ࡱ> wv  \pBIMCKEE Ba==j;a8X@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1 Arial1$Arial"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_)"Yes";"Yes";"No""True";"True";"False""On";"On";"Off"],[$ -2]\ #,##0.00_);[Red]\([$ -2]\ #,##0.00\)                + ) , *    ) -@ @ -@ @ -@ @ - -@ @ -@ @ - +@ @ +@ @ + + -@ @ -@ @ (@ @ (@ @  `P Exhibit 2  ;C  ;" x DescriptionD0120D0140D0150D0210D0220D0230D0272D0321D0330D0340D0460D0470D1110D1510D2330D2331D2335D2750D2752D2791D2920D2950D2952D2954D2980D2970D3310D3320D3330D4260D4910D5110D5120D5211D5214D5510D5730D5751D6240D6242D6750D6752D7110D7120D7210D7880D8210D9110D9210D9220D9221D9230D9310D9430D9610D9940D9950D9951D9952n/aD0160D0170D0240D0250D0260D0270D0273D0274D0277D0290D0320D0350D0360D0362D0363.periodic oral evaluation - established patient)limited oral evaluation - problem focused:comprehensive oral evaluation - new or established patientCdetailed and extensive oral evaluation - problem focused, by reportXre-evaluation - limited, problem focused (established patient; not post-operative visit)1intraoral - complete series (including bitewings)!intraoral - periapical first film+intraoral - periapical each additional filmintraoral - occlusal filmextraoral - first film extraoral - each additional filmbitewing - single filmbitewings - two filmsbitewings - three filmsbitewings - four films!vertical bitewings - 7 to 8 films?posterior-anterior or lateral skull and facial bone survey film7temporomandibular joint arthrogram, including injection.other temporomandibular joint films, by reportpanoramic filmcephalometric filmoral/facial photographic images(cone beam ct - craniofacial data capture^cone beam - two-dimensional image reconstruction using existing data, includes multiple images`cone beam - three-dimensional image reconstruction using existing data, includes multiple imagespulp vitality testsdiagnostic castsD1120prophylaxis - adultprophylaxis - child%space maintainer - fixed - unilateral$space maintainer - fixed - bilateral)space maintainer - removable - unilateral(space maintainer - removable - bilateral"re-cementation of space maintainer!removal of fixed space maintainerD1515D1520D1525D1550D2140D2150D2160D2161+amalgam - one surface, primary or permanent,amalgam - two surfaces, primary or permanent.amalgam - three surfaces, primary or permanent5amalgam - four or more surfaces, primary or permanentD2332-resin-based composite - one surface, anterior.resin-based composite - two surfaces, anterior0resin-based composite - three surfaces, anteriorSresin-based composite - four or more surfaces or involving incisal angle (anterior)D2390D2391D2392D2393D2394%resin-based composite crown, anterior.resin-based composite - one surface, posterior/resin-based composite - two surfaces, posterior1resin-based composite - three surfaces, posterior8resin-based composite - four or more surfaces, posteriorD2410D2420D2430gold foil - one surfacegold foil - two surfacesgold foil - three surfacesD2510D2520D2530D2542D2543D2544D2610D2620D2630D2642D2643D2644D2650D2651D2652D2662D2663D2664D2710D2712D2720D2721D2722D2740inlay - metallic - one surfaceinlay - metallic - two surfaces)inlay - metallic - three or more surfacesonlay - metallic-two surfacesonlay - metallic-three surfaces&onlay - metallic-four or more surfaces'inlay - porcelain/ceramic - one surface(inlay - porcelain/ceramic - two surfaces2inlay - porcelain/ceramic - three or more surfaces(onlay - porcelain/ceramic - two surfaces*onlay - porcelain/ceramic - three surfaces1onlay - porcelain/ceramic - four or more surfaces+inlay - resin-based composite - one surface,inlay - resin-based composite - two surfaces6inlay - resin-based composite - three or more surfaces,onlay - resin-based composite - two surfaces.onlay - resin-based composite - three surfaces5onlay - resin-based composite - four or more surfaces(crown - resin-based composite (indirect),crown - 3/4 resin-based composite (indirect)#crown - resin with high noble metal+crown - resin with predominantly base metalcrown - resin with noble metal#crown - porcelain/ceramic substrate+crown - porcelain fused to high noble metalD27513crown - porcelain fused to predominantly base metal&crown - porcelain fused to noble metalD2780!crown - 3/4 cast high noble metalD2781)crown - 3/4 cast predominantly base metalD2782crown - 3/4 cast noble metalD2783crown - 3/4 porcelain/ceramicD2790"crown - full cast high noble metal*crown - full cast predominantly base metalD2792crown - full cast noble metalD2794crown - titaniumD2799provisional crownD29106recement inlay, onlay, or partial coverage restorationD2915,recement cast or prefabricated post and corerecement crownD29303prefabricated stainless steel crown - primary toothD29315prefabricated stainless steel crown - permanent toothD2932prefabricated resin crownD29335prefabricated stainless steel crown with resin windowD2934Cprefabricated esthetic coated stainless steel crown - primary toothD2940protective restorationD29515pin retention - per tooth, in addition to restorationD29537each additional indirectly fabricated post - same tooth core buildup, including any pins9post and core in addition to crown, indirectly fabricated0prefabricated post and core in addition to crownD29559post removal (not in conjunction with endodontic therapy)D2957/each additional prefabricated post - same toothD2960*labial veneer (resin laminate) - chairsideD2961+labial veneer (resin laminate) - laboratoryD2962/labial veneer (porcelain laminate) - laboratoryD2971Uadditional procedures to construct new crown under existing partial denture frameworkD2975coping!temporary crown (fractured tooth)crown repair, by report@endodontic therapy, anterior tooth (excluding final restoration)@endodontic therapy, bicuspid tooth (excluding final restoration)7endodontic therapy, molar (excluding final restoration)wosseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrantperiodontal maintenanceD5130D5140complete denture - maxillarycomplete denture - mandibularimmediate denture - maxillaryimmediate denture - mandibularD5212D5213[maxillary partial denture - resin base (including any conventional clasps, rests and teeth)\mandibular partial denture - resin base (including any conventional clasps, rests and teeth)~maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)#repair broken complete denture baseD5520D5610D5620D5630D5640D5650D5660D5670D5671D5710D5711D5720?replace missing or broken teeth - complete denture (each tooth)repair resin denture baserepair cast frameworkrepair or replace broken clasp replace broken teeth - per tooth%add tooth to existing partial denture%add clasp to existing partial dentureAreplace all teeth and acrylic on cast metal framework (maxillary)Breplace all teeth and acrylic on cast metal framework (mandibular)!rebase complete maxillary denture"rebase complete mandibular denture rebase maxillary partial dentureD5721!rebase mandibular partial dentureD5731.reline complete mandibular denture (chairside)D5740,reline maxillary partial denture (chairside)D5741-reline mandibular partial denture (chairside)D5750.reline complete maxillary denture (laboratory)-reline complete maxillary denture (chairside)/reline complete mandibular denture (laboratory)D5760-reline maxillary partial denture (laboratory)D5761.reline mandibular partial denture (laboratory)D5810$interim complete denture (maxillary)D5811%interim complete denture (mandibular)D5820#interim partial denture (maxillary)D5821$interim partial denture (mandi< bular)D5850tissue conditioning, maxillaryD5851tissue conditioning, mandibularD5860!overdenture - complete, by reportD5861 overdenture - partial, by reportD5862precision attachment, by reportD5867dreplacement of replaceable part of semi-precision or precision attachment (male or female component)D5875>modification of removable prosthesis following implant surgeryD5937D5951)trismus appliance (not for TMD treatment) feeding aidD5982D5988surgical stentsurgical splintD6010D6012D6040D6050D6053D60545surgical placement of implant body: endosteal implantYsurgical placement of interim implant body for transitional prosthesis: endosteal implant$surgical placement: eposteal implant'surgical placement: transosteal implantKimplant/abutment supported removable denture for completely edentulous archJimplant/abutment supported removable denture for partially edentulous archD60558connecting bar - implant supported or abutment supportedD6056D6057D6058D6059+prefabricated abutment - includes placement$custom abutment - includes placement*abutment supported porcelain/ceramic crownDabutment supported porcelain fused to metal crown (high noble metal)D6060D6061D6062D6063D6064Labutment supported porcelain fused to metal crown (predominantly base metal)?abutment supported porcelain fused to metal crown (noble metal)6abutment supported cast metal crown (high noble metal)>abutment supported cast metal crown (predominantly base metal)1abutment supported cast metal crown (noble metal)D6065D6066D6067D6068D6069)implant supported porcelain/ceramic crown]implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)Jimplant supported metal crown (titanium, titanium alloy, high noble metal)5abutment supported retainer for porcelain/ceramic FPDOabutment supported retainer for porcelain fused to metal FPD (high noble metal)D6070D6071D6072D6073D6074Wabutment supported retainer for porcelain fused to metal FPD (predominantly base metal)Jabutment supported retainer for porcelain fused to metal FPD (noble metal)Aabutment supported retainer for cast metal FPD (high noble metal)Iabutment supported retainer for cast metal FPD (predominantly base metal)<abutment supported retainer for cast metal FPD (noble metal)D6075D6076D6077D6078D6079*implant supported retainer for ceramic FPDkimplant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)]implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)Gimplant/abutment supported fixed denture for completely edentulous archFimplant/abutment supported fixed denture for partially edentulous archD6080D6090D6091D6092D6093implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis.repair implant supported prosthesis, by reportreplacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment)recement implant/abutment supported crown9recement implant/abutment supported fixed partial dentureD6094D6095D6100D6190D6194%abutment supported crown - (titanium)"repair implant abutment, by reportimplant removal, by report.radiographic/surgical implant index, by report6abutment supported retainer crown for FPD - (titanium)D6205D6210D6211D6212D6214'pontic - indirect resin based compositepontic - cast high noble metal&pontic - cast predominantly base metalpontic - cast noble metalpontic - titaniumD6241,pontic - porcelain fused to high noble metal4pontic - porcelain fused to predominantly base metal'pontic - porcelain fused to noble metalD6245D6250D6251D6252D6253pontic - porcelain/ceramic$pontic - resin with high noble metal,pontic - resin with predominantly base metalpontic - resin with noble metalprovisional ponticD6545D65487retainer - cast metal for resin bonded fixed prosthesis>retainer - porcelain/ceramic for resin bonded fixed prosthesisD6710D6720D6721D6722D6740&crown - indirect resin based compositecrown - porcelain/ceramicD6751D6780D6781D6782D6783D6790D6791D6792D6793D6794provisional retainer crownD6920D6930D6940D6950D6970 connector barrecement fixed partial denturestress breakerprecision attachmentRpost and core in addition to fixed partial denture retainer, indirectly fabricatedD6972D6973D6975D6976D6977Iprefabricated post and core in addition to fixed partial denture retainer.core build up for retainer, including any pinscoping - metalD6980D6985'fixed partial denture repair, by report pediatric partial denture, fixedD7111.extraction, coronal remnants - deciduous toothD7140Lextraction, erupted tooth or exposed root (elevation and/or forceps removal)surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicatedD7290surgical repositioning of teethD7560D7610D7620D7630D7640Bmaxillary sinusotomy for removal of tooth fragment or foreign body8maxilla - open reduction (teeth immobilized, if present):maxilla - closed reduction (teeth immobilized, if present)9mandible - open reduction (teeth immobilized, if present);mandible - closed reduction (teeth immobilized, if present)D7650D7660D7670D7671D7680,malar and/or zygomatic arch - open reduction.malar and/or zygomatic arch - closed reduction=alveolus closed reduction may include stabilization of teeth;alveolus, open reduction may include stabilization of teethSfacial bones - complicated reduction with fixation and multiple surgical approachesD7710D7720D7730D7740D7750maxilla open reductionmaxilla - closed reductionmandible - open reductionmandible - closed reductionD7760D7770D7771D7780D78100alveolus - open reduction stabilization of teeth1alveolus, closed reduction stabilization of teethopen reduction of dislocationD7820D7830D7840D7850D7852closed reduction of dislocationmanipulation under anesthesia condylectomy)surgical discectomy, with/without implant disc repairD7854D7856 synovectomymyotomy#occlusal orthotic device, by reportD7910D7911D7912D7920(suture of recent small wounds up to 5 cmcomplicated suture - up to 5 cm&complicated suture - greater than 5 cmA skin graft (identify defect covered, location and type of graft)D79556repair of maxillofacial soft and/or hard tissue defectD7990emergency tracheotomyremovable appliance therapyD8220fixed appliance therapyD8691D8692D8693repair of orthodontic appliance&replacement of lost or broken retainerHrebonding or recementing; and/or repair, as required, of fixed retainersApalliative (emergency) treatment of dental pain - minor procedureD9211Ilocal anesthesia not in conjunction with operative or surgical proceduresregional block anesthesiaD9212D9215$trigeminal division block anesthesiaElocal anesthesia in conjunction with operative or surgical procedures3deep sedation/general anesthesia - first 30 minutes=deep sedation/general anesthesia - each additional 15 minutes3inhalation of nitrous oxide / anxiolysis, analgesiaD9241D9242D9248;intravenous conscious sedation/analgesia - first 30 minutesEintravenous conscious sedation/analgesia - each additional 15 minutes"non-intravenous conscious sedationmconsultation - diagnostic service provided by dentist or physician other than requesting dentist or physicianD9410!house/extended care facility callD9420+hospital or ambulatory surgical center call]office visit for observation (during regularly scheduled hours) - no other services performed2therapeutic parenteral drug, single administrationD9612D9630< Ptherapeutic parenteral drugs, two or more administrations, different medications)other drugs and/or medicaments, by reportocclusal guard, by report!occlusion analysis - mounted caseocclusal adjustment - limitedocclusal adjustment - completeD1555 NORTHSOUTHD0180D1351D4210D4261D4249D4263D4341D4355D4381D7250D7960Acomprehensive periodontal evaluation - new or established patientsealant - per toothbgingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant(clinical crown lengthening - hard tissuewosseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant/bone replacement graft - first site in quadrantFperiodontal scaling and root planing - four or more teeth per quadrantGfull mouth debridement to enable comprehensive evaluation and diagnosislocalized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report<surgical removal of residual tooth roots (cutting procedure)mfrenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another proceduresingle tooth (extraction)each add tooth (extraction)CDTz  RE  RE    P PU &A4 m [  = 0} <  %ra6W*wzY !#/"$o$&A&'b!(n( )~**$,),'->/g012 -4V 5 6y7Q8z9<93:\:N;w<-<=(?Qt@A-A,BUBC?DhEFHDyIJ%[JeL cc   <DnwĀ̉Ԓܛp  dMbP?_*+%"&CExhibit 2 Dental Fee Schedule&?M\\alotta\OFFCONFIN5C odXXLetterDINU"xD^xSMTJhXerox ColorQube 9301 PCL6RESDLLUniresDLLXrxTrueTypeFontDlOptionTTF_DOWNLOAD_AS_TRUETYPEXrxEdgeToEdgeEDGE_TO_EDGE_OFFColorMode24bppXrxHalftoneXRX_NORMAL_HTXEROX_JOB_SETUP_BEGINCBXEROX_JOB_SETUP_ENDCBXEROX_DOC_BEGINCBXEROX_DOC_SETUP_ENDCBXEROX_PAGE_SETUP_BEGINCBXEROX_PAGE_SETUP_ENDCBXEROX_PAGE_FINISH_BEGINCBXEROX_PAGE_FINISH_ENDCBXEROX_DOC_FINISH_BEGINCBXEROX_DOC_FINISH_ENDCBXEROX_JOB_FINISH_BEGINCBXEROX_JOB_FINISH_ENDCBOrientationPORTRAITCollateONDuplexNONEResolutionRes600x600PaperSizeLETTERD1NRX d  S MSCFq ,90R1//Uncompressed-Data// 1CK[}l+@`־K0Mg7D 6EϪR u( V 6!*KjUEjU #@VE*iIFJRU7oncmFnvf73o޼wg7Uf A7 tu Tj0>Tb zT@Ap#?\Ir p(*^-~R𻌿#k)ᾌ{9ɳW~QX2IZKWxFp?lrA5/r!n&>u=l?L'>[x I}QEf'dȭ-cd߉RϬ_.C'Ȕ_qW^+Fc4Yi5X{٦Yڬ6O3|r--0QM-ɜ=8>2Ih-՘;XN}v=Zj[wٕS6+OkV+SCNT~֮;hMUUV xv 3l؟4r?qw~R~o5:O4E4K&G-:KBZաzi6RtSOڋ!͒xWPcGo]ń0T 6i3޸:i3D[gF}/ҧJ#4#q?! 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