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No, Procedures (B/R means By Repest) No. Procedures (B/R mocha By R~est) Nlowaoce ~lowaoce 53! Apicoectomy (~pemte procedure) .......... 35.00 Allowances do not include final restoration 702 Partial ecrylic upper or lower with gold or chrome or nece~ary roent~enograms, cobalt alloy clasps - base .............. 75.00 712 Teeth and clasps - extra per unit ............ 5.00 RESTORATIVE DENTISTRY (6004~79) 7o3 Partial lower or upper with chrome cobalt alloy AMALGAM RESTORATIONS PRIMARY TEETH: lingual or palatal bar end acrylic saddles - ba~ , 150.00 600 Cavities involving one tooth surface .......... 6.00 704 Teeth and claspe - extra par unit ............ 5.00 601 Cavities involving two tooth surfaces ......... 9.00 705 Simple stra= breakers - extra ............. 14.00 602 Cavities involving three or more tooth surfaces... 12.00 706 Stayplate - base ...................... 30.00 AMALGAM RESTORATIONS PERMANENT TEETH: 716 Teeth and clasps - extra per unit ............ 3.00 611 Cavities involving one tooth surface .......... 8.00 720 Denture adjustment ..................... 4.00 612 Cavities involvir~g two tooth surfaces ......... 11.00 721 Office reline - cold cure - acrylic ........... 15.00 013 Cavities involving three or more tooth surfaces... 15.00 722 Denture reline ........................ 35.00 GOLD RESTORATIONS: 723 Special ti~ue conditioning, par denture, in addi- 635 One tooth surface ..................... 35.00 tier to reline - maximum 2 per denture ..... 15.00 636 Two tooth surfaces .................... 40.00 724 Denture duplication (jump case) per denture 55.00 637 Three or more tooth surfaces .............. 50.00 .... 638 Onlaye extra per tooth .................. 10.00 SILICATE, ACRYLIC, PLASTIC RESTORATIONS: REPAIRS, DENTURES, ACRYLIC: 640 Silicate cement filling ................... 9.00 790 Broken denture, repairing (no teeth involved) ... 12.00 645 Acrylic or plastic filling ................. 11.00 Replacing missing or broken teeth, each addi- tional ........................... 3.00 RESTORATIVE DENTISTRY UNDER GENERAL ANESTHESIA Adding teeth to partial denture to replace ex- (Special caess only) (Handicapped Patients) tracted natural teeth: 649 Long term operative cases performed under Gen- 793 First tooth .......................... 25.00 eral Aneathesia on hourly basis: 794 First tooth with clasp ................... 30.0~ - One hour duration from beginning to end .... 7E.00 795 Each additional tooth and clasp ............. 5.00 -Two and one half hours, maximum ........ 150.00 796 Partial denture repairs - bwod on time end - Three and one half hours, maximum ....... 175.00 laboratory charges ................... 0/R - Four or more hours ................. 200.00 The aPove includes all operative procedures, ex- nou$ fluoride end oral prophylaxis. Fees for th~o,ogi.s must be paid by patient. SPACE/V~AINTAINERS (800-899) AJIowances include ell adjustments ~thin fJx CROWNS: months following installation. 650 Acrylic ............................. 60.00 800 Fixed space maintainer (band type) .......... 35.00 051 Acrylic with metal ..................... 75.00 652 Porcelain ........................... 75.00 REMOVABLE ACRYLIC SPACE MAINTAINERB: 653 Porcelain with metal ................... 100.00 801 With steiflle~ steel round wire rest only ....... 40.00 660 Gold (full) ........................... 65.00 802 Stainle= steel clasps and/or activating wira~, in 663 ~ Gold ............................. 60.00 addition per wire or clasp ............... 5.00 670 Steinle= Steel (primary) ................. 17.00 803 Study models ........................ 5.00 671 Stainless Steel (permanent) ............... 20.00 810 Removable inhibiting appliance to correct thumb- 672 Gold dowel pin ....................... f0.00 sucking .......................... 40.00 CDS does not pay for facings on crowns, posterior 832 Fixed or cemented inhibiting appliance to correct to 2nd bicuspids (if placed, fees must be paid thumbsucking ...................... 40.00 by patient), Office visit for obsewation, adjustment and ecti~ PIIOSTHETI¢S (680-799} (Includes Fixed Bridges) ratio, per vi~t ..................... 4.OO PONTICS: 6~0 Cast gold (sanitary) .................... 40,00 681 Stesle's facing ........................ 45.00 682 Tru-Pnntic Type ...................... 55.00 FRACTURES AND DISLOCATIONS 632 Porcelain baked to gold .................. 80.00 693 Plastic preceded to gold ................. 55.00 900 Treatment of simple fraetura of the mexiga, open reduction ......................... 200.00 REMOVABLE (UNILATERAL BRIDGES): 901 Treatment of simple fracture of the maxilla, dosed 083 0aa piece casting, chrome cobalt alloy clasp et- reduction ......................... 125.00 tachment (all typ~) per unit -- including 902 Treatment of simple fracture of the mandible, pontics .......................... 20.00 open reduction ..................... 230.00 993 Treatment of simple fracture of the mandible, RECEMENTATION: closed reduction ..................... 125.00 685 Inlay ............................. 5.00 904 Treatment of compound or comminuted froctute 686 Crown ............................ 5.00 of the maxilla, closed reduction ........... 200.00 687 Bridp ............................ 10.00 905 Treatment of compound or comminuted fracture of the maxilla, open reduction ........... 300.00 REPAIRS, CROWN AND BRIDGES: 906 Treatment of compound or comminuted fracture 690 Repairs - based on time and laboratory chanje~. B/R of the mandible, closed reduction ......... 200.00 907 Treatment of compound or comminuted fracture of the mandible, open reduction .......... 300.00 DENTURES: 910 Treatment of luxation (dislocation) of the man- dible (uncomplicated) ................. 8.00 Dentures, per, ia1 dentur~ and reline allowances 911 Treatment of condylar fracture, open reduction .. 350.00 include adjustments for six month period follow- 912 Treatment of condylar fracture, clo~ed reduction . 150.00 lng installation. Fees for specialized techniques 913 Reduction of dislocation of temporomendibular involving p~ecision dentures, per~onalization or joint ............................ 35.00 characterization must be paid by patient. 915 Treatment of meier fracture, simple, clo~d reduc- tion ............................. 100.00 701 Complete mandibular denture ............ 155.00 dspm~ed, open reduction .............. 200.00