Download Survey of Charges–Oral Surgery

Professional Relations Dept.
601 S.W. Second Avenue
Portland, OR 97204-3156
503-243-3965 (fax)
www.odscompanies.com
Survey of Charges–Oral Surgery
This survey represents the most frequently billed procedure codes.
DIAGNOSTIC
D7280 $_________
CLINIC ORAL EVALUATIONS
D0140 $_________
D0150 $_________
D0484 $_________
D0485 $_________
Limited oral evaluation
Comprehensive oral evaluation
Consultation on slides prepared elsewhere
Consultation, including preparation of
slides from biopsy material supplied by
referring source
RADIOGRAPHS
D0210 $_________
D0330 $_________
$_________
$_________
$_________
D7285 $_________
D7286 $_________
D7310 $_________
D7311 $_________
D7320 $_________
Intraoral-complete series
Panoramic film
Additional codes
_____
_____
_____
D7283 $_________
______________________________
______________________________
______________________________
D7321 $_________
D7471 $_________
D7510 $_________
D7511 $_________
ORAL SURGERY
D7953 $_________
EXTRACTIONS (INCLUDES LOCAL ANESTHESIA,
SUTURING, IF NEEDED, AND ROUTINE POSTOPERATIVE CARE
D7960 $_________
D7111 $_________
D7140 $_________
Coronal remnants-deciduous tooth
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
SURGICAL EXTRACTIONS (INCLUDES LOCAL ANESTHESIA, SUTURING IF NEEDED, AND ROUTINE
POSTOPERATIVE CARE)
D7210 $_________
D7220 $_________
D7230 $_________
D7240 $_________
D7250 $_________
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and
removal of bone and/or section of tooth
Removal of impacted tooth-soft tissue
Removal of impacted tooth-partially
bony
Removal of impacted tooth-completely
bony
Surgical removal of residual tooth roots
(cutting procedures)
OTHER SURGICAL PROCEDURES
D7260 $_________
D7270 $_________
(1/13/05)
Oroantral fistula closure
Tooth reimplantation and/or stabilization
of accidentally evulsed or displaced
tooth and/or alveolus
D7963 $_________
D7970 $_________
Surgical exposure of impacted or
unerupted tooth for orthodontic reasons
(including orthodontic attachments)
Placement of device to facilitate eruption
of impacted tooth
Biopsy of oral tissue-hard (bone)
Biopsy of oral tissue-soft (all others)
Alveoloplasty in conjunction with
extractions -per quadrant
Alveoloplasty in conjunction with
extractions - one to three teeth or tooth
spaces
Alveoloplasty not in conjunction with
extractions-per quadrant
Alveoloplasty not in conjunction with
extractions -one to three teeth or tooth
spaces
Removal of exostosis-per site
Incision and drainage of abscess-intraoral soft tissue
Incision and drainage of abcess-intraoral
soft tissue
Bone replacement graft for ridge preservation-per site
Frenulectomy (frenectomy or frenotomy)-separate procedure
Frenuloplasty
Excision of pericoronal gingiva
Additional codes
_____
_____
_____
$_________
$_________
$_________
______________________________
______________________________
______________________________
ADJUNCTIVE GENERAL SERVICES
D9110 $_________
D9220 $_________
D9241 $_________
Palliative (emergency) treatment of dental pain-minor procedure
General anesthesia-first 30 minutes
Intravenous sedation/analgesia-first 30
minutes
Additional codes
_____
_____
_____
$_________
$_________
$_________
______________________________
______________________________
______________________________
*** If you practice at more than one office, you must submit fee filings for each location.***
Please print or type
Name ________________________________________
Office Address ________________________________
TIN #________________________________________
License Number ____________________________
City ________________
Zip ______________
Telephone ________________________________
Fax #
I certify that these are the fees I intend to charge my patients. I agree these fees and any future fees will not be used
on treatment forms until I have received notification from ODS of acceptance of all fees listed on this form.
Signature_________________________________ Date_____________ Specialty________________________