[Federal Register: August 9, 2002 (Volume 67, Number 154)] [Proposed Rules] [Page 52291-52340] From the Federal Register Online via GPO Access [wais.access.gpo.gov] [DOCID:fr09au02-40] [[pp. 52291-52340]] Medicare Program; Changes to the Hospital Outpatient Prospective Payment System and Calendar Year 2003 Payment Rates; and Changes to Payment Suspension for Unfiled Cost Reports [[Continued from page 52290]] [[Page 52290]] C1018..................... K Blood, L/R, IRRADIATED..... 1018 1.90 $98.82 ............ $19.76 C1058..................... G TC 99M oxidronate, per vial 1058 ............ $36.74 ............ $5.26 C1064..................... G I-131 cap, each add mCi.... 1064 ............ $5.86 ............ $.75 C1065..................... G I-131 sol, each add mCi.... 1065 ............ $15.81 ............ $2.03 C1066..................... N IN 111 satumomab pendetide. ............ ............ ............ ............ ............ C1079..................... N CO 57/58 per 0.5 uCi....... ............ ............ ............ ............ ............ C1087..................... N I-123 per 100 uCi.......... ............ ............ ............ ............ ............ C1088..................... T LASER OPTIC TR Sys......... 0980 ............ $1,875.00 ............ $375.00 C1091..................... K IN111 1091 4.36 $226.76 ............ $45.35 oxyquinoline,per0.5mCi. C1092..................... K IN 111 pentetate per 0.5 1092 4.78 $248.60 ............ $49.72 mCi. C1094..................... N TC99Malbumin aggr,per ............ ............ ............ ............ ............ 1.0mCi. C1096..................... K TC 99M EXAMETAZIME, PER 1096 3.35 $174.23 ............ $34.85 Dose. C1097..................... N TC 99M MEBROFENIN, PER Vial ............ ............ ............ ............ ............ C1098..................... N TC 99M PENTETATE, PER Vial. ............ ............ ............ ............ ............ C1099..................... N TC 99M PYROPHOSPHATE,PER ............ ............ ............ ............ ............ Via. C1122..................... K Tc 99M ARCITUMOMAB PER VIAL 1122 8.33 $433.23 ............ $86.65 C1166..................... N CYTARABINE LIPOSOMAL, 10 mg ............ ............ ............ ............ ............ C1167..................... K EPIRUBICIN HCL, 2 mg....... 1167 0.32 $16.64 ............ $3.33 C1178..................... K BUSULFAN IV, 6 Mg.......... 1178 0.53 $27.56 ............ $5.51 C1188..................... N I-131 cap, per 1-5 mCi..... ............ ............ ............ ............ ............ C1200..................... N TC 99M Sodium Glucoheptonat ............ ............ ............ ............ ............ C1201..................... N TC 99M SUCCIMER, PER Vial.. ............ ............ ............ ............ ............ C1202..................... N TC 99M SULFUR COLLOID, Vial ............ ............ ............ ............ ............ C1207..................... K OCTREOTIDE ACETATE DEPOT 1207 1.22 $63.45 ............ $12.69 1mg. C1300..................... S HYPERBARIC Oxygen.......... 0659 3.12 $162.27 ............ $32.45 C1305..................... K Apligraf................... 1305 12.47 $648.55 ............ $129.71 C1348..................... K I-131 sol, per 1-6 mCi..... 1348 0.19 $9.88 ............ $1.98 C1713..................... N Anchor/screw bn/bn,tis/bn.. ............ ............ ............ ............ ............ C1714..................... N Cath, trans atherectomy, ............ ............ ............ ............ ............ dir. C1715..................... N Brachytherapy needle....... ............ ............ ............ ............ ............ C1716..................... K Brachytx seed, Gold 198.... 1716 0.35 $18.20 ............ $3.64 C1717..................... N Brachytx seed, HDR Ir-192.. ............ ............ ............ ............ ............ C1718..................... K Brachytx seed, Iodine 125.. 1718 0.64 $33.29 ............ $6.66 C1719..................... K Brachytx seed,Non-HDR Ir- 1719 0.57 $29.65 ............ $5.93 192. C1720..................... K Brachytx seed, Palladium 1720 0.89 $46.29 ............ $9.26 103. C1721..................... N AICD, dual chamber......... ............ ............ ............ ............ ............ C1722..................... N AICD, single chamber....... ............ ............ ............ ............ ............ C1724..................... N Cath, trans ............ ............ ............ ............ ............ atherec,rotation. C1725..................... N Cath, translumin non-laser. ............ ............ ............ ............ ............ C1726..................... N Cath, bal dil, non-vascular ............ ............ ............ ............ ............ C1727..................... N Cath, bal tis dis, non-vas. ............ ............ ............ ............ ............ C1728..................... N Cath, brachytx seed adm.... ............ ............ ............ ............ ............ C1729..................... N Cath, drainage............. ............ ............ ............ ............ ............ C1730..................... N Cath, EP, 19 or few elect.. ............ ............ ............ ............ ............ C1731..................... N Cath, EP, 20 or more elec.. ............ ............ ............ ............ ............ C1732..................... N Cath, EP, diag/abl, 3D/vect ............ ............ ............ ............ ............ C1733..................... N Cath, EP, othr than cool- ............ ............ ............ ............ ............ tip. C1750..................... N Cath, hemodialysis,long- ............ ............ ............ ............ ............ term. C1751..................... N Cath, inf, per/cent/midline ............ ............ ............ ............ ............ C1752..................... N Cath,hemodialysis,short- ............ ............ ............ ............ ............ term. C1753..................... N Cath, intravas ultrasound.. ............ ............ ............ ............ ............ C1754..................... N Catheter, intradiscal...... ............ ............ ............ ............ ............ C1755..................... N Catheter, intraspinal...... ............ ............ ............ ............ ............ C1756..................... N Cath, pacing, transesoph... ............ ............ ............ ............ ............ C1757..................... N Cath, thrombectomy/embolect ............ ............ ............ ............ ............ C1758..................... N Catheter, ureteral......... ............ ............ ............ ............ ............ C1759..................... N Cath, intra ............ ............ ............ ............ ............ echocardiography. C1760..................... N Closure dev, vasc.......... ............ ............ ............ ............ ............ C1762..................... N Conn tiss, human(inc ............ ............ ............ ............ ............ fascia). C1763..................... N Conn tiss, non-human....... ............ ............ ............ ............ ............ C1764..................... N Event recorder, cardiac.... ............ ............ ............ ............ ............ C1765..................... H Adhesion barrier........... 1765 ............ ............ ............ ............ C1766..................... N Intro/sheath,strble,non- ............ ............ ............ ............ ............ peel. C1767..................... N Generator, neurostim, imp.. ............ ............ ............ ............ ............ [[Page 52291]] C1768..................... N Graft, vascular............ ............ ............ ............ ............ ............ C1769..................... N Guide wire................. ............ ............ ............ ............ ............ C1770..................... N Imaging coil, MR, ............ ............ ............ ............ ............ insertable. C1771..................... N Rep dev, urinary, w/sling.. ............ ............ ............ ............ ............ C1772..................... N Infusion pump, programmable ............ ............ ............ ............ ............ C1773..................... N Ret dev, insertable........ ............ ............ ............ ............ ............ C1774..................... G Darbepoetin alfa, 1 mcg.... 0734 ............ $4.74 ............ $.68 C1775..................... G FDG, per dose (4-40 mCi/ml) 1775 ............ $475.00 ............ $68.00 C1776..................... N Joint device (implantable). ............ ............ ............ ............ ............ C1777..................... N Lead, AICD, endo single ............ ............ ............ ............ ............ coil. C1778..................... N Lead, neurostimulator...... ............ ............ ............ ............ ............ C1779..................... N Lead, pmkr, transvenous VDD ............ ............ ............ ............ ............ C1780..................... N Lens, intraocular (new ............ ............ ............ ............ ............ tech). C1781..................... N Mesh (implantable)......... ............ ............ ............ ............ ............ C1782..................... N Morcellator................ ............ ............ ............ ............ ............ C1783..................... H Ocular imp, aqueous drain 1783 ............ ............ ............ ............ dev. C1784..................... N Ocular dev, intraop, det ............ ............ ............ ............ ............ ret. C1785..................... N Pmkr, dual, rate-resp...... ............ ............ ............ ............ ............ C1786..................... N Pmkr, single, rate-resp.... ............ ............ ............ ............ ............ C1787..................... N Patient progr, neurostim... ............ ............ ............ ............ ............ C1788..................... N Port, indwelling, imp...... ............ ............ ............ ............ ............ C1789..................... N Prosthesis, breast, imp.... ............ ............ ............ ............ ............ C1813..................... N Prosthesis, penile, ............ ............ ............ ............ ............ inflatab. C1815..................... N Pros, urinary sph, imp..... ............ ............ ............ ............ ............ C1816..................... N Receiver/transmitter, neuro ............ ............ ............ ............ ............ C1817..................... N Septal defect imp sys...... ............ ............ ............ ............ ............ C1874..................... N Stent, coated/cov w/del sys ............ ............ ............ ............ ............ C1875..................... N Stent, coated/cov w/o del ............ ............ ............ ............ ............ sy. C1876..................... N Stent, non-coa/non-cov w/ ............ ............ ............ ............ ............ del. C1877..................... N Stent, non-coat/cov w/o del ............ ............ ............ ............ ............ C1878..................... N Matrl for vocal cord....... ............ ............ ............ ............ ............ C1879..................... N Tissue marker, implantable. ............ ............ ............ ............ ............ C1880..................... N Vena cava filter........... ............ ............ ............ ............ ............ C1881..................... N Dialysis access system..... ............ ............ ............ ............ ............ C1882..................... N AICD, other than sing/dual. ............ ............ ............ ............ ............ C1883..................... N Adapt/ext, pacing/neuro ............ ............ ............ ............ ............ lead. C1885..................... N Cath, translumin angio ............ ............ ............ ............ ............ laser. C1887..................... N Catheter, guiding.......... ............ ............ ............ ............ ............ C1888..................... H Endovas non-cardiac abl 1888 ............ ............ ............ ............ cath. C1891..................... N Infusion pump,non-prog, ............ ............ ............ ............ ............ perm. C1892..................... N Intro/sheath,fixed,peel- ............ ............ ............ ............ ............ away. C1893..................... N Intro/sheath, fixed,non- ............ ............ ............ ............ ............ peel. C1894..................... N Intro/sheath, non-laser.... ............ ............ ............ ............ ............ C1895..................... N Lead, AICD, endo dual coil. ............ ............ ............ ............ ............ C1896..................... N Lead, AICD, non sing/dual.. ............ ............ ............ ............ ............ C1897..................... N Lead, neurostim test kit... ............ ............ ............ ............ ............ C1898..................... N Lead, pmkr, other than ............ ............ ............ ............ ............ trans. C1899..................... N Lead, pmkr/AICD combination ............ ............ ............ ............ ............ C1900..................... H Lead coronary venous....... 1900 ............ ............ ............ ............ C2615..................... N Sealant, pulmonary, liquid. ............ ............ ............ ............ ............ C2616..................... N Brachytx seed, Yttrium-90.. ............ ............ ............ ............ ............ C2617..................... N Stent, non-cor, tem w/o del ............ ............ ............ ............ ............ C2618..................... H Probe, cryoablation........ 2618 ............ ............ ............ ............ C2619..................... N Pmkr, dual, non rate-resp.. ............ ............ ............ ............ ............ C2620..................... N Pmkr, single, non rate-resp ............ ............ ............ ............ ............ C2621..................... N Pmkr, other than sing/dual. ............ ............ ............ ............ ............ C2622..................... N Prosthesis, penile, non-inf ............ ............ ............ ............ ............ C2625..................... N Stent, non-cor, tem w/del ............ ............ ............ ............ ............ sy. C2626..................... N Infusion pump, non- ............ ............ ............ ............ ............ prog,temp. C2627..................... N Cath, suprapubic/ ............ ............ ............ ............ ............ cystoscopic. C2628..................... N Catheter, occlusion........ ............ ............ ............ ............ ............ C2629..................... N Intro/sheath, laser........ ............ ............ ............ ............ ............ C2630..................... N Cath, EP, cool-tip......... ............ ............ ............ ............ ............ C2631..................... N Rep dev, urinary, w/o sling ............ ............ ............ ............ ............ C8900..................... S MRA w/cont, abd............ 0284 7.74 $402.55 $201.02 $80.51 C8901..................... S MRA w/o cont, abd.......... 0336 7.01 $364.58 $176.94 $72.92 [[Page 52292]] C8902..................... S MRA w/o fol w/cont, abd.... 0337 9.86 $512.81 $240.77 $102.56 C8903..................... S MRI w/cont, breast, uni.... 0284 7.74 $402.55 $201.02 $80.51 C8904..................... S MRI w/o cont, breast, uni.. 0336 7.01 $364.58 $176.94 $72.92 C8905..................... S MRI w/o fol w/cont, brst, 0337 9.86 $512.81 $240.77 $102.56 un. C8906..................... S MRI w/cont, breast, bi..... 0284 7.74 $402.55 $201.02 $80.51 C8907..................... S MRI w/o cont, breast, bi... 0336 7.01 $364.58 $176.94 $72.92 C8908..................... S MRI w/o fol w/cont, breast, 0337 9.86 $512.81 $240.77 $102.56 C8909..................... S MRA w/cont, chest.......... 0284 7.74 $402.55 $201.02 $80.51 C8910..................... S MRA w/o cont, chest........ 0336 7.01 $364.58 $176.94 $72.92 C8911..................... S MRA w/o fol w/cont, chest.. 0337 9.86 $512.81 $240.77 $102.56 C8912..................... S MRA w/cont, lwr ext........ 0284 7.74 $402.55 $201.02 $80.51 C8913..................... S MRA w/o cont, lwr ext...... 0336 7.01 $364.58 $176.94 $72.92 C8914..................... S MRA w/o fol w/cont, lwr ext 0337 9.86 $512.81 $240.77 $102.56 C9000..................... N Na chromateCr51, per ............ ............ ............ ............ ............ 0.25mCi. C9003..................... K Palivizumab, per 50 mg..... 9003 9.34 $485.76 ............ $97.15 C9007..................... N Baclofen Intrathecal kit- ............ ............ ............ ............ ............ 1am. C9008..................... N Baclofen Refill Kit-500mcg. ............ ............ ............ ............ ............ C9009..................... K Baclofen Refill Kit-2000mcg 9009 0.79 $41.09 ............ $8.22 C9010..................... K Baclofen Refill Kit-- 9010 0.95 $49.41 ............ $9.88 4000mcg. C9013..................... N Co 57 cobaltous chloride... ............ ............ ............ ............ ............ C9019..................... G Caspofungin acetate, 5 mg.. 9019 ............ $34.20 ............ $4.90 C9020..................... K Sirolimussolution, 1 mg.... 9020 0.05 $2.60 ............ $.52 C9100..................... N Iodinated I-131 Albumin.... ............ ............ ............ ............ ............ C9102..................... N 51 Na Chromate, 50mCi...... ............ ............ ............ ............ ............ C9103..................... N Na Iothalamate I-125, 10 ............ ............ ............ ............ ............ uCi. C9105..................... K Hep B imm glob, per 1 ml... 9105 1.58 $82.17 ............ $16.43 C9108..................... K Thyrotropin alfa, 1.1 mg... 9108 8.79 $457.16 ............ $91.43 C9109..................... K Tirofiban hcl, 6.25 mg..... 9109 2.32 $120.66 ............ $24.13 C9110..................... G Alemtuzumab, per 10mg/ml... 9110 ............ $486.88 ............ $69.70 C9111..................... G Inj, bivalirudin, 250mg 9111 ............ $397.81 ............ $56.95 vial. C9112..................... G Perflutren lipid micro, 2ml 9112 ............ $148.20 ............ $21.22 C9113..................... G Inj pantoprazole sodium, 9113 ............ $22.80 ............ $3.26 via. C9114..................... G Nesiritide, per 1.5 mg vial 9114 ............ $433.20 ............ $62.02 C9115..................... G Inj, zoledronic acid, 2 mg. 9115 ............ $406.78 ............ $58.23 C9200..................... G Orcel, per 36 cm2.......... 9200 ............ $1,135.25 ............ $162.52 C9201..................... G Dermagraft, per 37.5 sq cm. 9201 ............ $577.60 ............ $82.69 C9503..................... K Fresh frozen plasma, ea 9503 0.77 $40.05 ............ $8.01 unit. C9701..................... T Stretta System............. 0980 ............ $1,875.00 ............ $375.00 C9703..................... T Bard Endoscopic Suturing 0979 ............ $1,625.00 ............ $325.00 Sys. C9708..................... T Preview Tx Planning 0973 ............ $250.00 ............ $50.00 Software. C9711..................... T H.E.L.P. Apheresis System.. 0978 ............ $1,375.00 ............ $275.00 D0120..................... E Periodic oral evaluation... ............ ............ ............ ............ ............ D0140..................... E Limit oral eval problm ............ ............ ............ ............ ............ focus. D0150..................... S Comprehensve oral 0330 0.64 $33.29 ............ $6.66 evaluation. D0160..................... E Extensv oral eval prob ............ ............ ............ ............ ............ focus. D0170..................... E Re-eval,est pt,problem ............ ............ ............ ............ ............ focus. D0210..................... E Intraor complete film ............ ............ ............ ............ ............ series. D0220..................... E Intraoral periapical first ............ ............ ............ ............ ............ f. D0230..................... E Intraoral periapical ea add ............ ............ ............ ............ ............ D0240..................... S Intraoral occlusal film.... 0330 0.64 $33.29 ............ $6.66 D0250..................... S Extraoral first film....... 0330 0.64 $33.29 ............ $6.66 D0260..................... S Extraoral ea additional 0330 0.64 $33.29 ............ $6.66 film. D0270..................... S Dental bitewing single film 0330 0.64 $33.29 ............ $6.66 D0272..................... S Dental bitewings two films. 0330 0.64 $33.29 ............ $6.66 D0274..................... S Dental bitewings four films 0330 0.64 $33.29 ............ $6.66 D0277..................... S Vert bitewings-sev to eight 0330 0.64 $33.29 ............ $6.66 D0290..................... E Dental film skull/facial ............ ............ ............ ............ ............ bon. D0310..................... E Dental saliography......... ............ ............ ............ ............ ............ D0320..................... E Dental tmj arthrogram incl ............ ............ ............ ............ ............ i. D0321..................... E Dental other tmj films..... ............ ............ ............ ............ ............ D0322..................... E Dental tomographic survey.. ............ ............ ............ ............ ............ D0330..................... E Dental panoramic film...... ............ ............ ............ ............ ............ D0340..................... E Dental cephalometric film.. ............ ............ ............ ............ ............ D0350..................... E Oral/facial images......... ............ ............ ............ ............ ............ D0415..................... E Bacteriologic study........ ............ ............ ............ ............ ............ D0425..................... E Caries susceptibility test. ............ ............ ............ ............ ............ [[Page 52293]] D0460..................... S Pulp vitality test......... 0330 0.64 $33.29 ............ $6.66 D0470..................... E Diagnostic casts........... ............ ............ ............ ............ ............ D0472..................... S Gross exam, prep & report.. 0330 0.64 $33.29 ............ $6.66 D0473..................... S Micro exam, prep & report.. 0330 0.64 $33.29 ............ $6.66 D0474..................... S Micro w exam of surg 0330 0.64 $33.29 ............ $6.66 margins. D0480..................... S Cytopath smear prep & 0330 0.64 $33.29 ............ $6.66 report. D0501..................... S Histopathologic 0330 0.64 $33.29 ............ $6.66 examinations. D0502..................... S Other oral pathology 0330 0.64 $33.29 ............ $6.66 procedu. D0999..................... S Unspecified diagnostic 0330 0.64 $33.29 ............ $6.66 proce. D1110..................... E Dental prophylaxis adult... ............ ............ ............ ............ ............ D1120..................... E Dental prophylaxis child... ............ ............ ............ ............ ............ D1201..................... E Topical fluor w prophy ............ ............ ............ ............ ............ child. D1203..................... E Topical fluor w/o prophy ............ ............ ............ ............ ............ chi. D1204..................... E Topical fluor w/o prophy ............ ............ ............ ............ ............ adu. D1205..................... E Topical fluoride w/ prophy ............ ............ ............ ............ ............ a. D1310..................... E Nutri counsel-control ............ ............ ............ ............ ............ caries. D1320..................... E Tobacco counseling......... ............ ............ ............ ............ ............ D1330..................... E Oral hygiene instruction... ............ ............ ............ ............ ............ D1351..................... E Dental sealant per tooth... ............ ............ ............ ............ ............ D1510..................... S Space maintainer fxd unilat 0330 0.64 $33.29 ............ $6.66 D1515..................... S Fixed bilat space 0330 0.64 $33.29 ............ $6.66 maintainer. D1520..................... S Remove unilat space 0330 0.64 $33.29 ............ $6.66 maintain. D1525..................... S Remove bilat space maintain 0330 0.64 $33.29 ............ $6.66 D1550..................... S Recement space maintainer.. 0330 0.64 $33.29 ............ $6.66 D2110..................... E Amalgam one surface primary ............ ............ ............ ............ ............ D2120..................... E Amalgam two surfaces ............ ............ ............ ............ ............ primary. D2130..................... E Amalgam three surfaces ............ ............ ............ ............ ............ prima. D2131..................... E Amalgam four/more surf ............ ............ ............ ............ ............ prima. D2140..................... E Amalgam one surface ............ ............ ............ ............ ............ permanen. D2150..................... E Amalgam two surfaces ............ ............ ............ ............ ............ permane. D2160..................... E Amalgam three surfaces ............ ............ ............ ............ ............ perma. D2161..................... E Amalgam 4 or > surfaces ............ ............ ............ ............ ............ perm. D2330..................... E Resin one surface-anterior. ............ ............ ............ ............ ............ D2331..................... E Resin two surfaces-anterior ............ ............ ............ ............ ............ D2332..................... E Resin three surfaces- ............ ............ ............ ............ ............ anterio. D2335..................... E Resin 4/> surf or w incis ............ ............ ............ ............ ............ an. D2336..................... E Composite resin crown...... ............ ............ ............ ............ ............ D2337..................... E Compo resin crown ant-perm. ............ ............ ............ ............ ............ D2380..................... E Resin one surf poster ............ ............ ............ ............ ............ primar. D2381..................... E Resin two surf poster ............ ............ ............ ............ ............ primar. D2382..................... E Resin three/more surf post ............ ............ ............ ............ ............ p. D2385..................... E Resin one surf poster ............ ............ ............ ............ ............ perman. D2386..................... E Resin two surf poster ............ ............ ............ ............ ............ perman. D2387..................... E Resin three/more surf post ............ ............ ............ ............ ............ p. D2388..................... E Resin four/more, post perm. ............ ............ ............ ............ ............ D2410..................... E Dental gold foil one ............ ............ ............ ............ ............ surface. D2420..................... E Dental gold foil two ............ ............ ............ ............ ............ surface. D2430..................... E Dental gold foil three ............ ............ ............ ............ ............ surfa. D2510..................... E Dental inlay metalic 1 surf ............ ............ ............ ............ ............ D2520..................... E Dental inlay metallic 2 ............ ............ ............ ............ ............ surf. D2530..................... E Dental inlay metl 3/more ............ ............ ............ ............ ............ sur. D2542..................... E Dental onlay metallic 2 ............ ............ ............ ............ ............ surf. D2543..................... E Dental onlay metallic 3 ............ ............ ............ ............ ............ surf. D2544..................... E Dental onlay metl 4/more ............ ............ ............ ............ ............ sur. D2610..................... E Inlay porcelain/ceramic 1 ............ ............ ............ ............ ............ su. D2620..................... E Inlay porcelain/ceramic 2 ............ ............ ............ ............ ............ su. D2630..................... E Dental onlay porc 3/more ............ ............ ............ ............ ............ sur. D2642..................... E Dental onlay porcelin 2 ............ ............ ............ ............ ............ surf. D2643..................... E Dental onlay porcelin 3 ............ ............ ............ ............ ............ surf. D2644..................... E Dental onlay porc 4/more ............ ............ ............ ............ ............ sur. D2650..................... E Inlay composite/resin one ............ ............ ............ ............ ............ su. D2651..................... E Inlay composite/resin two ............ ............ ............ ............ ............ su. D2652..................... E Dental inlay resin 3/mre ............ ............ ............ ............ ............ sur. D2662..................... E Dental onlay resin 2 ............ ............ ............ ............ ............ surface. D2663..................... E Dental onlay resin 3 ............ ............ ............ ............ ............ surface. D2664..................... E Dental onlay resin 4/mre ............ ............ ............ ............ ............ sur. [[Page 52294]] D2710..................... E Crown resin laboratory..... ............ ............ ............ ............ ............ D2720..................... E Crown resin w/ high noble ............ ............ ............ ............ ............ me. D2721..................... E Crown resin w/ base metal.. ............ ............ ............ ............ ............ D2722..................... E Crown resin w/ noble metal. ............ ............ ............ ............ ............ D2740..................... E Crown porcelain/ceramic ............ ............ ............ ............ ............ subs. D2750..................... E Crown porcelain w/ h noble ............ ............ ............ ............ ............ m. D2751..................... E Crown porcelain fused base ............ ............ ............ ............ ............ m. D2752..................... E Crown porcelain w/ noble ............ ............ ............ ............ ............ met. D2780..................... E Crown 3/4 cast hi noble met ............ ............ ............ ............ ............ D2781..................... E Crown 3/4 cast base metal.. ............ ............ ............ ............ ............ D2782..................... E Crown 3/4 cast noble metal. ............ ............ ............ ............ ............ D2783..................... E Crown 3/4 porcelain/ceramic ............ ............ ............ ............ ............ D2790..................... E Crown full cast high noble ............ ............ ............ ............ ............ m. D2791..................... E Crown full cast base metal. ............ ............ ............ ............ ............ D2792..................... E Crown full cast noble metal ............ ............ ............ ............ ............ D2799..................... E Provisional crown.......... ............ ............ ............ ............ ............ D2910..................... E Dental recement inlay...... ............ ............ ............ ............ ............ D2920..................... E Dental recement crown...... ............ ............ ............ ............ ............ D2930..................... E Prefab stnlss steel crwn ............ ............ ............ ............ ............ pri. D2931..................... E Prefab stnlss steel crown ............ ............ ............ ............ ............ pe. D2932..................... E Prefabricated resin crown.. ............ ............ ............ ............ ............ D2933..................... E Prefab stainless steel ............ ............ ............ ............ ............ crown. D2940..................... E Dental sedative filling.... ............ ............ ............ ............ ............ D2950..................... E Core build-up incl any pins ............ ............ ............ ............ ............ D2951..................... E Tooth pin retention........ ............ ............ ............ ............ ............ D2952..................... E Post and core cast + crown. ............ ............ ............ ............ ............ D2953..................... E Each addtnl cast post...... ............ ............ ............ ............ ............ D2954..................... E Prefab post/core + crown... ............ ............ ............ ............ ............ D2955..................... E Post removal............... ............ ............ ............ ............ ............ D2957..................... E Each addtnl prefab post.... ............ ............ ............ ............ ............ D2960..................... E Laminate labial veneer..... ............ ............ ............ ............ ............ D2961..................... E Lab labial veneer resin.... ............ ............ ............ ............ ............ D2962..................... E Lab labial veneer porcelain ............ ............ ............ ............ ............ D2970..................... S Temporary- fractured tooth. 0330 0.64 $33.29 ............ $6.66 D2980..................... E Crown repair............... ............ ............ ............ ............ ............ D2999..................... S Dental unspec restorative 0330 0.64 $33.29 ............ $6.66 pr. D3110..................... E Pulp cap direct............ ............ ............ ............ ............ ............ D3120..................... E Pulp cap indirect.......... ............ ............ ............ ............ ............ D3220..................... E Therapeutic pulpotomy...... ............ ............ ............ ............ ............ D3221..................... E Gross pulpal debridement... ............ ............ ............ ............ ............ D3230..................... E Pulpal therapy anterior ............ ............ ............ ............ ............ prim. D3240..................... E Pulpal therapy posterior ............ ............ ............ ............ ............ pri. D3310..................... E Anterior................... ............ ............ ............ ............ ............ D3320..................... E Root canal therapy 2 canals ............ ............ ............ ............ ............ D3330..................... E Root canal therapy 3 canals ............ ............ ............ ............ ............ D3331..................... E Non-surg tx root canal obs. ............ ............ ............ ............ ............ D3332..................... E Incomplete endodontic tx... ............ ............ ............ ............ ............ D3333..................... E Internal root repair....... ............ ............ ............ ............ ............ D3346..................... E Retreat root canal anterior ............ ............ ............ ............ ............ D3347..................... E Retreat root canal bicuspid ............ ............ ............ ............ ............ D3348..................... E Retreat root canal molar... ............ ............ ............ ............ ............ D3351..................... E Apexification/recalc ............ ............ ............ ............ ............ initial. 0001T..................... C Endovas repr abdo ao ............ ............ ............ ............ ............ aneurys. D3352..................... E Apexification/recalc ............ ............ ............ ............ ............ interim. D3353..................... E Apexification/recalc final. ............ ............ ............ ............ ............ D3410..................... E Apicoect/perirad surg anter ............ ............ ............ ............ ............ D3421..................... E Root surgery bicuspid...... ............ ............ ............ ............ ............ D3425..................... E Root surgery molar......... ............ ............ ............ ............ ............ D3426..................... E Root surgery ea add root... ............ ............ ............ ............ ............ D3430..................... E Retrograde filling......... ............ ............ ............ ............ ............ D3450..................... E Root amputation............ ............ ............ ............ ............ ............ D3460..................... S Endodontic endosseous 0330 0.64 $33.29 ............ $6.66 implan. D3470..................... E Intentional replantation... ............ ............ ............ ............ ............ D3910..................... E Isolation- tooth w rubb dam ............ ............ ............ ............ ............ D3920..................... E Tooth splitting............ ............ ............ ............ ............ ............ D3950..................... E Canal prep/fitting of dowel ............ ............ ............ ............ ............ [[Page 52295]] D3999..................... S Endodontic procedure....... 0330 0.64 $33.29 ............ $6.66 D4210..................... E Gingivectomy/plasty per ............ ............ ............ ............ ............ quad. D4211..................... E Gingivectomy/plasty per ............ ............ ............ ............ ............ toot. D4220..................... E Gingival curettage per ............ ............ ............ ............ ............ quadr. D4240..................... E Gingival flap proc w/ ............ ............ ............ ............ ............ planin. D4245..................... E Apically positioned flap... ............ ............ ............ ............ ............ D4249..................... E Crown lengthen hard tissue. ............ ............ ............ ............ ............ D4260..................... S Osseous surgery per 0330 0.64 $33.29 ............ $6.66 quadrant. D4263..................... S Bone replce graft first 0330 0.64 $33.29 ............ $6.66 site. D4264..................... S Bone replce graft each add. 0330 0.64 $33.29 ............ $6.66 D4266..................... E Guided tiss regen resorble. ............ ............ ............ ............ ............ D4267..................... E Guided tiss regen nonresorb ............ ............ ............ ............ ............ D4268..................... S Surgical revision procedure 0330 0.64 $33.29 ............ $6.66 D4270..................... S Pedicle soft tissue graft 0330 0.64 $33.29 ............ $6.66 pr. D4271..................... S Free soft tissue graft proc 0330 0.64 $33.29 ............ $6.66 D4273..................... S Subepithelial tissue graft. 0330 0.64 $33.29 ............ $6.66 D4274..................... E Distal/proximal wedge proc. ............ ............ ............ ............ ............ D4320..................... E Provision splnt ............ ............ ............ ............ ............ intracoronal. D4321..................... E Provisional splint ............ ............ ............ ............ ............ extracoro. D4341..................... E Periodontal scaling & root. ............ ............ ............ ............ ............ D4355..................... S Full mouth debridement..... 0330 0.64 $33.29 ............ $6.66 D4381..................... S Localized chemo delivery... 0330 0.64 $33.29 ............ $6.66 D4910..................... E Periodontal maint ............ ............ ............ ............ ............ procedures. D4920..................... E Unscheduled dressing change ............ ............ ............ ............ ............ D4999..................... E Unspecified periodontal ............ ............ ............ ............ ............ proc. D5110..................... E Dentures complete maxillary ............ ............ ............ ............ ............ D5120..................... E Dentures complete mandible. ............ ............ ............ ............ ............ D5130..................... E Dentures immediat maxillary ............ ............ ............ ............ ............ D5140..................... E Dentures immediat mandible. ............ ............ ............ ............ ............ D5211..................... E Dentures maxill part resin. ............ ............ ............ ............ ............ D5212..................... E Dentures mand part resin... ............ ............ ............ ............ ............ D5213..................... E Dentures maxill part metal. ............ ............ ............ ............ ............ D5214..................... E Dentures mandibl part metal ............ ............ ............ ............ ............ D5281..................... E Removable partial denture.. ............ ............ ............ ............ ............ D5410..................... E Dentures adjust cmplt maxil ............ ............ ............ ............ ............ D5411..................... E Dentures adjust cmplt mand. ............ ............ ............ ............ ............ D5421..................... E Dentures adjust part maxill ............ ............ ............ ............ ............ D5422..................... E Dentures adjust part mandbl ............ ............ ............ ............ ............ D5510..................... E Dentur repr broken compl ............ ............ ............ ............ ............ bas. D5520..................... E Replace denture teeth ............ ............ ............ ............ ............ complt. D5610..................... E Dentures repair resin base. ............ ............ ............ ............ ............ D5620..................... E Rep part denture cast frame ............ ............ ............ ............ ............ D5630..................... E Rep partial denture clasp.. ............ ............ ............ ............ ............ D5640..................... E Replace part denture teeth. ............ ............ ............ ............ ............ D5650..................... E Add tooth to partial ............ ............ ............ ............ ............ denture. D5660..................... E Add clasp to partial ............ ............ ............ ............ ............ denture. D5710..................... E Dentures rebase cmplt maxil ............ ............ ............ ............ ............ D5711..................... E Dentures rebase cmplt mand. ............ ............ ............ ............ ............ D5720..................... E Dentures rebase part maxill ............ ............ ............ ............ ............ D5721..................... E Dentures rebase part mandbl ............ ............ ............ ............ ............ D5730..................... E Denture reln cmplt maxil ch ............ ............ ............ ............ ............ D5731..................... E Denture reln cmplt mand chr ............ ............ ............ ............ ............ D5740..................... E Denture reln part maxil chr ............ ............ ............ ............ ............ D5741..................... E Denture reln part mand chr. ............ ............ ............ ............ ............ D5750..................... E Denture reln cmplt max lab. ............ ............ ............ ............ ............ D5751..................... E Denture reln cmplt mand lab ............ ............ ............ ............ ............ D5760..................... E Denture reln part maxil lab ............ ............ ............ ............ ............ D5761..................... E Denture reln part mand lab. ............ ............ ............ ............ ............ D5810..................... E Denture interm cmplt maxill ............ ............ ............ ............ ............ D5811..................... E Denture interm cmplt mandbl ............ ............ ............ ............ ............ D5820..................... E Denture interm part maxill. ............ ............ ............ ............ ............ D5821..................... E Denture interm part mandbl. ............ ............ ............ ............ ............ D5850..................... E Denture tiss conditn maxill ............ ............ ............ ............ ............ D5851..................... E Denture tiss condtin mandbl ............ ............ ............ ............ ............ D5860..................... E Overdenture complete....... ............ ............ ............ ............ ............ D5861..................... E Overdenture partial........ ............ ............ ............ ............ ............ [[Page 52296]] D5862..................... E Precision attachment....... ............ ............ ............ ............ ............ D5867..................... E Replacement of precision ............ ............ ............ ............ ............ att. D5875..................... E Prosthesis modification.... ............ ............ ............ ............ ............ D5899..................... E Removable prosthodontic ............ ............ ............ ............ ............ proc. D5911..................... S Facial moulage sectional... 0330 0.64 $33.29 ............ $6.66 D5912..................... S Facial moulage complete.... 0330 0.64 $33.29 ............ $6.66 D5913..................... E Nasal prosthesis........... ............ ............ ............ ............ ............ D5914..................... E Auricular prosthesis....... ............ ............ ............ ............ ............ D5915..................... E Orbital prosthesis......... ............ ............ ............ ............ ............ D5916..................... E Ocular prosthesis.......... ............ ............ ............ ............ ............ D5919..................... E Facial prosthesis.......... ............ ............ ............ ............ ............ D5922..................... E Nasal septal prosthesis.... ............ ............ ............ ............ ............ D5923..................... E Ocular prosthesis interim.. ............ ............ ............ ............ ............ D5924..................... E Cranial prosthesis......... ............ ............ ............ ............ ............ D5925..................... E Facial augmentation implant ............ ............ ............ ............ ............ D5926..................... E Replacement nasal ............ ............ ............ ............ ............ prosthesis. D5927..................... E Auricular replacement...... ............ ............ ............ ............ ............ D5928..................... E Orbital replacement........ ............ ............ ............ ............ ............ D5929..................... E Facial replacement......... ............ ............ ............ ............ ............ D5931..................... E Surgical obturator......... ............ ............ ............ ............ ............ D5932..................... E Postsurgical obturator..... ............ ............ ............ ............ ............ D5933..................... E Refitting of obturator..... ............ ............ ............ ............ ............ D5934..................... E Mandibular flange ............ ............ ............ ............ ............ prosthesis. D5935..................... E Mandibular denture prosth.. ............ ............ ............ ............ ............ D5936..................... E Temp obturator prosthesis.. ............ ............ ............ ............ ............ D5937..................... E Trismus appliance.......... ............ ............ ............ ............ ............ D5951..................... E Feeding aid................ ............ ............ ............ ............ ............ D5952..................... E Pediatric speech aid....... ............ ............ ............ ............ ............ D5953..................... E Adult speech aid........... ............ ............ ............ ............ ............ D5954..................... E Superimposed prosthesis.... ............ ............ ............ ............ ............ D5955..................... E Palatal lift prosthesis.... ............ ............ ............ ............ ............ D5958..................... E Intraoral con def inter plt ............ ............ ............ ............ ............ D5959..................... E Intraoral con def mod palat ............ ............ ............ ............ ............ D5960..................... E Modify speech aid ............ ............ ............ ............ ............ prosthesis. D5982..................... E Surgical stent............. ............ ............ ............ ............ ............ D5983..................... S Radiation applicator....... 0330 0.64 $33.29 ............ $6.66 D5984..................... S Radiation shield........... 0330 0.64 $33.29 ............ $6.66 D5985..................... S Radiation cone locator..... 0330 0.64 $33.29 ............ $6.66 D5986..................... E Fluoride applicator........ ............ ............ ............ ............ ............ D5987..................... S Commissure splint.......... 0330 0.64 $33.29 ............ $6.66 D5988..................... E Surgical splint............ ............ ............ ............ ............ ............ D5999..................... E Maxillofacial prosthesis... ............ ............ ............ ............ ............ D6010..................... E Odontics endosteal implant. ............ ............ ............ ............ ............ D6020..................... E Odontics abutment placement ............ ............ ............ ............ ............ D6040..................... E Odontics eposteal implant.. ............ ............ ............ ............ ............ D6050..................... E Odontics transosteal implnt ............ ............ ............ ............ ............ D6055..................... E Implant connecting bar..... ............ ............ ............ ............ ............ D6056..................... E Prefabricated abutment..... ............ ............ ............ ............ ............ D6057..................... E Custom abutment............ ............ ............ ............ ............ ............ D6058..................... E Abutment supported crown... ............ ............ ............ ............ ............ D6059..................... E Abutment supported mtl ............ ............ ............ ............ ............ crown. D6060..................... E Abutment supported mtl ............ ............ ............ ............ ............ crown. D6061..................... E Abutment supported mtl ............ ............ ............ ............ ............ crown. D6062..................... E Abutment supported mtl ............ ............ ............ ............ ............ crown. D6063..................... E Abutment supported mtl ............ ............ ............ ............ ............ crown. D6064..................... E Abutment supported mtl ............ ............ ............ ............ ............ crown. D6065..................... E Implant supported crown.... ............ ............ ............ ............ ............ D6066..................... E Implant supported mtl crown ............ ............ ............ ............ ............ D6067..................... E Implant supported mtl crown ............ ............ ............ ............ ............ D6068..................... E Abutment supported retainer ............ ............ ............ ............ ............ D6069..................... E Abutment supported retainer ............ ............ ............ ............ ............ D6070..................... E Abutment supported retainer ............ ............ ............ ............ ............ D6071..................... E Abutment supported retainer ............ ............ ............ ............ ............ D6072..................... E Abutment supported retainer ............ ............ ............ ............ ............ D6073..................... E Abutment supported retainer ............ ............ ............ ............ ............ D6074..................... E Abutment supported retainer ............ ............ ............ ............ ............ [[Page 52297]] D6075..................... E Implant supported retainer. ............ ............ ............ ............ ............ D6076..................... E Implant supported retainer. ............ ............ ............ ............ ............ D6077..................... E Implant supported retainer. ............ ............ ............ ............ ............ D6078..................... E Implnt/abut suprtd fixd ............ ............ ............ ............ ............ dent. D6079..................... E Implnt/abut suprtd fixd ............ ............ ............ ............ ............ dent. D6080..................... E Implant maintenance........ ............ ............ ............ ............ ............ D6090..................... E Repair implant............. ............ ............ ............ ............ ............ D6095..................... E Odontics repr abutment..... ............ ............ ............ ............ ............ D6100..................... E Removal of implant......... ............ ............ ............ ............ ............ D6199..................... E Implant procedure.......... ............ ............ ............ ............ ............ D6210..................... E Prosthodont high noble ............ ............ ............ ............ ............ metal. D6211..................... E Bridge base metal cast..... ............ ............ ............ ............ ............ D6212..................... E Bridge noble metal cast.... ............ ............ ............ ............ ............ D6240..................... E Bridge porcelain high noble ............ ............ ............ ............ ............ D6241..................... E Bridge porcelain base metal ............ ............ ............ ............ ............ D6242..................... E Bridge porcelain nobel ............ ............ ............ ............ ............ metal. D6245..................... E Bridge porcelain/ceramic... ............ ............ ............ ............ ............ D6250..................... E Bridge resin w/high noble.. ............ ............ ............ ............ ............ D6251..................... E Bridge resin base metal.... ............ ............ ............ ............ ............ D6252..................... E Bridge resin w/noble metal. ............ ............ ............ ............ ............ D6519..................... E Inlay/onlay porce/ceramic.. ............ ............ ............ ............ ............ D6520..................... E Dental retainer two ............ ............ ............ ............ ............ surfaces. D6530..................... E Retainer metallic 3+ ............ ............ ............ ............ ............ surface. D6543..................... E Dental retainr onlay 3 surf ............ ............ ............ ............ ............ D6544..................... E Dental retainr onlay 4/more ............ ............ ............ ............ ............ D6545..................... E Dental retainr cast metl... ............ ............ ............ ............ ............ D6548..................... E Porcelain/ceramic retainer. ............ ............ ............ ............ ............ D6720..................... E Retain crown resin w hi ............ ............ ............ ............ ............ nble. D6721..................... E Crown resin w/base metal... ............ ............ ............ ............ ............ D6722..................... E Crown resin w/noble metal.. ............ ............ ............ ............ ............ D6740..................... E Crown porcelain/ceramic.... ............ ............ ............ ............ ............ D6750..................... E Crown porcelain high noble. ............ ............ ............ ............ ............ D6751..................... E Crown porcelain base metal. ............ ............ ............ ............ ............ D6752..................... E Crown porcelain noble metal ............ ............ ............ ............ ............ D6780..................... E Crown 3/4 high noble metal. ............ ............ ............ ............ ............ D6781..................... E Crown 3/4 cast based metal. ............ ............ ............ ............ ............ D6782..................... E Crown 3/4 cast noble metal. ............ ............ ............ ............ ............ D6783..................... E Crown 3/4 porcelain/ceramic ............ ............ ............ ............ ............ D6790..................... E Crown full high noble metal ............ ............ ............ ............ ............ D6791..................... E Crown full base metal cast. ............ ............ ............ ............ ............ D6792..................... E Crown full noble metal cast ............ ............ ............ ............ ............ D6920..................... S Dental connector bar....... 0330 0.64 $33.29 ............ $6.66 D6930..................... E Dental recement bridge..... ............ ............ ............ ............ ............ D6940..................... E Stress breaker............. ............ ............ ............ ............ ............ D6950..................... E Precision attachment....... ............ ............ ............ ............ ............ D6970..................... E Post & core plus retainer.. ............ ............ ............ ............ ............ D6971..................... E Cast post bridge retainer.. ............ ............ ............ ............ ............ D6972..................... E Prefab post & core plus ............ ............ ............ ............ ............ reta. D6973..................... E Core build up for retainer. ............ ............ ............ ............ ............ D6975..................... E Coping metal............... ............ ............ ............ ............ ............ D6976..................... E Each addtnl cast post...... ............ ............ ............ ............ ............ D6977..................... E Each addtl prefab post..... ............ ............ ............ ............ ............ D6980..................... E Bridge repair.............. ............ ............ ............ ............ ............ D6999..................... E Fixed prosthodontic proc... ............ ............ ............ ............ ............ D7110..................... S Oral surgery single tooth.. 0330 0.64 $33.29 ............ $6.66 D7120..................... S Each add tooth extraction.. 0330 0.64 $33.29 ............ $6.66 D7130..................... S Tooth root removal......... 0330 0.64 $33.29 ............ $6.66 D7210..................... S Rem imp tooth w mucoper flp 0330 0.64 $33.29 ............ $6.66 D7220..................... S Impact tooth remov soft 0330 0.64 $33.29 ............ $6.66 tiss. D7230..................... S Impact tooth remov part 0330 0.64 $33.29 ............ $6.66 bony. D7240..................... S Impact tooth remov comp 0330 0.64 $33.29 ............ $6.66 bony. D7241..................... S Impact tooth rem bony w/ 0330 0.64 $33.29 ............ $6.66 comp. D7250..................... S Tooth root removal......... 0330 0.64 $33.29 ............ $6.66 D7260..................... S Oral antral fistula closure 0330 0.64 $33.29 ............ $6.66 D7270..................... E Tooth reimplantation....... ............ ............ ............ ............ ............ D7272..................... E Tooth transplantation...... ............ ............ ............ ............ ............ [[Page 52298]] D7280..................... E Exposure impact tooth ............ ............ ............ ............ ............ orthod. D7281..................... E Exposure tooth aid eruption ............ ............ ............ ............ ............ D7285..................... E Biopsy of oral tissue hard. ............ ............ ............ ............ ............ D7286..................... E Biopsy of oral tissue soft. ............ ............ ............ ............ ............ D7290..................... E Repositioning of teeth..... ............ ............ ............ ............ ............ D7291..................... S Transseptal fiberotomy..... 0330 0.64 $33.29 ............ $6.66 D7310..................... E Alveoplasty w/ extraction.. ............ ............ ............ ............ ............ D7320..................... E Alveoplasty w/o extraction. ............ ............ ............ ............ ............ D7340..................... E Vestibuloplasty ridge ............ ............ ............ ............ ............ extens. D7350..................... E Vestibuloplasty exten graft ............ ............ ............ ............ ............ D7410..................... E Rad exc lesion up to 1.25 ............ ............ ............ ............ ............ cm. D7420..................... E Lesion > 1.25 cm........... ............ ............ ............ ............ ............ D7430..................... E Exc benign tumor to 1.25 cm ............ ............ ............ ............ ............ D7431..................... E Benign tumor exc > 1.25 cm. ............ ............ ............ ............ ............ D7440..................... E Malig tumor exc to 1.25 cm. ............ ............ ............ ............ ............ D7441..................... E Malig tumor > 1.25 cm...... ............ ............ ............ ............ ............ D7450..................... E Rem odontogen cyst to ............ ............ ............ ............ ............ 1.25cm. D7451..................... E Rem odontogen cyst > 1.25 ............ ............ ............ ............ ............ cm. D7460..................... E Rem nonodonto cyst to ............ ............ ............ ............ ............ 1.25cm. D7461..................... E Rem nonodonto cyst > 1.25 ............ ............ ............ ............ ............ cm. D7465..................... E Lesion destruction......... ............ ............ ............ ............ ............ D7471..................... E Rem exostosis any site..... ............ ............ ............ ............ ............ D7480..................... E Partial ostectomy.......... ............ ............ ............ ............ ............ D7490..................... E Mandible resection......... ............ ............ ............ ............ ............ D7510..................... E I&d absc intraoral soft ............ ............ ............ ............ ............ tiss. D7520..................... E I&d abscess extraoral...... ............ ............ ............ ............ ............ D7530..................... E Removal fb skin/areolar ............ ............ ............ ............ ............ tiss. D7540..................... E Removal of fb reaction..... ............ ............ ............ ............ ............ D7550..................... E Removal of sloughed off ............ ............ ............ ............ ............ bone. D7560..................... E Maxillary sinusotomy....... ............ ............ ............ ............ ............ D7610..................... E Maxilla open reduct simple. ............ ............ ............ ............ ............ D7620..................... E Clsd reduct simpl maxilla ............ ............ ............ ............ ............ fx. D7630..................... E Open red simpl mandible fx. ............ ............ ............ ............ ............ D7640..................... E Clsd red simpl mandible fx. ............ ............ ............ ............ ............ D7650..................... E Open red simp malar/zygom ............ ............ ............ ............ ............ fx. D7660..................... E Clsd red simp malar/zygom ............ ............ ............ ............ ............ fx. D7670..................... E Closd rductn splint ............ ............ ............ ............ ............ alveolus. D7680..................... E Reduct simple facial bone ............ ............ ............ ............ ............ fx. D7710..................... E Maxilla open reduct ............ ............ ............ ............ ............ compound. D7720..................... E Clsd reduct compd maxilla ............ ............ ............ ............ ............ fx. D7730..................... E Open reduct compd mandble ............ ............ ............ ............ ............ fx. D7740..................... E Clsd reduct compd mandble ............ ............ ............ ............ ............ fx. D7750..................... E Open red comp malar/zygma ............ ............ ............ ............ ............ fx. D7760..................... E Clsd red comp malar/zygma ............ ............ ............ ............ ............ fx. D7770..................... E Open reduc compd alveolus ............ ............ ............ ............ ............ fx. D7780..................... E Reduct compnd facial bone ............ ............ ............ ............ ............ fx. D7810..................... E Tmj open reduct-dislocation ............ ............ ............ ............ ............ D7820..................... E Closed tmp manipulation.... ............ ............ ............ ............ ............ D7830..................... E Tmj manipulation under ............ ............ ............ ............ ............ anest. D7840..................... E Removal of tmj condyle..... ............ ............ ............ ............ ............ D7850..................... E Tmj meniscectomy........... ............ ............ ............ ............ ............ D7852..................... E Tmj repair of joint disc... ............ ............ ............ ............ ............ D7854..................... E Tmj excisn of joint ............ ............ ............ ............ ............ membrane. D7856..................... E Tmj cutting of a muscle.... ............ ............ ............ ............ ............ D7858..................... E Tmj reconstruction......... ............ ............ ............ ............ ............ D7860..................... E Tmj cutting into joint..... ............ ............ ............ ............ ............ D7865..................... E Tmj reshaping components... ............ ............ ............ ............ ............ D7870..................... E Tmj aspiration joint fluid. ............ ............ ............ ............ ............ D7871..................... E Lysis + lavage w catheters. ............ ............ ............ ............ ............ D7872..................... E Tmj diagnostic arthroscopy. ............ ............ ............ ............ ............ D7873..................... E Tmj arthroscopy lysis ............ ............ ............ ............ ............ adhesn. D7874..................... E Tmj arthroscopy disc ............ ............ ............ ............ ............ reposit. D7875..................... E Tmj arthroscopy synovectomy ............ ............ ............ ............ ............ D7876..................... E Tmj arthroscopy discectomy. ............ ............ ............ ............ ............ D7877..................... E Tmj arthroscopy debridement ............ ............ ............ ............ ............ D7880..................... E Occlusal orthotic appliance ............ ............ ............ ............ ............ [[Page 52299]] D7899..................... E Tmj unspecified therapy.... ............ ............ ............ ............ ............ D7910..................... E Dent sutur recent wnd to ............ ............ ............ ............ ............ 5cm. D7911..................... E Dental suture wound to 5 cm ............ ............ ............ ............ ............ D7912..................... E Suture complicate wnd > 5 ............ ............ ............ ............ ............ cm. D7920..................... E Dental skin graft.......... ............ ............ ............ ............ ............ D7940..................... S Reshaping bone orthognathic 0330 0.64 $33.29 ............ $6.66 D7941..................... E Bone cutting ramus closed.. ............ ............ ............ ............ ............ D7943..................... E Cutting ramus open w/graft. ............ ............ ............ ............ ............ D7944..................... E Bone cutting segmented..... ............ ............ ............ ............ ............ D7945..................... E Bone cutting body mandible. ............ ............ ............ ............ ............ D7946..................... E Reconstruction maxilla ............ ............ ............ ............ ............ total. D7947..................... E Reconstruct maxilla segment ............ ............ ............ ............ ............ D7948..................... E Reconstruct midface no ............ ............ ............ ............ ............ graft. D7949..................... E Reconstruct midface w/graft ............ ............ ............ ............ ............ D7950..................... E Mandible graft............. ............ ............ ............ ............ ............ D7955..................... E Repair maxillofacial ............ ............ ............ ............ ............ defects. D7960..................... E Frenulectomy/frenulotomy... ............ ............ ............ ............ ............ D7970..................... E Excision hyperplastic ............ ............ ............ ............ ............ tissue. D7971..................... E Excision pericoronal ............ ............ ............ ............ ............ gingiva. D7980..................... E Sialolithotomy............. ............ ............ ............ ............ ............ D7981..................... E Excision of salivary gland. ............ ............ ............ ............ ............ D7982..................... E Sialodochoplasty........... ............ ............ ............ ............ ............ D7983..................... E Closure of salivary fistula ............ ............ ............ ............ ............ D7990..................... E Emergency tracheotomy...... ............ ............ ............ ............ ............ D7991..................... E Dental coronoidectomy...... ............ ............ ............ ............ ............ D7995..................... E Synthetic graft facial ............ ............ ............ ............ ............ bones. D7996..................... E Implant mandible for ............ ............ ............ ............ ............ augment. D7997..................... E Appliance removal.......... ............ ............ ............ ............ ............ D7999..................... E Oral surgery procedure..... ............ ............ ............ ............ ............ D8010..................... E Limited dental tx primary.. ............ ............ ............ ............ ............ D8020..................... E Limited dental tx ............ ............ ............ ............ ............ transition. D8030..................... E Limited dental tx ............ ............ ............ ............ ............ adolescent. D8040..................... E Limited dental tx adult.... ............ ............ ............ ............ ............ D8050..................... E Intercep dental tx primary. ............ ............ ............ ............ ............ D8060..................... E Intercep dental tx transitn ............ ............ ............ ............ ............ D8070..................... E Compre dental tx transition ............ ............ ............ ............ ............ D8080..................... E Compre dental tx adolescent ............ ............ ............ ............ ............ D8090..................... E Compre dental tx adult..... ............ ............ ............ ............ ............ D8210..................... E Orthodontic rem appliance ............ ............ ............ ............ ............ tx. D8220..................... E Fixed appliance therapy ............ ............ ............ ............ ............ habt. D8660..................... E Preorthodontic tx visit.... ............ ............ ............ ............ ............ D8670..................... E Periodic orthodontc tx ............ ............ ............ ............ ............ visit. D8680..................... E Orthodontic retention...... ............ ............ ............ ............ ............ D8690..................... E Orthodontic treatment...... ............ ............ ............ ............ ............ D8691..................... E Repair ortho appliance..... ............ ............ ............ ............ ............ D8692..................... E Replacement retainer....... ............ ............ ............ ............ ............ D8999..................... E Orthodontic procedure...... ............ ............ ............ ............ ............ D9110..................... N Tx dental pain minor proc.. ............ ............ ............ ............ ............ D9210..................... E Dent anesthesia w/o surgery ............ ............ ............ ............ ............ D9211..................... E Regional block anesthesia.. ............ ............ ............ ............ ............ D9212..................... E Trigeminal block anesthesia ............ ............ ............ ............ ............ D9215..................... E Local anesthesia........... ............ ............ ............ ............ ............ D9220..................... E General anesthesia......... ............ ............ ............ ............ ............ D9221..................... E General anesthesia ea ad ............ ............ ............ ............ ............ 15m. D9230..................... N Analgesia.................. ............ ............ ............ ............ ............ D9241..................... E Intravenous sedation....... ............ ............ ............ ............ ............ D9242..................... E IV sedation ea ad 30 m..... ............ ............ ............ ............ ............ D9248..................... N Sedation (non-iv).......... ............ ............ ............ ............ ............ D9310..................... E Dental consultation........ ............ ............ ............ ............ ............ D9410..................... E Dental house call.......... ............ ............ ............ ............ ............ D9420..................... E Hospital call.............. ............ ............ ............ ............ ............ D9430..................... E Office visit during hours.. ............ ............ ............ ............ ............ D9440..................... E Office visit after hours... ............ ............ ............ ............ ............ D9610..................... E Dent therapeutic drug ............ ............ ............ ............ ............ inject. D9630..................... S Other drugs/medicaments.... 0330 0.64 $33.29 ............ $6.66 D9910..................... E Dent appl desensitizing med ............ ............ ............ ............ ............ [[Page 52300]] D9911..................... E Appl desensitizing resin... ............ ............ ............ ............ ............ D9920..................... E Behavior management........ ............ ............ ............ ............ ............ D9930..................... S Treatment of complications. 0330 0.64 $33.29 ............ $6.66 D9940..................... S Dental occlusal guard...... 0330 0.64 $33.29 ............ $6.66 D9941..................... E Fabrication athletic guard. ............ ............ ............ ............ ............ D9950..................... S Occlusion analysis......... 0330 0.64 $33.29 ............ $6.66 D9951..................... S Limited occlusal adjustment 0330 0.64 $33.29 ............ $6.66 D9952..................... S Complete occlusal 0330 0.64 $33.29 ............ $6.66 adjustment. D9970..................... E Enamel microabrasion....... ............ ............ ............ ............ ............ D9971..................... E Odontoplasty 1-2 teeth..... ............ ............ ............ ............ ............ D9972..................... E Extrnl bleaching per arch.. ............ ............ ............ ............ ............ D9973..................... E Extrnl bleaching per tooth. ............ ............ ............ ............ ............ D9974..................... E Intrnl bleaching per tooth. ............ ............ ............ ............ ............ D9999..................... E Adjunctive procedure....... ............ ............ ............ ............ ............ E0100..................... A Cane adjust/fixed with tip. ............ ............ ............ ............ ............ E0105..................... A Cane adjust/fixed quad/3 ............ ............ ............ ............ ............ pro. E0110..................... A Crutch forearm pair........ ............ ............ ............ ............ ............ E0111..................... A Crutch forearm each........ ............ ............ ............ ............ ............ E0112..................... A Crutch underarm pair wood.. ............ ............ ............ ............ ............ E0113..................... A Crutch underarm each wood.. ............ ............ ............ ............ ............ E0114..................... A Crutch underarm pair no ............ ............ ............ ............ ............ wood. E0116..................... A Crutch underarm each no ............ ............ ............ ............ ............ wood. E0130..................... A Walker rigid adjust/fixed ............ ............ ............ ............ ............ ht. E0135..................... A Walker folding adjust/fixed ............ ............ ............ ............ ............ E0141..................... A Rigid walker wheeled wo ............ ............ ............ ............ ............ seat. E0142..................... A Walker rigid wheeled with ............ ............ ............ ............ ............ se. E0143..................... A Walker folding wheeled w/o ............ ............ ............ ............ ............ s. E0144..................... A Enclosed walker w rear seat ............ ............ ............ ............ ............ E0145..................... A Walker whled seat/crutch ............ ............ ............ ............ ............ att. E0146..................... A Folding walker wheels w ............ ............ ............ ............ ............ seat. E0147..................... A Walker variable wheel ............ ............ ............ ............ ............ resist. E0148..................... A Heavyduty walker no wheels. ............ ............ ............ ............ ............ E0149..................... A Heavy duty wheeled walker.. ............ ............ ............ ............ ............ E0153..................... A Forearm crutch platform ............ ............ ............ ............ ............ atta. E0154..................... A Walker platform attachment. ............ ............ ............ ............ ............ E0155..................... A Walker wheel ............ ............ ............ ............ ............ attachment,pair. E0156..................... A Walker seat attachment..... ............ ............ ............ ............ ............ E0157..................... A Walker crutch attachment... ............ ............ ............ ............ ............ E0158..................... A Walker leg extenders set ............ ............ ............ ............ ............ of4. E0159..................... A Brake for wheeled walker... ............ ............ ............ ............ ............ E0160..................... A Sitz type bath or equipment ............ ............ ............ ............ ............ E0161..................... A Sitz bath/equipment w/ ............ ............ ............ ............ ............ faucet. E0162..................... A Sitz bath chair............ ............ ............ ............ ............ ............ E0163..................... A Commode chair stationry fxd ............ ............ ............ ............ ............ E0164..................... A Commode chair mobile fixed ............ ............ ............ ............ ............ a. E0165..................... A Commode chair stationry det ............ ............ ............ ............ ............ E0166..................... A Commode chair mobile detach ............ ............ ............ ............ ............ E0167..................... A Commode chair pail or pan.. ............ ............ ............ ............ ............ E0168..................... A Heavyduty/wide commode ............ ............ ............ ............ ............ chair. E0169..................... A Seatlift incorp ............ ............ ............ ............ ............ commodechair. E0175..................... A Commode chair foot rest.... ............ ............ ............ ............ ............ E0176..................... A Air pressre pad/cushion ............ ............ ............ ............ ............ nonp. E0177..................... A Water press pad/cushion ............ ............ ............ ............ ............ nonp. E0178..................... A Gel pressre pad/cushion ............ ............ ............ ............ ............ nonp. E0179..................... A Dry pressre pad/cushion ............ ............ ............ ............ ............ nonp. E0180..................... A Press pad alternating w ............ ............ ............ ............ ............ pump. E0181..................... A Press pad alternating w/ ............ ............ ............ ............ ............ pum. E0182..................... A Pressure pad alternating ............ ............ ............ ............ ............ pum. E0184..................... A Dry pressure mattress...... ............ ............ ............ ............ ............ E0185..................... A Gel pressure mattress pad.. ............ ............ ............ ............ ............ E0186..................... A Air pressure mattress...... ............ ............ ............ ............ ............ E0187..................... A Water pressure mattress.... ............ ............ ............ ............ ............ E0188..................... E Synthetic sheepskin pad.... ............ ............ ............ ............ ............ E0189..................... E Lambswool sheepskin pad.... ............ ............ ............ ............ ............ E0191..................... A Protector heel or elbow.... ............ ............ ............ ............ ............ E0192..................... A Pad wheelchr low press/ ............ ............ ............ ............ ............ posit. [[Page 52301]] E0193..................... A Powered air flotation bed.. ............ ............ ............ ............ ............ E0194..................... A Air fluidized bed.......... ............ ............ ............ ............ ............ E0196..................... A Gel pressure mattress...... ............ ............ ............ ............ ............ E0197..................... A Air pressure pad for ............ ............ ............ ............ ............ mattres. E0198..................... A Water pressure pad for ............ ............ ............ ............ ............ mattr. E0199..................... A Dry pressure pad for ............ ............ ............ ............ ............ mattres. E0200..................... A Heat lamp without stand.... ............ ............ ............ ............ ............ E0202..................... A Phototherapy light w/ ............ ............ ............ ............ ............ photom. E0205..................... A Heat lamp with stand....... ............ ............ ............ ............ ............ E0210..................... A Electric heat pad standard. ............ ............ ............ ........
