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TAGLE OF ALLOWANCES APPENDIX B ~?*L This is not a !ee schedule. The amounts listed in this Table are allowances which are made toward usual and customary fees. Usual and customary fees vary with ~ndivldual dental practices. I~ Prec. ~ Pr~edu~ (B/R mflns By Repo~) No. Pr~edum (BIR ~m ~ ~) V~ AND DIAGNOSTIC (~0-199) ASide CYSTS AND NEOPLASMS: 020 Office vi~ for treatment and ob~mation of 260 Ifltrmoralincision and drainage of ab~e~ ...... 10.00 injuries to ~eeth and suppoKing ~ructure, other 261 Extra-ora4 incision and draifl~e of ab~ ..... ~ S.00 or B/R ~han for routine operative proce~ur~ (Regul~r 262 Excision per(coronal gingiva ............... 10.00 office houm) ...................... 4.00 263 Sialolithotomy: removal o~ ml~a~ calculus, 030 ~ofe~onal visi~ after houm (Defltis~ may elect orally ........................... 33.00 payment on basis of m~ices rendered or visi~ 264 SialolithGtomy: mmowl of ~liva~ ~lculu~ extra- which~r is greater) ................. 10.00 orally ........................... 100.00 ~ Special con~ttBtion (by speciali~ for ca~ prm 265 CIo~re of ~l~a~ fibula ................. G0.00 ~ntatiofl when diagnomic procedures have been 26G Dilation of ~liva~ duct ................. p~ormed by general denti~) .......... ~0.00 Z70 tie.cOon of benign tumor of soft ti~e (2.S cm ~ Prophylaxis - children to age 14 ........... 6.00 or larger) ......................... 0~ Prophybxis - to include ~aliflg and polishing ... 9.00 ~71 Reaction of malignant tumor ............. ~1 Topi~l application of sodium fluoride (one treat- 275 Trafl~lafltatiofl of ~oo~h or Tooth bud ........ 70.00 merit including prophylaxis under age 4) ..... 12.00 276 Removal of foreign body from bone (independent 062 Top,al application of stannous fluoride (one procedure) ......................... B/R treatment including prophyl~x~s - payment 277 Radical r~ction of bone for tumor with bona limited to once each year to age 18) ....... ~4.00 9rah ............................. B/R 080 Emergency tmatmen~ - parliative per visi~ ..... 5.00 278 MGxilla~ sinusotomy for removal of tooth fr~ merit o~ foreign body ................. 6S.~ or B/R 279 Cloture of oral fistula of maxilla~ sinus ....... 40.~ or B/R FNm ~ include ~am and diagn~ 280 Excision of cyst, small .................. 25.~ or B/R 110 Single film .......................... 4.00 281 Excision of cyst, large (2.~ cm or larger) ....... 75.00 or B/R 111 A~ditional, up TO 12 films, each ............ 1.00 282 Sequemrectomy far o~eamyelitis or bona 112 Entire ~enture mries, including examination corn supe~icial ......................... 20.00 or 8/R si~ing of at lea~ 14 films (bi~e wings if 285 Condylectomy of temporomandibularjoint ..... ~0.~ n~) ........................ 17.00 289 Meni~emomy of ~emporomandibul~r joint ..... 113 In~rmoml, occlu~l view, maxillary or mafldi~ ular, each ......................... 4.00 MISCELLANEOUS: ~14 Superior or inferior maxiHa~, extra oral, one 290 Inci~on and ~moval of foreign body f~m ~ film ............................ 10.00 timue ............................ 10.~ or B/R TIS Superior o~ inferior maxilla~, extra oral, ~o 291 Frenectomy ......................... 25.00 films ............................ 15.00 292 Suture of soft timue wound or inju~ ......... 6/R 116 Bite wing fil~, including examination 293 Crown exposure for orthodontia ............ 15.00 2 films ........................... 5.00 294 Injection of ~lerosing agent into temporamandi~ 4 films ........................... 7.00 ular join~ ......................... ~.00 Additional films, each ................ 1.D0 295 Treatment trigemin~l neuralgia by injection into 1~ Biop~ of oral tJ~e .................... 8.00 ~ond and third d~isions .............. ~.00 ~eo ~cro~o~= ~x=m~..O.. ................. ~.00 DRUGS (3~-3~) O~L SURGERY {2~2~) 3o0 nru~ .d=~.~,~, ,v ~e.t~ - ,cd o. cc... '*"AIl ho~ital co~s are the r~ponsibility of the patient. ANESTHESIA (~9) COS will allow for the procedures flsted ~n thb schedule. 400 Ane~hesia: General .................... 15.00 Additional f~ ch~ed by the denti~ for peHorming procedures in the ho~ital ,re the responsibility of the PERIODONTICS (4504~) ~tJent. Specbl consultation (by speciali~ for cam p~ntm tion when prelimina~ diagno~ic pracedu~ "HCOS allo~nces for General (films, models, mc.) h~e been peHormed by An~h~ia ........................... See Procedure ~400 general denti~) .................... ~ Proc~u~ ~040 Any ~dher char~s for ane~hetics, anestheO~s, or a~h~ologJ~s am the m~onsibilit? of the patient Prophylaxis (includes ~aling and policing)... S~ Procedure ~050 451 Emergency treatment (periodontal ab~e~ ~ute 'HAIlo~ncm for procedures not listed in this ~hedure per(adohr(tis, etc.) ..................... 10.00 will be p=id at the rate listed ~n the Relative Value 452 ~bgingival curret~e, root planing per quad~nt Study as approved by the Americ=n Society of Oral (not prophylaxis) .................... 12.00 ~r~on~ Con~lt~ian (by speciali~ for cam pr~n~m 453 Correction of occlusion per quadrant ......... 12.00 tion when diagnomJc procedures h~e been pedormed 472 Gingivectomy per quadrant (including po~ by ~ne~l denti~) ....................... See Procedure ~0 visits) ........................... 50.~ 473 Gingivectam~, o~ous or muco-ging~al EXTRACTIONS: per quadrant {i~cludes po~ surgical visits) ... 80.00 2~ Uncompli~ted single, including routine po~ oper- 474 Gingivectomy, tre~tmen{ per tooth (f~r than ~x et(ye visits ......................... 8.00 teeth) .......................... 10.00 201 Each additional tooth, including routine po~ oper- =t~, ~s~ts ......................... ~.oo ENDODONTICS 202 ~rgical removal of erupted teeth ........... B/R Special consultation (by ~eciali~ for ~m p~ntm 220 Po~-oper=tive visit (sutur~ and complications)... 3.00 tion when diagnostic procedur~ have b~n performed by general denti~) .......... ~e Proc~um ~040 IMPACTED TEETH (e~lo~ fi(m): 500 Pulp cappin9 ........................ 6.00 230 Rem~al of tooth (soil timue) ............. 17.00 501 Therapeutic pulpotomy (in addition to re.oration, 231 Removal of tooth (ps~iaily bony) ........... 25.00 per treatment) ...................... 6.00 ~2 Rem~al of tooth (completely bony) ......... 40.00 or B/R 502 Vital pulpotomy ....................... 12.00 503 Remineralization (Caoh, tempora~ r~oration) ALVEOLAR OR GINGIVAL RECONSTRUCTION: per tooth ......................... 10.00 250 Alveol~tomy (edemulous) per quadrant ....... 25.00 252 Alveolectomy (in addition to removal of teeth) ROOT CANALS: per quadrant ....................... 10.00 510 Culturing canal ....................... 7.00 2~ Al~opi~ty with ridge extension, per arch ..... 42.00 511 Single rooted canal tooth therapy ........... 45.00 257 Removal of palate; toms ................. 35.00 or 8IR 512 8(-rooted tooth canal therapy .............. 60.00 2~ Removal of mandibular tori per quadrant ..... 35.00 513 Tn-rooted tooth canaJ themDv ............. 75.00 ~ Exci~on of by,er pla~ic ti~e per arch ....... 32.00 530 Apicoectomy (including filling of root canal) .... 50.00