| 0150 |
Comprehensive Oral Exam |
*Perio Only
|
| 0110 |
Initial Oral Exam |
*MH Exam only to age 21
|
| 0120 |
Periodic Oral Exam |
|
| 9110 |
Emergency Exam/Palliative Treatment |
|
| |
|
|
| 0210 |
Full Mouth X-rays |
|
| 0220 |
Periapical-First |
|
| 0230 |
Periapical-Second |
|
| 0272 |
(2)Bite Wing X-rays |
|
| 0274 |
(4)Bite Wing X-rays |
|
| |
|
|
| 1110 |
Prophy |
*14yr + up
|
| 1120 |
Prophy - Child |
|
| 1124 |
Difficult Prophy |
|
| 4910 |
Perio Prophy |
|
| |
|
|
| 1203 |
Fluoride Treatment |
*Through Age 17
|
| |
|
|
| 2140 |
1-Surface Amalgam |
|
| 2150 |
2-Surface Amalgam |
|
| 2160 |
3-Surface Amalgam |
|
| 2161 |
4+Surface Amalgam |
|
| |
|
|
| 2330 |
1-Surface Composite |
|
| 2331 |
2-Surface Composite |
|
| 2332 |
3-Surface Composite |
|
| 2335 |
4+Surface Composite |
|
| |
|
|
| 7110 |
Extraction |
|
| 7120 |
Extraction Additional |
|
| |
|
|
| |
|
|
| 2954 |
Post & Core |
|
| 2951 |
Pin |
|
| |
|
|
| 2750 |
Crown-Porcelain fused to high noble gold |
|
| 2751 |
Crown |
|
| 2920 |
Re-cement Crown |
|
| 2790 |
Gold Crown Full Cast |
|
 |
| |
|
|
| 5110 |
Upper Denture |
|
| 5120 |
Lower Denture |
|
| 5130 |
Immediate Upper Denture |
|
| 5140 |
Immediate Lower Denture |
|
| |
|
|
| 5510 |
Repair Base of Denture |
|
| 5520 |
Replace Tooth |
|
| |
|
|
| 5213 |
Upper Partial Bilateral Valplast Upper |
|
| 5214 |
Partial bilateral Valplast Lower |
|
| 5211 |
Upper Partial |
|
| 5212 |
Lower Partial |
|
| 5281 |
Removable unilateral partial denture Valplast |
|
| |
|
|
| 5610 |
Repair Base of Partial |
|
| 5630 |
Repair Broken Clasp |
|
| 5640 |
Replace Broken Tooth |
|
| 5650 |
Add Tooth |
|
| |
|
|
| 5710 |
Reline Upper Denture |
|
| 5711 |
Reline Lower Denture |
|
| |
|
|
| 1351 |
Sealants |
|
| |
|
|
| 9940 |
Night Guard |
|
| |
|
|
| 6930 |
Re-cement Bridge |
|
| |
|
|
| 2940 |
Sedative Filling/IRM |
|
| |
|
|
| 1510 |
Space Maintainer |
|
| |
|
|
| 4260 |
Osseous Surgery Per Qd |
|
| |
|
|
| 4341 |
Scale & Root Plane Per QD |
|
