| Service |
USUAL |
SAVON |
|
| Diagnostic |
|
| 0110 |
Infection Control Fee |
12 |
6 |
| 0120 |
Periodic Oral Evaluation |
22 |
11 |
| 0140 |
Limited Oral Exam..Emergency Exam -- Problem Focused --
During Regular Office Hours |
74 |
37 |
| 0150 |
Comprehensive Oral Evaluation ( new or established patient ) |
82 |
N/C |
| 0180 |
Comprehensive Perio Evaluation
(includes perio probing and charting) |
84 |
42 |
| Radiographs |
(top) |
| 0210 |
X-Rays - Complete Series
(IF NOT CHARGED FOR 0330) |
114 |
57 |
| 0220 |
Intraoral Periapical - Single First Film |
22 |
N/C |
| 0230 |
Intraoral Periapical - Each Additional Film |
18 |
N/C |
| 0240 |
Intraoral - Occlusal Film |
32 |
N/C |
| 0272 |
Bitewings - Two Films |
35 |
N/C |
| 0274 |
Bitewings - Four Films |
49 |
N/C |
| 0330 |
Panoramic X-Ray
(IF NOT CHARGED FOR 0210) |
100 |
50 |
| Other |
(top) |
| 0416 |
Viral Culture (a test to identify viral organisms) |
152 |
76 |
| 0460 |
Pulp Vitality Test |
58 |
29 |
| - Plus Actual Lab fee |
| 0470 |
Diagnostic Casts (Study Models) |
96 |
48 |
| Preventative |
(top) |
| 1110 |
Adult Prophylaxis
This Fee is for regular cleanings. The first cleaning may be charged
under the Periodontal Section |
78 |
39 |
| 1120 |
Child Prophylaxis
This Fee is for regular cleanings. The first cleaning may be charged
under the Periodontal Section |
58 |
29 |
| 1330 |
Oral Hygiene Instruction |
54 |
N/C |
| Fluoride Treatments |
(top) |
| 1201 |
Topical Application of Fluoride -- (Including Prophy - Child) |
82 |
41 |
| 1203 |
Topical Application of Fluoride -- (In addition to prophy - Child) |
32 |
16 |
| 1351 |
Sealants -- (Fee is per tooth) |
48 |
24 |
| Special Maintainers |
(top) |
| 1510 |
Fixed - Unilateral Type --(To Include Adjustments) |
280 |
140 |
| 1515 |
Fixed - Bilateral Type --(To Include Adjustments) |
394 |
197 |
| 1520 |
Removable - Unilateral Type --(To Include Adjustments) |
350 |
175 |
| 1525 |
Removable - Bilateral Type --(To Include Adjustments) |
436 |
218 |
| Restorative Amalgam |
(top) |
| 2140 |
Amalgam - One Surface -- Primary or Permanent Tooth |
110 |
55 |
| 2150 |
Amalgam - Two Surfaces -- Primary or Permanent Tooth |
148 |
74 |
| 2160 |
Amalgam - Three Surfaces -- Primary or Permanent Tooth |
170 |
85 |
| 2161 |
Amalgam - Four or More Surfaces -- Primary or Permanent Tooth |
200 |
100 |
| Restorative Composite |
(top) |
| 2330 |
Resin - Based Composite - One Surface Anterior |
182 |
91 |
| 2331 |
Resin - Based Composite - Two Surfaces Anterior |
230 |
115 |
| 2332 |
Resin - Based Composite - Three Surfaces Anterior |
286 |
143 |
| 2335 |
Resin - Based Composite - Four or More Surfaces or Involving Incisal Angle - Anterior |
358 |
179 |
| 2391 |
Resin - Based Composite - One Surface Posterior |
204 |
102 |
| 2392 |
Resin - Based Composite - Two Surfaces Posterior |
262 |
131 |
| 2393 |
Resin - Based Composite - Three Surfaces Posterior |
326 |
163 |
| 2394 |
Resin - Based Composite - Four or More Surfaces Posterior |
392 |
196 |
| 2510 |
Inlay - Metallic - One Surface |
682 |
341 |
| - Plus Actual Lab fee |
| - Plus Gold or Metal Charges |
| 2520 |
Inlay - Metallic - Two Surfaces |
750 |
375 |
| - Plus Actual Lab fee |
| - Plus Gold or Metal Charges |
| 2530 |
Inlay - Metallic - Three Surfaces |
818 |
409 |
| - Plus Actual Lab fee |
| - Plus Gold or Metal Charges |
| 2542 |
Onlay - Metallic - Two Surfaces |
846 |
423 |
| - Plus Actual Lab fee |
| - Plus Gold or Metal Charges |
| 2543 |
Onlay - Metallic - Three Surfaces |
878 |
439 |
| - Plus Actual Lab fee |
| - Plus Gold or Metal Charges |
| 2544 |
Onlay - Metallic - Four or More Surfaces |
912 |
456 |
| - Plus Actual Lab fee |
| - Plus Gold or Metal Charges |
| Other Restorative Services |
(top) |
| 2910 |
Recement Inlay |
92 |
46 |
| 2915 |
Re-cement cast or prefabricated post and core |
96 |
48 |
| 2920 |
Recement Crowns |
92 |
46 |
| 2930 |
Prefabricated Stainless Steel Crown - Primary Tooth |
250 |
125 |
| 2931 |
Prefabricated Stainless Steel Crown - Permanent Tooth |
302 |
151 |
| 2932 |
Prefabricated Resin Crown |
320 |
160 |
| 2934 |
Prefabricated esthetic coated stainless steel crown (primary tooth) |
356 |
178 |
| 2940 |
Sedative Filling - Temporary Restoration Intended to Relieve Pain |
706 |
53 |
| 2950 |
Core Build up - Including any Pins |
242 |
121 |
| 2951 |
Pin Retention - Per Tooth - In Addition to Restoration |
64 |
32 |
| 2952 |
Cast Post and Core - In Addition to Crown indirectly fabricated |
386 |
193 |
| 2954 |
Prefabricated Post and Core - In Addition to Crown |
314 |
157 |
| Crowns |
(top) |
| 2740 |
Crown - Porcelain/Ceramic Substrate |
1176 |
588 |
| - Plus Actual Lab fee |
| 2750 |
Crown - Porcelain Fused to High Noble Metal |
990 |
495 |
| - Plus Lab Fee Not to Exceed $125.00 |
| - Plus Gold or Metal Charges |
| 2751 |
Crown - Procelain Fused to Predominantly Base Metal |
906 |
453 |
| - Plus Lab Fee Not to Exceed $125.00 |
| 2752 |
Crown - Porcelain Fused to Noble Metal |
948 |
474 |
| - Plus Lab Fee Not to Exceed $125.00 |
| - Plus Gold or Metal Charges |
| 2780 |
Crown - 3/4 Cast High Noble Metal |
966 |
483 |
| - Plus Lab Fee Not to Exceed $125.00 |
| - Plus Gold or Metal Charges |
| 2790 |
Crown - Full Cast High Noble Metal |
1020 |
510 |
| - Plus Lab Fee Not to Exceed $125.00 |
| - Plus Gold or Metal Charges |
| 2792 |
Crown - Full Cast Noble Metal |
938 |
469 |
| - Plus Lab Fee Not to Exceed $125.00 |
| - Plus Gold or Metal Charges |
| 2794 |
Crown - Porcelain Fused to Titanium Metal |
1074 |
536 |
| - Plus Lab Fee Not to Exceed $125.00 |
| - Plus Gold or Metal Charges |
| Veneers |
(top) |
| 2960 |
Labial Veneer - Resin Laminate - Performed Chairside |
608 |
304 |
| 2961 |
Labial Veneer - Resin Laminate - Performed In Laboratory |
844 |
422 |
| - Plus Actual Lab fee |
| 2962 |
Labial Veneer - Porcelain Laminate - Performed In Laboratory |
1050 |
525 |
| - Plus Actual Lab fee |
| Bleaching |
(top) |
| 9972 |
External Bleaching - Per Arch |
408 |
204 |
| 9973 |
External Bleaching - Per Tooth |
258 |
129 |
| 9974 |
Internal Bleaching - Per Tooth |
336 |
168 |
| Endodontics |
(top) |
| 3110 |
Pulp Cap - Direct - Exposed Pulp - Excluding Final Restoration - Per Tooth |
74 |
37 |
| 3120 |
Pulp Cap - Indirect - Nearly Exposed Pulp - Excluding Final Restoration - Per Tooth |
72 |
38 |
| 3220 |
Therapeutic Pulpotomy - Excluding Final Restoration |
178 |
85 |
| 3221 |
Therapeutic Pulpectomy - Pulpal Debridement - Primary and Permanent Teeth |
186 |
93 |
| 3310 |
Root Canal - Anterior - Excluding Final Restoration |
600 |
300 |
| 3320 |
Root Canal - Bicuspid - Excluding Final Restoration |
778 |
389 |
| 3330 |
Root Canal - Molar - Up to Three Canals - Excluding Final Restoration |
952 |
476 |
| 3332 |
Incomplete Endodontic Therapy; Inoperable, Unrestorable or Fractured Tooth |
378 |
189 |
| 3346 |
Retreatment of Previous Root Canal Therapy- Anterior |
818 |
409 |
| 3920 |
Hemisection - Including any Root Removal - Not Including Root Canal Therapy |
436 |
218 |
| Periapical Services |
(top) |
| 3410 |
Apicoetomy - Per Tooth - First Root |
606 |
303 |
| 3426 |
Apicoetomy - Per Tooth - Each Additional Root |
364 |
182 |
| 3426 |
Apicoetomy - Per Tooth - Each Additional Root |
364 |
182 |
| 3430 |
Retrograde Filling - Per Root - In addition to the Apicoectomy if a separate charge is made |
304 |
152 |
| Periodontics |
(top) |
| 4210 |
Gingivectomy or Gingivoplasty - Four or More Contiguous Teeth or Bounded Teeth Spaces - Per Quadrant |
620 |
310 |
| 4211 |
Gingivectomy or Gingivoplasty - One to Three Teeth or Bounded Teeth Spaces - Per Quadrant |
238 |
119 |
| 4240 |
Gingival Flap Curettage - Including Root Planing - Four or More Contiguous Teeth or Bounded Teeth Spaces - Per Quadrant |
724 |
362 |
| 4241 |
Gingival Flap Procedure (including root planning) ( per quadrant) (1-3 or more contigous teeth or bound teeth spaces) |
606 |
303 |
| 4245 |
Apically Positioned Flap Procedure - Per quadrant |
838 |
419 |
| 4249 |
Clinical Crown Lengthening - Hard Tissue |
754 |
377 |
| 4260 |
Osseous Surgery - Including Flap Entry and Closure |
1044 |
522 |
| 4263 |
Bone Replacement Graft - First Site in Quadrant - Does Not Include Flap Entry, Closure or Donor Site |
750 |
375 |
| 4264 |
Bone Replacement Graft - Each Additional Site in Quadrant - Does Not Include Flap Entry, Closure or Donor Site |
514 |
257 |
| 4270 |
Pedicle Soft Tissue Procedure |
814 |
407 |
| 4271 |
Free Soft Tissue Graft Procedure - Including Donor Site Surgery |
862 |
431 |
| 4341 |
Periodontal Scaling and Root Planing - (4 or more contigous teeth - Per Quadrant) |
244 |
122 |
| 4342 |
Periodontal Scaling and Root Planing - (1 to 3 contigous teeth - Per Quadrant) |
170 |
85 |
| 4355 |
Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis |
224 |
112 |
| 4910 |
Periodontal Maintenance - After completion of Active Periodontal Treatment |
164 |
82 |
| Prosthodontics-Removable |
(top) |
| 5110 |
Complete Denture - Maxillary - Including Routine Post - Delivery Care ( This fee is for Medium Grade Acrylic Liner and Medium Grade IPN or similar tee |
1448 |
724 |
| - Plus Actual Lab fee |
| 5120 |
Complete Denture - Mandibular - Including Routine Post - Delivery Care ( This fee is for Medium Grade Acrylic Liner and Medium Grade IPN or similar te |
1448 |
724 |
| - Plus Actual Lab fee |
| 5130 |
Immediate Denture - Maxillary - ( NOT INCLUDING EXTRACTIONS ) - Includes Limited Follow Up Care Only: Does Not Include required future Rebasing/Relin |
1558 |
779 |
| - Plus Actual Lab fee |
| 5140 |
Immediate Denture - Mandibular - ( NOT INCLUDING EXTRACTIONS ) - Includes Limited Follow Up Care Only: Does Not Include required future Rebasing/Reli |
1568 |
784 |
| - Plus Actual Lab fee |
| 5211 |
Partial Denture Maxillary - Resin Base - ( includes any conventional clasps, rest and teeth) - Includes acrylic resin base denture with resin or wroug |
1200 |
600 |
| - Plus Actual Lab fee |
| 5212 |
Partial Denture Mandibular - Resin Base - ( includes any conventional clasps, rest and teeth) - Includes acrylic resin base denture with resin or wrou |
1222 |
611 |
| - Plus Actual Lab fee |
| 5213 |
Partial Denture - Maxillary - Cast chrome base with acrylic saddles - Including any conventional Clasps, rests and teeth - Including Routine Post - De |
1540 |
770 |
| - Plus Actual Lab fee |
| 5214 |
Partial Denture - Mandibular - Cast chrome base with acrylic saddles - Including any conventional Clasps, rests and teeth - Including Routine Post - D |
1538 |
769 |
| - Plus Actual Lab fee |
| 5225 |
Partial Denture Maxillary - Flexible base - ( includes any clasps, rests and teeth ) |
1610 |
805 |
| - Plus Actual Lab fee |
| 5226 |
Partial Denture Mandibular - Flexible base - ( includes any clasps, rests and teeth ) |
1610 |
805 |
| - Plus Actual Lab fee |
| 5410 |
Adjust complete Denture - Maxillary |
80 |
40 |
| 5411 |
Adjust complete Denture - Mandibular |
80 |
40 |
| 5421 |
Adjust Partial Denture - Maxillary |
80 |
40 |
| 5422 |
Adjust Partial Denture - Mandibular |
80 |
40 |
| 5520 |
Replace Missing or Broken Teeth - Complete Denture - Each Tooth |
170 |
85 |
| - Plus Actual Lab fee |
| 5610 |
Repair Resin Base Denture - Cold Cure |
184 |
92 |
| - Plus Actual Lab fee |
| 5630 |
Repair or Replace Broken Clasp - Partial Denture |
230 |
115 |
| - Plus Actual Lab fee |
| 5640 |
Replace broken tooth - partial denture - per tooth |
160 |
80 |
| - Plus Actual Lab fee |
| 5650 |
Add Tooth to Existing Partial Denture |
194 |
97 |
| - Plus Actual Lab fee |
| 5660 |
Add Clasp to Existing Partial Denture |
242 |
121 |
| - Plus Actual Lab fee |
| 5710 |
Rebase Complete Denture - Maxillary - The Process of Refitting a Denture by Replacing the Base Material |
544 |
272 |
| - Plus Actual Lab fee |
| 5711 |
Rebase Complete Denture - Mandibular - The Process of Refitting a Denture by Replacing the Base Material |
544 |
272 |
| - Plus Actual Lab fee |
| 5720 |
Rebase Partial Denture - Maxillary - The Process of Refitting a Denture by Replacing the Base Material |
518 |
259 |
| - Plus Actual Lab fee |
| 5721 |
Rebase Partial Denture - Mandibular - The Process of Refitting a Denture by Replacing the Base Material |
518 |
259 |
| - Plus Actual Lab fee |
| 5730 |
Reline Complete Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary - Done Chairside |
354 |
177 |
| 5731 |
Reline Complete Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular - Done Chariside |
354 |
177 |
| 5740 |
Reline Partial Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary - Done Chariside |
348 |
174 |
| 5741 |
Reline Partial Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular - Done Chariside |
348 |
174 |
| 5750 |
Reline Complete Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary - Done in Laboratory |
446 |
223 |
| - Plus Actual Lab fee |
| 5751 |
Reline Complete Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular - Done in Laboratory |
446 |
223 |
| - Plus Actual Lab fee |
| 5760 |
Reline Partial Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Maxillary - Done in Laboratory |
440 |
220 |
| - Plus Actual Lab fee |
| 5761 |
Reline Partial Denture - Resurfacing the Tissue Side of a Denture with New Base Material - Mandibular - Done in Laboratory |
440 |
220 |
| - Plus Actual Lab fee |
| 5810 |
Interim Denture - Complete Maxillary |
724 |
362 |
| - Plus Actual Lab fee |
| 5811 |
Interim Denture - Complete Mandibular |
724 |
362 |
| - Plus Actual Lab fee |
| 5820 |
Interim Partial Denture - Maxillary - Includes any Necessary Clasps and Rests |
604 |
302 |
| - Plus Actual Lab fee |
| 5821 |
Interim Partial Denture - Mandibular - Includes any Necessary Clasps and Rests |
604 |
302 |
| - Plus Actual Lab fee |
| 5850 |
Tissue Conditioning - Treatment Reline Using Materials Designed to Heal Unhealthy Ridges Prior to More Definitive Final Restoration - Maxillary -( Per |
174 |
87 |
| 5851 |
Tissue Conditioning - Treatment Reline Using Materials Designed to Heal Unhealthy Ridges Prior to More Definitive Final Restoration - Mandibular -( Pe |
180 |
90 |
| Prosthodontics-Fixed-Bridges |
(top) |
| 6210 |
Bridge Pontic - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Cast High Noble Metal |
966 |
483 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6211 |
Bridge Pontic - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Cast Non Precious Metal |
896 |
448 |
| - Plus Lab Fee Not to Exceed $135.00 |
| 6212 |
Bridge Pontic - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Cast Noble Metal |
930 |
465 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6214 |
Pontic - Titanium |
1006 |
503 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6240 |
Bridge Pontic - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to High Noble Metal |
990 |
495 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6241 |
Bridge Pontic - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to Predominantly Base Metal |
906 |
453 |
| - Plus Lab Fee Not to Exceed $135.00 |
| 6242 |
Bridge Pontic - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to Noble Metal |
954 |
477 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6245 |
Bridge Pontic - Each Abutment and Each Pontic Constitutes a Unit in a Bridge Bridge - Porcelain/Ceramic (procera, empress, etc.) |
1088 |
544 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Rural - Not Listed 20% Discount |
| 6545 |
Retainer - Cast Metal for Resin Bonded Fixed Prosthesis |
664 |
332 |
| 6740 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain/Ceramic (procera, empress, etc.) |
1176 |
588 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Rural - Not Listed 20% Discount |
| 6750 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to High Noble Metal |
996 |
498 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6751 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to Predominantly Base Metal |
906 |
453 |
| - Plus Lab Fee Not to Exceed $135.00 |
| 6752 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Porcelain Fused to Noble Metal |
954 |
477 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6780 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - 3/4 Cast High Noble Metal |
966 |
483 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6790 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Full Cast High Noble Metal |
1014 |
507 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6791 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Full Cast Predominantly Base Metal |
902 |
451 |
| - Plus Lab Fee Not to Exceed $135.00 |
| 6792 |
Bridge Abutment - Each Abutment and Each Pontic Constitutes a Unit in a Bridge - Full Cast Noble Metal |
940 |
470 |
| - Plus Lab Fee Not to Exceed $135.00 |
| - Plus Gold or Metal Charges |
| 6794 |
Crown - Titanium |
1070 |
535 |
| - Plus Gold or Metal Charges |
| - Plus Lab Fee Not to Exceed $135.00 |
| 6930 |
Re-Cement Bridge |
146 |
73 |
| Extractions |
(top) |
| 7111 |
Coronal Remnants - Deciduous Tooth - Includes Soft Tissue Retained Coronal Remnants |
120 |
60 |
| 7140 |
Extraction - Erupted Tooth or Exposed Root - Elevation and/or Forceps Removal |
142 |
71 |
| Oral Extractions |
(top) |
| 7210 |
Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth |
242 |
121 |
| 7220 |
Removal of Impacted Tooth - Soft Tissue |
280 |
140 |
| 7230 |
Removal of Impacted Tooth - Partially Bony |
362 |
181 |
| 7240 |
Removal of Impacted Tooth - Completely Bony |
436 |
218 |
| 7241 |
Removal of Impacted Tooth - Completely Bony with Unusual Surgical Complications |
544 |
272 |
| 7250 |
Surgical Removal of Residual Tooth Roots - Cutting Procedure |
270 |
135 |
| Other Surgical |
(top) |
| 7260 |
Oroantral Fistula Closure - Excision of Fistulous Track Between Maxillary Sinus and Oral Cavity and Closure by Advancement Flap |
1044 |
522 |
| 7270 |
Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth |
606 |
303 |
| 7280 |
Surgical Access of an Unerupted Tooth |
606 |
303 |
| 7285 |
Biopsy of Oral Tissue - Hard - Bone -Tooth |
444 |
222 |
| 7286 |
Biopsy of Oral Tissue - Soft - All Others |
336 |
168 |
| 7310 |
Alveoloplasty - Surgical Preparation for a Prosthesis - In Conjunction with Extractions - Per Quadrant |
286 |
143 |
| 7320 |
Alveoloplasty - Surgical Preparation for a Prosthesis - Not In Conjunction with Extractions - Per Quadrant |
426 |
213 |
| 7340 |
Vestibuloplasty - Ridge Extension - Secondary Epithelialization |
1288 |
644 |
| 7350 |
Vestibuloplasty - Ridge Extension - Including Soft Tissue Grafts, Muscle Reattachment, Revision of Soft Tissue Attachment and Management of Hypertroph |
2164 |
1082 |
| 7450 |
Surgical Excision of Intra-Osseous Lesions - Removal of Benign Odontogenic Cyst or Tumor- Up to 1.25 cm |
606 |
303 |
| 7451 |
Surgical Excision of Intra-Osseous Lesions - Removal of Benign Odontogenic Cyst or Tumor- Greater than 1.25 cm |
888 |
444 |
| 7460 |
Surgical Excision of Intra-Osseous Lesions - Removal of Benign Nonodontogenic Cyst or Tumor- Up to 1.25 cm |
622 |
311 |
| 7461 |
Surgical Excision of Intra-Osseous Lesions - Removal of Benign Nonodontogenic Cyst or Tumor- Greater than 1.25 cm |
1004 |
502 |
| 7471 |
Excision of Bone Tissue - Removal of Lateral Exostosis - Maxilla or Mandible |
70 |
365 |
| 7510 |
Surgical Incision - Incision and Drainage of Abscess - Intraoral Soft Tissue |
242 |
121 |
| 7520 |
Surgical Incision - Incision and Drainage of Abscess - Extraoral Soft Tissue |
472 |
236 |
| 7620 |
Treatment of Fractures - Simple - Maxilla - Closed Reduction - Teeth Immobilized, if Present |
3840 |
1920 |
| 7640 |
Treatment of Fractures - Simple - Mandible - Closed Reduction - Teeth Immobilized, if Present |
3744 |
1872 |
| 7960 |
Frenulectomy - Frenectomy or Frenotomy - Seprate Procedure - The Frenum may be excised when the tongue has limited mobility; for large diastemas betwe |
490 |
245 |
| 7970 |
Excision of Hyperplastic Tissue - Per Arch |
596 |
298 |
| 7971 |
Excision of Pericoronal Gingiva - Surgical removal of inflammatory or hypertrophied tissues surrounding partially erupted/impacted teeth |
278 |
139 |
| Orthodontics |
(top) |
| 8010 |
Limited Orthodontic Treatment of the Primary Dentition |
2380 |
1190 |
| - Plus Actual Lab fee |
| 8020 |
Limited Orthodontic Treatment of the Transitional Dentition |
2616 |
1308 |
| - Plus Actual Lab fee |
| 8030 |
Limited Orthodontic Treatment of the Adolescent Dentition |
2958 |
1479 |
| - Plus Actual Lab fee |
| 8040 |
Limited Orthodontic Treatment of the Adult Dentition |
3428 |
1714 |
| - Plus Actual Lab fee |
| 8050 |
Interceptive Orthodontic Treatment of the Primary Dentition |
3016 |
1508 |
| - Plus Actual Lab fee |
| 8060 |
Interceptive Orthodontic Treatment of the Adult Dentition |
3280 |
1640 |
| - Plus Actual Lab fee |
| 8070 |
Comprehensive Orthodontic Treatment of the Transitional Dentition |
5554 |
2777 |
| - Plus Actual Lab fee |
| 8080 |
Comprehensive Orthodontic Treatment of the Adolescent Dentition |
5694 |
2847 |
| - Plus Actual Lab fee |
| 8090 |
Comprehensive Orthodontic Treatment of the Adult Dentition |
6238 |
3119 |
| - Plus Actual Lab fee |
| 8210 |
Removable Appliance Therapy - Removable indicates patient can remove; Includes appliances for thumb sucking and tongue thrusting |
966 |
483 |
| - Plus Actual Lab fee |
| 8220 |
Fixed Appliance Therapy - Fixed indicates patient cannot remove; Includes appliances for thumb sucking and tongue thrusting |
1140 |
570 |
| - Plus Actual Lab fee |
| 8660 |
Pre-Orthodontic Treatment Visit - Initial Exam including Diagnostic aids and Creation of Records |
364 |
182 |
| 8670 |
Periodic Orthodontic Treatment Visit - As part of Contract |
258 |
N/C |
| 8680 |
Orthodontic Retention - Removal of appliances, construction and placement of retainer(s) |
740 |
370 |
| - Plus Actual Lab fee |
| 8691 |
Repair of Orthodontic Appliance - Does not include bracket and standard Orthodontic appliances - It does include Functional appliances and Palatal Exp |
222 |
111 |
| - Plus Actual Lab fee |
| 8692 |
Replacement of lost or broken Retainer |
422 |
211 |
| - Plus Actual Lab fee |
| TMJ |
(top) |
| 1 |
TMJ Screening Exam |
88 |
N/C |
| 10 |
Splint Adjustment |
302 |
151 |
| 3 |
Tomographic Radiographs |
0 |
N/C |
| - Plus Actual Lab fee |
| 4 |
TMJ Treatment - Includes Oral Appliance and Five (5) Adjustment Visits - Treatment Not to Exceed Five (5) Months |
4258 |
2129 |
| 5 |
Night Orthotic - Includes Follow Up Adjustment |
1088 |
544 |
| 6 |
Lost Appliance |
750 |
375 |
| 7 |
Ultrasound Therapy - Unilateral - Each |
146 |
73 |
| 8 |
Ultrasound Therapy - Bilateral - Each |
160 |
80 |
| 9 |
Drug Injection Therapy |
606 |
303 |
| Adjunctive General Services |
(top) |
| 9110 |
Emergency Palliative Treatment of Dental Pain - Minor Procedure |
114 |
57 |
| 9215 |
Local Anesthetic |
64 |
N/C |
| 9220 |
Deep Sedation/General Anesthesia - First 30 Minutes |
384 |
192 |
| 9221 |
Deep Sedation/General Anesthesia - Each additional 15 Minutes |
162 |
81 |
| 9230 |
Analgesia - Anxiolysis - Inhalation of Nitrous Oxide |
74 |
37 |
| 9248 |
Non Intravenous Conscious Sedation |
318 |
159 |
| 9440 |
Emergency Office Visit - After Regularly Scheduled Hours |
224 |
112 |
| 9920 |
Behavior Management - Difficult Patient - In addtion to treatment provided - Reported in 15 minute increments |
122 |
61 |
| Savon Specific Codes |
(top) |
| 12001 |
Bleaching Kit - Refill |
106 |
53 |
| 14345 |
Difficult Cleaning - Excessive Buildup |
164 |
82 |
| 19900 |
Missed Appointment - Reported in 15 Minute Increments |
94 |
47 |
| 19901 |
Copy of a Panoramic X-Ray |
58 |
29 |
| 19902 |
Copy of Dental Records |
36 |
18 |
| 19903 |
Non Emergency -Pallative Treatment of Dental Pain - Minor Procedure |
58 |
29 |
| 20010 |
Bleaching Kit - Take Home - Complete Kit |
702 |
351 |
|
