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Proc. Proc. '-
<br />No. Procedures No. Procedures .~
<br />
<br />RESTORATIVE DENTISTRY (600-679) DENTURES
<br />600 Amalgam restoration-primary teeth, one surface Procedures relating to dentures, partial dentures and relines
<br />601 Amalgam restoration--primary teeth, two surfaces include adjustments for six-month period following installation.
<br />602 Amalgam restoration--primary teeth, three or more sur- Such procedures do not include Specialized techniques involving
<br /> faces precision dentures, per$onalization or characterizations.
<br />611 Amalgam restoration--permanent teeth, one surface 700 Complete upper denture
<br />612 Amalgam restoration--permanent teeth, two surfaces 701 Complete lower denture
<br />613 Amalgam restoration-permanent teeth, three surfaces 702 Partial acrylic upper or lower, cast metal clasps--base
<br />614 Amalgam restoration--permanent teeth, four or more 703 Partial upper or ~ower with chrome cobalt alloy palatal
<br /> surfaces or lingual bar and acrylic saddles-base
<br />635 6old restoration, one surface 704 Teeth and c~asps-extra per unit (for 702, 703)
<br />636 Gold restoration, two surfaces 705 Simple stress breakers-extra
<br />637 Gold restoration, three or more surfaces 706 Anterior stayplate (temporary)--base
<br />638 Onlay, in addition to inlay per tooth--extra 716 Teeth and clasps extra per unit (for 706)
<br />640 Silicate cement restoration 720 Denture adjustment
<br />645 Plastic or composite restoration 721 Office reline--(cold cure)-acrylic
<br />646 Plastic or composite restoration, proximal surface involv- 722 Denture reline (laboratory)
<br /> lng incisal angle 723 Special tissue conditioning, per denture-maximum 2 per
<br />648 Pin retention, per tooth, additional (when necessary and denture
<br /> final restoration is amalgam, plastic or composite) 724 Denture duplication (jump case), per denture
<br />
<br /> REPAIRS, FULL DENTURES
<br />CROWNS 790 Broken full denture (no teeth involved)
<br />650 Crown, plastic (permanent, processed) 791 Replace missing or broken teeth, each
<br />651 Plastic with metal
<br />652 Porcelain REPAIRS, PARTIAL DENTURES
<br />653 Porcelain with metal Adding teeth to partial denture to replace extracted natural teeth:
<br />
<br />660 Full cast, metal 793 First tooth, or clasp
<br />663 3/4 metal 794 First tooth with clasp
<br />667 Crown build-up. Procedure is included under crowns 795 Each additional tooth, or clasp
<br /> (see above) except in the exceptional instance where 796 Partial denture repairs, other than 793, 794 or 795
<br />
<br /> extensive build-up is needed (by written report and sub- (based on time and laboratory charges)
<br />
<br /> stantiating radiographic support). Amalgam or plastic
<br /> build-up, includin,~ pins. SPACE MAINTAINERS, MODELS (800-832)
<br />670 Stainless steel (primary) The following procedures include all adjustments within six
<br />671 Stainless steel (permanent) months following installation.
<br />672 Preformed dowel post (endodonticelly treated tooth), 801 Removable, plastic
<br /> commercial 802 Additional clasps
<br />673 Cast post with core or coping (endodontically treated 803 Diagnostic study models
<br /> tooth), office or laboratory castings 800 Fixed, unilateral band type
<br /> 811 Fixed, stainless steel crown type
<br />RESTORATIVE DENTISTRY UNDER 812 Fixed, lingual or palatal bar type
<br />GENERAL ANESTHESIA 832 Fixed or removable inhibiting appliance to correct thumb-
<br />(Special cases only) (Handicapped Patients) sucking
<br />649 Long-term operative cases performed under General
<br /> Anesthesia on hourly basis:
<br /> -One hour duration from beginning to end FRACTURES & DISLOCATIONS (900-999)
<br /> Two and one-half hours, maximum 900 Treatment of simple fracture of the maxilla, open reduc-
<br /> -Three and one-half hours, maximum lion
<br /> -Four or more hours 901 Treatment of simple fracture of the maxilla, closed
<br /> The above includes all operative procedures, extractions, reduction
<br /> pulpotomies, necessary treatments, fluoride and oral pro- 902 Treatment of simple fracture of the mandible, open
<br /> phylaxis. Services of anesthesiologists are not included, reduction
<br /> 903 Treatment of simple fracture of the mandible, closed
<br /> reduction
<br />PROSTHETIC$ (680-799) 904 Treatment of compound or comminuted fracture of the
<br /> maxilla, closed reduction
<br />PONTICS 905 Treatment of compound or comminuted fracture of the
<br /> 680 Cast (sanitary), metal maxilla, open reduction
<br /> 681 Slotted facing (Steele's type) 906 Treatment of compound or comminuted fracture of the
<br /> 682 Slotted pontic (Truopontic type) mandible, closed reduction
<br /> 684 Pin facing 907 Treatment of compound or comminuted fracture of the
<br /> 692 Porcelain with metal mandible, open reduction
<br /> 693 Plastic with metal 910 Treatment of luxation (dislocation) of the mandible
<br /> REMOVABLE UNILATERAL (uncomplicated)
<br /> 683 1 piece casting, chrome cobalt alloy clasp attachment 911 Treatment of condular fracture, open reduction
<br /> (all types), per unit--including pontics 912 Treatment of condular fracture, closed reduction
<br />
<br /> RECEMENTATION 913 Reduction of dislocation of a temporomandibular joint
<br /> requiring general anesthesia
<br /> 685 Inlay (recementation) 915 Reduction of malar arch fracture
<br /> 686 Crown (recementation) 916 Reduction of malar complex fracture without wiring,
<br /> 687 Bridge (recementation) orbital floor exploration, or sinus packing
<br /> REPAIRS, CROWN & BRIDGE 917 Reduction of malar complex fracture with wiring, orbital
<br /> 690 Bridge repair-based on time and laboratory charges floor exploration, and/or sinus packing, and/or alloplasty
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