Professional Relations Dept. 601 S.W. Second Avenue Portland, OR 97204-3156 503-243-3965 (fax) www.odscompanies.com Survey of Charges–Endodontics This survey represents the most frequently billed procedure codes.

DIAGNOSTIC _____ $______CLINIC ORAL EVALUATIONS _____ $______

D0140 $______Limited oral evaluation ENDODONTIC THERAPY D0150 $______Comprehensive oral evaluation (INCLUDES ALL CLINICAL PROCEDURES, I.E. EXTIR- D0484 $______Consultation on slides prepared else- PATION, TREATMENTS, , X-RAYS, where CULTURES & FOLLOW-UP CARE) D0485 $______Consultation, including preparation of slides from biopsy material supplied by D3310 $______Anterior (excluding final restoration) referring source D3320 $______Bicuspid (excluding final restoration) D3330 $______Molar (excluding final restoration) Additional codes D3332 $______Incomplete endodontic therapy _____ $______D3333 $______Internal root repair of perforation defects _____ $______D3346 $______Retreatment of previous _____ $______therapy-anterior D3347 $______Retreatment of previous root canal RADIOGRAPHS therapy-bicuspid D3348 $______Retreatment of previous root canal D0210 $______Intraoral-complete series therapy-molar D0220 $______Intraoral-periapical first film D0230 $______Intraoral-periapical each additional film Additional codes D0240 $______Intraoral-occlusal film _____ $______D0330 $______Panoramic film _____ $______$______Additional codes _____ $______APEXIFICATION/RECALCIFICATION _____ $______D3351 $______Apexification/recalcification- initial visit _____ $______D3352 $______Apexification/recalcification- interim medication replacement D3353 $______Apexification/recalcification- final visit D3110 $______Pulp cap-direct (excluding final restora- tion) /PERIRADICULAR SER- Additional codes _____ $______VICES _____ $______D3410 $______Apicoectomy/- _____ $______anterior D3421 $______Apicoectomy/periradicular surgery- bicuspid (first root) D3425 $______Apicoectomy/periradicular surgery- molar (first root) D3220 $______Therapeutic pulpotomy (excluding final D3426 $______Apicoectomy/periradicular surgery (each restoration)-removal of pulp coronal to additional root) the dentinocemental junction and appli- D3430 $______Retrograde filling-per root cation of medicament D3450 $______Root amputation-per root D3221 $______Gross pulpal debridement, primary and permanent teeth Additional codes _____ $______Additional codes _____ $______$______$______

(Rev. 01/12/05) ADJUNCTIVE GENERAL SERVICES D3950 $______Canal preparation and fitting of pre- D9110 $______Palliative (emergency) treatment of den- formed dowel or post tal pain D9220 $______Deep sedation/general anesthesia-first 30 Additional codes minutes _____ $______D9221 $______Deep sedation/general anesthesia-each _____ $______additional 15 minutes _____ $______

OTHER ENDODONTIC SERVICES D3920 $______Hemisection (including any root removal), not including root canal therapy

*** If you practice at more than one office, you must submit fee filings for each location.***

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Name______License Number ______Office Address ______City ______Zip ______TIN #______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______

(01/12/05)