Metropolitan Government of Nashville and Davidson County Delta Preferred Option Plan (Group #8800) Covered Services and Copayments

Transcription

1 Code D 0120 Periodic oral evaluation Diagnostic Member Copay No Copay D 0140 Limited oral evaluation-problem focused No Copay D 0145 Oral Evaluation for a patient under three years of age No Copay D 0150 Comprehensive oral evaluation No Copay D 0160 Detailed and extensive oral evaluation No Copay D 0170 Re-evaluation- limited, problem focused No Copay D 0180 Comprehensive periodontal evaluation No Copay D 0210 Intraoral radiographs - complete series No Copay D 0220 Intraoral- periapical first film No Copay D 0230 Intraoral- periapical each additional film No Copay D 0240 Intraoral- occlusal film No Copay D 0250 Extraoral - first film D 0260 Extraoral - each additional film D 0270 Bitewing- single film No Copay D 0272 Bitewings- two films No Copay D 0273 Bitewings - three films No Copay D 0274 Bitewings- four films No Copay D 0277 Vertical Bitewings - 7 to 8 films D 0290 Posterior-Anterior or lateral skull and facial bone survey film D 0310 Sialography D 0320 Tempromandibular joint arthrogram, including injection D 0321 Other tempromandibular joint films, by report D 0322 Tomographic Survey D 0330 Panoramic film No Copay D 0340 Cephalometric film D 0350 Oral/facial photographic images D 0360 Cone beam ct-craniofacial data capture D 0362 Cone beam-two-dimensional image reconstruction using existing data D 0363 Cone beam- three-dimensional image reconstruction using existing data

2 D 0415 Collection of microorganisms for culture and sensitivity D 0416 Viral Culture D 0421 Genetic test for susceptibility to oral diseases D 0425 Caries susceptibility tests D 0431 Adjunctive pre-diagnostic test D 0460 Pulp vitality tests No Copay D 0470 Diagnostic Casts D 0472 Accession of tissue, gross examination D 0473 Accession of tissue, gross and microscopic examination D 0474 Accession of tissue, gross and microscopic examinationt D 0480 Accession of exfoliative cytologic smears, microscopic examination D 0486 Accession of brush biopsy sample, microscopic examination D 0475 Decalcification procedure D 0476 Special stains for microorganisms D 0477 Special stains, not for microorganisms D 0478 Immunohistochemical stains D 0479 Tissue in-situ hybridization, including interpretation D 0481 Electron microscopy - diagnostic D 0482 Direct immunofluorescence D 0483 Indirect immunofluorescence D 0485 Consultation D 0502 Other oral pathology procedures, by report Preventive D 1110 Prophylaxis [(cleaning)] No Copay D 1120 Prophylaxis [(cleaning)] - child up to age 14 No Copay D 1203 Topical application of fluoride ( prophy not included) child to age 19 No Copay D 1204 Topical application of fluoride ( prophylaxis not included) adult D 1206 Topical fluoride varnish - child No Copay D 1310 Nutritional counseling for control of dental disease D 1320 Tobacco counseling for the control and prevention of oral disease

3 D 1330 Oral hygiene instructions No Copay D 1351 Sealant, per tooth -through age 15 $5.00 D 1510 Space maintainer- fixed-unilateral $65.00 D 1515 Space maintainer- fixed-bilateral $90.00 D 1520 Space maintainer - removable - unilateral $ D 1525 Space maintainer - removable - bilateral $ D 1550 Recementation of space maintainer $20.00 D 1555 Removal of fixed space maintainer Restorative D 2140 Amalgam - one surface, primary or permanent No Copay D 2150 Amalgam - two surfaces, primary or permanent No Copay D 2160 Amalgam - three surfaces, primary or permanent No Copay D 2161 Amalgam - four or more surfaces, primary or permanent No Copay D 2330 Resin-based composite - one surface, anterior No Copay D 2331 Resin-based composite - two surfaces, anterior No Copay D 2332 Resin-based composite - three surfaces, anterior No Copay D 2335 Resin-based composite - four or more surfaces, anterior $65.00 D 2390 Resin-based composite crown, anterior $ D 2391 Resin-based composite one surface, posterior $20.00 D 2392 Resin-based composite two surfaces, posterior $30.00 D 2393 Resin-based composite three surfaces, posterior $40.00 D 2394 Resin-based composite four or more surfaces, posterior $45.00 D 2410 Gold foil - one surface D 2420 Gold foil -two surfaces D 2430 Gold foil - three surfaces D 2510 Inlay- metallic- one surface $ D 2520 Inlay- metallic- two surfaces $ D 2530 Inlay- metallic- three or more surfaces $ D 2542 Onlay- metallic- two surfaces $ D 2543 Onlay- metallic- three surfaces $275.00

4 D 2544 Onlay- metallic - four or more surfaces $ D 2610 Inlay-porcelain/ceramic - one surface D 2620 Inlay-porcelain/ceramic - two surfaces D 2630 Inlay-porcelain/ceramic - three or more surfaces D 2642 Onlay-porcelain/ceramic- two surfaces D 2643 Onlay-porcelain/ceramic- three surfaces D 2644 Onlay-porcelain/ceramic-four or more surfaces D 2650 Inlay-resin-based composite-one surface D 2651 Inlay-resin-based composite-two surfaces D 2652 Inlay-resin-based composite-three or more surfaces D 2662 Onlay-resin-based composite - two surfaces D 2663 Onlay-resin-based composite - three surfaces D 2664 Onlay-resin based composite - four or more surfaces D 2710 Crown-resin based composite (indirect) D 2712 Crown- 3/4 resin based composite (indirect) D 2720 Crown - resin with high noble metal D 2721 Crown - resin with predominantly base metal D 2722 Crown - resin with noble metal D 2740 Crown - porcelain /ceramic substrate $ D 2750 Crown - porcelain fused to high noble $ D 2751 Crown- porcelain fused to predominantly base metal $ D 2752 Crown- porcelain fused to noble metal $ D 2780 Crown- ¾ cast high noble metal $ D 2781 Crown- ¾ cast predominantly base metal $ D 2782 Crown- ¾ cast noble metal $ D 2783 Crown - 3/4 porcelain/ceramic metal D 2790 Crown- full cast high noble metal $ D 2791 Crown- full cast predominantly base metal $ D 2792 Crown - full cast noble metal $ D 2794 Crown - titanium

5 D 2799 Provisional Crown $55.00 D 2910 Recement inlay $15.00 D 2915 Recement cast or prefabricated post and core D 2920 Recement crown $15.00 D 2930 Prefabricated stainless steel crown -primary tooth $60.00 D 2931 Prefabricated stainless steel crown -permanent tooth $90.00 D 2932 Prefabricated resin crown (anterior teeth only) $ D 2933 Prefabricated stainless steel crown with resin window $ D 2934 Prefabricated esthetic coated stainless steel crown-primary tooth D 2940 Sedative filling No Copay D 2950 Core buildup, including any pins $65.00 D 2951 Pin retention - per tooth, in addition to restoration $10.00 D 2952 Cast post and core in addition to crown $ D 2953 Each additional cast post - same tooth No Copay D 2954 Prefabricated post and core in addition to crown $ D 2955 Post Removal (not in conjunction with endodontic therapy) D 2957 Each additional prefabricated post - same tooth D 2960 Labial veneer (resin laminate) - chairside D 2961 Labial veneer (resin laminate) - laboratory D 2962 Labial veneet (porcelain laminate) - laboratory D 2970 Temporary crown (fractured tooth) $55.00 D 2971 Additional procedures to construct new crown under existing denture D 2975 Coping D 2980 Crown repair, by report Endodontics D 3110 Pulp cap - direct (excluding final restoration) No Copay D 3120 Pulp cap - indirect (excluding final restoration) No Copay D 3220 Therapeutic pulpotomy (excluding final restoration) No Copay D 3221 Pulpal debridement, primary and permanent teeth $10.00

6 D 3222 Partial pulpotomy for apexogensis-permanent tooth w/ incomplete root $60.00 development D 3230 Pulpal therapy(resorbable filling)- anterior,primary tooth $10.00 D 3240 Pulpal therapy(resorbable filling) - posterior, primary tooth $10.00 D 3310 Root canal- anterior (excluding final restoration) $ D 3320 Root canal - bicuspid (excluding final restoration) $ D 3330 Root canal - molar (excluding final restoration) $ D 3331 Treatment of root canal obstruction;non-surgical access D 3332 D 3333 Incomplete endodontic therapy;inoperable,unrestorable,fractured tooth Internal root repair of perforation defects D 3346 Retreatment of previous root canal therapy- anterior $ D 3347 Retreatment of previous root canal therapy- bicuspid $ D 3348 Retreatment of previous root canal therapy- molar $ D 3351 Apexification/recalcification- initial visit $60.00 D 3352 Apexification/recalcification- interim medication replacement D 3353 Apexification/recalcification-final visit D 3410 Apicoectomy/periradicular surgery - anterior $ D 3421 Apicoectomy/periradicular surgery - bicuspid (first root) $ D 3425 Apicoectomy/periradicular surgery - molar (first root) $ D 3426 Apicoectomy/periradicular surgery (each additional root) $ D 3430 Retrograde filling - per root $75.00 D 3450 Root Amputation - per root D 3460 Endodontic osseous implant D 3470 Intentional reimplantation (including necessary splinting) D 3910 Surgical procedure for isolation of tooth with rubber dam D 3920 Hemisection, not including root canal therapy $90.00 D 3950 Canal preparation and fitting of performed dowel or post Periodontics D 4210 D 4211 Gingivectomy or gingivoplasty-four or more contiguous teeth per quad Gingivectomy or gingivoplasty - one to three teeth, per quadrant $ $75.00

7 D 4230 D 4231 Anatomical crown exposure - four or more contiguous teeth per quad Anatomical crown exposure - one to three teeth per quadrant D 4240 Gingival flap procedures, including root planing four or more teeth $ D 4241 Gingival flap procedures, including root planing,one-three teeth/quad $ D 4245 Apically positioned flap $ D 4249 Clinical crown lengthening - hard tissue $ D 4260 D 4261 Osseous surgery- four or more teeth per quadrant Osseous surgery - one to three teeth, per quadrant $ $ D 4263 Bone replacement graft - first site in quadrant $ D 4264 Bone replacement graft - each additional site in quadrant $75.00 D 4265 Biologic materials to aid in soft and osseous tissue regeneration D 4266 Guided tissue regeneration - resorbable barrier, per site $ D 4267 Guided tissue regeneration - nonresorbable barrier, per site $ D 4268 Surgical revision procedure, per tooth D 4270 Pedicle soft tissue graft procedure $ D 4271 Free soft tissue graft procedure (including donor site surgery) $ D 4273 Subepithelial connective tissue graft procedure $ D 4274 Distal or proximal wedge procedure $ D 4275 Soft tissue allograft D 4276 Combined connective tissue and double pedicle graft, per tooth D 4320 Provisional splinting - intracoronal D 4321 Provisional splinting -extracoronal D 4341 Periodontal scaling and root planing - four or more teeth per quadrant $45.00 D 4342 Periodontal scaling and root planing - one to three teeth, per quadrant $30.00 D 4355 Full mouth debridement $45.00 D 4381 Localized delivery of antimicrobial agents D 4910 Periodontal maintenance procedures (following active therapy) $35.00 D 4920 Unscheduled dressing change Prosthodontics, removable D 5110 Complete denture - maxillary $ D 5120 Complete denture - mandibular $405.00

8 D 5130 Immediate denture - maxillary $ D 5140 Immediate denture - mandibular $ D 5211 Maxillary partial denture $ D 5212 Mandibular partial denture $ D 5213 Maxillary partial denture $ D 5214 Mandibular partial denture $ D 5225 Maxillary partial denture - flexible base $ D 5226 Mandibular partial denture - flexible base $ D 5281 Removable unilateral partial denture $ D 5410 Adjust complete denture-- maxillary $30.00 D 5411 Adjust complete denture-- mandibular $30.00 D 5421 Adjust partial denture-- maxillary $30.00 D 5422 Adjust partial denture-- mandibular $30.00 D 5510 Repair broken complete denture base $60.00 D 5520 Replace missing or broken teeth - complete denture (each tooth) $45.00 D 5610 Repair resin denture base $55.00 D 5620 Repair cast framework $75.00 D 5630 Repair or replace broken clasp $80.00 D 5640 Replace broken teeth - per tooth $50.00 D 5650 Add tooth to existing partial denture $60.00 D 5660 Add clasp to existing partial denture $70.00 D 5670 Replace all teeth and acrylic on cast metal framework ( maxillary) $ D 5671 Replace all teeth and acrylic on cast metal framework ( mandibular) $ D 5710 Rebase complete maxillary denture $ D 5711 Rebase complete mandibular denture $ D 5720 Rebase maxillary partial denture $ D 5721 Rebase mandibular partial denture $ D 5730 Reline complete maxillary denture (chairside) $ D 5731 Reline complete mandibular denture (chairside) $ D 5740 Reline maxillary partial denture (chairside) $105.00

9 D 5741 Reline mandibular partial denture (chairside) $ D 5750 Reline complete maxillary denture (laboratory) $ D 5751 Reline complete mandibular denture (laboratory) $ D 5760 Reline maxillary partial denture (laboratory) $ D 5761 Reline mandibular partial denture (laboratory) $ D 5810 Interim complete denture (maxillary) D 5811 Interim complete denture (mandibular) D 5820 Interim partial denture (maxillary) - Anterior only $ D 5821 Interim partial denture (mandibular) - Anterior only $ D 5850 Tissue conditioning, maxillary D 5851 Tissue conditioning, mandibular D 5860 Overdenture - complete, by report D 5861 Overdenture - partial, by report D 5862 Precision attachment, by report D 5867 Replacement of precision attachment D 5875 Modification of removable prosthesis following implant surgery Maxillofacial Prosthetics D 5911 Facial moulage (sectional) D 5912 Facial moulage (complete) D 5913 Nasal prosthesis D 5914 Auricular prosthesis D 5915 Orbital prosthesis D 5916 Ocular prosthesis D 5919 Facial prosthesis D 5922 Nasal septal prosthesis D 5923 Ocular prosthesis, interim D 5924 Cranial prosthesis D 5925 Facial augmentation, implant prosthesis D 5926 Nasal prosthesis, replacement D 5927 Auricular prosthesis, replacement

10 D 5928 Orbital prosthesis, replacement D 5929 Facial prosthesis, replacement D 5931 Obturator prosthesis, surgical D 5932 Obturator prosthesis, definitive D 5933 Obturator prosthesis, modification D 5934 Mandibular resection prosthesis with guide flange D 5935 Mandibular resection prosthesis without guide flange D 5936 Obturator prosthesis, interim D 5937 Trismus appliance (not for TMD treatment) D 5951 Feeding aid D 5952 Speech aid prosthesis, pediatric D 5953 Speech aid prosthesis, adult D 5954 Palatal augmentation prosthesis D 5955 Palatal lift prosthesis, definitive D 5958 Palatal lift prosthesis, interim D 5959 Palatal lift prosthesis, modification D 5960 Speech aid prosthesis, modification D 5982 Surgical Stent D 5983 Radiation carrier D 5984 Radiation shield D 5985 Radiation cone locator D 5986 Fluoride gel carrier D 5987 Commissure splint D 5988 Surgical splint Surgical Services D 6010 Surgical placement of implant body; endosteal implants D 6012 Surgical placement of interim implant body D 6040 Surgical placement; eposteal implant D 6050 Surgical placement; transosteal implant Implant Supported Prosthetics - Supporting Structures

11 D 6055 Dental Implant supported connecting bar D 6056 Prefabricated abutment-includes placement D 6057 Custom Abutment-includes placement Implant/Abutment Supported Removable Dentures D 6053 Implant/abutment supported removable complete denture D 6054 Implant/abutment supported removable partial denture Implant/Abutment Supported Fixed Dentures (Hybrid Prosthesis) D 6078 Implant/Abutment Supported Fixed Complete Denture D 6079 Implant/Abutment Supported Fixed Denture for partially edentulous arch Single Crowns, Abutment Supported D 6058 Abutment supported porcelain/ceramic crown $ D 6059 Abutment supported porcelain fused to metal crown (high noble crown) $ D 6060 Abutment supported porcelain fused to metal crown (base metal) $ D 6061 Abutment supported porcelain fused to metal crown (noble metal) $ D 6062 Abutment supported cast metal crown (high noble metal) $ D 6063 Abutment supported cast metal crown (predominantly base metal) $ D 6064 Abutment supported cast metal crown (noble metal) $ D 6094 Abutment supported crown - (titanium) Single Crowns, Implant Supported D 6065 Implant supported porcelain/ceramic crown $ D 6066 Implant supported porcelain fused to high noble metal crown $ D 6067 D 6068 Implant supported metal crown (titanium, titanium alloy, high noble Abutment supported retainer for porcelain/ceramic FPD $ $ D 6069 D 6070 Abutment supported retainer porcelain fused to high noble metal FPD Abutment supported retainer for porcelain fused to metal FPD $ $ D 6071 D 6072 Abutment supported retainer for porcelain fused to metal FPD (noble Abutment supported retainer for cast metal FPD (high noble metal) $ $ D 6073 D 6074 Abutment supported retainer for cast metal FPD (predominantly base Abutment supported retainer for cast metal FPD (noble metal) $ $ Fixed Partial Denture, Implant Supported D 6075 Implant supported retainer for ceramic FPD $500.00

12 D 6076 Implant supported retainer for porcelain fused tohigh noble metal FPD $ D 6077 Implant supported retainer for cast high noble metal FPD $ Other implant Services D 6080 Implant maintenance procedures D 6090 Repair implant supported prosthesis, by report D 6091 D 6092 Replacement of semi-precision or precision attachment Recement implant/abutment supported crown D 6093 Recement implant/abutment supported fixed partial denture D 6095 Repair Implant abutment, by report D 6100 Implant removal, by report D 6190 Radiographic. surgical implant index, by report D 6194 Abutment supported retainer crown for FPD-titanium Prosthodontics, fixed D 6205 Pontic-indirect resin based composite D 6210 Pontic- cast high noble metal $ D 6211 Pontic- cast predominantly base metal $ D 6212 Pontic - cast noble metal $ D 6214 Pontic - titanium D 6240 Pontic - porcelain fused to high noble metal $ D 6241 Pontic- porcelain fused to predominantly base metal $ D 6242 Pontic - porcelain fused to noble metal $ D 6245 Pontic - porcelain/ceramic D 6250 Pontic - resin with high noble metal D 6251 Pontic - resin with predominantly base metal D 6252 Pontic - resin with noble metal D 6253 Provisional pontic D 6545 Retainer - cast metal for resin bonded fixed prosthesis D 6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis D 6600 Inlay- porcelain/ceramic, two surfaces D 6601 Inlay- porcelain/ceramic, three or more surfaces

13 D 6602 Inlay - cast high noble metal, two surfaces D 6603 Inlay - cast high noble metal, three or more surfaces D 6604 Inlay - cast predominantly base metal, two surfaces D 6605 Inlay - cast predominantly base metal, three or more surfaces D 6606 Inlay - cast noble metal, two surfaces D 6607 Inlay - cast noble meta, three or more surfaces D 6608 Onlay - porcelain/ceramic, two surfaces D 6609 Onlay- porcelain/ceramic, three or more surfaces D 6610 Onlay- cast high noble metal, two surfaces $ D 6611 Onlay - cast high noble metal, three or more surfaces $ D 6612 Onlay - cast predominantly base metal, two surfaces $ D 6613 Onlay - cast predominantly base metal, three or more surfaces $ D 6614 Onlay- cast noble metal, two surfaces $ D 6615 Onlay- cast noble metal, three or more surfaces $ D 6624 Inlay - titanium D 6634 Onlay - titanium D 6710 Crown - indirect resin based composite D 6720 Crown - resin with high noble metal D 6722 Crown - resin with predominantly base metal D 6740 Crown - porcelain/ceramic D 6750 Crown - porcelain fused to high noble metal $ D 6751 Crown- porcelain fused to predominantly base metal $ D 6752 Crown - porcelain fused to noble metal $ D 6780 Crown- 3/4 cast high noble metal $ D 6781 Crown ¾ cast predominantly base metal $ D 6782 Crown ¾ cast noble metal $ D 6783 Crown - 3/4 porcelain/ceramic D 6790 Crown - full cast high noble metal $ D 6791 Crown - full cast predominantly base metal $ D 6792 Crown - full cast noble metal $290.00

14 D 6793 Provisional retainer crown D 6794 Crown - titanium D 6920 Connector bar D 6930 Recement fixed partial denture $40.00 D 6940 Stress breaker D 6950 Precision attachment D 6970 Cast post and core in addition to fixed partial denture retainer $ D 6972 D 6973 Prefabricated post and core in addition to fixed partial denture retainer Core buildup for retainer, including any pins $ $65.00 D 6975 Coping - metal D 6976 Additional cast post - same tooth No Copay D 6977 Each additional pre-fabricated post- same tooth No Copay D 6980 Fixed partial denture repair, by report D 6985 Pediatric partial denture, fixed Oral and Maxillofacial Surgery D 7111 Extraction, coronal remnants - deciduous tooth D 7140 Extraction No Copay D 7210 Surgical removal of erupted tooth $25.00 D 7220 Removal of impacted tooth - soft tissue $25.00 D 7230 Removal of impacted tooth - partially bony $60.00 D 7240 Removal of impacted tooth - completely bony $75.00 D 7241 Removal of impacted tooth - completely bony (complex) $90.00 D 7250 Surgical removal of residual tooth roots (cutting procedure) $45.00 D 7260 Oroantral fistula closure D 7261 Primary closure of a sinus perforation D 7270 Tooth reimplantation and/or stabilization $ D 7272 Tooth transplantation D 7280 Surgical access of an erupted tooth $ D 7283 D 7285 Placement of device to facilitate eruption of impacted tooth Biopsy of oral tissue - hard (bone, tooth) $125.00

15 D 7286 Biopsy of oral tissue - soft (all others) $ D 7287 Exfoliative cytological sample collection D 7288 Brush biopsy - transepithelial sample collection D 7290 Surgical repositioning of teeth D 7291 Transseptal fiberotomy/supra fiberotomy, by report D 7292 Surgical placement: temporary anchorage device D 7293 Surgical placement: temporary anchorage device requiring surgical flap D 7294 Surgical placement: temporary anchorage device without surgical flap D 7310 Alveoloplasty in conjunction with extractions - per quadrant $40.00 D 7311 Alveoloplasty in conjunction with extractions - one to three teeth D 7320 D 7321 Alveoloplasty not in conjunction with extractions - four or more teeth Alveoloplasty not in conjunction with extractions - one to three teeth $60.00 D 7340 Vestibuloplasty - ridge extension (secondary epithelialization) D 7350 Vestibuloplasty - ridge extension Surgical Excision of Soft Tissue Lesions D 7410 Excision of benign lesion up to 1.25cm D 7411 Excision of benign lesion greater than 1.25cm D 7412 Excision of benign lesion, complicated D 7413 Excision of malignant lesion up to 1.25cm D 7414 Excision of malignant lesion greater than 1.25cm D 7415 Excision of malignant lesion, complicated D 7465 Destruction of lesion(s) by physical or chemical method, by report Surgical Excision of Intra-osseous Lesions D 7440 Excision of malignant - lesion diameter up to 1.25 cm D 7441 Excision of malignant - lesion diameter greater than 1.25 cm D 7450 Removal of benign odotogenic cyst or tumor D 7451 Removal of benign odotogenic cyst or tumor D 7460 Removal of benign nonodontogenic cyst or tumor D 7461 Removal of benign nonodontogenic cyst or tumor Excision of Bone Tissue

16 D 7471 Removal of lateral exostosis (maxilla or mandible) $ D 7472 Removal of torus palatinus $ D 7473 Removal of torus mandibular $ D 7485 Surgical reduction of osseous tuberosity D 7490 Radical resection of maxilla Surgical Excision D 7510 Incision and drainage of abscess- intraoral soft tissue $45.00 D 7511 Incision and drainage of abscess- intraoral soft tissue - complicated D 7520 Incision and drainage of abscess - extraoral soft tissue D 7521 D 7530 Incision and drainage of abscess - extraoral soft tissue - complicated Removal of foreign body from mucosa D 7540 Removal of reaction of producing foreign bodies D 7550 Partial ostectomy/sequestrectomy for removal of non-vital bone D 7560 Maxillary sinusotomy for removal of tooth fragment of foreign body D 7610 Maxilla - open reduction (teeth immobilized, if present) D 7620 Maxilla - closed reduction (teeth immobilized, if present) D 7630 Mandible - open reduction (teeth immobilized, if present) D 7640 Mandible - closed reduction (teeth immobilized, if present) D 7650 Malar and /or zygomatic arch - open reduction D 7660 Malar and /or zygomatic arch - closed reduction D 7670 Alveolus - closed reduction, may include stabilization of teeth D 7671 Alveolus - open reduction, may include stabilization of teeth D 7680 Facial bones - complicated reduction with fixation Treatment of Fractures - Compound D 7710 Maxilla - open reduction D 7720 Maxilla - closed reduction D 7730 Mandible - open reduction D 7740 Mandible - closed reduction D 7750 Malar and /or zygomatic arch - open reduction D 7760 Malar and /or zygomatic arch - closed reduction

17 D 7770 Alveolus - open reduction stabilization of teeth D 7771 Alveolus - closed reduction stabilization of teeth D 7780 Facial bones - complicated reduction with fixation D 7810 Open reduction of dislocation D 7820 Closed reduction of dislocation D 7830 Manipulation under anesthesia D 7840 Condylectomy D 7850 Surgical Discectomy, with/without implant D 7852 Disc repair D 7854 Synovectomy D 7856 Myotomy D 7858 Joint reconstruction D 7860 Arthrotomy D 7865 Arthroplasty D 7870 Arthrocentesis D 7871 Non-arthroscopic lysis and lavage D 7872 Arthroscopy-diagnosis; with or without biopsy D 7873 Arthroscopy - surgical, lavage and lysis of adhesions D 7874 Arthroscopy - surgical, disc repositioning and stabilization D 7875 Arthroscopy - surgical, synovectomy D 7876 Arthroscopy - surgical, discectomy D 7877 Arthroscopy - surgical, debridement D 7880 Occlusal orthotic device, by report Repair of Traumatic Wounds D 7910 Suture of recent small wounds up to 5cm Complicated Suturing D 7911 Complicated suture - up to 5cm D 7912 Complicated suture - greater than 5cm Other Repair Procedures D 7920 Skin graft (identify defect covered, location, and type of graft)

18 D 7940 Osteoplasty - for orthognathic deformities D 7941 Osteotomy - mandibular rami D 7943 Osteotomy - mandibular rami with bone graft D 7944 Osteotomy - segmented or subapical D 7945 Osteotomy - body of the mandible D 7946 LeFort I (maxilla - total) D 7947 LeFort I (maxilla - segmented) D 7948 LeFort II or LeFort III - without bone graft D 7949 LeFort II or LeFort III - with bone graft D 7950 Osseous, osteoperiosteal,or cartilage graft of mand./max D 7951 Sinus augmentation with bone or bone substitutes D 7953 Bone replacement graft for ridge preservation - per site D 7955 Repair of maxillofacial sort and /or hard tissue D 7960 Frenulectomy, (frenectomy or frenotomy) - separate procedure $75.00 D 7963 Frenuloplasty D 7970 Excision of hyperplasic tissue - per arch D 7971 Excision of pericoronal gingiva D 7972 Surgical reduction of fibrous tuberosity D 7980 Sialolithotomy D 7981 Excision of salivary gland, by report D 7982 Sialodochoplasty D 7982 Closure of salivary fistula D 7990 Emergence tracheotomy D 7991 Coronoidectomy D 7995 Synthetic graft - mandible or facial bones, by report D 7996 Implant - mandible for augmentation purposes, by report D 7997 Appliance removal D 7998 D 7999 Intraoral placement of a fixation device not in conjunction with fracture Unspecified oral surgery procedure, by report Orthodontics

19 D 8660 Pre-orthodontic treatment visit and records solely for the purpose of $ Orthodontics-(pre-records) including: 0210 Intraoral - complete series (including bitewings 0340 Cephalometric film 0330 Panoramic film 0322 Tomographic survey 0350 Oral/facial images (includes intra and extra oral images) 0470 Diagnostic casts D 8010 Limited orthodontic treatment of the primary dentition D 8020 Limited orthodontic treatment of the transitional dentition $1, D 8030 Limited orthodontic treatment of the adolescent dentition $1, D 8040 Limited orthodontic treatment of the adult dentition $2, D 8050 Interceptive orthodontic treatment of the primary dentition D 8060 Interceptive orthodontic treatment of the transitional dentition D 8070 Comprehensive orthodontic treatment of the transitional dentition $1, D 8080 Comprehensive orthodontic treatment of the adolescent dentition $1, D 8090 Comprehensive orthodontic treatment of the adult dentition $2, D 8210 Removable appliance therapy $ D 8220 Fixed appliance therapy $ D 8670 D 8680 Periodic orthodontic treatment visit (as part of contract) Orthodontic retention Inclusive of total case $ D 8690 Orthodontic treatment (alternative billing to a contract fee) D 8691 Repair of orthodontic appliance D 8692 Replacement of lost or broken retainer D 8693 Rebonding or recementing; and or repair of fixed retainers D 8999 Unspecified orthodontic procedure, by report Adjunctive General Services D 9110 Palliative (emergency) treatment of dental pain - minor procedure $30.00 D 9120 Fixed partial denture sectioning D 9210 Local anesthesia not in conjunction with operative/surgical procedure

20 D 9212 Trigeminal division block anesthesia D 9215 Local anesthesia No Copay D 9220 Deep sedation/general anesthesia - first 30 minutes $ D 9221 Deep sedation/general anesthesia - each additional 15 minutes $50.00 D 9230 Analgesia, anxiolysis, inhalation of nitrous oxide $15.00 D 9241 IV conscious sedation/analgesia first 30 minutes $ D 9242 IV conscious sedation/analgesia each additional 15 minutes $30.00 D 9310 Consultation $40.00 D 9410 House/extended care facility call D 9420 Hospital Call D 9430 Office visit for observation $15.00 D 9450 Case Presentation D 9610 Therapeutic parenteral drug, single administration D 9612 Therapeutic parenteral drug, two or more administrations D 9630 Other drugs and /or medicaments, by report D 9910 Application of desensitizing medicaments D 9911 Application of desensitizing resin for cervical and/or root surface D 9920 Behavior Management, by report D 9930 Treatment of complications ( post -surgical) D 9940 Occlusal guard $ D 9941 Fabrication of athletic mouth guard D 9942 Repair and /or reline of occlusal guard D 9950 Occlusion analysis D 9951 Occlusal adjustment - limited $25.00 D 9952 Occlusal adjustment - complete $55.00