Fee schedule changes for the next fiscal year

2010-11

DEPT DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG DIAG EMRG

CODE D0010 D0011 D0012 D0013 D0014 D0015 D0016 D0017 D0018 D0019 D0020 D0021 D0022 D0023 D0024 D0025 D0026 D0120 D0140 D0145 Cambra Project

DESCRIPTION

DELTA

BA Fee

Caries Risk Assessment (D/C) Saliva test I (Denti-Cal) Saliva test II (Denti-Cal) Saliva test III (Denti-Cal) High Flouride Toothpaste (D/C) Rx or disp chlorhexidine D/C Rx or disp fluoride varn. D/C Rx or disp xylitol Gum-360 D/C Rx or disp Iodine (D/C) Rx or disp Calcium Phos D/C Rx or disp Mint - 600 (D/C) Rx or CariFree Maintenance Rinse CariFree Treatment Rinse CariFree Boost Dietary Counseling Oral hyg. instructions Periodic oral evaluation Limited oral eval-prob focused Oral evaluation under 3 years old Comprehensive oral evaluation Implant - Detailed oral eval Re-eval-limited-prob focused Comprehensive perio evaluation Intraoral-complete series Intraoral-periapical 1st film Intraoral-periapical addl film Intraoral - occlusal film Extraoral - first film Extraoral - each addl film Bitewing - single film Bitewing - 2 films Bitewings, 3 films Bitewing - 4 films

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

33 44 50 57 49 53 86 22 12 35 35 23 22 35 41 46

DIAG DIAG DIAG DIAG DIAG RADI RADI RADI RADI RADI RADI RADI RADI RADI

D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

47 71 64 81 146 65 88 123 27 22 39 57 50 27 43 53 60

New Fee $ 15 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 25 $ 27 $ 22 $ 33 $ 42 $ 35 $ 49 $ 46 $ 80 $ 18 $ 11 $ 28 $ 34 $ 17 $ 14 $ 25 $ 29 $ 36

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DEPT RADI RADI RADI RADI DIAG RADI RADI RADI RADI RADI RADI RADI RADI RADI ENDO PATH DIAG DIAG DIAG DIAG DIAG DIAG DIAG PERI PATH DIAG PERI DIAG PERI PERI DIAG PERI PERI PERI

CODE D0277 D0290 D0310 D0321 D0322 D0330 D0340 D0350 D0360 D0362 D0363 D0373 D0376 D03AST D0415 D0416 D0431 D0460 D0470 D0472 D0473 D0474 D04PSA D0501 D0999 D1110 D1111 D1120 D1201 D1203 D1204 D1205 D1206 D1310

DESCRIPTION Vertical bitewing - 7-8 films Post.-ant. Skull & facial bone Sialography Other TMJ films, by report Tomographic survey Panoramic film Cephalometric film Oral/facial images Cone beam ct - craniofacial dc Cone beam - 2-dim img (ACUTOMO) Cone beam - 3-dim img reconstr (i-CAT) Tomo Small Volume I-Cat Endodontic Assist Bact. studies for path. agents Viral culture Pre-diagnostic mucosal test Pulp vitality tests Diagnostic casts Accession of tissue-gross exam Accession of tissue Accession of tissue, w/ assess Perio Assist Histopathologic exams Unspecified diagnostic proc. Prophy - adult Prophy Adult (16 teeth or less) Prophy - child Fluoride, incl. prophy - child Fluoride, w/o prophy - child Fluoride, w/o prophy - adult Fluoride, incl. prophy - adult Topical fluoride varnish Nutritional counseling

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $

85 35 77 87 -

$ $ $ $ $ $ $ $ $ $ $

92 125 308 196 475 106 118 67 520 323 379

$ $ $ $ $ $

131 35 131 131 131

$ $ $ $ $ $ $ $

163 162 72 53 100 111 156 168

$ $ $ $ $ $ $ $

79 66 52 40 41

$ $ $ $ $ $

87 64 34 35 39 65

New $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Fee 85 35 77 264 65 63 48 341 251 341 341 103 40 35 131 131 131 69 33 52 49 26 28 81 26 -

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2010-11

DEPT DIAG DIAG REST ORTH ORTH ORTH DIAG DIAG DIAG DIAG REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST

CODE D1330 D1351 D1510 D1515 D1520 D1525 D1550 D1555 D2100 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2410 D2420 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642

DESCRIPTION Oral hygiene instructions Sealant - per tooth Space maint - fixed-unilateral Space maint - fixed-bilateral Space maint - remov-unilateral Space maint - remov-bilateral Re-cementation of space maintainer Removal of fixed space maintai Amalgam Restorations Amalgam - 1 surface Amalgam - 2 surfaces Amalgam - 3 surfaces Amalgam - 4 or more surfaces Resin-based comp-1 surf, ant. Resin-based comp-2 surf, ant. Resin-based comp-3 surf, ant. Resin-based comp-4+surf, ant. Resin-based comp crown, ant. Resin-based comp-1 surf, post. Resin-based comp-2 surf, post. Resin-based comp-3 surf, post. Resin-based comp-4+surf, post. Gold foil - 1 surface Gold foil - 2 surfaces Inlay - metallic - 1 surface Inlay - metallic - 2 surfaces Inlay - metallic - 3 or more Onlay - metallic - 2 surfaces Onlay - metallic - 3 surfaces Onlay - metallic - 4 or more Inlay - porc/cer - 1 surface Inlay - porc/cer - 2 surfaces Inlay - porc/cer - 3 or more Onlay - porc/cer - 2 surfaces

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

41 367 392 422 414 77 77 80 94 117 129 110 131 143 222 263 143 172 203 222 430 482 503 596 682 682 -

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

50 51 307 419 379 476 78 76 129 163 199 236 153 190 231 290 415 168 218 274 325 563 629 763 839 920 949 989 1,021 862 923 960 995

New $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Fee 34 367 392 422 414 77 77 63 84 97 112 100 114 123 215 263 135 156 191 222 195 129 410 482 503 540 545 560 570 620 690 797

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DEPT FIXP REST REST REST REST REST REST REST FIXP

CODE D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2712

DESCRIPTION Onlay - porc/cer - 3 surfaces Onlay - porc/cer - 4 or more Inlay - resin - 1 surface Inlay - resin - 2 surfaces Inlay - resin - 3 or more Onlay - resin - 2 surfaces Onlay - resin - 3 surfaces Onlay - resin - 4 or more Crown - resin (indirect) Crown - 3/4 resin-based comp (indirect) Crown - resin, high noble mtl Crown - resin, predom base mtl Crown - resin, noble metal Crown - porcelain/ceramic subs Post and core, ceramic Crown - PFM high noble metal Crown - PFM predom. base metal Crown - PFM noble metal Crown - 3/4 cast high noble mt Crown - 3/4 cast pred base mtl Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Crown -Full cast high noble mt Crown -Full cast pred base mtl Crown -Full cast noble metal Crown - titanium Provisional crown Recement Inlay Recement post and core Recement crown Prefab SS crown - prim. tooth Prefab SS crown - perm. tooth Prefab resin crown Prefab SS crown - resin window

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

545 660 774 660 682 803 431 745 607 625 911 797 630 676 762 710 710 762 619 665 710 67 64 77 153 228 176 340

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

1,025 1,057 788 833 881 911 942 955 839 1,012 949 986 1,097 1,068 979 1,007 1,048 1 048 1,005 1,026 1,071 1,063 957 1,007 1,069 395 102 106 103 260 308 336 340

FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP REST REST FIXP FIXP FIXP FIXP

D2720 D2721 D2722 D2740 D2741 D2750 D2751 D2752 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2799 D2910 D2915 D2920 D2930 D2931 D2932 D2933

New $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Fee 799 799 401 411 471 509 582 592 431 171 745 607 625 799 295 568 630 619 547 710 599 542 542 599 557 35 55 64 55 153 77 176 340

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DEPT FIXP FIXP EMRG FIXP REST FIXP REST FIXP REST FIXP FIXP FIXP FIXP FIXP FIXP REST ENDO ENDO ENDO

CODE D2934 D2940 D2950 D2951 D2952 D2954 D2957 D2960 D2961 D2962 D2970 D2971 D2975 D2980 D2999 D3110 D3120 D3220 D3221 D3222

DESCRIPTION Prefab esthetic SS primary tth Sedative filling Core buildup - including pins Pin retention - per tooth Cast post and core, metal Prefab post and core Addl prefab post - same tooth Labial veneer, resin-chairside Labial veneer, resin-lab Labial veneer, porcelain-lab Temporary crown, fractured tth Add proc crown under RPD Coping Crown repair Unspecified restorative proc. Pulp cap - direct Pulp cap - indirect Theraputic pulpotomy Pulpal debridement, prim/perm Partial pulpotomy Ant. - primary tooth Post. - primary tooth Endo therapy - anterior Endo therapy - bicuspid Endo therapy - molar Endo-Rt canal obstruc-non surg Endo - internal root repair Retreatment, anterior Retreatment, bicuspid Retreatment, molar Apex/recalc - initial visit Apex/recalc-interim med replac Apex/recalc - final visit Apicoectomy - anterior

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

201 117 52 267 195 329 545 653 404 67 92 67 67 558 682 797 94 655 787 917 99 92 888 441

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

353 109 263 67 403 325 177 597 895 1,066 330 1,066 561 271 78 77 186 206 253 289 705 824 988 287 791 914 1,081 336 241 495 651

ENDO ENDO ENDO ENDO ENDO ENDO FIXP ENDO ENDO ENDO ENDO ENDO ENDO ENDO

D3230 D3240 D3310 D3320 D3330 D3331 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3410

New $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Fee 201 53 81 41 267 149 144 329 508 653 404 425 113 56 67 88 64 67 67 469 547 576 71 94 483 565 603 99 67 417 381

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2010-11

DEPT ENDO ENDO ENDO ENDO ENDO

CODE D3421 D3425 D3426 D3430 D3450 D3460

DESCRIPTION Apicoectomy - bicusp(1st root) Apicoectomy - molar (1st root) Apicoectomy - addl roots Retrograde filling - per root Root amputation - per root Endodontic Implant Intentional reimplantation Hemisection, incl root removal Unspecified endo procedure Gingivectomy/plasty -4 of more Gingivectomy/plasty - 1-3 tth Anatomical crown exp - Over 4 Anatomical crown exp - 1 to 3 Gingival flap - 4 of more/quad Gingival flap - 1-3 teeth/quad Apically positioned flap Crown lengthen, hard tissue Osseous surgery-4 or more/quad Osseous surgery - 1-3 tth/quad Osseous graft, multi site Bone repl graft -1st site/quad Bone repl graft -Add site/quad Biologic materials-tissue regn Guided tissue regen-resorb Guided tissue regen-nonresorb Surg. revision proc. - per tth Pedicle soft tissue graft Free soft tissue graft Subepithellal conn tissue grft Distal or proximal wedge Soft tissue allograft Comb. connective tissue/graft Bone Graft / Single Site Biological Materials

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

464 274 361 475 305 403 242 358 551 331 367 222 315 426 494 494 579 222 -

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

725 833 354 259 453 781 438 590 238 612 540 700 583 795 710 1,001 825 631 476 482 788 923 771 785 837 1,031 642 932 1,049

PERI PERI PERI ENDO PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI

D3470 D3920 D3999 D4210 D4211 D4230 D4231 D4240 D4241 D4245 D4249 D4260 D4261 D4262 D4263 D4264 D4265 D4266 D4267 D4268 D4270 D4271 D4273 D4274 D4275 D4276 D4277 D4278

New Fee $ 424 $ 453 $ $ 53 $ 226 $ 985 $ $ 206 $ $ 370 $ 184 $ $ $ 401 $ 242 $ 358 $ 380 $ 551 $ 331 $ 1,210 $ 267 $ 216 $ 330 $ 267 $ 277 $ 155 $ 473 $ 473 $ 579 $ 238 $ $ $ 567 $ 300

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2010-11

DEPT PERI PERI PERI PERI PERI PERI PERI PERI PERI PERI REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP

CODE D4279 D4320 D4321 D4341 D4342 D4355 D4381 D4910 D4999 D5102 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670

DESCRIPTION Osseous Greaft-Sinus Lift Provisional splint-Intracoronl Provisional splint-Extracoronl Scaling/rt planing 4 or more Scaling/rt planing 1-3 teeth Full mouth debridement Chemotherapy - per tooth Periodontal maintenance Unspecified periodontal proc. Denture Block Assist Complete denture - maxillary Complete denture - mandibular Immediate denture - maxillary Immediate denture - mandibular Max. part denture - resin base Mand Part denture - resin base Max partial - cast metal frame Mand partial -cast metal frame Max RPD flexible base Mand RPD flexible Unil. partial-1 pce cast metal Adjust complete denture - Max Adjust complete denture - Mand Adjust partial denture - Max Adjust partial denture - Mand Repair denture base Replace teeth - per tooth Repair resin denture base Repair cast framework Repair or replace broken clasp Replace teeth - per tooth Add tooth to existing partial Add clasp to existing partial Replace all teeth - max

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

161 104 74 126 920 920 1,002 1,002 682 738 1,198 1,198 810 831 212 72 72 72 72 195 161 195 172 154 161 184 -

$ $ $ $ $ $ $

477 437 244 166 173 67 132

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

1,573 1,587 1,679 1,682 1,165 1,170 1,669 1,679 1,453 1 453 1,451 938 84 84 84 84 196 176 196 280 252 175 213 260 666

New Fee $ 1,025 $ 256 $ 256 $ 94 $ 57 $ 53 $ 69 $ 85 $ $ $ 719 $ 719 $ 719 $ 719 $ 434 $ 434 $ 916 $ 916 $ 810 $ 831 $ 26 $ 46 $ 46 $ 46 $ 46 $ 98 $ 96 $ 92 $ 143 $ 134 $ 95 $ 98 $ 155 $ -

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2010-11

DEPT REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP REMP

CODE D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5752 D5753 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5860 D5861 D5862 D5864 D5875

DESCRIPTION Replace all teeth - mand Rebase complete max. denture Rebase complete mand. denture Rebase max. partial denture Rebase mand. partial denture Reline comp max - chairside Reline comp mand - chairside Reline max part - chairside Reline mand part - chairside Reline comp max - laboratory Reline comp mand - laboratory Reline w/ imm dent max Reline w/ imm dent mandibular Reline max part - laboratory Reline mand part - laboratory Interim complete denture - Max Interim complete denture -Mand Interim partial denture - Max Interim partial denture - Mand Tissue conditioning - Max. Tissue conditioning - Mand. Overdenture - complete Overdenture - partial Precision attachment Implant Supported Overdenture Mod of rem prosth after implnt Chrome single denture (maxillary or mandibular) Wrought wire clasp - each Gold Crown on Denture Unspec removable prosth proc. Auricular prosthesis Obturator prosthesis - def. Obturator prosthesis - int. Surgical stent

DELTA

BA Fee

IMPL REMP REMP REMP REMP REMP REMP ORTH

D5882 D5886 D5887 D5899 D5914 D5932 D5936 D5982

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

429 429 429 429 397 283 189 489 286 286 286 286 528 528 126 126 -

$ $ $ $ $ $ $ $ $ $ $

672 560 560 538 537 353 353 347 347 451 453

$ $ $ $ $ $ $ $ $ $ $ $

488 448 778 784 638 644 193 193 1,926 1,880 648 364

392

New Fee $ $ 267 $ 267 $ 267 $ 267 $ 42 $ $ $ $ 215 $ 215 $ 215 $ 215 $ 215 $ 215 $ 452 $ 452 $ 434 $ 434 $ 63 $ 63 $ 916 $ 868 $ 231 $ 1,231 $ $ 785 $ 70 $ 171 $ $ 1,188 $ 1,092 $ $ 52

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2010-11

DEPT ORSG REST REMP ORSG ORSG IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL

CODE D5986 D5999 D6010 D6012 D6014 D6015 D6020 D6040 D6050 D6052 D6053 D6054 D6055 D6055A D6055B D6056 D6057 D6057G D6057T D6057Z D6058 D6058Z D6059 D6060

DESCRIPTION Fluoride gel carrier Unspecified max. prosthesis Surg placement, endosteal impl Interim implant: endosteal imp Ball attachments Locator Abutment placement or substitution Surg placement, eposteal impl Surg placemnt, transosteal imp Mini implant abutment Mini Implant supported denture Implt/abut denture, part edent Impl-supp connecting bar x2 Impl-supp connecting bar x3 Impl-supp connecting bar x4 Prefabricated abutment Custom abutment Custom abutment (Gold) Custom abutment (Titanium) Custom abutment (Zirconium) Abutment - porc/ceramic crown Abutment - porc/ceramic crown (Zirconium) Abutment - PFM,high noble metl Abutment - porcelain to metal base Implant or Abutment Supporte- PFM, noble metal Abutment-cast metal,high noble Abutment supported crown-base metal Abutment-cast metal,noble metl Implant - porc/ceramic crown Implant - PFM,high noble metal Implant - PFM, noble metal Implant -metal crwn,high noble Implant -metal crwn, noble Abutment-retainer,porc/cer FPD

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

1,261 1,700 2,122 1,273 2,094 1,925 1,249 736 770 1,154 1,273 1,273 1,273 1,273 1,236 1,273 1,273 1,273

$ $ $

185 1,930 1,551

$ $ $ $ $

7,803 5,349 2,608 2,574 2,703

$ $

694 893

$ $ $ $ $ $ $ $ $

1,388 1,345 1,303 1,341 1,289 1,454 1,455 1,503 1,415

IMPL IMPL

D6061 D6062 D6063

IMPL IMPL IMPL IMPL IMPL IMPL IMPL

D6064 D6065 D6066 D6066N D6067 D6067N D6068

New Fee $ 77 $ $ 1,195 $ 1,700 $ 386 $ 386 $ $ 2,122 $ 1,273 $ 323 $ 736 $ 911 $ 1,249 $ 1,391 $ 1,483 $ 180 $ 361 $ 361 $ 412 $ 464 $ 1,154 $ 1,185 $ 1,123 $ 1,273 $ 1,133 $ 1,123 $ 1,273 $ 1,215 $ 1,236 $ 1,236 $ 1,215 $ 1,123 $ 1,195 $ 1,257

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DEPT IMPL

CODE D6069 D6070

DESCRIPTION Abutment-ret,PFM FPD,high nobl Abutment-retainer PFM FPD, base metal Abutment-ret,PFM FPD,noble met Additional Lab Fee Abut-ret,cast metal-high noble Abutment-retainer, cast metal-base metal Abut-ret,cast metal-noble metl Implant - retainer for ceramic FPD Implant - retainer for PFM FPD Implant - retainer for PFM FPD Noble Implant - ret, cast metal FPD Implant - ret. cast noble metal FPD Hybrid prosthesis/edentulous mandible Marius Bridge Implant/abut, part edent arch Implant maintenance proc. Hybrid prosthesis endentulous maxilla Marius bridge, primary Marius bridge, secondary Repair implant -prosthesis Recement Implant/abutment fixed partial Abut supp crown - titanium Repair implant abutment Implant removal Xray/surg implant index/report Abut supp retainer - titanium Implant annual recall Unspecified implant proc. Pontic - indirect resin based Pontic - cast high noble metal Pontic - cast predom base metl Pontic - cast noble metal Pontic - titanium Pontic-porc fuse to high noble

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

1,273 1,273 1,273 1,273 1,236 1,273 1,206 3,963 3,623 -

$ $ $ $ $ $ $ $ $ $

1,399 1,289 1,375 1,258 1,455 1,479 1,500 4,477 3,395 266

IMPL IMPL IMPL

D6071 D6071L D6072 D6073

IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL REMP IMPL IMPL IMPL FIXP FIXP

D6074 D6075 D6076 D6076N D6077 D6077N D6078 D6078M D6079 D6080 D6081 D6082 D6083 D6090 D6093

$ $ $ $ $ $ $ $ $ $ $ 1,287 1,287 716 676 688 710 796 $ $ $ $

707 1,208 700 717 1,334

IMPL IMPL IMPL IMPL IMPL IMPL IMPL IMPL FIXP FIXP FIXP FIXP FIXP

D6094 D6095 D6100 D6190 D6194 D6198 D6199 D6205 D6210 D6211 D6212 D6214 D6240

$ $ $ $ $ $

951 1,043 979 1,006 1,057 1,063

New Fee $ 1,112 $ 1,273 $ 1,236 $ 348 $ 972 $ 1,273 $ 1,215 $ 1,236 $ 1,112 $ 1,215 $ 972 $ 1,195 $ 3,963 $ 8,755 $ 3,623 $ 87 $ 7,483 $ 8,755 $ 5 356 5,356 $ 136 $ 204 $ 1,287 $ $ 386 $ $ 1,287 $ 52 $ $ 489 $ 542 $ 676 $ 576 $ 710 $ 687

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DEPT FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP REMP FIXP FIXP REST REST REST REST REST REST REST REST REST REST REST REST REST REST REST

CODE D6241 D6242 D6242L D6245 D6250 D6251 D6252 D6253 D6545 D6548 D6600 D6601 D6602 D6603 D6604 D6605 D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624

DESCRIPTION Pontic-porc fuse to base metal Pontic-porc fuse to noble metl Additional Lab Fee Pontic-porcelain/ceramic Pontic-resin, high noble metal Pontic-resin, predom base metl Pontic-resin with noble metal Provisional pontic Retainer, metal, resin bond FP Retainer, porc/cera, bonded FP Inlay - porc/ceramic, 2 surf Inlay - porc/ceramic, 3+ surf Inlay - high noble mtl, 2 surf Inlay - high noble mtl, 3+ sur Inlay - pred. base mtl, 2 surf Inlay - pred. base mtl, 3+ sur Inlay - cast noble mtl, 2 surf Inlay - cast noble mtl, 3+ sur Onlay - porc/ceramic, 2 surf Onlay - porc/ceramic, 3+ surf Onlay - high noble mtl, 2 surf Onlay - high noble mtl, 3+ sur Onlay - pred. base mtl, 2 surf Onlay - pred. base mtl, 3+ sur Onlay - cast noble mtl, 2 surf Onlay - cast noble mtl, 3+ sur Inlay - titanium Onlay - titanium Crown - indirect resin based Crown - resin, high noble metl Crown - resin, predom base mtl Crown - resin, noble metal Crown - porcelain/ceramic Crown - porcelain to high nobl

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

688 711 796 699 711 344 470 528 568 568 568 568 596 643 636 636 636 636 636 738 704 711 796

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

983 1,013 1,075 1,048 987 1,011 625 739 894 960 1,023 974 1,029 951 1,012 951 1,014 1,019 1 019 1,103 1,051 1,108 1,005 1,091 1,015 1,094 1,138 996 1,025 998 1,007 1,103 1,075

REST REST FIXP FIXP FIXP FIXP FIXP

D6634 D6710 D6720 D6721 D6722 D6740 D6750

New $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Fee 688 609 523 781 796 699 711 344 782 781 781 442 442 568 568 596 512 781 781 488 488 636 636 530 535 568 636 489 738 704 711 781 568

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2010-11

DEPT FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP REST REMP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP FIXP ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG

CODE D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6793 D6794 D6920 D6930 D6940 D6950 D6970 D6971 D6972 D6973 D6975 D6976 D6977 D6980 D6999 D7111 D7130 D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7260

DESCRIPTION Crown - porcelain to base metl Crown - porcelain to noble mtl Crown- 3/4 cast high noble mtl Crown- 3/4 cast pred. base mtl Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Crown-full cast high noble mtl Crown-full cast pred. base mtl Crown - full cast noble metal Provisional retainer crown Crown - titanium Connector bar Recement FPD Stress breaker Precision attachment Cast post & core - add. to FPD Cast post - part of FPD ret Pref post & core - add. to FPD Core build up for ret. w/ pins Coping - metal Each add cast post - same tth Each add prefab post -same tth FPD repair Unspecified fixed pros. proc. Coronal remnants - decid. tth Root removal - exposed root Extraction, eruptd tth/ exp rt Surg removal of erupted tooth Rem of impacted tth, soft tiss Rem of impacted tth, part bony Rem of impacted tth, comp bony Rem of impacted tth, surg comp Removal of residual tth roots Oroantral fistula closure

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

688 711 796 710 711 796 688 711 734 98 241 241 199 171 -

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

991 1,007 1,041 1,007 1,007 1,066 1,063 970 1,007 448 1,010 159 392 616 414 330 269 673 271 179 367 125 157 264 302 381 465 550 290 784

$ $ $ $ $ $ $ $ $ $ $

59 109 177 212 292 367 177 313

New Fee $ 688 $ 609 $ 547 $ 592 $ 593 $ 781 $ 542 $ 688 $ 576 $ $ 734 $ 1,030 $ 81 $ 193 $ $ 241 $ $ 199 $ 171 $ 387 $ $ $ 83 $ $ 59 $ $ 102 $ 167 $ 193 $ 264 $ 308 $ 329 $ 156 $ 397

Printed: 7/13/2010

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Fee schedule changes for the next fiscal year

2010-11

DEPT ORSG ORSG ORSG IMPL ORSG ORSG ORSG ORSG ORSG ORSG PATH PATH ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG PATH PATH ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG

CODE D7261 D7270 D7272 D7280 D7281 D7282 D7283 D7285 D7286 D7287 D7288 D7310 D7311 D7320 D7321 D7340 D7350 D7410 D7411 D7440 D7450 D7451 D7460 D7461 D7465 D7471 D7472 D7473 D7485 D7490 D7510 D7511 D7520 D7521

DESCRIPTION Primary closure of sinus perf. Tooth reimplantation/stabilize Tooth transplantation Surg exposure - ortho reasons Surg exposure - impacted or unerupted tooth Mobilization of tth for erupt Device to erupt impacted tooth Biopsy of oral tissue - hard Biopsy of oral tissue - soft Cytology sample collection Brush biopsy - transepithelial Alveoloplasty with extractions Alveoloplasty inc ext: 1-3 tth Alveoloplasty w/o extractions Alveoloplasty no ext: 1-3 tth Vestibuloplasty - second epith Vestibuloplasty -tissue grafts Excision, benign lesion<1.25cm Excision, benign lesion>1.25cm Exc malign tumor-lesion<1.25cm Rem odonto cyst/tumor < 1.25cm Rem odonto cyst/tumor > 1.25cm Rem nonodonto cyst < 1.25cm Rem nonodonto cyst > 1.25cm Destruction - lesion Removal of lateral exostosis Removal of torus palatinus Removal of torus mandibularis Surg reduct of osseous tuberos Resection, mandible-bone graft Incision/drainage,abscess-intr I&D abscess, intraoral, compl Incision/drainage,abscess-extr I&D abscess, extraoral, compl

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

246 253 590 267 199 137 150 92 185 119 650 1,228 446 561 223 269 207 207 286 286 286 286 143 166

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

705 513 668 450 477 490 373 288 158 168 276 291 403 402 996 2,015 374 567 588 508 669 504 757 345 590 753 700 666 7,918 215 328 366 562

New Fee $ 163 $ 168 $ 590 $ 267 $ 155 $ $ 106 $ 194 $ 135 $ $ 236 $ 147 $ 92 $ 170 $ 119 $ 650 $ 1,228 $ 446 $ 561 $ $ 173 $ 211 $ 207 $ 207 $ 565 $ 275 $ 231 $ 231 $ 231 $ $ 123 $ $ 131 $ -

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Fee schedule changes for the next fiscal year

2010-11

DEPT ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG DIAG ORSG IMPL ORSG

CODE D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7670 D7710 D7720 D7730 D7740 D7820 D7830 D7840 D7850 D7880 D7910 D7944 D7950 D7951 D7951CL

DESCRIPTION Removal of foreign body/skin Removal-musculoskeletal system Part. ostectomy/sequestrectomy Max. sinusotomy - removal Maxilla - open reduction Maxilla - closed reduction Mandible - open reduction Mandible - closed reduction Alveolus - closed reduction Maxilla - open reduction Maxilla - closed reduction Mandible - open reduction Mandible - closed reduction Closed reduction of dislocatio Manipulation under anesthesia Condylectomy Surg discectomy w/ w/o implant Occlusal orthotic device Suture of recent small wounds Osteotomy - segment/subapical/distraction Veener graft/per site Sinus augmentation with bone Sinus lift plus bone or bone substitute Sinus tap plus bone or bone substitute Bone graft ridge preserve,site without teeth Frenulectomy - separate proc. Frenuloplasty Excision - hyperplastic tiss Excision - pericoronal gingiva Surg reduct, fibrs. tuberosity Sialolithotomy Excision of salivary gland Sialodochoplasty Closure of salivary fistula

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

347 347 427 744 2,479 2,240 2,732 2,479 230 3,464 2,974 3,470 2,974 278 674

ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG ORSG

D7951-O D7953 D7960 D7963 D7970 D7971 D7972 D7980 D7981 D7982 D7983

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

824 211 222 138 138 165 372 676

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

336 620 486 1,119 3,998 3,189 4,046 3,158 1,264 4,257 3,316 4,603 3,358 545 756 5,205 5,189 791 280 6,940 2,798

$ $ $ $ $ $ $ $ $

504 431 491 481 231 703 676 1,599 1,205

New Fee $ 347 $ 397 $ 103 $ 744 $ 2,479 $ 2,240 $ 2,732 $ 2,479 $ 230 $ 3,464 $ 2,974 $ 3,470 $ 2,974 $ 278 $ 629 $ $ $ 824 $ 112 $ 2,627 $ 1,030 $ 1,190 $ 1,190 $ 412 $ 361 $ 206 $ $ 222 $ 138 $ 138 $ 165 $ $ 372 $ 676

Printed: 7/13/2010

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Fee schedule changes for the next fiscal year

2010-11

DEPT ORSG ORSG ORSG ORTH ORTH ORTH

CODE D7997 D7999 D8010 D8020 D8030 D8040 D8050 D8060

DESCRIPTION Appliance removal, w/ archbar Unspecified oral surgery proc. Limited ortho - primary Limited ortho - transitional Limited ortho - adolescent Limited ortho - adult Interceptive ortho of primary dentition Interceptive ortho of transitional dentition Comprehensive Ortho Tx - trans Comprehensive Ortho Tx - adole Comprehensive Ortho Tx - adult Removable appliance therapy Fixed appliance therapy Pre-ortho treatment visit Periodic ortho treatment visit Unspecified ortho proc. Palliative Tx of dental pain Fixed part. denture sectioning Trigeminal division block anes General anesthesia -1st 30 min General anesthesia -add 15 min Analg, anxiolysis, inhal of NO Intrav sedate/analg-1st 30 min Intrav sedate/analg-add 15 min Consultation Diagnostic Service (INR measurement) House/ext. care facility call Hospital call Office visit -observation only Office visit -observation only Office visit - after hours Office Visit - No Charge Therapeutic drug injection Other drugs, by report

DELTA

BA Fee

$ $ $ $ $ 2,982 2,982 2,982 3,448 $ $ $ $

280 1,866 2,169 2,518 2,573

ORTH ORTH ORTH ORTH DIAG ORTH ORTH ORTH ORTH EMRG ORSG ORSG ORSG ORSG ORSG ORSG ORSG DIAG DIAG DIAG ORSG PERI PERI DIAG DIAG ORSG

D8070 D8080 D8090 D8210 D8220 D8660 D8670 D8999 D9110 D9120 D9212 D9220 D9221 D9230 D9241 D9242 D9310 D9310I D9410 D9420 D9430 D9430A D9440 D9460 D9610 D9630

$ $ $ $ $ $

5,665 5,665 6,180 455 654 50

$ $ $ $ $ $

5,149 5,269 5,373 789 290 214

93 $ $ $ $ $ $ $ $ $ $ $ $ $ 207 259 384 163 63 385 112 207 248 69 158 90 30

$ $ $ $ $

402 180 284 248 197

$ $ $

87 121 -

New Fee $ $ $ 2,982 $ 2,982 $ 2,982 $ 3,448 $ 2,982 $ 2,982 $ 5,665 $ 5,665 $ 6,180 $ 455 $ 654 $ 50 $ $ $ 62 $ $ $ 319 $ 160 $ 104 $ 284 $ 242 $ 29 $ 10 $ $ $ 22 $ 22 $ 121 $ $ 23 $ 3

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Fee schedule changes for the next fiscal year

2010-11

DEPT ORSG PERI

CODE D9910 D9911 D9920

DESCRIPTION Applicate desensitizing medica Applicate desens resin-per tth Behavior management Tx,complications-unusual circs Occlusal guard Fabrication of athl mouthguard Repair/reline occlusal guard Occlusion analysis-mountd case Occlusal adjustment - limited Occlusal adjustment - complete External Home (tray) bleaching - per arch External bleaching - per tooth Internal bleaching - per tooth External Office bleaching-Smile Clinic External Office bleaching-Smile Clinic External bleaching-refill (home) Unspecified adjunctive proc.

DELTA

BA Fee

$ $ $ $ $ $ $ $ $ $ $

56 124 122 548 209 330 166 628 262 213 274

DIAG ORSG FIXP FIXP FIXP FIXP FIXP FIXP REST FIXP ENDO REST REST REST

D9930 D9940 D9941 D9942 D9950 D9951 D9952 D9972 D9973 D9974 D9976 D9976B D9977 D9999

$ $ $ $ $ $ $ $ $ $ $ $ $ $

115 316 197 304 171 188 -

New $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

Fee 30 39 115 298 361 133 112 77 143 170 79 184 200 195 30 -

Printed: 7/13/2010

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