Page 96

Effective Date:

Approval Date: 96

D3470 Intentional reimplantation D3910 Surgical procedure for isolation of tooth D3950 Canal preparation D4230 Anatomical crown exposure 4 or more teeth D4231 Anatomical crown exposure 1-3 teeth D4320 Splinting intracoronal D4321 Splinting extracoronal D5810 Complete denture upper (interim) D5811 Complete denture lower (interim) D5820 Partial denture upper (interim) D5821 Partial denture lower (interim) D5862 Precision Attachment D5867 Replacement Precision Attachment D5986 Fluoride Gel Carrier D6057 Custom abutment D6253 Provisional Pontic D6920 Connector bar D6940 Stress breaker D6950 Precision Attachment D6975 Coping – metal D9210 Local Anesthesia not in conjunction with operative or surgical procedures D9211 Regional Block Anesthesia D9212 Trigeminal Division Block Anesthesia D9215 Local Anesthesia D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9248 Non-intravenous conscious sedation D9410 House / extended care facility call D9420 Hospital Call D9450 Case presentation D9630 Other drugs and or medicaments D9920 Behavior Management D9941 Fabrication of athletic mouthguard D9950 Occlusion analysis - mounted case D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9970 Enamel microabrasion D9971 Odontoplasty 1-2 teeth D9972 External bleaching - per arch D9973 External bleaching - per tooth D9974 Internal bleaching - per tooth D0310 Sialography D0472 Oral Pathology lab D0473 Oral Pathology lab D0474 Oral Pathology lab D0480 Oral Pathology lab D0502 Oral Pathology lab D5911 Facial Moulage (sectional) D5912 Facial Moulage (complete)