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PROCEDURE NUMBERS APPENDIX B Proc. Proc. No. Procedures No. Procedures VISITS (020-099) 265 Closure of salivary fistula 020 Office visit; to include observation and/or treatment of 266 Dilation of salivary duct injuries and observation of patient when no other services 269 Resection of benign tumor, to 1.25 cm are provided (regular office hours) 270 Resection of benign tumor, larger than 1.25 cm 030 Professional visit; after hours; in addition to service 271 Resection of a malignant rumor provided 273 Reimplantation and/or stabilization of accidentally 040 Special consultation (by specialist only when patient evulsed or displaced teeth and/or alveolus not treated by consultant) 275 Transplant of tooth or tooth bud 049 Prophylaxis-children to age 14 276 Removal of foreign body from bone (independent pro- 050 Prophylaxis-treatment to include scaling of unattached cedure) tooth surfaces, and polishing--adult 277 Radical resection of bone for tumor with bone graft 061 Topical application of fluoride including prophylaxis- 278 Maxillary sinusotomy for removal of tooth fragment or to age 14 foreign body 062 Topical application of fluoride including prophylaxis- 279 Closure of oral fistula of maxillary sinus adult 280 Excision of cyst, to 1.25 cm 080 Emergency treatment-palliative, per visit 281 Excision of cyst, larger than 1.25 cm 282 Sequestrectomy for osteomyelitis or abscess, superficial DIAGNOSTIC (100-199) 285 Condylectomy of temporomandibular joint Film procedures include exam and diagnosis. 289 Meniscectomy of temporomandibular joint 110 Single film 290 Incision and removal of foreign body from soft tissue 111 Additionat, up to 12 films 291 Frenectomy 112 Entire denture series consisting of at least 14 films 292 Suture of softtissuewoundorinjury (including bite-wings, if necessary) 293 Crown exposure with attachment placed for orthodontic 113 Intra-oral, occlusal view, maxillary or mandibular, each traction 114 Lateral jaw, lateral or P/A Head, one film 294 Injection of temporomandibu[ar joint 115 Lateral jaw, laterat or P/A Head, two films 295 Treatment tr[geminal neuralgia by injection into second 116 Bite-wing films, 2 films and third divisions 117 Bite-wing films, 4 films 296 Crown exposure to aid eruption 125 Panographic-type film only 126 Cephalometric film only DRUGS (300-399) 127 Cephalometric film, each additional 300 Drugs administered by dentist--injectable therapeutic 128 Temporomandibular articulation x-ray survey (includes all necessary films) ANESTHESIA (400-449) 129 Orthodontic x-ray survey (entire denture series and all 400 Anesthesia, general, one-half hour (office administration) other films, including cephalometric and photos) 401 Anesthesia, general, each additional 15 minutes (office 150 Biopsy of oral tissue, incisional administration) 160 Microscopic examination of biopsied material PERIODONTICS (450-499) ORAL SURGERY (200-299) 450 Recall following active surgical periodontal treatment General Anesthes/a-See Procedure #400. after four months (includes any prophylaxis, root plan- ing, and curettage as necessary) EXTRACTIONS 451 Emergency treatment (periodontal abscess, acute perio- Includes local anesthesia and rout/ne postoperative visits, dontitis, etc.) 200 Uncomplicated-single 452 Subgingival curettage and root planing per quadrant (not 201 Each additional uncomplicated tooth (same date of prophylaxis and scaling--see Procedure #050~ service) 453 Correction of occ[usion--per quadrant (minor spot grind- 202 Surgical removal of an erupted tooth lng, not equilibration) 203 Removal of residual root totally covered by bone 472 Gingivectomy per quadrant (including post-surgical visits) 220 Post-operative visit-complications (i.e. osteitis) 473 Gingivectomy, osseous or muco-gingival surgery per 230 Removal of impacted tooth (soft tissue) quadrant (includes post-surgical visits) 231 Removal of impacted tooth (partially bony) 474 Gingivectomy, treatment per tooth (fewer than six teeth) 232 Removal of impacted tooth (completely bony) ALVEOLAR AND GINGIVAL RECONSTRUCTION ENDODONTICS (500-599) 250 A[veolectomy (edentulous), per quadrant 500 Direct pulp capping 252 Alveolectomy (in addition to removal of teeth), per 501 Therapeutic pulpotomy (in addition to restoration) per quadrant treatment 253 Reduction of tuberosity, unilateral 502 Vital Pulpotomy 255 Vestibuloplasty, submucosal resection (does not include 503 Indirect pulp capping (recalcification) including tempo- skin, bone or mucosal grafts) rary restoration 256 Alveoplasty with ridge extension (secondary epitheliali- ROOT CANAL THERAPY zation) 510 Culture canal 257 Removal of palatal torus 511 Single canal 258 Removal of mandibular tori, per quadrant 512 Two canais 259 Excision of hyper-p[astic tissue, per arch 513 Three canals CYSTS, NEOPLASMS. MISCELLANEOUS 514 Four canals 260 Intra-oral incision and drainage of abscess (soft tissue) 530 Apical Surgery inc/ud/ng filling of root canal and/or 261 Extra-oral incision and drainage of abscess retrograde therapy-single operation ~ 262 Excision pericoronal gingiva 531 Apicoectomy {separate procedure) 263 Sialolithotomy: removal of salivary calculus, intra-orally 532 Hemisection, root amputation 264 Sialolithotomy: removal of salivary calculus, extra-orally 534 Apexification, per visit