Removal of Fixed Periodontal Splints

One unit of time

Each additional unit of time

ROOT PLANING, PERIODONTAL

Root Planing

One unit of time

Two units of time

Three units of time

Four units of time

Five units of time

Six units of time

1/2 unit of time

Each additional unit over six

CHEMOTHERAPEUTIC and/or ANTIMICROBIAL AGENTS

Chemotherapeutic and/or Antimicrobial Agents, Topical Application

One unit of time

Each additional unit of time

Chemotherapeutic and/or antimicrobial therapy, intra-sulcular application

One unit of time

Each additional unit of time

PERIODONTAL SERVICES, MISCELLANEOUS

PERIODONTAL RE-EVALUATION/EVALUATION

Note: This follow-up service applies to the evaluation of ongoing periodontal treatment or to a post-
surgical re-evaluation performed more than one (1) month after surgery, or if performed by another
practitioner

One unit of time

Two units

Each additional unit over two

SOFT TISSUE PROSTHESIS

Gingival Mask
(Removable appliance to mask unaesthetic embrasures Note: For extensive gingival prostheses
required after maxilla facial surgery see sub-classification 57300 Prosthesis Maxillofacial, other, code
57372 Gingival Prosthesis)

PROSTHODONTICS - REMOVABLE

Special Aesthetic and anatomical considerations involving additional chair time and/or responsibility
may require an increase over the basic fee.
Special aesthetic and functional laboratory costs beyond normal laboratory charges will require an
increase over the basic fee.
EXAMINATION, DIAGNOSIS AND TREATMENT PLAN - Refer to Diagnostic Services, separate fee.

DENTURE COMPLETE

(includes: impressions, initial and final jaw relation records, try-in evaluation and check records,
insertion and adjustments, including three month post insertion care)

DENTURE COMPLETE, STANDARD

Maxillary

Mandibular

Liners, Processed, Resilient, in addition to above

DENTURES, COMPLETE, COMPLEX

Maxillary

Mandibular

Liners, Processed, Resilient in addition to above

DENTURES, SURGICAL, STANDARD, (IMMEDIATE)

includes first tissue conditioner, but not a processed reline

Maxillary

Mandibular