0150Comprehensive Oral Exam*Perio Only
0110Initial Oral Exam*MH Exam only to age 21
0120Periodic Oral Exam
9110Emergency Exam/Palliative Treatment
0210Full Mouth X-rays
0220Periapical-First
0230Periapical-Second
0272(2)Bite Wing X-rays
0274(4)Bite Wing X-rays
1110Prophy*14yr + up
1120Prophy - Child
1124Difficult Prophy
4910Perio Prophy
1203Fluoride Treatment*Through Age 17
21401-Surface Amalgam
21502-Surface Amalgam
21603-Surface Amalgam
21614+Surface Amalgam
23301-Surface Composite
23312-Surface Composite
23323-Surface Composite
23354+Surface Composite
7110Extraction
7120Extraction Additional
2954Post & Core
2951Pin
2750Crown-Porcelain fused to high noble gold
2751Crown
2920Re-cement Crown
2790Gold Crown Full Cast
5110Upper Denture
5120Lower Denture
5130Immediate Upper Denture
5140Immediate Lower Denture
5510Repair Base of Denture
5520Replace Tooth
5213Upper Partial Bilateral Valplast Upper
5214Partial bilateral Valplast Lower
5211Upper Partial
5212Lower Partial
5281Removable unilateral partial denture Valplast
5610Repair Base of Partial
5630Repair Broken Clasp
5640Replace Broken Tooth
5650Add Tooth
5710Reline Upper Denture
5711Reline Lower Denture
1351Sealants
9940Night Guard
6930Re-cement Bridge
2940Sedative Filling/IRM
1510Space Maintainer
4260Osseous Surgery Per Qd
4341Scale & Root Plane Per QD