FEE SCHEDULE 2019 Proc Code EXPLANATION OF CODE Fee Amount Proc Code EXPLANATION OF CODE Fee Amount 120 ORAL EXAMPERIODIC 1500 2644 ONLAY PORCCERAMIC 4 SURF 35000 140 LIMITED ORAL EVALUATIO ID: 823874
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SELE-DENT, INCFEE SCHEDULE 2019Proc
SELE-DENT, INCFEE SCHEDULE 2019Proc CodeEXPLANATION OF CODEFee AmountProc CodeEXPLANATION OF CODEFee Amount120ORAL EXAM(PERIODIC)15.002644ONLAY PORC/CERAMIC 4 SURF350.00140 LIMITED ORAL EVALUATION15.002710CROWN ACRYLIC225.00150COMP ORAL EVALUATION15.002720CROWN ACRYLIC W/GOL225.00160EXTENSIVE ORAL Exam28.002740CROWN PORCELAIN225.00180COMP PERIO EVAL15.002750CROWN PORCELAIN/ MET330.00210XRYS INT COMP SERIES25.002751CROWN PORC/BASE MET330.00220XRYS INT PER 1ST FILM4.002752CROWN PORC/NOBEL MET330.00230XRYS INT PER ADD FILM3.002790CROWN GOLD(FULL)275.00240XRYS INT OCCLUSAL 9.002799PROVISIONAL CROWN200.00250XRYS-EXTRA ORAL18.002910RECEMENT INLAY15.00260XRYS EXTRA ORAL ADD18.002915RECEMENT POST15.00270XRYS BITEWING EACH5.002920RECEMENT CROWN15.00272XRYS 2 BITEWINGS9.002930CROWN-STNLESS60.00274XRYS 4 BITEWINGS17.002932PREFABRICATED RESIN CROWN38.00320XRYS TEMPORO-MAND25.002940SEDATIVE FILLING15.00322TOMOGRAPHIC SURVEY375.002950CORE BUILD UP INCLUDING ANY PINS28.00330XRYS PANORAMIC FILM39.002952CRN-CAST POST/CORE80.00340XRYS-CEPHAL FILM25.002954PREFABRICATED POST & CORE80.00364CONE BEAM CT CAPTURE75.002955POST REMOVAL125.00365CONE BEAM CT CAP MANDIBLE75.002960LAMINATE- VENEER CHAIRSIDE175.00366CONE BEAM CT CAP MAXILLA75.002999CROWN-TEMP-CRACKED 30.00367CONE BEAM CT CAP MAN/MAX75.003110PULP CAP DIRECT12.50368CONE BEAM CT CAP TMJ SERIES75.003120PULP CAP INDIRECT11.00431ADJUNCTIVE PRE-DIAG TEST50.003220PULPOTOMY-THERAP22.00460PULP VITALITY TEST10.003221VITAL PULPOTOMY-30.00470DIAGNOSTIC STUDY20.003310ROOT CANAL 1 CANAL135.00490MISC TEST/LAB15.003320ROOT CANAL 2 CANALS220.001110PROPHYLAXIS – ADULT25.003330ROOT CANAL 3 CANALS300.001120PROPHYLAXIS – CHILD20.003331ROOT CANAL OBSTRUCTION175.001206FLUORIDE TOPICAL VARNISH12.003346RETREAT 1 CANAL135.001208FLUORIDE TOPICAL W/O VARNISH12.003347RETREAT 2 CANALS220.001310DIET PLANNING12.003348RETREAT 3 CANALS300.001330DENTAL HYGIENE INSTR10.003351RECALCIFICATION12.501351TOP APPL OF SEALANTS12.003410APICOECTOMY ANTERIOR70.001510SPACE MAINT FIXED UNI75.003421APICOECTOMY PREMOLAR105.001516FIXED SPACE MAINT MAXILLARY100.003425APICOECTOMY MOLOR 200.001517FIXED SPACE MAINT MANDIBULAR100.003426APICOECTOMY / ADD ROOT36.001520SPACE MAINT-REMOVABLE UNILATERAL100.003430RETROGRADE FILLING50.001526SPACE MAINT- REMOVABLE MAXILLARY95.003440APICAL CURETTAGE80.001527SPACE MAINT- REMOVABLE MANDIBULAR95.003450ROOT AMPUTATION85.001550RECEMENT SPACE MAINTAINER20.003910ISOLAT OF TTH W/RUBBER DAM200.001555REMOVAL OF FIXED SPACE MAINT30.003920ENDO-HEMISECTION110.002140AMALGAM 1 SURFACE16.503950CANAL PREP FOR POST60.002150AMALGAM 2 SURFACE28.004210GING PER QUADRANT155.002160AMALGAM 3 SURFACE38.004211GING PER SECTANT80.002161AMALGAM 4 SURFACE40.004212GINGIVECTOMY PER TOOTH20.002330RESIN-BASED COMP/1SUF28.004231ANATOMICAL CRN EXPOSURE330.002331RESIN-BASED COMP/2SUF44.004240GINGIVAL FLAP PROCEDURE100.002332RESIN-BASED COMP/3SUF80.004241GINGIVAL FLAP CURETTAGE50.002335RESIN-BASED COMP/4SUF80.004249CROWN LENGTHENING80.002391RES BAS COMP 1 SURF POST38.004260OSSEOUS SURGERY QUAD325.002392RES BAS COMP 2 SURF POST54.00426
1OSS SURG 1 TO 3 PER QUAD162.502393R
1OSS SURG 1 TO 3 PER QUAD162.502393RES BAS COMP 3 SURF POST90.004263BONE REPLACE GRAFT FIRST QUAD150.002394RBC COMP 4 SURF OR MORE100.004264BONE REPLACE GRAFT EACH ADD150.002510INLAY-METALLIC 1 SURF135.004265OSSEOUS TISSUE REGENERAT60.002520INLAY-METALLIC 2 SURF160.004266GUIDED TISSUE REGION75.002530INLAY-METALLIC 3 SURF200.004267GUIDED TISSUE REG./ NON150.002544ONLAY METALLIC PER 150.004268SURGICAL REVISION, PER TTH375.002610INLAY-PORCELAIN 1SURF80.004270PEDICLE SOFT TISSUE GRAFT80.002620INLAY-PORC/CERAMIC 1 SURF80.004273AUTO CONNECT TISSUE GRAFT100.002630INLAY PORC/CERAMIC 2 SURF350.004320PROV SPLINTING INTRACORONAL55.002642ONLAY PORC/CERAMIC 2 SURF350.004321PROV SPLINTING EX80.002643ONLAY-PORC/CERAMIC 3 SURF350.004341PERIO SCALING22.50SELE-DENT, INCFEE SCHEDULE 2019Proc CodeEXPLANATION OF CODEFee AmountProc CodeEXPLANATION OF CODEFee Amount4342PERIO SCAL ROOT PLAN 1-3 TTH11.256241PONTIC-PORCELAIN/BASE METAL265.004346PERIO SCALING FULL MOUTH90.006245PONTIC PORCELAIN/CERAMIC265.004355FULL MOUTH DEBRIDEMENT60.006250PONTIC-RESIN/HIGH NOBLE METAL265.004381ACTISITE40.006251PONTIC-RESIN/BASE METAL265.004910PERIO PROPHYLAXIS40.006252PONTIC- RESIN/NOBLE METAL265.004921GINGIVAL IRRIGATION25.006710RETAINER CROWN RESIN BASED COMP135.005110DENTURES-COMP UPPER385.006720RETAINER CROWN HIGH NOBLE METAL265.005120DENTURES COMP LOWER385.006722RETAINER CROWN HIGH NOBLE METAL175.005130DENTURES IMM UPPER410.006740RETAINER CROWN PORCELAIN/CERAMIC330.005140DENTURES IMM LOWER410.006750RETAINER CROWN PORCELAIN/H NOBLE METAL330.005211PRTL DENT UPP 2 CLSP360.006751RETAINER CROWN PORCELAIN BASE METAL330.005212PRTL DENT LOW 2 CLSP360.006752RETAINER CROWN NOBLE METAL330.005213PRTL DEN CAST 2 CLSP375.006780RETAINER CROWN 3/4 HIGH NOBLE METAL200.005214PRTL DEN CAST 2 CLSP375.006790RETIANER CROWN FULL HIGH NOBLE METAL275.005221IMMEDIATE MAX PART DENTURE RESIN375.006792RETAINER CROWN FULLNOBLE METAL275.005222IMMEDIATE MAN PART DENTURE RESIN375.006793PROVISIONAL RETAINER CROWN135.005223IMMEDIATE MAX PART DENTURE METAL375.006930RECEMENT BRIDGE25.005224IMMEDIATE MAN PART DENTURE METAL375.006940STRESS BREAKER38.005225PART UPP DENT-FLEX BASE375.006950PRECISION ATTACH55.005226PART LOW DENT-FLEX BASE375.006985PEDIATRIC PARTIAL DENT FIXED55.005282PRTL DENT UNI REMOV MAXILLARY165.007111DECIDUOUS TOOTH EXTRACTION35.005283PRTL DENT UNI REMOV MANDIBULAR165.007140ERUPT TTH EXPOSED ROOT EXT65.005410ADJ.COMPL.DENT UPPER65.007210EXTRACT ERUOTED TTH100.005411ADJ.COMPL. DENT LOWER38.007220EXTRACT IMPACT TTH110.005421PRTL DENT UPPER38.007230EXTRACT IMPACT PART160.005422PRTL DENT LOWER28.007240EXTRACT IMPACT FULL245.005511REPAIR BROKEN COMPLETE DENT MAN 60.007250TOOTH RECOVERY65.005512REPAIR BROKEN COMPLETE DENT MAX 60.007260ORAL ANT FISTULA155.005520REPL MISSING/BROKEN TTH28.007261MAX SINUSOTOMY155.005611REPAIR RESIN PARTIAL MAN35.007270TOOTH REIMPLANT155.005612REPAIR RESIN PARTIAL MAX35.007272TTH TRANSPLANTATION200.005621REPAIR CAST PARTIAL FRAME MAN35.007280EXPOSE IMPACT UNC0PL55.005622REPAIR CAST PARTIAL FRAME MAX35.007282MOBILIZATION MALPOSITION TTH135.005630PRTL DENT ADD TTH18.007283DEVICE FACILITATE ERRU
PT IMP200.005640REPLACE BROKEN TEETH
PT IMP200.005640REPLACE BROKEN TEETH -PER TOOTH28.007285BIOPSY HARD TISSUE55.005650ADD TOOTH TO EXISTING PARTIAL DENT44.007286BIOPSY SOFT TISSUE35.005660PRTL DENTADD’L CLASP62.007287CYTOLOGY55.005670REP ALL TEETH (MAX)36.007290SURGICAL REPOSITION85.005671REP ALL TEETH (MANDI)44.007310ALVEOL W/EXTRACT90.005710DENT COMP UP REBASE200.007311ALVEOL UPPER JAW W/EXT90.005711DENT COMP LOWER REBASE200.007320ALVEOL NON EXTRACT135.005720DENT PART UPPER REBASE165.007340VESTIBIOPLASTY60.005721DENT PART LOWER REBASE165.007350PER ARCH COMPL82.005730RELINING COMPL UPPER85.007410RADICAL EXCISION <5”60.005731RELINING COMPL LOWER85.007411EXC BENIGN LESIO�N 1.25 CM60.005740DENT RELINE COMP UPPER62.007412EXC BENIGN LESION COMP82.005741DENT RELINE COMP LOWER62.007413EXC MALIG LES UP TO 1.25 CM82.005750RELINING COMP UPPER LAB90.007450ODO CYST <5”125.005751RELINING COMP LOWER LAB90.007451ODO CYST >5”180.005760DENT RELINE PRTL UPPER77.007472REMOVAL OF TORUS PALATINUS82.005761DENT RELINE PRTL LOWER77.007473REMOVAL TORUS MANDIBULARIS110.005810TEMP COMP UPPER DENT85.007485SURG REDUCTION OF OSSEOUS190.005811TEMP COMP LOWER DENT85.007490RADICAL RESECT MAND1265.005820TEMP PART UPPER DENT55.007510RAD INCIS INTRA ORAL65.005821TEMP PART LOWER DENT55.007530REMOVE FOREIGN BODY60.005850TISSUE CONDITIONING UPPER25.007610FRAC SIM MAXILLA OP360.005851TISSUE CONDITIONING LOWER25.007620FRAC SIM MAXILLA CL250.005862PRECISION ATTACHMENT75.007630FRAC SIMP MAND OPEN375.006210PONTIC- CAST HIGH NOBLE METAL200.007640FRAC SIMP MAN CLOSED440.006212PONTIC- CAST NOBLE METAL120.007650MALAR/ZYG ARCH OPEN440.006240PONTIC- PORCELAIN/HIGH NOBLE METAL265.007660MALAR/ZYG ARCH CLOS165.00SELE-DENT, INCFEE SCHEDULE 2019Proc CodeEXPLANATION OF CODEFee Amount7670ALVEOLUS, RED SPLINT110.007671ALVEOLUS - OPEN REDUCTION110.00 ORTHODONTICS SERVICES7710MAXILLA, OPEN550.00LIFETIME MAXIMUM OF $ 4,400 7720MAXILLA, CLOSED250.00* AS LONG AS MEMBERSHIP ACTIVE7730MANDIBLE, OPEN575.007750MALAR/ZYG ARCH OPEN440.007760MALAR/ZYG ARCH CLOS190.007770ALVEOLUS, RED SPLINT110.007771FX ALEVEOLUS CLOSED REDUCT110.007810OPEN REDUC OF DISLOC440.007820CLOS REDUC OF DISLOC105.007830MANIPU UNDER ANESTH65.007880OCCLUS ORTHIC APPLIAN100.007910SUTURE WOUND <2”55.007943OSTEOTOMY-BONY GRAFT450.007950OSTEOPERIOSTEAL by report400.007951SINUS AUGMENTATION400.007953BONE REPLACEMENT GRAFT225.007955REPAIR MAXILLOFACIAL SOFT/HARD400.007960FRENECTOMY60.007972SURGICAL REDUCTION OF FIBROUS60.009110PALLIATIVE TRTMENT18.009210LOCAL ANESTHESIA15.009211REGIONAL BLOCK ANESTHESIA28.009212TRIGEMINAL DIV BLOCK ANES38.009215LOCAL ANEST W/OPER OR SURG75.009222GENERAL ANESTHESIA FIRST 15MINS75.009223GENERAL ANESTHESIA + ADD 15MINS75.009230ANALGESIA75.009239IV- SEDATION/ANALGESIA 15MINS75.009243IV- MODERATE SEDATION 15MINS75.009248NON-IV CONSCIOUS SEDATION 15MINS75.009310CONSULTATION75.009450CASE PRESENT DETAIL/EXTEN75.009610THERAPEUTIC DRUG INJ40.009612THERAP PARENTERAL DRUG40.009911DESENSITIZING RESIN PER TTH32.009944OCCLUSAL GUARD HARD APPLIANCE150.009945OCCLUSAL GUARD SOFT APPLIANCE150.009951OCCLUSAL ADJUST60.009952OCCLUSAL ADJUST COM135.