLOFACIAL SURGERY 0
0 00000 0 0 0
0 00000 0 The following surgical services include necessary local anaesthetic, removal of excess gingival tissue, 0
suturing and one post-operative treatment, when required. A surgical site is an area that lends itself to
one or more procedures. It is considered to include a full quadrant, sextant or a group of teeth or in
some cases a single tooth.

0 00000 0 0 0
71000 00 REMOVALS, (EXTRACTIONS), ERUPTED TEETH 0
0 00000 0 0 0
71100 00 REMOVALS, ERUPTED TEETH, UNCOMPLICATED 0
0 00000 0 0 0
0 00000 71101 Single tooth, Uncomplicated 0 154.42
0 00000 71109 Each additional tooth, same quadrant, same appointment 0 154.42
0 00000 0 0 0
71200 00 REMOVALS, ERUPTED TEETH, COMPLICATED 0
0 00000 0 0 0
0 00000 71201 Odontectomy, (extraction), Erupted Tooth, Surgical Approach, Requiring Surgical Flap and/or 0 278.49
Sectioning of Tooth
0 00000 71209 Each additional tooth, same quadrant 0 278.49
0 00000 0 0 0
0 71210 0 Requiring elevation of a Flap, Removal of Bone and may include Sectioning of Tooth for Removal of 0
Tooth
0 00000 71211 Single Tooth 0 303.64
0 00000 71219 Each Additional tooth, same quadrant 0 303.64
0 00000 0 0 0
72000 00 REMOVALS, (EXTRACTIONS), SURGICAL 0
0 00000 0 0 0
72100 00 REMOVALS, IMPACTIONS, SOFT TISSUE COVERAGE 0
0 00000 0 0 0
0 72110 0 Removals, Impaction, Requiring Incision of Overlying Soft Tissue and Removal of The Tooth 0
0 00000 0 0 0
0 00000 72111 Single tooth 0 278.49
0 00000 72119 Each additional tooth, same quadrant 0 278.49
0 00000 0 0 0
72200 00 REMOVALS, IMPACTIONS, INVOLVING TISSUE AND/OR BONE COVERAGE 0
0 00000 0 0 0
0 72210 0 Removals, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of A Flap and Either 0
Removal of Bone and Tooth or Sectioning and Removal of Tooth ( Partial Bone Impaction)

0 00000 0 0 0
0 00000 72211 Single tooth 0 412.97
0 00000 72219 Each additional tooth, same quadrant 0 412.97
0 00000 0 0 0
0 72220 0 Removals, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of A Flap, Removal of 0
Bone and Sectioning of Tooth For Removal (Complete Bone Impaction)
0 00000 0 0 0
0 00000 72221 Single tooth 0 550.64
0 00000 72229 Each additional tooth, same quadrant 0 550.64
0 00000 0 0 0
0 72230 0 Removals, Impactions, Requiring Incision of Overlaying Soft Tissue, Elevation of A Flap, Removal of 0
Bone, And/Or Sectioning of the Tooth for Removal And/Or Presemts Unusual Difficulties and
Circumstances
0 00000 0 0 0
0 00000 72231 Single tooth 0 750.74
0 00000 72239 Each additional tooth, same quadrant 0 750.74

45
0 00000 0 0 0
0 72240 0 Coronectomy (Deliberate Vital Root Retention) 0
0 00000 0 0 0
0 00000 72241 Coronectomy (Deliberate Vital Root Retention of Unerupted Mandibular Molar) 0 I.C.
0 00000 72242 Coronectomy (Deliberate Vital Root Retention to Prevent Complications Associated with Extraction) 0 I.C.

0 00000 0 0 0
72300 00 REMOVALS, (EXTRACTIONS), RESIDUAL ROOTS 0
0 00000 0 0 0
0 72310 0 Removals, Residual Roots, Erupted 0
0 00000 0 0 0
0 00000 72311 First tooth 0 127.47
0 00000 72319 Each additional tooth, same quadrant 0 127.47
0 00000 0 0 0
0 72320 0 Removals, Residuals Roots, Soft Tissue Coverage 0
0 00000 0 0 0
0 00000 72321 First tooth 0 187.75
0 00000 72329 Each additional tooth, same quadrant 0 187.75
0 00000 0 0 0
0 72330 0 Removals, Residual Roots, Bone Tissue Coverage 0
0 00000 0 0 0
0 00000 72331 First tooth 0 275.32
0 00000 72339 Each additional tooth, same quadrant 0 275.32
0 00000 0 0 0
72400 0 0 ALVEOLAR BONE PRESERVATION 0
0 00000 0 0 0
0 72410 0 Alveolar Bone Preservation – Autograft 0
0 00000 0 0 0
0 00000 72411 First tooth +E 350.25
0 00000 72419 Each additional tooth +E 350.25
0 00000 0 0 0
0 72420 0 Alveolar Bone Preservation - Allograft 0
0 00000 72421 First tooth +E 350.25
0 00000 72429 Each additional tooth +E 350.25
0 00000 0 0 0
0 72430 0 Alveolar Bone Preservation – Xenograft 0
0 00000 72431 First tooth +E 350.25
0 00000 72439 Each additional tooth +E 350.25
0 00000 0 0 0
72500 00 SURGICAL EXPOSURES OF TEETH 0
0 00000 0 0 0
0 72510 0 Surgical Exposures, Unerupted, Uncomplicated, Soft Tissue Coverage (includes operculectomy) 0

0 00000 0 0 0
0 00000 72511 Single tooth 0 250.33
0 00000 72519 Each additional tooth, same quadrant 0 250.33
0 00000 0 0 0
0 72520 0 Surgical Exposures, Complex, Hard Tissue Coverage 0
0 00000 0 0 0
0 00000 72521 Single tooth 0 450.43
0 00000 72529 Each additional tooth, same quadrant 0 450.43
0 00000 0 0 0
0 72530 0 Surgical Exposures, Unerupted Tooth, With Orthodontic Attachment 0
0 00000 0 0 0
0 00000 72531 Single tooth +E 600.59
0 00000 72539 Each additional tooth, same quadrant +E 600.59
0 00000 0 0 0
0 72540 0 Surgical Exposures, Unerupted Tooth, Soft Tissue Coverage With Positioning of Attached Gingivae 0

0 00000 0 0 0
0 00000 72541 Single tooth 0 375.50
0 00000 0 0 0
0 72550 0 Surgical Exposures, Unerupted Tooth, Hard Tissue Coverage With Positioning of Attached Gingivae 0

0 00000 0 0 0
0 00000 72551 Single tooth 0 500.70
0 00000 0 0 0
0 72560 0 Rigid Osseous Anchorage For Orthodontics 0

46
0 00000 0 0 0
0 00000 72561 Placement of anchorage device without elevation of a flap +E I.C.
0 00000 72562 Placement of anchorage device with elevation of a flap +E I.C.
0 00000 72563 Removal of anchorage device without elevation of a flap 0 I.C.
0 00000 72564 Removal of anchorage device with elevation of a flap 0 I.C.
0 00000 0 0 0
72600 00 SURGICAL MOVEMENT OF TEETH 0
0 00000 0 0 0
0 72610 0 Transplantation of Erupted Tooth 0
0 00000 0 0 0
0 00000 72611 First tooth 0 750.74
0 00000 72619 Each additional tooth, same quadrant 0 750.74
0 00000 0 0 0
0 72620 0 Transplantation of Unerupted Tooth 0
0 00000 0 0 0
0 00000 72621 First tooth 0 900.90
0 00000 72629 Each additional tooth, same quadrant 0 900.90
0 00000 0 0 0
0 72630 0 Repositioning, Surgical 0
0 00000 0 0 0
0 00000 72631 First tooth 0 550.64
0 00000 72639 Each additional tooth, same quadrant 0 550.64
0 00000 0 0 0
72700 00 ENUCLEATION, SURGICAL 0
0 00000 0 0 0
0 72710 0 Unerupted Tooth Follicle 0
0 00000 0 0 0
0 00000 72711 First tooth 0 550.64
0 00000 72719 Each additional tooth, same quadrant 0 550.64
0 00000 0 0 0
72800 0 0 REMOVAL OF FRACTURED CUSP AS A SEPARATE PROCEDURE, NOT IN CONJUCTION WITH SURGICAL 0
OR RESTORATIVE PROCEDURES ON THE SAME TOOTH
0 00000 0 0 0
0 00000 72801 First tooth 0 92.81
0 00000 72809 Each Additional Tooth 0 92.81
0 00000 0 0 0
73000 00 REMODELLING AND RECONTOURING ORAL TISSUES IN PREPARATION FOR REMOVABLE PROSTHESES 0
(To include codes 73110, 73120, 73140, 73150, 73160, 73170, 73180)
0 00000 0 0 0
73100 00 ALVEOLOPLASTY 0
0 00000 0 (Bone remodelling of ridge with soft tissue revisions) 0
0 00000 0 0 0
0 73110 0 Alveoloplasty, In Conjunction with Extractions 0
0 00000 0 0 0
0 00000 73111 Per sextant 0 128.61
0 00000 0 0 0
0 73120 0 Alveoloplasty, Not In Conjunction with Extractions 0
0 00000 0 0 0
0 00000 73121 Per sextant 0 250.33
0 00000 0 0 0
0 73140 0 Remodelling of Bone 0
0 00000 0 0 0
0 00000 73141 Mylohyoid Ridge Remodelling 0 487.90
0 00000 73142 Genial Tubercle Remodelling 0 469.18
0 00000 0 0 0
0 73150 0 Excision of Bone 0
0 00000 0 0 0
0 00000 73151 Nasal Spine, Excision 0 469.18
0 00000 73152 Torus Palatinus, Excision 0 550.64
0 00000 73153 Torus Mandibularis, Unilateral, Excision 0 412.97
0 00000 73154 Torus Mandibularis, Bilateral, Excision 0 688.29
0 00000 0 0 0
0 73160 0 Removal of Bone, Exostosis, Multiple 0
0 00000 0 0 0
0 00000 73161 Per quadrant 0 412.97
0 00000 0 0 to 825.97
0 00000 0 0 0
0 73170 0 Reduction of Bone, Tuberosity 0

47
0 00000 0 0 0
0 00000 73171 Unilateral, Reduction 0 250.33
0 00000 73172 Bilateral, Reduction 0 500.70
0 00000 0 0 0
0 73180 0 Augmentation of Bone 0
0 00000 0 0 0
0 00000 73181 Unilateral, Pterygomaxillary Tuberosity, Augmentation +E 487.90
0 00000 73182 Bilateral, Pterygomaxillary Tuberosity, Augmentation +E 975.83
0 00000 73183 Unilateral, Mandibular Ridge, Augmentation +E 600.30
0 00000 0 0 to 800.40
0 00000 73184 Bilateral, Mandibular Ridge, Augmentation +E 1,200.59
0 00000 0 0 to 1,600.82
0 00000 0 0 0
73200 00 GINGIVOPLASTY AND/OR STOMATOPLASTY, ORAL SURGERY 0
0 00000 0 0 0
0 73210 0 Independent Procedure 0
0 00000 0 0 0
0 00000 73211 Per sextant 0 275.32
0 00000 0 0 0
0 73220 0 Miscellaneous Procedures 0
0 00000 0 0 0
0 00000 73221 Gingivoplasty, in Conjunction with Tooth Removal 0 275.32
0 00000 73222 Excision of Vestibular Hyperplasia (per sextant) 0 275.32
0 00000 73223 Surgical Shaving of Papillary Hyperplasia of the Palate 0 487.90
0 00000 73224 Excision of Pericoronal Gingiva (for retained tooth/implant) per tooth/implant 0 137.64
0 00000 0 0 0
0 73230 0 Removals, Tissue, Hyperplastic (includes the incision of the mucous membrane, the dissection and 0
removal of hyperplastic tissue, the replacing and adapting of the mucous membrane)

0 00000 0 0 0
0 00000 73231 Per sextant 0 275.32
0 00000 0 0 0
0 73240 0 Removal, Mucosa, Excess (complete removal without dissection) 0
0 00000 0 0 0
0 00000 73241 Per sextant 0 275.32
0 00000 0 0 0
73300 00 REMODELING, FLOOR OF THE MOUTH 0
0 00000 0 0 0
0 00000 73301 Full Arch Lowering of the Floor of the Mouth 0 2,401.22
0 00000 73302 Partial Arch Lowering of the Floor of the Mouth 0 1,200.59
0 00000 73303 Reinsertion of the Mylohyoid Muscle 0 1,000.49
0 00000 0 0 0
73400 00 VESTIBULOPLASTY 0
0 00000 0 0 0
0 73410 0 Vestibuloplasty, Sub-Mucous 0
0 00000 0 0 0
0 00000 73411 Per sextant 0 262.75
0 00000 0 0 0
0 73420 0 Sulcus Deepening and Ridge Reconstruction 0
0 00000 0 0 0
0 00000 73421 Per sextant 0 211.09
0 00000 0 0 0
0 73430 0 Vestibuloplasty, with Secondary Epithelization 0
0 00000 0 0 0
0 00000 73431 Per sextant 0 325.27
0 00000 0 0 0
0 73440 0 Vestibuloplasty, with Labial Inverted Flap 0
0 00000 0 0 0
0 00000 73441 Per sextant 0 487.90
0 00000 0 0 0
0 73450 0 Vestibuloplasty, with Skin Graft 0
0 00000 0 0 0
0 00000 73451 Per sextant 0 600.30
0 00000 0 0 0
0 73460 0 Vestibuloplasty, with Mucosal Graft 0
0 00000 0 0 0
0 00000 73461 Per sextant 0 600.30

48
0 00000 0 0 0
0 73470 0 Vestibuloplasty – with Dermal Graft - Autograft 0
0 00000 0 0 0
0 00000 73471 Per Sextant +E 211.09
0 00000 0 0 0
0 73480 0 Vestibuloplasty – with Dermal Graft - Allograft 0
0 00000 0 0 0
0 00000 73481 Per Sextant 0 211.09
0 00000 0 0 0
0 73490 0 Vestibuloplasty – with Connective Tissue for Ridge Augmentation 0
0 00000 0 0 0
0 00000 73491 Per sextant 0 211.09
0 00000 0 0 0
73500 0 0 RECONSTRUCTION, ALVEOLAR RIDGE 0
0 00000 0 0 0
0 73510 0 Reconstruction, Alveolar Ridge, with Autogenous Bone 0
0 00000 0 0 0
0 00000 73511 Per sextant +E 800.40
0 00000 0 0 0
0 73520 0 Reconstruction, Alveolar Ridge, with Alloplastic Material 0
0 00000 0 0 0
0 00000 73521 Per sextant +E 800.40
0 00000 0 0 0
73600 0 0 EXTENSIONS, MUCOUS FOLDS 0
0 00000 0 0 0
0 73610 0 Extensions, Mucous Folds with Secondary Epithelization 0
0 00000 0 0 0
0 00000 73611 Per sextant 0 581.55
0 00000 0 0 0
0 73620 0 Extensions, Mucous Folds, with Skin Grafts 0
0 00000 0 0 0
0 00000 73621 Per sextant 0 581.55
0 00000 0 0 0
0 73630 0 Extensions, Mucous Folds, with Mucous Graft 0
0 00000 0 0 0
0 00000 73631 Per sextant 0 581.55
0 00000 0 0 0
74000 0 0 SURGICAL EXCISIONS (not in conjunction with tooth removal, including biopsy) 0
0 00000 0 0 0
74100 0 0 SURGICAL EXCISIONS, TUMORS, BENIGN 0
0 00000 0 0 0
0 74110 0 Tumors, Benign, Scar Tissue, Inflammatory or Congenital Lesions of Soft Tissue of the Oral Cavity 0

0 00000 0 0 0
0 00000 74111 1 cm. and under 0 375.37
0 00000 74112 1-2 cm. 0 487.90
0 00000 74113 2-3 cm. 0 591.08
0 00000 74114 3-4 cm. 0 675.52
0 00000 74115 4-6 cm. 0 816.17
0 00000 74116 6-9 cm. 0 906.85
0 00000 74117 9-15 cm. 0 1,031.88
0 00000 74118 15 cm. and over 0 1,163.13
0 00000 0 0 0
0 74120 0 Tumors, Benign, Bone Tissue 0
0 00000 0 0 0
0 00000 74121 1 cm. and under 0 450.43
0 00000 74122 1-2 cm. 0 625.58
0 00000 74123 2-3 cm. 0 813.20
0 00000 74124 3-4 cm. 0 1,013.30
0 00000 74125 4-6 cm. 0 1,182.17
0 00000 74126 6-9 cm. 0 1,401.02
0 00000 74127 9-15 cm. 0 1,576.13
0 00000 74128 15 cm. and over 0 1,813.69
0 00000 0 0 0
74200 0 0 SURGICAL EXCISION, TUMORS, MALIGNANT 0
0 00000 0 0 0
0 74210 0 Tumors, Malignant, Soft Tissue, Oral Cavity 0

49
0 00000 0 0 0
0 00000 74211 1 cm. and under 0 350.25
0 00000 74212 1-2 cm. 0 525.36
0 00000 74213 2-3 cm. 0 725.46
0 00000 74214 3-4 cm. 0 906.85
0 00000 74215 4-6 cm. 0 1,125.66
0 00000 74216 6-9 cm. 0 1,313.28
0 00000 74217 9-15 cm. 0 1,550.85
0 00000 74218 15 cm. and over 0 1,744.71
0 00000 0 0 0
0 74220 0 Tumors, Malignant, Bone Tissue 0
0 00000 0 0 0
0 00000 74221 1 cm. and under 0 525.36
0 00000 74222 1-2 cm. 0 700.51
0 00000 74223 2-3 cm. 0 906.85
0 00000 74224 3-4 cm. 0 1,088.23
0 00000 74225 4-6 cm. 0 1,313.28
0 00000 74226 6-9 cm. 0 1,500.90
0 00000 74227 9-15 cm. 0 1,744.71
0 00000 74228 15 cm. and over 0 2,001.02
0 00000 0 0 0
0 74230 0 Selective neck dissection 0
0 00000 0 0 0
0 00000 74231 Unilateral 0 I.C.
0 00000 74232 Bilateral 0 I.C.
0 00000 0 0 0
0 74240 0 Radical neck dissection 0
0 00000 0 0 0
0 00000 74241 Unilateral 0 I.C.
0 00000 74242 Bilateral 0 I.C.
0 00000 0 0 0
74300 00 SURGICAL EXCISIONS, MAXILLOFACIAL COMPLEX, TRAUMA, TUMORS, BENIGN, MALIGNANT 0

0 74310 0 Lips, Throat, Face, Skull 0

0 00000 0 0 0
0 00000 74311 Cheiloplasty, Partial (Lip Shave) 0 700.51
0 00000 74312 Cheiloplasty, Total (Lip Shave) 0 1,050.76
0 00000 0 0 to 1,401.02
0 00000 0 0 0
74400 0 0 HARD TISSUE GRAFTS TO THE JAW 0
0 00000 0 0 0
0 00000 74401 Autograft – per site – Maxilla or Mandible +E 800.40
0 00000 74402 Allograft – per site – Maxilla or Mandible +E 800.40
0 00000 74403 Xenograft – per site – Maxilla or Mandible +E 800.40
0 00000 0 0 0
74500 00 AUGMENTATIONS, PROSTHETIC, OF THE JAW 0
0 00000 0 0 0
0 74520 0 Augmentation, Synthetic, of the Jaw 0
0 00000 0 0 0
0 00000 74521 Augmentation, of the Chin 0 I.C.
0 00000 0 0 0
74600 00 SURGICAL EXCISION, CYSTS/GRANULOMAS 0
0 00000 0 0 0
0 74610 0 Enucleation of Cyst/Granuloma, Odontogenic and Non-Odontogenic, Requiring Prior Removal of 0
Bony Tissue and Subsequent Suture(s)
0 00000 0 0 0
0 00000 74611 1 cm. and under 0 431.72
0 00000 74612 1-2 cm. 0 600.59
0 00000 74613 2-3 cm. 0 781.97
0 00000 74614 3-4 cm. 0 975.83
0 00000 74615 4-6 cm. 0 1,182.17
0 00000 74616 6-9 cm. 0 1,401.02
0 00000 74617 9-15 cm. 0 1,632.34
0 00000 74618 15 cm. and over 0 1,876.15
0 00000 0 0 0
0 74620 0 Marsupialization 0
0 00000 0 0 0
0 00000 74621 Cyst, Marsupialization 0 550.64

50
0 00000 0 0 0
0 74630 0 Excision of Cyst 0
0 00000 0 0 0
0 00000 74631 1 cm. and under 0 431.72
0 00000 74632 1-2 cm. 0 600.59
0 00000 74633 2-3 cm. 0 781.97
0 00000 74634 3-4 cm. 0 975.83
0 00000 74635 4-6 cm. 0 1,182.17
0 00000 74636 6-9 cm. 0 1,401.02
0 00000 74637 9-15 cm. 0 1,632.34
0 00000 74638 15 cm. and over 0 1,876.15
0 00000 0 0 0
75000 00 SURGICAL INCISIONS 0
0 00000 0 0 0
75100 00 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, INTRAORAL 0
0 00000 0 0 0
0 75110 0 Surgical Incision and Drainage and/or Exploration, Intraoral Soft Tissue 0
0 00000 0 0 0
0 00000 75111 Intraoral, Surgical Exploration, Soft Tissue 0 275.32
0 00000 75112 Intraoral, Abscess, Soft Tissue 0 275.32
0 00000 75113 Intraoral, Abscess, In Major Anatomical area with Drain 0 469.18
0 00000 0 0 0
0 75120 0 Surgical Incision and Drainage and/or Exploration, Intraoral Hard Tissue 0
0 00000 0 0 0
0 00000 75121 Intraoral, Abscess, Hard Tissue, Trephination and Drainage 0 287.80
0 00000 75122 Intraoral, Surgical Exploration, Hard Tissue 0 450.43
0 00000 75123 Intraoral, Abscess, Hard Tissue, Trephination and Drainage in a Major Anatomical Area 0 625.58

0 00000 0 0 0
75200 00 SURGICAL INCISION AND DRAINAGE AND/OR EXPLORATION, EXTRAORAL 0
0 00000 0 0 0
0 75210 0 Surgical Incision and Drainage and/or Exploration, Extraoral, Soft Tissue 0
0 00000 0 0 0
0 00000 75211 Extraoral, Abscess, Superficial 0 650.53
0 00000 75212 Extraoral, Abscess, Deep 0 813.20
0 00000 0 0 0
0 75220 0 Surgical Incision and Drainage and/or Exploration, Extraoral Hard Tissue 0
0 00000 0 0 0
0 00000 75221 Extraoral, Surgical Exploration, Hard Tissue 0 650.53
0 00000 0 0 0
75300 00 SURGICAL INCISION FOR REMOVAL OF FOREIGN BODIES 0
0 00000 0 0 0
0 00000 75301 Removal, from Skin or Subcutaneous Alveolar Tissue 0 875.62
0 00000 0 0 to 1,751.27
0 00000 75302 Removal, of Reaction Producing Foreign Bodies 0 875.62
0 00000 0 0 to 1,751.27
0 00000 75303 Removal, of Needle from Musculo-skeletal System 0 875.62
0 00000 0 0 to 1,751.27
75400 00 SEQUESTRECTOMY (FOR OSTEOMYELITIS) 0
0 00000 0 0 0
0 00000 75401 Intraoral Sequestrectomy 0 600.59
0 00000 75402 Saucerization 0 1,050.76
0 00000 75403 Osteomyelitis, Non Surgical Treatment of 0 225.22
0 00000 0 0 0
0 75410 0 Extraoral Sequestrectomy 0
0 00000 0 0 0
0 00000 75411 3 cm. and less 0 600.59
0 00000 75412 3-4 cm. 0 750.74
0 00000 75413 4-6 cm. 0 938.36
0 00000 75414 6-9 cm. 0 1,094.76
0 00000 75415 9 cm. and over 0 1,301.10
0 00000 0 0 0
75500 00 MANDIBULECTOMY 0
0 00000 0 0 0
0 75510 0 Mandibulectomy 0
0 00000 0 0 0
0 00000 75511 3 cm. or less 0 525.36

51
0 00000 75512 3-4 cm. 0 700.51
0 00000 75513 4-6 cm. 0 906.85
0 00000 75514 6-9 cm. 0 1,125.66
0 00000 75515 9-12 cm. 0 1,356.99
0 00000 75516 12-15 cm. 0 1,600.82
0 00000 75517 15 cm. and over 0 1,800.92
0 00000 75518 Total Mandibulectomy 0 2,201.12
0 00000 0 0 to 2,851.46
0 00000 0 0 0
75600 00 MAXILLECTOMY 0
0 00000 0 0 0
0 75610 0 Maxillectomy 0
0 00000 0 0 0
0 00000 75611 3 cm. or less 0 875.62
0 00000 75612 3-4 cm. 0 1,050.76
0 00000 75613 4-6 cm. 0 1,269.58
0 00000 75614 6-9 cm. 0 1,500.90
0 00000 75615 9-12 cm. 0 1,744.71
0 00000 75616 12-15 cm. 0 2,001.02
0 00000 75617 15 cm. and over 0 2,301.17
0 00000 75618 Total Maxillectomy 0 2,551.31
0 00000 0 0 to 3,401.75
0 00000 0 0 0
76000 00 FRACTURES, TREATMENT OF 0
0 00000 0 0 0
76100 00 INTERMAXILLARY FIXATION (WIRING) 0
0 00000 0 0 0
0 76110 0 Splints Per Arch, One or More Per Jaw 0
0 00000 0 0 0
0 00000 76111 Wiring of Dentures or Arch Bar 0 450.43
0 00000 76112 Acrylic Prosthesis or Cap Splint 0 450.43
0 00000 76113 Circumzygomatic Wiring, Unilateral 0 150.12
0 00000 76114 Perialveolar or Transpalatal Wiring 0 150.12
0 00000 76115 Intra or Periosseous Splinting for Pericranial Suspension 0 150.12
0 00000 76116 Intermaxillary Fixation 0 450.43
0 00000 0 0 0
0 76120 0 Intra Maxillary Suspension (Wiring) 0
0 00000 0 0 0
0 00000 76121 Nasal Spine Wiring 0 150.12
0 00000 76122 Piriform Apertures Suspension 0 150.12
0 00000 76123 Frontal Suspension 0 650.53
0 00000 76124 Orbital Rim Suspension, Bilateral 0 650.53
0 00000 76125 Head Frame Suspension 0 1,050.76
0 00000 0 0 0
0 76130 0 Circummandibular Wiring 0
0 00000 0 0 0
0 00000 76131 Wiring, one 0 150.12
0 00000 76132 Wiring, two 0 300.28
0 00000 76133 Wiring, three or over 0 450.43
0 00000 0 0 0
0 76140 0 Splints/Wires, Removal of 0
0 00000 0 0 0
0 00000 76141 Removal of Wire 0 250.33
0 00000 76142 Removal of Arch Splint (one or more per jaw) 0 250.33
0 00000 76143 Removal of Interosseous Ligature or Bone Plate 0 600.59
0 00000 76144 Removal of Intra or Periosseous Rod or Wire for Pericranial Suspension and/or Pericranial Apparatus 0 600.59

0 00000 76145 Removal of Acrylic Prosthesis or Cap Splint, Attached to Maxilla or to Teeth (one or more per jaw) 0 469.18

0 00000 76146 Removal of Wire Plate or Screw used in Osteosynthesis (one or more at the same site) 0 600.59

0 00000 0 0 0
76200 00 FRACTURES, REDUCTIONS, MANDIBULAR 0
0 00000 0 0 0
0 00000 76201 Reduction, Mandibular, Closed 0 1,201.21
0 00000 0 0 to 1,501.49
0 00000 76202 Reduction, Mandibular, Open, Single 0 1,751.27
0 00000 76203 Reduction, Mandibular, Open, Double 0 2,101.52

52
0 00000 76204 Reduction, Mandibular, Open, Multiple 0 2,326.29
0 00000 0 0 0
76300 00 FRACTURES, REDUCTIONS, MAXILLARY, HORIZONTAL LE FORT'S l 0
0 00000 0 0 0
0 00000 76301 Reduction, Maxillary, Closed 0 1,201.21
0 00000 76302 Reduction, Maxillary, Open, Single 0 1,751.27
0 00000 76303 Reduction, Maxillary, Open, Double 0 2,101.52
0 00000 76304 Reduction, Maxillary, Open, Multiple 0 2,401.22
0 00000 0 0 to 3,201.65
0 00000 76305 Reduction, Compound Fracture of Maxilla (requiring reduction and soft tissue repair) 0 3,401.75

0 00000 0 0 to 4,252.18
0 00000 0 0 0
76400 00 FRACTURES, REDUCTIONS, MAXILLARY, PYRAMIDAL LE FORT'S ll 0
0 00000 0 0 0
0 00000 76401 Reduction, Maxillary, Closed 0 1,401.02
0 00000 76402 Reduction, Maxillary, Open, Unilateral 0 1,401.02
0 00000 76403 Reduction, Maxillary, Open, Bilateral 0 2,101.52
0 00000 0 0 0
76500 00 FRACTURES, REDUCTIONS, NASO-ORBITAL 0
0 00000 0 0 0
0 00000 76501 Reduction, Closed Unilateral 0 1,088.23
0 00000 76502 Reduction, Closed Bilateral 0 2,176.46
0 00000 76503 Reduction, Naso-orbital, Open, External Approach 0 1,938.57
0 00000 76504 Reduction, Naso-orbital, Open, Sinusal Approach 0 1,938.57
0 00000 76505 Reduction, Naso-orbital, Open, Orbital Approach with Insertion of Subperiosteal Implant 0 2,132.43

0 00000 76506 Exploration, of Orbital Blowout Fracture 0 1,401.02

0 00000 76507 Exploration, of Orbital Blowout Fracture and Reconstruction with Insertion of a Subperiosteal Implant 0 2,326.29

0 00000 0 0 0
76600 00 FRACTURES, REDUCTIONS, MALAR BONE 0
0 00000 0 0 0
0 00000 76601 Reduction, Malar Bone, Closed 0 600.59
0 00000 76602 Reduction, Malar Bone, Open, by Simple Elevation 0 900.90
0 00000 76603 Reduction, Malar Bone, Open, by Osteosynthesis 0 1,600.82
0 00000 76604 Reduction, Malar Bone, Open, by Sinus Approach 0 1,313.28
0 00000 76605 Reduction, Malar Bone, Simple Fracture, (open reduction with antrostomy and packing) 0 1,313.28

0 00000 0 0 0
76700 00 FRACTURES, REDUCTIONS, ZYGOMATIC ARCH 0
0 00000 0 0 0
0 00000 76701 Reduction, Zygomatic Arch, Intraoral Approach 0 600.59
0 00000 76702 Reduction, Zygomatic Arch, Temporal Approach 0 1,401.02
0 00000 76703 Reduction, Zygomatico-Maxillary Fracture Dislocation, Complex, Closed Reduction 0 900.90
0 00000 76704 Reduction, Zygomatico-Maxillary Fracture Dislocation, Open Reduction 0 1,751.27
0 00000 0 0 0
76800 00 FRACTURES, REDUCTIONS, CRANIOFACIAL OTHER (specify type of procedure according to previous 0
code used for fracture)
0 00000 0 0 0
0 00000 76801 Reduction, Craniofacial Dysjunction, Closed 0 2,401.22
0 00000 76802 Reduction, Craniofacial Dysjunction, Open 0 3,401.75
0 00000 0 0 0
76900 00 FRACTURES, REDUCTIONS, ALVEOLAR 0
0 00000 0 0 0
0 76910 0 Fracture, Alveolar, Debridement, Teeth Removed 0
0 00000 0 0 0
0 00000 76911 3 cm. or less 0 750.74
0 00000 0 0 to 1,501.49
0 00000 76912 3-6 cm. 0 750.74
0 00000 0 0 to 1,501.49
0 00000 76913 6 cm. and over 0 781.97
0 00000 0 0 to 1,563.94
0 00000 0 0 0
0 76920 0 Reduction, Alveolar, Closed, with Teeth 0
0 00000 0 0 0
0 00000 76921 3 cm. and less +E 750.74
0 00000 0 0 to 1,501.49

53
0 00000 76922 3-6 cm. +E 750.74
0 00000 0 0 to 1,501.49
0 00000 76923 6-9 cm. +E 781.97
0 00000 0 0 to 1,563.94
0 00000 76924 9 cm. and over +E 781.97
0 00000 0 0 to 1,563.94
0 00000 0 0 0
0 76930 0 Reduction, Alveolar, Open, with Teeth 0
0 00000 0 0 0
0 00000 76931 3 cm. and less +E 750.74
0 00000 0 0 to 1,501.49
0 00000 76932 3-6 cm. +E 750.74
0 00000 0 0 to 1,501.49
0 00000 76933 6-9 cm. +E 781.97
0 00000 0 0 to 1,563.94
0 00000 76934 9 cm. and over +E 813.20
0 00000 0 0 to 1,626.39
0 00000 0 0 0
0 76940 0 Replantation, Avulsed Tooth/Teeth (including splinting) 0
0 00000 0 0 0
0 00000 76941 Replantation, first tooth 0 469.18
0 00000 76949 Each additional tooth 0 469.18
0 00000 0 0 0
0 76950 0 Repositioning of Traumatically Displaced Teeth 0
0 00000 0 0 0
0 00000 76951 One unit of time 0 143.88
0 00000 76952 Two units of time 0 287.76
0 00000 76959 Each additional unit over two 0 143.88
0 00000 0 0 0
0 76960 0 Repairs, Lacerations, Uncomplicated, Intraoral or Extraoral 0
0 00000 0 0 0
0 00000 76961 2 cm. or less 0 300.28
0 00000 76962 2-4 cm. 0 337.84
0 00000 76963 4-6 cm. 0 375.37
0 00000 76964 6-9 cm. 0 412.90
0 00000 76965 9-12 cm. 0 469.18
0 00000 76966 12-16 cm. 0 508.26
0 00000 76967 16-20 cm. 0 547.38
0 00000 76968 20-25 cm. 0 609.90
0 00000 76969 25 cm. and over 0 650.53
0 00000 0 0 0
0 76970 0 Repairs, Lacerations, Through and Through 0
0 00000 0 0 0
0 00000 76971 2 cm. or less 0 325.27
0 00000 76972 2-4 cm. 0 365.93
0 00000 76973 4-6 cm. 0 406.60
0 00000 76974 6-9 cm. 0 447.23
0 00000 76975 9-12 cm. 0 506.65
0 00000 76976 12-16 cm. 0 548.87
0 00000 76977 16-20 cm. 0 591.08
0 00000 76978 20-25 cm. 0 656.71
0 00000 76979 25 cm. and over 0 700.51
0 00000 0 0 0
0 76980 0 Repairs, Lacerations, Complicated (local tissue shifts) 0
0 00000 0 0 0
0 00000 76981 2 cm. or less 0 350.25
0 00000 76982 2-4 cm. 0 394.02
0 00000 76983 4-6 cm. 0 437.79
0 00000 76984 6-9 cm. 0 481.60
0 00000 76985 9-12 cm. 0 544.11
0 00000 76986 12-16 cm. 0 589.44
0 00000 76987 16-20 cm. 0 634.79
0 00000 76988 20-25 cm. 0 703.55
0 00000 76989 25 cm. and over 0 750.45
0 00000 0 0 0
77000 00 MAXILLOFACIAL DEFORMITIES, TREATMENT OF 0
0 00000 0 0 0

54
77100 00 OSTEOTOMY/OSTECTOMY, RAMUS OF THE MANDIBLE 0
0 00000 0 0 0
0 00000 77101 Osteotomy, Subcondylar, Closed 0 5,352.76
0 00000 77102 Osteotomy, Subcondylar, Open 0 5,352.76
0 00000 77103 Osteotomy, Ramus of the Mandible, Oblique, Extraoral 0 5,352.76
0 00000 77104 Osteotomy, Ramus of the Mandible, Oblique, Intraoral 0 5,352.76
0 00000 77105 Osteotomy/Ostectomy, Body of the Mandible 0 5,352.76
0 00000 77106 Osteotomy, Coronoidectomy 0 2,551.31
0 00000 77107 Osteotomy, Condylar Neck 0 2,551.31
0 00000 77108 Osteotomy, Sagittal Split 0 5,352.76
0 00000 0 0 0
77200 00 OSTEOTOMY, MISCELLANEOUS 0
0 00000 0 0 0
0 00000 77201 Osteotomy, Oblique with Bone Graft 0 5,002.57
0 00000 77202 Osteotomy, Inverted "L" 0 5,002.57
0 00000 77203 Osteotomy, "C" 0 5,002.57
0 00000 77204 Osteotomy of the Ramus of the Mandible for Distraction Osteogenesis – Unilateral 0 5,002.57
0 00000 77205 Osteotomy of the Ramus of the Mandible for Distraction Osteogenesis – Bilateral 0 5,002.57
0 00000 77206 Activation of Distraction Device - Unilateral 0 5,002.57
0 00000 77207 Activation of Distraction Device - Bilateral 0 5,002.57
0 00000 77208 Removal of Distraction Device - Unilateral 0 5,002.57
0 00000 77209 Removal of Distraction Device - Bilateral 0 5,002.57
0 00000 0 0 0
77300 00 OSTEOTOMY, MAXILLARY 0
0 00000 0 0 0
0 00000 77301 Osteotomy, Maxillary, Le Fort l 0 5,352.76
0 00000 77302 Osteotomy, Maxillary, Le Fort ll 0 5,652.91
0 00000 77303 Osteotomy, Maxillary, Le Fort lll 0 6,753.48
0 00000 77304 Additional to the Above Osteotomy Requiring Two Segments 0 700.35
0 00000 77305 Additional to the Above Osteotomy Requiring Three Segments 0 900.44
0 00000 77306 Additional to the Above Osteotomy Requiring Four Segments 0 1,150.58
0 00000 77307 Additional to the Above Osteotomy Requiring a Cranial Flap 0 900.44
0 00000 77308 Closure of Cleft Fistula (Alveolar) 0 850.44
0 00000 77309 Closure of Cleft Fistula (Palatal) 0 850.44
0 00000 77311 Pharyngoplasty 0 1,350.68
0 00000 77312 Submuccous Resection 0 850.44
0 00000 77313 Osteotomy, Maxillary, Le Fort I – for Distraction Osteogenesis 0 I.C.
0 00000 77314 Osteotomy, Maxillary, Le Fort II – for Distraction Osteogenesis 0 I.C.
0 00000 77315 Osteogenesis, Maxillary, Le Fort III – for Distraction Osteogenesis 0 I.C.
0 00000 77316 Activation of Distraction Device – Le Fort I Level 0 I.C.
0 00000 77317 Activation of Distraction Device – Le Fort II Level 0 I.C.
0 00000 77318 Activation of Distraction Device – Le Fort III Level 0 I.C.
0 00000 77319 Removal of Maxillary Distraction Device 0 I.C.
0 00000 0 0 0
77400 00 OSTEOTOMY, MAXILLARY/MANDIBULAR, SEGMENTAL 0
0 00000 0 0 0
0 77410 0 Osteotomy, Segmental, Maxillary 0
0 00000 0 0 0
0 00000 77411 Osteotomy, Segmental, Anterior 0 2,401.22
0 00000 77412 Osteotomy, Segmental, Posterior 0 2,401.22
0 00000 77413 Osteotomy, Mid-palatal Split, Anterior 0 1,600.82
0 00000 77414 Osteotomy, Mid-palatal Split, Complete 0 2,401.22
0 00000 77415 Osteotomy, Segmental, Anterior – for Distraction Osteogenesis 0 I.C.
0 00000 77416 Osteotomy, Segmental, Posterior – for Distraction Osteogenesis 0 I.C.
0 00000 77417 Activation of Distraction Device 0 I.C.
0 00000 77418 Removal of Segmentation Maxillary Distraction Device 0 I.C.
0 00000 0 0 0
0 77420 0 Osteotomy, Segmental, Mandible 0
0 00000 0 0 0
0 00000 77421 Osteotomy, Segmental, Anterior with Transfer of Mental Eminence 0 2,401.22
0 00000 77422 Osteotomy, Segmental, Anterior, without the Transfer of Mental Eminence 0 2,401.22
0 00000 77423 Osteotomy, Segmental, Posterior 0 2,176.46
0 00000 77424 Osteotomy, Lower Border, Mandible 0 2,401.22
0 00000 77425 Osteotomy, Total Dento-Alveolar, Mandible 0 5,002.57
0 00000 77426 Osteotomy, Segmental, Anterior – for Distraction Osteogenesis 0 I.C.
0 00000 77427 Osteotomy, Segmental, Posterior – for Distraction Osteogenesis 0 I.C.
0 00000 77428 Activation of Distraction Device 0 I.C.

55
0 00000 77429 Removal of Segmental Mandibular Distraction Device 0 I.C.
0 00000 0 0 0
0 77430 0 Osteotomy When "Interpositional Graft" Is Required 0
0 00000 0 0 0
0 00000 77431 Using Bone 0 600.30
0 00000 77432 Using Alloplast +E 562.83
0 00000 77433 Using Cartilage 0 600.30
0 00000 0 0 0
0 77440 0 Osteotomy When "Onlay Graft" Is Required For Osteotomy, Trauma or Reconstructive Procedures 0

0 00000 0 0 0
0 00000 77441 Using Bone 0 400.20
0 00000 77442 Using Alloplast +E 375.21
0 00000 77443 Using Cartilage 0 400.20
0 00000 0 0 0
77500 00 GENIOPLASTY 0
0 00000 0 0 0
0 00000 77501 Genioplasty, Sliding, Reduction or Augmentation 0 2,401.22
0 00000 77502 Genioplasty, Reduction (vertical) 0 2,401.22
0 00000 77503 Genioplasty, Augmentation with Graft (see grafting codes) 0 2,401.22
0 00000 77504 Myotomy, Suprahyoid 0 600.59
0 00000 0 0 0
77600 00 MISCELLANEOUS TREATMENT OF MAXILLOFACIAL DEFORMITIES 0
0 00000 0 0 0
0 00000 77601 Corticotomy 0 700.51
0 00000 77602 Interdental Septotomy 0 700.51
0 00000 77603 Surgical Expansion of the Palate 0 1,200.59
0 00000 77604 Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique, Maxilla – per Sextant 0 I.C.

0 00000 77605 Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique, Mandible – per Sextant 0 I.C.

0 00000 0 0 0
77700 00 PALATORRHAPHY 0
0 00000 0 0 0
0 00000 77701 Palatorrhaphy, Anterior (closure of palatine fissure) 0 2,401.22
0 00000 77702 Palatorrhaphy, Posterior 0 2,401.22
0 00000 77703 Palatorrhaphy, Total 0 3,001.55
0 00000 77704 Palatorrhaphy, with Bone Graft 4,002.04
0 00000 77705 Palatorrhaphy, Bone Graft to Anterior Alveolar Ridge 2,601.32
0 00000 0 0 0
77800 00 FRENECTOMY/FRENOPLASTY 0
0 00000 0 0 0
0 00000 77801 Frenectomy, Upper Labial 0 262.81
0 00000 77802 Frenectomy, Lower Labial 0 262.81
0 00000 77803 Frenectomy, Lower Lingual or "Z" Plasty 0 262.81
0 00000 77804 Frenectomy, Lower Lingual or "Z" Plasty with Myotomy of Genioglossus 0 450.43
0 00000 77805 Frenoplasty, Upper "Z" 0 394.25
0 00000 77806 Frenoplasty, Lower "Z" 0 394.25
0 00000 0 0 0
77900 00 GLOSSECTOMY 0
0 00000 0 0 0
0 00000 77901 Glossectomy, Partial, Anterior Wedge 0 700.51
0 00000 77902 Glossectomy, Partial, for Orthodontic Purposes 0 700.51
0 00000 77903 Glossectomy, Full Postero-Anterior Wedge 0 1,300.64
0 00000 0 0 0
0 77910 0 Cleft Surgery 0
0 00000 0 0 0
0 00000 77911 Primary Unilateral Cleft Lip Repair 0 1,350.68
0 00000 77912 Secondary Unilateral Cleft Lip Repair 0 1,350.68
0 00000 77913 Primary Bilateral Cleft Lip Repair 0 1,800.92
0 00000 77914 Secondary Bilateral Cleft Lip Repair 0 1,800.92
0 00000 77915 Reconstruction of Cleft Lip with Lip Switch Flap 0 1,800.92
0 00000 77916 Complex Reconstruction or Revision of Cleft Lip 0 2,251.16
0 00000 77917 Closure of Alveolar Cleft (see grafting Codes) 0 2,251.16
0 00000 0 0 0
0 77920 0 Oral Nasal Fistula 0
0 00000 0 0 0
0 00000 77921 Primary Closure at Time of Initial Surgery 0 800.40

56
0 00000 77922 Secondary Closure with Palatal Flap 0 1,200.59
0 00000 77923 Secondary Closure with Pharyngeal Flap 0 1,200.59
0 00000 77924 Secondary Closure with Tongue Flap 0 1,350.68
0 00000 77925 Secondary Closure with Buccal Flap 0 1,200.59
0 00000 0 0 0
0 77930 0 Rigid Fixation 0
0 00000 0 0 0
0 00000 77931 Rigid Internal Fixation 0 Add
0 00000 77932 Rigid Internal Fixation Using Bone 0 25% to
0 00000 77933 Rigid Internal Fixation Using Alloplast +E Surgical
0 00000 77934 Rigid Internal Fixation Using Cartilage 0 fee
0 00000 0 0 0
78000 00 TEMPOROMANDIBULAR JOINT DYSFUNCTIONS, TREATMENT OF 0
0 00000 0 0 0
78100 0 0 TEMPOROMANDIBULAR JOINT, DISLOCATION MANAGEMENT OF 0
(Sedation and general anaesthesia services to be coded separately with appropriate 90000 series
codes)
0 00000 0 0 0
0 00000 78101 TMJ, Dislocation, Open Reduction 0 1,300.64
0 00000 78102 TMJ, Dislocation, Closed Reduction, Uncomplicated 0 118.92
0 00000 0 0 to 237.86
0 00000 78103 TMJ, Dislocation, Closed Reduction, Complicated (Requiring Sedation or General Anaesthesia) 0 250.33

0 00000 78104 TMJ, Subluxation, Closed Reduction, Uncomplicated 0 237.86

0 00000 78105 TMJ, Subluxation, Closed Reduction, Complicated (Requiring Sedation or General Anaesthesia) 0 250.33

0 00000 78106 TMJ, Manipulation, under Sedation or General Anaesthesia 0 375.50

0 00000 78107 TMJ, Fixation (Application of devices to prevent recurrent dislocation in the short term (arch bars, 0 375.50
MMF screws, Ivy Loops)
0 00000 0 0 0
78200 00 TEMPOROMANDIBULAR JOINT, OPEN PROCEDURES (ARTHROTOMY) 0
0 00000 0 0 0
0 00000 78201 Condyloplasty 0 2,001.02
0 00000 78202 Condylotomy 0 1,200.59
0 00000 78203 Condylectomy 0 2,151.11
0 00000 78204 Eminoplasty 0 2,151.11
0 00000 78205 Re-contour of Glenoid Fossa 0 2,151.11
0 00000 78206 Menisectomy 0 2,001.02
0 00000 78207 Plication of Meniscus 0 2,151.11
0 00000 78208 Repair of Meniscus 0 2,151.11
0 00000 78209 Replacement of Meniscus (see grafting codes) 0 2,151.11
0 00000 0 0 0
78300 00 TEMPOROMANDIBULAR JOINT, ARTHROTOMY FOR MAJOR RECONSTRUCTION 0
0 00000 0 0 0
0 00000 78301 Fossa Replacement (see grafting codes) 0 2,151.11
0 00000 78302 Condylar Replacement (see grafting codes) 0 2,151.11
0 00000 78303 Gap, Arthroplasty for Ankylosis (see grafting codes) 0 3,401.75
0 00000 0 0 0
78400 00 ARTHROSCOPY OF TEMPOROMANDIBULAR JOINT 0
0 00000 0 0 0
0 00000 78401 TMJ Arthroscopic Examination and Diagnosis 0 600.30
0 00000 78402 Biopsy 0 850.44
0 00000 78403 Removal of Loose Bodies 0 850.44
0 00000 78404 Lavage 0 600.30
0 00000 78405 Lysis of Adhesions 0 850.44
0 00000 78406 Synovectomy 0 1,300.64
0 00000 78407 Condyloplasty 0 1,300.64
0 00000 78408 Eminoplasty 0 1,300.64
0 00000 78409 Re-contour of Glenoid Fossa 0 1,300.64
0 00000 78411 Menisectomy 0 1,500.77
0 00000 78412 Plication of Meniscus 0 1,500.77
0 00000 78413 Repair of Meniscus 0 1,500.77
0 00000 0 0 0
78500 00 TEMPOROMANDIBULAR JOINT, ARTHROCENTESIS (puncture and aspiration) 0
0 00000 0 0 0
0 00000 78501 One unit of time 0 143.88
0 00000 78502 Two units 0 287.76
0 00000 78509 Each additional unit over two 0 143.88

57
0 00000 0 0 0
78600 00 TEMPOROMANDIBULAR JOINT, MANAGEMENT BY INJECTIONS 0
0 00000 0 0 0
0 00000 78601 Injection, therapeutic drug with or without local anaesthetic drug, "per site", +E 150.12
0 00000 78602 Injection, with Sclerosing Agent 0 150.12
0 00000 0 0 0
78700 00 TEMPOROMANDIBULAR JOINT, APPLIANCE SPLINTS, ORTHOPEDIC REHABILITATION (post operative) 0

0 00000 0 0 0
0 00000 78701 Appliance Splint, Maxillary +L 1,013.30
0 00000 78702 Appliance Splint, Mandibular +L 1,013.30
0 00000 0 0 0
79000 00 MAXILLOFACIAL SURGERY PROCEDURES, OTHER 0
0 00000 0 0 0
79100 00 SALIVARY GLANDS, TREATMENT OF 0
0 00000 0 0 0
0 00000 79101 Salivary Duct, Dilation of 0 206.47
0 00000 79102 Salivary Duct, Insertion of Polyethylene Tube 0 275.32
0 00000 79103 Salivary Duct, Sialodochoplasty 0 600.59
0 00000 79104 Salivary Duct, Reconstruction of 0 900.90
0 00000 0 0 0
0 79110 0 Salivary Duct, Sialolithotomy 0
0 00000 0 0 0
0 00000 79111 Sialolithotomy, Anterior 1/3 of Canal 0 550.64
0 00000 79112 Sialolithotomy, Posterior 2/3 of Canal 0 1,501.49
0 00000 79113 Sialolithotomy, External Approach 0 2,326.29
0 00000 0 0 0
0 79120 0 Salivary Gland, Excisions 0
0 00000 0 0 0
0 00000 79121 Excision of Submaxillary Gland 0 1,500.90
0 00000 79122 Excision of Sublingual Gland 0 1,876.15
0 00000 79123 Excision of Mucocele 0 187.75
0 00000 79124 Excision of Ranula 0 600.59
0 00000 79125 Marsupialization of Ranula 0 550.64
0 00000 0 0 0
0 79130 0 Salivary Gland, Removal 0
0 00000 0 0 0
0 00000 79131 Salivary Gland, Removal, Parotid (sub total) 0 2,001.02
0 00000 79132 Salivary Gland, Removal, Parotid (radical, including facial nerve) 0 3,201.65
0 00000 0 0 0
79200 00 NEUROLOGICAL DISTURBANCES, TREATMENT OF 0
0 00000 0 0 0
0 79210 0 Neurological Disturbances, Trigeminal Nerve 0
0 00000 0 0 0
0 00000 79211 Trigeminal Nerve, Injection for Destruction 0 300.28
0 00000 79212 Trigeminal Nerve, Avulsion at Periphery 0 625.58
0 00000 79213 Trigeminal Nerve, Total Avulsion of a Branch 0 1,138.46
0 00000 79214 Trigeminal Nerve, Alcoholization of a Branch 0 300.28
0 00000 79215 Trigeminal Nerve, Infiltration of a Branch for Diagnosis 0 143.88
0 00000 79216 Trigeminal Nerve, Intraoperative, diagnostic or physiologic monitoring 0 275.32
0 00000 0 (stimulation with recording evoked potentials, ultrasound, or impedance) 0
0 00000 79217 Trigeminal Nerve, Neurolysis or tumor excision of trigeminal nerve branch in soft tissue 0 900.90

0 00000 79218 Trigeminal Nerve, Neurolysis or tumor excision of trigeminal nerve branch in bone (mandible, maxilla 0 1,751.27
or orbit) (not to include osteotomy)
0 00000 0 0 0
0 79220 0 Neurological Disturbances, Mental Nerve 0
0 00000 0 0 0
0 00000 79221 Mental Nerve, Transportation of 0 1,050.76
0 00000 79222 Mental Nerve, Decompression in Canal 0 1,050.76
0 00000 0 0 0
0 79230 0 Neurological Disturbances, Inferior Dental Nerve 0
0 00000 0 0 0
0 00000 79231 Inferior Dental Nerve, Complete Avulsion 0 1,050.76
0 00000 79232 Inferior Dental Nerve, Decompression in the Canal 0 1,088.23
0 00000 0 0 0
0 79240 0 Neurological Disturbances, Surgery 0
0 00000 0 0 0

58
0 00000 79241 Injured Nerve Repair, Primary 0 1,401.02
0 00000 79242 Injured Nerve Repair, Secondary 0 3,551.84
0 00000 79243 Injured Nerve Repair, Secondary, (when repair delayed more than four weeks) 0 4,002.04
0 00000 79244 Neural Transposition and Decompression 0 1,050.76
0 00000 79245 Implantation of Electrode for Peripheral Nerve Stimulation 0 1,401.02
0 00000 79246 Excision of Tumor or Neuroma 0 1,500.90
0 00000 79247 Nerve Repair with Graft +E 5,002.57
0 00000 79248 Harvesting of Nerve Graft 0 1,751.27
0 00000 79251 Epineurial Suture of Trigeminal Nerve Branch per Anastomosis 0 1,088.23
0 00000 79252 Fascicular Suture of Trigeminal Nerve Branch per Anastomosis 0 1,088.23
0 00000 79253 Conduit Implant for Repair of Nerve Gap up to 3 cm. 0 2,801.45
0 00000 79254 Conduit Implant for Repair of Nerve Gap greater than 3 cm. 0 4,002.04
0 00000 79255 Fibrin adhesive per nerve anastomosis 0 700.51
0 00000 79256 Laser coagulation per verve anastomosis 0 750.45
0 00000 79258 In addition to above procedures, when using operating microscopes 0 150.12
0 00000 0 0 0
79300 00 ANTRAL SURGERY 0
0 00000 0 0 0
0 79310 0 Antral Surgery, Recovery, Foreign Bodies 0
0 00000 0 0 0
0 00000 79311 Antral Surgery, Immediate Recovery of a Dental Root or Foreign Body from the Antrum 0 625.58

0 00000 0 0 to 938.36
0 00000 79312 Antral Surgery, Immediate Closure of Antrum by Another Dental Surgeon 0 625.58
0 00000 0 0 to 938.36
0 00000 79313 Antral Surgery, Delayed Recovery of a Dental Root with Oral Antrostomy 0 625.58
0 00000 0 0 to 938.36
0 00000 79314 Antral Surgery with Nasal Antrostomy 0 625.58
0 00000 0 0 to 938.36
0 00000 0 0 0
0 79320 0 Antral Surgery, Lavage 0
0 00000 0 0 0
0 00000 79321 Lavage, Oral Approach 0 131.41
0 00000 79322 Lavage, Nasal Approach 0 131.41
0 00000 0 0 0
0 79330 0 Antral Surgery, Oro-Antral Fistula Closure, (same session) 0
0 00000 0 0 0
0 00000 79331 Oro-Antral Fistula Closure with Buccal Flap 0 600.59
0 00000 0 0 to 900.90
0 00000 79332 Oro-Antral Fistula Closure with Gold Plate +L 600.59
0 00000 0 0 to 900.90
0 00000 79333 Oro-Antral Fistula Closure with Palatal Flap 0 600.59
0 00000 0 0 to 900.90
0 00000 0 0 0
0 79340 0 Antral Surgery, Oro-Antral Fistula Closure, (subsequent session) 0
0 00000 0 0 0
0 00000 79341 Oro-Antral Fistula Closure with Buccal Flap 0 600.59
0 00000 0 0 to 900.90
0 00000 79342 Oro-Antral Fistula Closure with Gold Plate 0 600.59
0 00000 0 0 to 900.90
0 00000 79343 Oro-Antral Fistula Closure with Palatal Flap 0 600.59
0 00000 0 0 to 900.90
0 00000 0 0 0
0 79350 0 Sinus Osseous Augmentation 0
0 00000 0 0 0
0 00000 79351 Sinus Osseous Augmentation, Open Lateral Approach - Autograft +E I.C.
0 00000 79352 Sinus Osseous Augmentation, Open Lateral Approach – Allograft +E I.C.
0 00000 79353 Sinus Osseous Augmentation, Open Lateral Approach – Xenograft +E I.C.
0 00000 79354 Sinus Osseous Augmentation, Indirect Inferior Approach – Autograft +E I.C.
0 00000 79355 Sinus Osseous Augmentation, Indirect Inferior Approach – Allograft +E I.C.
0 00000 79356 Sinus Osseous Augmentation, Indirect Inferior Approach – Xenograft +E I.C.
0 00000 0 0 0
79400 00 HEMORRHAGE, CONTROL OF 0
0 00000 0 0 0
0 00000 79401 Primary Hemorrhage, Control 0 150.12
0 00000 0 0 to 600.59
0 00000 79402 Secondary Hemorrhage, Control 0 175.11

59
0 00000 0 0 to 1,751.27
0 00000 79403 Hemorrhage Control, using Compression and Hemostatic Agent 0 175.11
0 00000 0 0 to 1,751.27
0 00000 79404 Hemorrhage Control, using Hemostatic Substance and Suture (including 0 175.11
0 00000 0 removal of bony tissue, if necessary) to 1,751.27
0 00000 0 0 0
79500 00 GRAFTS AND RECONSTRUCTION, SURGICAL 0
0 00000 0 0 0
0 79510 0 Harvesting of Intraoral Tissue For Grafting To Operative Site 0
0 00000 0 0 0
0 00000 79511 Bone 0 506.65
0 00000 79512 Cartilage 0 506.65
0 00000 79513 Skin 0 506.65
0 00000 79514 Mucosa 0 506.65
0 00000 79515 Fascia 0 506.65
0 00000 79516 Muscle 0 506.65
0 00000 79517 Dermis 0 506.65
0 00000 0 0 0
0 79520 0 Harvesting of Extraoral Tissue For Grafting To Operative Site (To Include Ilium, Rib, Etc.) 0
0 00000 0 0 0
0 00000 79521 Bone 0 700.51
0 00000 79522 Cartilage 0 700.51
0 00000 79523 Costochondral 0 700.51
0 00000 79524 Skin 0 700.51
0 00000 79525 Fat 0 700.51
0 00000 79526 Fascia 0 700.51
0 00000 79527 Muscle 0 700.51
0 00000 79528 Dermis 0 700.51
0 00000 79529 Nerve 0 I.C.
0 00000 0 0 0
0 79530 0 Vascularized Tissue Flaps, Extraoral 0
0 00000 0 0 0
0 00000 79531 Elevation Free Soft Tissue Flap 0 I.C.
0 00000 79532 Elevation Free Hard Tissue Flap 0 I.C.
0 00000 79539 Artery/Vein/Nerve Graft/Patch, Autogenous/Allograft/Alloplastic +E I.C.
0 00000 0 0 0
0 79540 0 Harvesting and Preparation of Platelet Rich Plasma 0
0 00000 0 0 0
0 00000 79541 Harvesting and Preparation of Platelet Rich Plasma +E I.C.
0 00000 0 0 0
0 79550 0 Delivery of Growth Factors 0
0 00000 0 0 0
0 00000 79551 Delivery of Growth Factors – Autologous – per site +E I.C.
0 00000 79552 Delivery of Growth Factors – Allogenic – per site +E I.C.
0 00000 79553 Delivery of Growth Factors – Human Recombinant – per site +E I.C.
0 00000 0 0 0
79600 00 POST SURGICAL CARE (Required by complications and unusual circumstances, refer to comment 0
under section heading 70000)
0 00000 0 0 0
0 00000 79601 Post Surgical Care, Subsequent to Initial Post Surgical Treatment, Minor, by Treating Dentist 0 125.17

0 00000 79602 Post Surgical Care, Minor, by Other Than Treating Dentist 0 131.41
0 00000 79603 Post Surgical Care, Major, by Treating Dentist 0 131.41
0 00000 0 0 to 1,314.19
0 00000 79604 Post Surgical Care, Major, by Other Than Treating Dentist 0 131.41
0 00000 0 0 to 1,314.19
0 00000 79605 Post Surgical Care, Alveolitis, Treatment of (without Anaesthesia) 0 131.41
0 00000 79606 Post Surgical Care, Alveolitis, Treatment of (with Anaesthesia) 0 131.41
0 00000 0 0 0
79700 00 AIRWAY PROCEDURES 0
0 00000 0 0 0
0 00000 79701 Tracheotomy 0 800.40
0 00000 79702 Crico-Thyroidotomy 0 800.40
0 00000 0 0 0
79800 00 MUSCULAR DISORDERS, TREATMENT OF 0
0 00000 0 0 0
0 00000 79801 Treatment of Muscular Dysfunctions 0 I.C.
0 00000 79802 Myotomy 0 I.C.

60
0 00000 0 0 0
79900 00 IMPLANTOLOGY (Includes placement of implant, post-surgical care, uncovering and placement of 0
attachment but not prosthesis)
0 00000 0 0 0
0 79910 0 Implants, Blade 0
0 00000 0 0 0
0 00000 79911 Maxillary per implant +E I.C.
0 00000 79912 Mandibular per implant +E I.C.
0 00000 0 0 0
0 79920 0 Implants, Subperiosteal 0
0 00000 0 0 0
0 00000 79921 Maxillary +L I.C.
0 00000 79922 Mandibular +L I.C.
0 00000 0 0 0
0 79930 0 Implants, Ossenointegrated, Root Form, More than one component 0
0 00000 0 0 0
0 00000 79931 Surgical Installation of Implant with Cover Screw – per Implant +E I.C.
0 00000 79932 Surgical Installation of Implant with Healing Transmucosal Element – per Implant +E I.C.
0 00000 79933 Surgical Installation of Implant with Final Transmucusal Element – per Implant +E I.C.
0 00000 79934 Surgical Re-entry, Removal of Healing Screw and Placement of Healing Transmucosal Element – per +E I.C.
Implant
0 00000 79935 Surgical Re-entry, Removal of Healing Screw and Placement of Final Standard Transmucosal Element – +E I.C.
per Implant
0 00000 79936 Surgical Re-entry, Removal of Healing Screw and Placement of Final Custom Transmucosal Element – +L +E I.C.
per Implant
0 00000 0 0 0
0 79940 0 Implants Osseointegrated, Root Form, Single Component 0
0 00000 0 0 0
0 00000 79941 Surgical Installation of Implant – per Implant +E I.C.
0 00000 0 0 0
0 79950 0 Implants, Osseointegrated, Provisional 0
0 00000 0 0 0
0 00000 79951 Installation of Provisional Implant – per Implant +E I.C.
0 00000 79952 Removal of Provisional Implant – per Implant +E I.C.
0 00000 0 0 0
0 79960 0 Implants, Removal of 0
0 00000 0 0 0
0 00000 79961 Per implant, Uncomplicated 0 I.C.
0 00000 79962 Per implant, Complicated 0 I.C.
0 00000 0 0 0
80000 00000 0 ORTHODONTICS 0
0 00000 0 0 0
80600 00 ORTHODONTIC, OBSERVATIONS AND ADJUSTMENTS 0
0 00000 0 0 0
0 00000 80601 Orthodontic Observation - for Tooth Guidance (i.e. tooth position, eruption sequence, serial extraction 0 88.84
supervision, etc.) per appointment
0 00000 80602 Orthodontic Observation and adjustment - to Orthodontic Appliances and/or the Reduction of 0 88.84
Proximal Surfaces of Teeth per appointment
0 00000 0 0 0
0 80630 0 Repairs to Removable or Fixed Appliances (not including removal and recementation) 0
0 00000 0 0 0
0 00000 80631 One unit of time +L 96.24
0 00000 80632 Two units +L 192.48
0 00000 80639 Each additional unit over two 0 96.24
0 00000 0 0 0
0 80640 0 Alterations to Removable or Fixed Appliances 0
0 00000 0 0 0
0 00000 80641 One unit of time +L 96.24
0 00000 80642 Two units +L 192.48
0 00000 80649 Each additional unit over two 0 96.24
0 00000 0 0 0
0 80650 0 Recementation of Fixed Appliances 0
0 00000 0 0 0
0 00000 80651 One unit of time 0 96.24
0 00000 80659 Each additional unit of time 0 96.24
0 00000 0 0 0
0 80660 0 Separation (except where included in the fabrication of an appliance) 0
0 00000 0 0 0

61
0 00000 80661 One unit of time 0 96.24
0 00000 80669 Each addition unit of time 0 96.24
0 00000 0 0 0
0 80670 0 Removal of Fixed Orthodontic Appliances (By a Practitioner Other Than The Original Treatment 0
Practice Or Practitioner)
0 00000 0 0 0
0 00000 80671 One unit of time 0 96.23
0 00000 80679 Each additional unit of time 0 96.23
0 00000 0 0 0
81000 00 APPLIANCES, ACTIVE, FOR TOOTH GUIDANCE OR MINOR TOOTH MOVEMENT 0
0 00000 0 0 0
81100 00 APPLIANCES, REMOVABLE 0
0 00000 0 A maximum of eight observations or adjustment appointments may be charged for these appliances. 0

0 00000 0 0 0
0 81110 0 Appliances, Removable, Space Regaining 0
0 0 0
0 81111 Appliance, Maxillary, Unilateral +L 384.71
0 81112 Appliance, Mandibular, Unilateral +L 384.71
0 81113 Appliance, Maxillary, Bilateral +L 384.71
0 81114 Appliance, Mandibular, Bilateral +L 384.71
0 00000 0 0 0
0 81120 0 Appliances, Removable, Cross-Bite Correction 0
0 00000 0 0 0
0 00000 81121 Appliance, Maxillary, Simple +L 364.88
0 00000 81122 Appliance, Mandibular, Simple +L 364.88
0 00000 0 0 0
0 81130 0 Appliances, Removable, Dental Arch Expansion 0
0 00000 0 0 0
0 00000 81131 Appliance, Maxillary, Simple +L 384.71
0 00000 81132 Appliances, Mandibular, Simple +L 384.71
0 00000 0 0 0
0 81140 0 Appliances, Removable, Closure of Diastemas 0
0 00000 0 0 0
0 00000 81141 Appliance, Maxillary, Simple +L 384.71
0 00000 81142 Appliance, Mandibular, Simple +L 384.71
0 00000 0 0 0
0 81150 0 Appliances, Removable, Alignment of Anterior Teeth 0
0 00000 0 0 0
0 00000 81151 Appliance, Maxillary, Simple +L 384.71
0 00000 81152 Appliance, Mandibular, Simple +L 384.71
0 00000 0 0 0
81200 00 APPLIANCES, FIXED OR CEMENTED 0
0 00000 0 A maximum of eight observations or adjustment appointments may be charged for these appliances. 0

0 00000 0 0 0
0 81210 0 Appliance, Fixed, Space Regaining (e.g. lingual or labial arch with molar bands, tubes, locks) 0
0 00000 0 0 0
0 00000 81211 Appliance, Maxillary +L 384.71
0 00000 81212 Appliance, Mandibular +L 384.71
0 00000 0 0 0
0 81220 0 Appliance, Fixed, Spaces Regaining, Unilateral 0
0 00000 0 0 0
0 00000 81221 Appliance, Maxillary +L 288.73
0 00000 81222 Appliance, Mandibular +L 288.73
0 00000 0 0 0
0 81230 0 Appliance, Fixed, Cross-Bite Correction - Anterior 0
0 00000 0 0 0
0 00000 81231 Appliance, Maxillary +L 384.71
0 00000 81232 Appliance, Mandibular +L 384.71
0 00000 0 0 0
0 81240 0 Appliance, Fixed, Cross-Bite Correction - Posterior 0
0 00000 0 0 0
0 00000 81241 Appliance, Maxillary +L 384.71
0 00000 81242 Appliance, Mandibular +L 384.71
0 00000 81243 Appliance, Two-Molar Band, Hooked and Elastics +L 308.27
0 00000 0 0 0
0 81250 0 Appliance, Fixed, Dental Arch Expansion 0

62
0 00000 0 0 0
0 00000 81251 Appliance, Maxillary +L 481.23
0 00000 81252 Appliance, Mandibular +L 481.23
0 00000 81253 Appliance, Maxillary, Rapid Expansion +L 384.71
0 00000 0 0 0
0 81260 0 Appliance, Fixed, Closure of Diastemas 0
0 00000 0 0 0
0 00000 81261 Appliance, Maxillary, Simple +L 384.71
0 00000 81262 Appliance, Mandibular, Simple +L 384.71
0 00000 0 0 0
0 81270 0 Appliance, Fixed, Alignment of Incisor Teeth 0
0 00000 0 0 0
0 00000 81271 Appliance, Maxillary, Simple +L 481.23
0 00000 81272 Appliance, Mandibular, Simple +L 481.22
0 00000 0 0 0
0 81280 0 Appliances, Fixed, Ligatures 0
0 00000 0 0 0
0 00000 81281 Grassline or Elastic Ligatures per visit +L 96.24
0 00000 0 0 0
0 81290 0 Appliances, Fixed, Mechanical Eruption of Tooth/Teeth 0
0 00000 0 0 0
0 00000 81291 Appliance, Maxillary, Impaction +L 384.71
0 00000 81292 Appliance, Mandibular, Impaction +L 384.71
0 00000 81293 Appliance, Maxillary, Erupted +L 384.71
0 00000 81294 Appliance, Mandibular, Erupted +L 384.71
0 00000 0 0 0
83000 0 0 APPLIANCES, RETENTION, ORTHODONTIC RETAINING APPLIANCES 0
0 00000 0 0 0
83100 0 0 APPLIANCES, REMOVABLE, RETENTION 0
0 00000 0 0 0
0 00000 83101 Appliance, Maxillary +L 288.73
0 00000 83102 Appliance, Mandibular +L 288.73
0 00000 83103 Appliance, Tooth Positioner +L 288.73
0 00000 0 0 0
83200 0 0 APPLIANCES, FIXED/CEMENTED, RETENTION 0
0 00000 0 0 0
0 00000 83201 Appliance, Maxillary +L 384.71
0 00000 83202 Appliance, Mandibular +L 384.71
0 00000 0 0 0
0 0 0 COMPREHENSIVE ORTHODONTIC TREATMENT 0
0 00000 0 0 0
0 00000 0 CASE TYPE - Fixed Appliance (includes formal full banded treatment and retention) 0
0 00000 0 0 0
0 00000 0 The range of fees with these procedure codes reflects such variables as length of time required to 0
complete the treatment, degree of difficulty, co-operation of the patient, etc. and the fee charged
should be determined accordingly.
0 00000 0 0 0
84000 00 PERMANENT DENTITION 0
0 00000 0 0 0
0 00000 84101 Class l Malocclusion +L 3,849.92
0 00000 0 0 to 11,549.77
0 00000 84201 Class ll Malocclusion +L 5,774.87
0 00000 0 0 to 15,399.71
0 00000 84301 Class lll Malocclusions +L 5,774.87
0 00000 0 0 to 15,399.71
0 00000 84401 Malocclusions Not Requiring Complete Banding +L 1,924.95
0 00000 0 0 to 4,812.41
0 00000 0 0 0
85000 00 MIXED DENTITION 0
0 00000 0 0 0
0 00000 85101 Class l Malocclusion +L 3,849.92
0 00000 0 0 to 11,549.77
0 00000 85201 Class ll Malocclusion +L 5,774.87
0 00000 0 0 to 15,399.71
0 00000 85301 Class lll Malocclusion +L 5,774.87
0 00000 0 0 to 15,399.71
87000 00000 0 PERMANENT DENTITION 0

63
0 00000 0 CASE TYPE - Removable Appliances (includes removable appliance therapy and retention; e.g. 0
functional appliances)
0 00000 0 0 0
0 00000 87101 Class l Malocclusion +L I.C.
0 00000 87201 Class ll Malocclusion +L I.C.
0 00000 87301 Class lll Malocclusion +L I.C.
0 00000 0 0 0
88000 0 0 MIXED DENTITION 0
0 00000 0 0 0
0 00000 88101 Class l Malocclusion +L 1,924.95
0 00000 0 0 to 5,774.87
0 00000 88201 Class ll Malocclusion +L 2,887.44
0 00000 0 0 to 7,699.85
0 00000 88301 Class lll Malocclusion +L 2,887.44
0 00000 0 0 to 7,699.85
0 00000 0 0 0
89500 0 0 NEONATAL DENTO-FACIAL ORTHOPEDICS 0
0 00000 0 (comprehensive treatment for first six months of life) 0
0 00000 0 0 0
0 00000 0 (1) Diagnostic procedures (includes radiographs and/or photographs); 0
0 00000 0 (2) Parent consultation; 0
0 00000 0 (3) Impression and appliance construction; 0
0 00000 0 (4) Insertion and parent instruction; 0
0 00000 0 (5) Post treatment evaluation; 0
0 00000 0 (6) Adjustment of appliances (includes soft relines); 0
0 00000 0 (7) Reconstruction and/or reevaluation (may include up to two remakes). 0
0 00000 0 0 0
0 00000 89501 Expansion Appliance for Infants with Cleft Palate +L 384.99
0 00000 0 0 to 3,464.91
0 00000 89502 Extraoral Retraction Appliance for Infants with Cleft Palate +L 384.99
0 00000 0 0 to 3,464.91
0 00000 89503 Stage l - Initial Expansion +L 1,443.71
0 00000 0 0 to 2,887.44
0 00000 89504 Stage ll - Anterior Alignment +L 1,443.71
0 00000 0 0 to 2,887.44
0 00000 89505 Stage lll - Final Alignment (complete banding) +L 2,887.44
0 00000 0 0 to 7,699.85
0 00000 89506 Stage lll - Where Stage l and ll were not provided for +L 5,774.87
0 00000 0 0 to 15,399.71
0 00000 0 0 0
0 00000 0 0 0
90000 00000 0 GENERAL SERVICES 0
0 00000 0 0 0
91000 0 0 UNCLASSIFIED TREATMENTS 0
0 00000 0 0 0
91100 0 0 UNCLASSIFIED TREATMENT, DENTAL PAIN 0
0 00000 0 0 0
0 91110 0 Palliative (emergency) Treatment of Dental Pain, Minor Procedure 0
0 00000 0 0 0
0 00000 91111 One unit of time 0 118.93
0 00000 91112 Two units 0 237.86
0 00000 91113 Three units 0 356.79
0 00000 91119 Each additional unit over three 0 118.93
0 00000 0 0 0
0 91120 0 Emergency Services Not Otherwise Specified In Guide 0
0 00000 0 0 0
0 00000 91121 One unit of time 0 125.16
0 00000 91122 Two units 0 250.32
0 00000 91123 Three units 0 375.48
0 00000 91129 Each additional unit over three 0 125.16
0 00000 0 0 0
91200 0 0 UNCLASSIFIED TREATMENTS, UNUSUAL TIME AND RESPONSIBILITIES (Note: If the service affected is 0
anaesthesia, Service Class 92000, and the unusual time and responsibility is the result of a patient
BMI of 35 or above, refer to code series 92900)
0 00000 0 0 0
0 91210 0 Unusual Time and Responsibility Requirement, in Addition to Usual Procedures in Guide 0
0 00000 0 0 0
0 00000 91211 One unit of time 0 137.64

64
0 00000 91212 Two units 0 275.28
0 00000 91213 Three units 0 412.92
0 00000 91219 Each additional unit over three 0 137.64
0 00000 0 0 0
0 91220 0 Second Surgeon (team approach) 0
0 00000 0 0 0
0 00000 91221 One unit of time 0 118.93
0 00000 91222 Two units 0 237.86
0 00000 91223 Three units 0 356.79
0 00000 91224 Four units 0 475.72
0 00000 91225 Five units 0 594.65
0 00000 91226 Six units 0 713.58
0 00000 91227 Seven units 0 832.51
0 00000 91228 Eight units 0 951.44
0 00000 91229 Each additional unit over eight 0 118.93
0 00000 0 0 0
0 91230 0 Management of Exceptional Patient 0
0 00000 0 0 0
0 00000 91231 One unit of time 0 137.64
0 00000 91232 Two units 0 275.28
0 00000 91233 Three units 0 412.92
0 00000 91234 Four units 0 550.56
0 00000 91239 Each additional unit over four 0 137.64
0 00000 0 0 0
92000 00 ANAESTHESIA 0
0 00000 0 0 0
92100 0 0 ANAESTHESIA, LOCAL 0
0 00000 0 (not in conjunction with operative or surgical procedures, includes pre-anaesthetic evaluation and post- 0
anaesthetic evaluation and post-anaesthetic follow-up)
0 00000 0 0 0
0 00000 92101 Regional Block Anaesthesia (not in conjunction with operative or surgical procedures) 0 125.17

0 00000 92102 Trigeminal Division Block (not in conjunction with operative or surgical procedures) 0 125.17
0 00000 0 0 0
92200 00 ANAESTHESIA, GENERAL 0
0 00000 0 (includes pre-anaesthetic evaluation and post-anaesthetic evaluation and post-anaesthetic follow-up) 0

0 00000 0 0 0
0 92210 0 General Anaesthesia +PS
0 00000 0 0 0
0 00000 92212 Two units of time 0 262.82
0 00000 92213 Three units 0 394.23
0 00000 92214 Four units 0 525.64
0 00000 92215 Five units 0 657.05
0 00000 92216 Six units 0 788.46
0 00000 92217 Seven units 0 919.87
0 00000 92218 Eight units 0 1,051.28
0 00000 92219 Each additional unit over eight 0 131.41
0 00000 0 0 0
0 92220 0 Provision of facilities, equipment and support services for general anaesthesia when provided by a 0
separate practitioner
0 00000 0 0 0
0 00000 92222 Two units of time 0 262.82
0 00000 92223 Three units 0 394.23
0 00000 92224 Four units 0 525.64
0 00000 92225 Five units 0 657.05
0 00000 92226 Six units 0 788.46
0 00000 92227 Seven units 0 919.87
0 00000 92228 Eight units 0 1,051.28
0 00000 92229 Each additional unit over eight 0 131.41
0 00000 0 0 0
0 92300 0 ANAESTHESIA, DEEP SEDATION +PS

65
 Anaesthesia, Deep Sedation - a controlled state of depressed consciousness accompanied by partial
loss of protective reflexes, including inability to respond purposefully to verbal command. These states
apply to any technique that has depressed the patient beyond conscious sedation except general
anaesthesia. Any intravenous technique leading to these conditions in a patient including
neuroleptanalgesia or anaesthesia, regardless of route of administration, would fall within this
category of service. (includes pre-anaesthetic evaluation and post anaesthetic follow-up)

0 00000 0 0 0
0 00000 92302 Two units of time 0 237.86
0 00000 92303 Three units 0 356.79
0 00000 92304 Four units 0 475.72
0 00000 92305 Five units 0 594.65
0 00000 92306 Six units 0 713.58
0 00000 92307 Seven units 0 832.51
0 00000 92308 Eight units 0 951.44
0 00000 92309 Each additional unit over eight 0 118.93
0 00000 0 0 0
0 92320 0 Provision of facilities, equipment and support services for deep sedation when provided by a
separate practitioner
0 00000 0 0 0
0 00000 92322 Two units 0 237.86
0 00000 92323 Three units 0 356.79
0 00000 92324 Four units 0 475.72
0 00000 92325 Five units 0 594.65
0 00000 92326 Six units 0 713.58
0 00000 92327 Seven units 0 832.51
0 00000 92328 Eight units 0 951.44
0 00000 92329 Each additional unit over eight 0 118.93
0 00000 0 0 0
92400 00 ANAESTHESIA, CONSCIOUS SEDATION +PS
0 00000 0 Anaesthesia, Conscious Sedation - a medically controlled state of depressed consciousness that allows 0
protective reflexes to be maintained, retains the patient's ability to maintain a patent airway
independently and continuously and permits appropriate response by the patient to physical
stimulation or verbal command, e.g., "open your eyes". (includes pre-anaesthetic evaluation and post
anaesthetic follow-up)

0 00000 0 0 0
0 00000 0 Any technique leading to these conditions in a patient would fall within this category of service. 0
Conscious sedation is a varied technique which can require different levels of monitoring, in
accordance with the Regulatory Authority Guidelines for the Use of Sedation and General Anaesthesia
in Dental Practice. The Guidelines should be consulted and observed.

0 00000 0 0 0
0 92410 0 Nitrous Oxide Time is measured from the placement of the inhalation device and terminates with the 0
removal of the inhalation device
0 00000 0 0 0
0 00000 92411 One unit of time 0 62.87
0 00000 92412 Two units of time 0 94.32
0 00000 92413 Three units 0 125.78
0 00000 92414 Four units 0 157.24
0 00000 92415 Five units 0 188.69
0 00000 92416 Six units 0 220.14
0 00000 92417 Seven units 0 251.60
0 00000 92418 Eight units 0 283.05
0 00000 92419 Each additional unit over eight 0 31.45
0 00000 0 0 0
0 92420 0 Oral Sedation, Sedation sufficient to require monitored care. Time is measured from the start of 0
patient monitoring to release from the treatment/recovery room
0 00000 0 0 0
0 00000 92421 One unit of time 0.00 56.79
0 00000 92422 Two units of time 0.00 63.88
0 00000 92423 Three units of time 0.00 82.50
0 00000 92424 Four units of time 0.00 101.08
0 00000 92425 Five units of time 0.00 119.70
0 00000 92426 Six units of time 0.00 138.29
0 00000 92427 Seven units of time 0.00 156.91
0 00000 92428 Eight units of time 0.00 175.50
0 00000 92429 Each addition unit over eight 0.00 21.85

66
0 00000 0 0 0.00
0 92440 0 Parenteral Conscious Sedation (regardless of method -IM or IV) 0
0 00000 0 0 0
0 00000 92441 One unit 0.00 77.81
0 00000 92442 Two units 0.00 155.62
0 00000 92443 Three units 0.00 233.43
0 00000 92444 Four units 0.00 311.24
0 00000 92445 Five units 0.00 389.05
0 00000 92446 Six units 0.00 466.86
0 00000 92447 Seven units 0.00 544.67
0 00000 92448 Eight units 0.00 622.48
0 00000 92449 Each additional unit over eight 0.00 77.81
0 00000 0 0 0
92500 00 NON PHARAMACOLOGICAL PAIN CONTROL AND PATIENT MANAGEMENT 0
0 00000 0 0 0
0 92510 0 Hypnosis 0
0 00000 0 0 0
0 00000 92511 One unit of time 0 62.87
0 00000 92512 Two units 0 94.32
0 00000 92513 Three units 0 125.78
0 00000 92514 Four units 0 157.24
0 00000 92519 Each additional unit over four 0 31.45
0 00000 0 0 0
0 92520 0 Acupuncture 0
0 00000 0 0 0
0 00000 92521 One unit of time 0 62.87
0 00000 92522 Two units 0 94.32
0 00000 92523 Three units 0 125.78
0 00000 92524 Four units 0 157.24
0 00000 92529 Each additional unit over four 0 31.45
0 00000 0 0 0
0 92530 0 Electronic Dental Anaesthesia 0
0 00000 0 0 0
0 00000 92531 One Unit of Time 0 62.87
0 00000 92532 Two units 0 94.32
0 00000 92533 Three units 0 125.78
0 00000 92534 Four units 0 157.24
0 00000 92539 Each additional unit over four 0 31.45
0 00000 0 0 0
0 92900 0 Anaesthesia – General Anaesthesia Or Deep Sedation, Unusual Time and Responsibility 0
0 00000 0 0 0
0 00000 92901 Management of patient with BMI 35 or above, in addition to code series 92200 or 92300 0 I.C.

0 00000 0 0 0
93000 00 PROFESSIONAL CONSULTATIONS 0
0 00000 0 (diagnostic services provided by dentist other than practitioner providing treatment) 0
0 00000 0 0 0
93100 00 PROFESSIONAL COMMUNICATIONS 0
0 00000 0 0 0
0 93110 0 Consultation with Member of the Profession or other Healthcare Providers, in or out of the office 0

0 00000 0 0 0
0 00000 93111 One unit of time +E 101.70
0 00000 93112 Two units +E 203.40
0 00000 93119 Each additional unit over two +E 101.70
0 00000 0 0 0
0 93120 0 Dental Legal Letters, Reports and Opinions 0
0 00000 0 0 0
0 00000 93121 A dental-legal report - a short factually written or verbal communication given to any lay person (e.g. 0 83.15
lawyer, insurance representative, local, municipal or government agency, etc.) in relation the patient
with prior patient approval.
0 00000 0 0 to 166.30
0 00000 0 0 0
0 00000 93122 A dental-legal report - a comprehensive written report with patient approval, on systems, history and 0 166.30
records giving diagnosis, treatment, results and present condition. The report is a factual summary of
all information available on the case and could contain prognostic information regarding patient
response.
0 00000 0 0 to 332.60

67
0 00000 0 0 0
0 00000 93123 A dental-legal opinion - a comprehensive written report primarily in the field of expert opinion. The 0 I.C.
report may be an opinion regarding the possible course of events (when these cannot be determined
factually), with possible long term consequences and complications in the development of the
conditions. The report will require expert knowledge and judgment with respect to the facts leading
to a detailed prognosis.

0 00000 0 0 0
0 93130 0 Consultation and/or Participation During Autopsy (other than forensic) 0
0 00000 0 0 0
0 00000 93131 One unit of time +E 109.35
0 00000 93132 Two units +E 218.70
0 00000 93139 Each additional unit over two 0 109.35
0 00000 0 0 0
93300 00 CLAIM FORMS AND TREATMENT FORMS 0
0 00000 0 0 0
0 00000 93301 Completing CDA "Blank" Approved Standard Claim Forms. 0 NO FEE
0 00000 93302 Upon request, Providing a Written Treatment Plan/Outline for a Patient, Similar to the Example in the 0 NO FEE
CDA Policy Manual on Claim Form Completion.
0 00000 93303 Completing Prepaid Claim Forms which do not conform with Code 93301 0 29.45
0 00000 0 0 0
0 93310 0 For Extraordinary Time Spent in Relation to Claim Forms/Treatment Plan Forms, the Claim Problem 0
of the Patient or Processing of Payments
0 00000 0 0 0
0 00000 93311 One unit of time +E 96.71
0 00000 93312 Two units +E 193.42
0 00000 93319 Each additional unit over two 0 96.71
0 00000 0 0 0
0 93320 0 For Extraordinary office Time Spent, In Forwarding Predetermination Records, In Predeterminations 0
Situations, To Third Parties Plus Expenses (i.e. registration, postage, etc.)
0 00000 0 0 0
0 00000 93321 One unit of time +E 25.68
0 00000 93322 Two units +E 51.36
0 00000 93329 Each additional unit over two 0 25.68
0 00000 0 0 0
0 93330 0 Payment for Orthodontic Treatment In Progress 0
0 00000 0 0 0
0 00000 93331 Payment/Installment for treatment in progress 0 I.C.
0 00000 93332 Monthly payment/Instalments for treatment in progress 0 I.C.
0 00000 93333 Quarterly payment/installment for treatment in progress 0 I.C.
0 00000 93334 One time appliance 0 I.C.
0 00000 0 0 0
0 93340 0 Predetermination of available benefit. NO FEE 0
0 00000 0 0 0
0 00000 93341 Orthodontic Treatment (fee entered is the value of the treatment plan being predetermined) 0 NO FEE

0 00000 0 0 0
94000 00 PROFESSIONAL VISITS 0
0 00000 0 0 0
94100 00 HOUSE CALLS 0
0 00000 0 0 0
0 00000 94101 House Call, Non Emergency Visit (in addition to procedures performed) 0 105.39
0 00000 94102 House Call, Emergency Visit, when one must immediately leave home, office or hospital (in addition to 0 210.82
procedures performed)
0 00000 0 0 0
94300 00 OFFICE OR INSTITUTIONAL VISITS 0
0 00000 0 0 0
0 00000 94301 Office (of another professional) or Institutional Visit, During Regular Scheduled Office Hours (in 0 87.31
addition to services performed)
0 00000 94302 Office (of another professional) or Institutional Visit Unscheduled, After Regular Scheduled Office 0 108.07
Hours (in addition to services performed)
0 00000 94303 Missed or Canceled Appointment, with Insufficient Notice, During Regular Scheduled Office Hours 0 55.34

0 00000 94304 Missed or Canceled Appointment with insufficient Notice, being a Special Appointment Outside 0 91.87
Regular Scheduled Office Hours
0 00000 0 0 to 385.90
0 00000 94305 Traveling Expenses 0 I.C.
0 00000 94306 Professional Visits Out of Office, plus actual services performed + E, (out of pocket expenses, etc.) +E 163.50

68
0 00000 0 0 0
94400 00 COURT APPEARANCE AND/OR PREPARATION 0
0 00000 0 0 0
0 94410 0 Preparation as an Expert Witness 0
0 00000 0 0 0
0 00000 94411 One unit of time 0 I.C.
0 00000 94412 Two units 0 I.C.
0 00000 94413 Three units 0 I.C.
0 00000 94414 Four units 0 I.C.
0 00000 94419 Each additional unit over four 0 I.C.
0 00000 0 0 0
0 94420 0 Court Appearance as an Expert Witness 0
0 00000 0 0 0
0 00000 94421 One half day 0 I.C.
0 00000 94422 Full day 0 I.C.
0 00000 0 0 0
95000 00 FORENSIC DENTAL SERVICES 0
0 00000 0 0 0
95100 00 FORENSIC SERVICES, MISCELLANEOUS 0
0 00000 0 0 0
0 00000 95101 Identification - opinion as an expert assisting in civil or criminal cases +E 483.40
0 00000 0 0 0 per hour
0 00000 95102 Full or Part Time Participation in Civil Disaster +E 2,657.66
0 00000 0 0 0 per diem
0 00000 95104 Written Odontology Report +E 51.78
0 00000 0 0 to 557.74
0 00000 95105 Post Mortem Examination of Tissues in Forensic Cases (non-identification) 0 I.C.
0 00000 95106 Management of Oral Disease or Abnormality 0 91.87
0 00000 0 0 to 192.93
0 00000 0 0 0
95200 00 IDENTIFICATION SYSTEMS 0
0 00000 0 0 0
0 00000 95201 Identification Disk System, Acid Etch/Bonded +L 87.31
0 00000 0 0 0
96000 00 DRUGS/MEDICATION, DISPENSING 0
0 00000 0 0 0
96100 00 PRESCRIPTIONS 0
0 00000 0 0 0
0 00000 96101 Prescription, Emergency 0 39.78
0 00000 96102 Emergency Dispensing of One or Two Doses of a Therapeutic Drug, plus Giving a Written Prescription +E 54.15

0 00000 96103 Dispensing, Non Emergency (e.g. fluorides, vitamins, other drugs/medications) +E 43.59
0 00000 96104 Prescription, vaccine 0 39.78

96200 00 INJECTIONS, THERAPEUTIC 0

0 00000 0 0 0
0 00000 96201 Intramuscular Drug Injection +E 58.47
0 00000 96202 Intravenous Drug Injection +E 58.47
0 00000 96203 Intralesional Delivery (Intra-articular Injections - see 78600) +E 58.47
0 00000 0 0 0
96300 0 0 INJECTIONS AESTHETIC – ADMINISTRATION OF AESTHETIC NEUROMODULATORS (EG. BOTULINUM 0
TOXIN TYPE A) (Note “units” refers to a drug dosage)
0 00000 0 0 0
0 00000 96301 Injections of neuromodulator, aesthetic 1 to 5 units +E I.C.
0 00000 96302 Injections of neuromodulator, aesthetic 6 to 10 units +E I.C.
0 00000 96303 Injections of neuromodulator, aesthetic 11 to 20 units +E I.C.
0 00000 96304 Injections of neuromodulator, aesthetic 21 to 30 units +E I.C.
0 00000 96305 Injections of neuromodulator, aesthetic 31 to 40 units +E I.C.
0 00000 96306 Injections of neuromodulator, aesthetic 41 to 50 units +E I.C.
0 00000 96307 Injections of neuromodulator, aesthetic 51 to 60 units +E I.C.
0 00000 96308 Injections of neuromodulator, aesthetic 61 to 70 units +E I.C.
0 00000 96309 Injections of neuromodulator, aesthetic more than 70 units +E I.C.
0 00000 0 0 0
96400 00 INJECTIONS AESTHETIC – ADMINISTRATION OF AESTHETIC DERMAL FILLERS 0
0 00000 0 0 0
0 00000 96401 Aesthetic dermal filler first syringe +E I.C.
0 00000 96409 Aesthetic dermal filler subsequent syringe (use once for each syringe) +E I.C.
0 00000 0 0 0

69
96500 00000 0 VACCINE ADMINISTRATION 0
0 00000 0 0 0
0 00000 96501 Vaccine injection +E 58.47
0 00000 96502 Vaccine, administered by other routes (e.g. nasal/oral) +E 58.47

97000 00 BLEACHING, VITAL 0

0 00000 0 0 0
0 97110 0 Bleaching, Vital, In Office 0
0 00000 0 0 0
0 00000 97111 One unit of time 0 96.47
0 00000 97112 Two units 0 192.94
0 00000 97113 Three units 0 289.41
0 00000 97119 Each additional unit over three 0 96.47
0 00000 0 0 0
0 97120 0 Bleaching, Vital Home (Includes the Fabrication of Bleaching Trays, Dispensing the System and Follow- 0
up Care)
0 00000 0 0 0
0 00000 97121 Maxillary Arch +L and/or 275.66
+E
0 00000 97122 Mandibular Arch +L and/or 275.66
+E
0 00000 0 0 0
0 97130 0 Micro-Abrasion 0
0 00000 0 0 0
0 00000 97131 One unit of time 0 87.30
0 00000 97132 Two units of time 0 174.60
0 00000 97133 Three units of time 0 261.90
0 00000 97134 Four units of time 0 349.20
0 00000 97139 Each additional unit over four 0 87.30
0 00000 0 0 0
98000 00 COUNSELLING 0
0 00000 0 0 0
0 98100 0 TOBACCO OR CANNABIS-USE CESSATION SERVICES To include: identifying patients who use tobacco 0
or cannabis, informing patients of oral health consequences associated with tobacco or cannabis;
advising tobacco or cannabis users to quit; provide appropriate self-help material; and discuss
treatment options.
0 00000 0 0 0
0 00000 98101 One unit of time +E 87.30
0 00000 98102 Two units of time +E 174.60
0 00000 98109 Each additional unit of time +E 87.30
0 00000 0 0 0
0 98300 0 Vaccine/Vaccination Consultation, with patient (includes analysis of medical status, indications and 0
contraindications, and the risks and benefits)
0 00000 0 0 0
0 00000 98301 One unit of time 0 87.30
0 00000 98302 Two units of time 0 174.60
0 00000 98309 Each additional unit of time 0 87.30
0 00000 0 0 0
99000 00 LABORATORY, EXPENSE AND PROFESSIONAL SERVICE PROCEDURES 0
0 00000 0 0 0
0 00000 0 (This code is used in conjunction with the "+L" and "+E" and "+P.S." designation following specific 0
codes in the guide. The addition of these codes are to facilitate computer or manual input for third
party claims processing, personal records and statistics, providing one description for a specific
procedure code.)
0 00000 0 0 0
0 00000 0 When filling out the third party claim forms, these codes must follow immediately after the 0
corresponding dental procedure code carried out by the dentist, so as to correlate the lab expenses
with the correct procedures.
0 00000 0 0 0
0 00000 99111 "+L" Commercial Laboratory Procedures (A commercial laboratory is defined as an independent +L
business which performs laboratory services and bills the dental practices for these services on a case
by case basis)
0 00000 0 0 0
0 00000 99222 "+L" For oral pathology biopsy services when provided in relation to surgical services from the 30000, +L
40000, or 70000 code services.
0 00000 0 0 0
0 00000 99333 "+L" In-Office Laboratory Procedures (An in-office laboratory is defined as a laboratory service(s) +L
performed within the same business entity).
0 00000 0 0 0

70
0 00000 99555 "+E" Additional Expense of Materials +E
0 00000 0 0 0
0 00000 99777 "+PS" Charges for professional services billed to the dentist and passed through to the patient. +PS

71