Revised

SPACE MAINTENANCE (PASSIVE APPLIANCES) | January 1, 2025

SPACE MAINTAINER – FIXED, UNILATERAL – PER QUADRANT

OTHER IMPLANT SERVICES | January 1, 2025

REPAIR OF IMPLANT/ABUTMENT SUPPORTED PROSTHESIS

MISCELLANEOUS SERVICES | January 1, 2025

ODONTOPLASTY – PER TOOTH

DIAGNOSTIC | IMAGE CAPTURE WITH INTERPRETATION | January 1, 2025

INTRAORAL – COMPREHENSIVE SERIES OF RADIOGRAPHIC IMAGES

DRUGS | January 1, 2025

INFILTRATION OF SUSTAINED RELEASE THERAPEUTIC DRUG, PER QUADRANT