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					                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
            Clinical Oral Evaluations                                                                         Please fill in your Dental Fees Below
         D 0120      Periodic oral evaluation
         D 0140      Limited oral evaluation - problem focused
         D 0145      Oral evaluation for patient under 3 yrs of age
         D 0150      Comprehensive oral evaluation
         D 0160      Detailed & extensive oral evaluation - problem-focused, by report
         D 0170      Re-evaluation - limited, problem focused
         D 0180      Comprehensive periodontal eval-new or established patient
            Radiographs
         D 0210      Intraoral - complete series (w/ bitewings)
         D 0220      Intraoral - periapical, first film
         D 0230      Intraoral - periapical, each additional film
         D 0240      Intraoral - occusal film
         D 0250      Extraoral - first film
         D 0260      Extraoral - each additional film
         D 0270      Bitewing - 1 film




                                                                                              Page 1 of 123
                                                                                       2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 0272      Bitewing - 2 films
         D 0273      Bitewings - 3 films
         D 0274      Bitewing - 4 films
         D 0277      Vertical bitewings- 7- 8 films
         D 0290      Posterior - anterior or lateral skull & facial bone survey film
         D 0310      Sialography
         D 0320      Temporomandibular joint arthrogram, incl. injection
         D 0321      Other temporomandibular joint films, by report
         D 0322      Tomographic survey
         D 0330      Panoramic
         D 0340      Cephalometric
         D 0350      Oral/facial photographic images
         D 0360      Cone beam ct - craniofacial data capture
         D 0362      Cone beam - two dimensioan image reconstruction
         D 0363      Cone beam - three dimensional image reconstruction
            Tests and Examinations




                                                                                              Page 2 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 0415      Bacteriologic studies for determination of pathologic agents
         D 0416      Viral Culture
         D 0421      Genetic test fir susceptibility to oral diseases
         D 0425      Caries susceptibility tests
         D 0431      Adjunctive pre-diagnostic tests
         D 0460      Pulp vitality tests
         D 0470      Diagnostic casts
            Dental Prophylaxis
         D 1110      Prophylaxis - adult
         D 1120      Prophylaxis - child
            Topical Fluoride Treatment (Office)
         D 1203      Topical application of fluroride (w/o prophy) - child
         D 1204      Topical application of fluoride (w/o prophy) - adult
         D 1206      Topical fluoride varnish, therapeutic application for mod to high caries risk pts
            Other Preventive Services
         D 1310      Nutritional counseling for control of dental disease




                                                                                               Page 3 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 1320      Tobacco counseling for control & prevention of oral disease
         D 1330      Oral hygiene instructions
         D 1351      Sealant - per tooth
            Space Maintenance (Passive Appliances)
         D 1510      Space maintainer - fixed, unilateral
         D 1515      Space maintainer - fixed, bilateral
         D 1520      Space maintainer - removable, unilateral
         D 1525      Space maintainer - removable, bilateral
         D 1550      Recementation of space maintainer
         D 1555      removal of fixed space maintainer
            Amalgam Restorations (including polishing)
         D 2140      Amalgam - 1 surface, primary or permanent
         D 2150      Amalgam - 2 surfaces, primary or permanent
         D 2160      Amalgam - 3 surfaces, primary or permanent
         D 2161      Amalgam - 4+ surfaces, primary or permanent
            Resin-based Composite Restorations - Direct




                                                                                              Page 4 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 2330      Resin - 1 surface, anterior
         D 2331      Resin - 2 surfaces, anterior
         D 2332      Resin - 3 surfaces, anterior
         D 2335      Resin - 4+ surfaces or involving incisal angle, anterior
         D 2390      Resin-Composite crown, anterior
         D 2391      Resin - 1 surface, posterior
         D 2392      Resin - 2 surfaces, posterior
         D 2393      Resin - 3 surfaces, posterior
         D 2394      Resin - 4+ surfaces, posterior
            Gold Foil Restorations
         D 2410      Gold foil - 1 surface
         D 2420      Gold foil - 2 surfaces
         D 2430      Gold foil - 3 surfaces
            Inlay/Onlay Restorations
         D 2510      Inlay - metallic, 1 surface
         D 2520      Inlay - metallic, 2 surfaces




                                                                                              Page 5 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 2530      Inlay - metallic, 3+ surfaces
         D 2542      Onlay - metallic, 2 surfaces
         D 2543      Onlay - metallic, 3 surfaces
         D 2544      Onlay - metallic, 4+ surfaces
         D 2610      Inlay - porcelain/cereamic, 1 surface
         D 2620      Inlay - porcelain/ceramic, 2 surfaces
         D 2630      Inlay - porcelain/ceramic, 3+ surfaces
         D 2642      Onlay - porcelain/ceramic, 2 surfaces
         D 2643      Onlay - porcelain/ceramic, 3 surfaces
         D 2644      Onlay - porcelain/ceramic, 4+ surfaces
         D 2650      Inlay - composite/resin, 1 surface (lab)
         D 2651      Inlay - composite/resin, 2 surfaces (lab)
         D 2652      Inlay - composite/resin, 3+ surfaces (lab)
         D 2662      Onlay - composite/resin, 2 surfaces (lab)
         D 2663      Onlay - composite/resin, 3 surfaces (lab)
         D 2664      Onlay - composite/resin, 4+ surfaces (lab)




                                                                                              Page 6 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
            Crowns - Single restoration only
         D 2710      Crown - resin-based composite (indirect)
         D 2712      Crown - 3/4 resin-based composite (indirect)
         D 2720      Crown - resin with high noble metal
         D 2721      Crown - resin with predominantly base metal
         D 2722      Crown - resin with noble metal
         D 2740      Crown - porcelain/ceramic substrate
         D 2750      Crown - porcelain fused to high noble metal
         D 2751      Crown - porcelain fused to predominantly base metal
         D 2752      Crown - porcelain fused to noble metal
         D 2780      Crown - 3/4 cast high noble metal
         D 2781      Crown - 3/4 cast predominantly base metal
         D 2782      Crown - 3/4 cast noble metal
         D 2783      Crown - 3/4 cast porcelain/ceraminc
         D 2790      Crown - full cast high noble metal
         D 2791      Crown - full cast predominantly base metal




                                                                                              Page 7 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Contact Person:
                                                                                                              Email Address:
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                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 2792      Crown - full cast noble metal
         D 2794      Crown - titanium
         D 2799      Provisional crown
            Other Restorative Services
         D 2910      Recement inlay, onlay, or partial coverage restoration
         D 2915      Recement cast or prefabricated post and core
         D 2920      Recement crown
         D 2930      Prefabricated stainless steel crown - primary tooth
         D 2931      Prefabricated stainless steel crown - permanent tooth
         D 2932      Prefabricated resin crown
         D 2933      Prefabricated stainless stell crown with resin window
         D 2934      Prefabricated esthetic coated stainless steel crown - primary tooth
         D 2940      Sedative filling
         D 2950      Core buildup, including pins
         D 2951      Pin retention - per tooth, in addition to restoration
         D 2952      Post and core in addition to crown, indirectly fabricated




                                                                                              Page 8 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Contact Person:
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                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 2953      Each additional indirectly fabricated post - same tooth
         D 2954      Prefabricated post and core in addition to crown
         D 2955      Post removal (not w/ endodontic therapy)
         D 2957      Each additional prefabricated post - same tooth
         D 2960      Labial veneer - laminate, chairside
         D 2961      Labial veneer - resin laminate, laboratory
         D 2962      Labial veneer - porcelain laminate, laboratory
         D 2970      Temporary crown
         D 2971      Additional procedures to contruct new crown under existing part dent framework
         D 2975      Coping
         D 2980      Crown repair, by report
         D 2999      Unspecified restorative procedure, by report
            Pulp Capping
         D 3110      Pulp cap - direct
         D 3120      Pulp cap - indirect
            Pulpotomy




                                                                                              Page 9 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Practice Name:
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                                                                                                              Contact Person:
                                                                                                              Email Address:
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                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 3220      Therapeutic pulpotomy
         D 3221      Pulpal debridement, primary and permanent teeth
            Endodontic Therapy on Primary Teeth
         D 3230      Pulpal therapy - anterior, primary tooth
         D 3240      Pulpal therapy - posterior, primary tooth
            Endodontic Therapy
         D 3310      Anterior
         D 3320      Bicuspid
         D 3330      Molar
         D 3331      Treatment of root canal obstruction; non-surgical access
         D 3332      Incomplete endodontic therapy;inoperable,unrestorable or fractured tooth
         D 3333      Internal root repair of perforation defects
            Endodontic Retreatment
         D 3346      Retreatment of previous root canal - anterior
         D 3347      Retreatment of previous root canal - bicuspid
         D 3348      Retreatment of previous root canal - molar




                                                                                             Page 10 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
            Apexification/Recalcification Procedures
         D 3351      Apexification/recalcification - initial visit
         D 3352      Apexification/recalcification - interim medication replacement
         D 3353      Apexification/recalcification - final visit
            Apioectomy/Periapical Services
         D 3410      Apicoectomy/Periradicular surgery - anterior
         D 3421      Apicoectomy/Periradicular surgery - bicuspid
         D 3425      Apicoectomy/Periradicular surgery - molar
         D 3426      Apicoectomy/Periradicular surgery - each additional root
         D 3430      Retrograde filling - per root
         D 3450      Root amputation - per root
         D 3460      Endodontic endosseous implant
         D 3470      Intentional reimplantation, incl. splinting
            Other Endodontic Procedures
         D 3910      Surgical procedure for isolation of tooth with rubber dam
         D 3920      Hemisection (incl. root removal), not including root canal




                                                                                             Page 11 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Contact Person:
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                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 3950      Canal preparation and fitting of preformed dowel or post
         D 3999      Unspecified endodontic procedure, by report
            Surgical Services-Periodontal
         D 4210      Gingivectomy or gingivoplasty - per quadrant
         D 4211      Gingivectomy or gingivoplasty - per tooth
         D 4230      Anatomical crown exposure-four or more contiguous teeth per quad
         D 4231      Anatomical crown exposure-one to three teeth per quad
         D 4240      Gingival flap procedure, including root planing - four or more contiguous
                     teeth or bounded teeth spaces per quadrant
         D 4241      Gingival flap procedure, including root planing - one to three teeth per quadrant
         D 4245      Apically positioned flap
         D 4249      Clinical crown lengthening - hard tissue
         D 4260      Osseous surgery (incl. flap entry and closure) - four or more contiguous teeth
                     or bounded teeth spaces per quadrant
         D 4261      Osseous surgery (incl. flap entry and closure) - 1 - 3 teeth per quadrant
         D 4263      Bone replacement graft - first site in quadrant




                                                                                             Page 12 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Practice Name:
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                                                                                                              Contact Person:
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                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 4264      Bone replacement graft - each additional site in quadrant
         D 4265      Biologic materials to aid in soft and osseous tissue regeneration
         D 4266      Guided tissue regeneration - resorbable barrier, per site, per tooth
         D 4267      Guided tissue regeneration - nonresorbable barrier, per site, per tooth
         D 4268      Surgical revision procedure, per tooth
         D 4270      Pedicle soft tissue graft procedure
         D 4271      Free soft tissue graft procedure (incl. donor site surgery)
         D 4273      Subepithelial connective tissue graft procedure (incl. donor site surgery)
         D 4274      Distal or proximal wedge procedure
         D 4275      Soft tissue allograft
         D 4276      Combined connective tissue and double pedicle graft
            Adjunctive Periodontal Services
         D 4320      Provisional splinting - intracoronal
         D 4321      Provisional splinting - extracoronal
         D 4341      Periodontal scaling and root planing - four or more contiguous teeth or
                     bounded teeth spaces per quadrant




                                                                                               Page 13 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 4342      Periodontal scaling and root planing - one to three teeth per quadrant
         D 4355      Full mouth debridement, for periodontal evaluation and diagnosis
         D 4381      Localized delivery of chemotherapeutic agents, per tooth, by report
            Other Periodontal Services
         D 4910      Periodontal maintenance procedures (following active therapy)
         D 4920      Unscheduled dressing change (by someone other than treating dentist)
         D 4999      Unspecified periodontal procedure, by report
            Complete Dentures
         D 5110      Complete denture - maxillary
         D 5120      Complete denture - mandibular
         D 5130      Immediate denture - maxillary
         D 5140      Immediate denture - mandibular
            Partial Dentures
         D 5211      Maxillary partial denture - resin base (including clasps)
         D 5212      Mandibular partial denture - resin base (including clasps)
         D 5213      Maxillary partial denture - cast metal frame w/ resin base (incl. clasps)




                                                                                                 Page 14 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 5214      Mandibular partial denture - cast metal frame w/ resin base (incl. clasps)
         D 5225      Maxillary partial denture - flexible base
         D 5226      Mandibular partial denture - flexible base
         D 5281      Removable unilateral partial denture - one piece cast metal (incl. clasps)
            Adjustments to Removable Prostheses
         D 5410      Adjust complete denture - maxillary
         D 5411      Adjust complete denture - mandibular
         D 5421      Adjust partial denture - maxillary
         D 5422      Adjust partial denture - mandibular
            Repairs to Complete Dentures
         D 5510      Repair broken complete denture base
         D 5520      Replace missing or broken teeth - complete denture (each tooth)
            Repairs to Partial Dentures
         D 5610      Repair resin denture base
         D 5620      Repair cast framework
         D 5630      Repair or replace broken clasp




                                                                                             Page 15 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 5640      Replace broken teeth - per tooth
         D 5650      Add tooth to existing partial denture
         D 5660      Add clasp to existing partial denture
         D 5670      Replace all teeth and acrylic on cast metal framework(maxillary)
         D 5671      Replace all teeth and acrylic on cast metal framework(mandibular)
            Denture Rebase Procedures
         D 5710      Rebase copmlete maxillary denture
         D 5711      Rebase copmlete mandibular denture
         D 5720      Rebase maxillary partial denture
         D 5721      Rebase mandibular partial denture
            Denture Reline Procedures
         D 5730      Reline complete maxillary denture (office)
         D 5731      Reline complete mandibular denture (office)
         D 5740      Reline maxillary partial denture (office)
         D 5741      Reline mandibular partial denture (office)
         D 5750      Reline complete maxillary denture (lab)




                                                                                             Page 16 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Practice Name:
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                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 5751      Reline complete mandibular denture (lab)
         D 5760      Reline complete maxillary partial denture (lab)
         D 5761      Reline mandibular partial denture (lab)
            Interim Prothesis
         D 5810      Interim complete denture (maxillary)
         D 5811      Interim complete denture (mandibular)
         D 5820      Interim partial denture (maxillary)
         D 5821      Interim partial denture (mandibular)
            Other Removable Prosthetic Services
         D 5850      Tissue conditioning, maxillary
         D 5851      Tissue conditioning, mandibular
         D 5860      Overdenture - complete, by report
         D 5861      Overdenture - complete, by report
         D 5862      Precision attachment, by report
         D 5867      Replacement of replaceable part of semi-precision or precision attachment
         D 5875      Modification of removable prosthesis following implant surgery




                                                                                             Page 17 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Practice Name:
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                                                                                                              Contact Person:
                                                                                                              Email Address:
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                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 5899      Unspecified removable prosthodontic procedure, by report
            Maxillofacial Prosthetics
         D 5911      Facial moulage (sectional)
         D 5912      Facial moulage (complete)
         D 5913      Nasal prosthesis
         D 5914      Auricular prosthesis
         D 5915      Orbital prosthesis
         D 5916      Ocular prosthesis
         D 5919      Facial prosthesis
         D 5922      Nasal septal prosthesis
         D 5923      Ocular prosthesis, interim
         D 5924      Cranial prosthesis
         D 5925      Facial augmentation implant prosthesis
         D 5926      Nasal prosthesis, replacement
         D 5927      Auricular prosthesis, replacement
         D 5928      Orbital prosthesis, replacement




                                                                                             Page 18 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Practice Name:
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                                                                                                              Contact Person:
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                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 5929      Facial prosthesis, replacement
         D 5931      Obturator prosthesis, surgical
         D 5932      Obturator prosthesis, definitive
         D 5933      Obturator prosthesis, modification
         D 5934      Mandibular resection prosthesis with guide flange
         D 5935      Mandibular resection prosthesis without guide flange
         D 5936      Obturator prosthesis, interim
         D 5937      Trismus appliance (not for TMD)
         D 5951      Feeding aid
         D 5952      Speech aid prosthesis, pediatric
         D 5953      Speech aid prosthesis, adult
         D 5954      Palatal augmentation prosthesis
         D 5955      Palatal lift prosthesis, definitive
         D 5958      Palatal lift prosthesis, interim
         D 5959      Palatal lift prosthesis, modification
         D 5960      Speech aid prosthesis, modification




                                                                                             Page 19 of 123
                                                                                      2010 SVA Dental Fee Survey




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                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
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                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 5982      Surgical stent
         D 5983      Radiation carrier
         D 5984      Radiation shield
         D 5985      Radiation cone locator
         D 5986      Fluoride gel carrier
         D 5987      Commissure splint
         D 5988      Surgical splint
         D 5999      Unspecified maxillofacial prosthesis, by report
            Implant Services
            Pre Surgical Services
         D 6190      Pre-Surgical Radiographic/surgical implant index,by report
            Surgical Services
         D 6010      Surgical placement of implant body - endosteal implant
         D 6012      Surgical placement of interim implant body for transitional prothesis
         D 6040      Surgical placement - eposteal implant
         D 6050      Surgical placement - transosteal implant




                                                                                             Page 20 of 123
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CDT CODE DESCRIPTION
         D 6100      Implant removal, by report
            Supporting Structures
         D 6055      Dental implant supported connecting bar
         D 6056      Prefabricated abutment - includes placement
         D 6057      Custom abutment - includes placement
            Implant/Abutment Supported Removable Dentures
         D 6053      Implant/abutment supported removable denture for completely edentulous arch
         D 6054      Implant/abutment supported removable denture for partially edentulous arch
            Implant/Abutment Supported Fixed Dentures (Hybrid Prosthesis)
         D 6078      Implant/abutment supported fixed denture for completely edentulous arch
         D 6079      Implant/abutment supported fixed denture for partially edentulous arch
            Single Crowns/Abutment Supported
         D 6058      Abutment supported procelain/ceramic crown
         D 6059      Abutment supported procelain fused to metal crown(high noble metal)
         D 6060      Abutment supported porcelain fused to metal crown(base metal)
         D 6061      Abutment supported porcelain fused to metal crown(noble metal)




                                                                                              Page 21 of 123
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CDT CODE DESCRIPTION
         D 6062      Abutment supported cast metal crown(high noble metal)
         D 6063      Abutment supported cast metal crown(base metal)
         D 6064      Abutment supported cast metal crown(noble metal)
         D 6094      Abutment supported crown - (titanium)
            Single Crowns, Implant Supported
         D 6065      Implant supported porcelain/ceramic crown
         D 6066      Implant supported porcelain fused to metal crown
         D 6067      Implant supported metal crown
            Fixed Partial Denture, Abutment Supported
         D 6068      Abutment supported retainer for porcelain/ceramic FPD
         D 6069      Abutment supported retainer for porcelain fused to metal FPD(high noble)
         D 6070      Abutment supported retainer for porcelain fused to metal FPD(base metal)
         D 6071      Abutment supported retainer for porcelain fused to metal FPD(noble)
         D 6072      Abutment supported retainer for cast metal FPD(high noble)
         D 6073      Abutment supported retainer for cast metal FPD(base)
         D 6074      Abutment supported retainer for cast metal FPD(noble)




                                                                                             Page 22 of 123
                                                                                      2010 SVA Dental Fee Survey




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CDT CODE DESCRIPTION
         D 6194      Abutment supported retainer crownf or FPD - (titanium)
            Fixed Partial Denture, Implant Supported
         D 6075      Implant supported retainer for ceramic FPD
         D 6076      Implant supported retainer for porcelain fused to metal FPD
         D 6077      Implant supported retainer for cast metal FPD
            Other Implant Services
         D 6080      Implant maintenance procedures, incl. removal, cleansing, reinsertion
         D 6090      Repair implant supported prosthesis, by report
         D 6095      Repair implant abutment, by report
         D 6091      Replacement of semi-precision or precision attachment (male or female
                     component)of implant/abutment supported prothesis, per attachment
         D 6092      Recement implant/abutment supported crown
         D 6093      Recement implant/abutment supported fixed partial denture
         D 6199      Unspecified implant procedure, by report
            Fixed Partial Denture Pontics
         D 6205      Pontic - indirect resin based composite




                                                                                             Page 23 of 123
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CDT CODE DESCRIPTION
         D 6210      Pontic - cast high noble metal
         D 6211      Pontic - cast predominantly base metal
         D 6212      Pontic - cast noble metal
         D 6214      Pontic - titanium
         D 6240      Pontic - porcelain fused to high noble metal
         D 6241      Pontic - porcelain fused to predominantly base metal
         D 6242      Pontic - porcelain fused to noble metal
         D 6245      Pontic - porcelain/ceramic
         D 6250      Pontic - resin with high noble metal
         D 6251      Pontic - resin with predominantly base metal
         D 6252      Pontic - resin with noble metal
         D 6253      Provisional pontic
            Fixed Partial Denture Retainers - Inlays/Onlays
         D 6545      Retainer - cast metal for resin bonded fixed prosthesis
         D 6548      Retainer - porcelain/ceramic for resin bonded fixed prosthesis
         D 6600      Inlay-procelain/ceramic, two surfaces




                                                                                             Page 24 of 123
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CDT CODE DESCRIPTION
         D 6601      Inlay-procelain/ceramic, three or more surfaces
         D 6602      Inlay-cast high noble metal, two surfaces
         D 6603      Inlay-cast high noble metal, three or more surfaces
         D 6604      Inlay-cast predominantly base metal, two surfaces
         D 6605      Inlay-cast predominantly base metal, threee or more surfaces
         D 6606      Inlay-cast noble metal, two surfaces
         D 6607      Inlay-cast noble metal,three or more surfaces
         D 6624      Inlay - titanium
         D 6608      Onlay-porcelain/ceramic, two sufraces
         D 6609      Onlay-procelain/ceramic, three or more surfaces
         D 6610      Onlay-cast high noble metal, two surfaces
         D 6611      Onlay-cast high noble metal, three or more surfaces
         D 6612      Onlay-cast predominantly base metal, two surfaces
         D 6613      Onlay-cast predominantly base metal, three or more surfaces
         D 6614      Onlay-cast noble metal, two surfaces
         D 6615      Onlay-cast noble metal, three or more surfaces




                                                                                             Page 25 of 123
                                                                                      2010 SVA Dental Fee Survey




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Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 6634      Onlay - titanium
            Fixed Partial Denture Retainers - Crown
         D 6710      Crown - indirect resin based composite
         D 6720      Crown - resin with high noble metal
         D 6721      Crown - resin with predominantly base metal
         D 6722      Crown - resin with noble metal
         D 6740      Crown-porcelain/ceramic
         D 6750      Crown - porcelain fused to high noble metal
         D 6751      Crown - porcelain fused to predominantly base metal
         D 6752      Crown - porcelain fused to noble metal
         D 6780      Crown - 3/4 cast high noble metal
         D 6781      Crown - 3/4 cast predominantly base metal
         D 6782      Crown - 3/4 cast noble metal
         D 6783      Crown - 3/4 porcelain/ceramic
         D 6790      Crown - full cast high noble metal
         D 6791      Crown - full cast predominantly base metal




                                                                                             Page 26 of 123
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CDT CODE DESCRIPTION
         D 6792      Crown - full cast noble metal
         D 6794      Crown - titanium
         D 6793      Provisional retainer crown
            Other Fixed Partial Denture Services
         D 6920      Connector bar
         D 6930      Recement fixed partial denture
         D 6940      Stress breaker
         D 6950      Precision attachment
         D 6970      Post and core, in addition to fixed partial denture retainer,indirectly fabricated
         D 6972      Prefabricated post and core, in addition to fixed partial denture retainer
         D 6973      Core build up for retainer, including pins
         D 6975      Coping - metal
         D 6976      each additional indirectly fabricated post-same tooth
         D 6977      each aditional prefabricated post - same tooth
         D 6980      Fixed partial denture repair, by report
         D 6985      pediatric partial denture-fixed




                                                                                                Page 27 of 123
                                                                                      2010 SVA Dental Fee Survey




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CDT CODE DESCRIPTION
         D 6999      Unspecified fixed prosthodontic procedure, by report
            Extractions
         D 7111      Coronal remnants - deciduous tooth
         D 7140      Extraction, erupted tooth or exposed root


            Surgical Extractions
         D 7210      Surgical removal of erupted tooth, with elevation of mucoperiosteal
                     flap and removal of bone and/or section of tooth
         D 7220      Removal of impacted tooth - soft tissue
         D 7230      Removal of impacted tooth - partially bony
         D 7240      Removal of impacted tooth - completely bony
         D 7241      Removal of impacted tooth - completely bony, w/ unusual surgical complications
         D 7250      Surgical removal of residual tooth roots (cutting procedure)
            Other Surgical Procedures
         D 7260      Oroantral fistula closure
         D 7261      Primary closure of sinus perforation




                                                                                             Page 28 of 123
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CDT CODE DESCRIPTION
         D 7270      Tooth reimplantation and/or stablization - accidentally evulsed/displaced
         D 7272      Tooth transplanation (incl. reimplantation, splinting, stabilization
         D 7280      Surgical exposure of impacted or unerupted tooth for orthodontic reasons
                     (including orthodontic attachments)
         D 7282      Mobilization of erupted or malpositioned tooth to aid eruption
         D 7283      Placement of device to facilitate eruption of impacted tooth
         D 7285      Biopsy of oral tissue - hard(bone, tooth)
         D 7286      Biopsy of oral tissue - soft
         D 7287      Cytology sample collecion
         D 7288      Brush biopsy - transepithelial sample collection
         D 7290      Surgical repositioning of teeth
         D 7291      Transseptal fiberotomy, by report
         D 7292      Surgical placement:temporary anchorage device (screw retained plate)
                     requiring surgical flap
         D 7293      Surgical placement:temporary anchorage device requiring surgical flap
         D 7294      Surgical placement:temporary anchorage device without surgical flap




                                                                                             Page 29 of 123
                                                                                        2010 SVA Dental Fee Survey




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CDT CODE DESCRIPTION
            Alveoplasty - Surgical Preparation of Ridge for Dentures
         D 7310      Alveoloplasty in conjunction with extractions - per quadrant
         D 7311      Alveoloplasty in conjunction with extractions - 1 - 1 teeth per quadrant
         D 7320      Alveoloplasty not in conjunction with extractions - per quadrant
         D 7321      Alveoloplasty not in conjunction with extractions - 1 - 1 teeth per quadrant
            Vestibuloplasty
         D 7340      Vestibuloplasty - ridge extension (secondary epithelialization)
         D 7350      Vestibuloplasty - ridge extension (including soft tissue grafts, muscle
            Surgical Excision of Soft Tissue Lesions
         D 7410      Excision of benign lesion up to 1.25 cm
         D 7411      Excision of benign lesion greater than 1.25 cm
         D 7412      Excision of benign lesion, complicated
         D 7413      Excision of malignant lesion up to 1.25 cm
         D 7414      Excision of malignant lesion greater than 1.25 cm
         D 7415      Excisiohn of malignant lesion, complicated
         D 7465      Destruction of lesion(s) by physical or chemical method, by report




                                                                                                Page 30 of 123
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CDT CODE DESCRIPTION
            Removal of Tumors, Cysts, and Neoplasms
         D 7440      Excision of malignant tumor - lesion diameter up to 1.25 cm
         D 7441      Excision of malignant tumor - lesion diameter greater than 1.25 cm
         D 7450      Removal of odontogenic cyst or tumor - lesion diameter up to 1.25 cm
         D 7451      Removal of odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
         D 7460      Removal of nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
         D 7461      Removal of nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
            Excision of Bone Tissue
         D 7471      Removal of exostosis - maxilla or mandible
         D 7472      Removal of torus palatinus
         D 7473      Removal of torus madibularis
         D 7485      Surgical reduction of osseous tuberosity
         D 7490      Radical resection of mandible with bone graft
            Surgical Incision
         D 7510      Incision and drainage of abscess - intraoral soft tissue
         D 7511      Incision and drainage of abscess - intraoral soft tissue-complicated




                                                                                             Page 31 of 123
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CDT CODE DESCRIPTION
         D 7520      Incision and rainage of abscess - extraoral soft tissue
         D 7521      Incision and rainage of abscess - extraoral soft tissue-complicated
         D 7530      Removal of foreign body, skin, or subcutaneous areolar tissue
         D 7540      Removal of reaction-producing foreign bodies - musculoskeletal
         D 7550      Sequestrectomy for osteomyelitis
         D 7560      Maxillary sinusotomy for removal of tooth fragment or foreign body
            Treatment of Fracture - Simple
         D 7610      Maxilla - open reduction (teeth immobilized, if present)
         D 7620      Maxilla - closed reduction (teeth immobilized, if present)
         D 7630      Mandible - open reduction (teeth immobilized, if present)
         D 7640      Mandible - closed reduction (teeth immobilized, if present)
         D 7650      Malar and/or zygomatic arch - open reduction
         D 7660      Malar and/or zygomatic arch - closed reduction
         D 7670      Alveolus - closed reduction, may include stabilization of teeth
         D 7671      Alveolus - open reduction, may include stabilization of teeth
         D 7680      Facial bones - complicated reduction w/ fixation & multiple surgical approaches




                                                                                             Page 32 of 123
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Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
            Treatment of Fractures - Compound
         D 7710      Maxilla - open reduction
         D 7720      Maxilla - closed reduction
         D 7730      Mandible - open reduction
         D 7740      Mandible - closed reduction
         D 7750      Malar and/or zygomatic arch - open reduction
         D 7760      Malar and/or zygomatic arch - closed reduction
         D 7770      Alveolus - stabilization of teeth, open reduction
         D 7771      Alveolus - closed reduction stabilization of teeth
         D 7780      Facial bones - completed reduction w/ fixation and multiple surgical approaches
            Reduction of Dislocation and Management of Other Temporomandibular
            Joint Dysfunctions (procedures integral to primary procedure)
         D 7810      Open reduction of dislocation
         D 7820      Close reduction of dislocation
         D 7830      Manipulation under anesthesia
         D 7840      Condylectomy




                                                                                             Page 33 of 123
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CDT CODE DESCRIPTION
         D 7850      Surgical discectomy, with or without implant
         D 7852      Disc repair
         D 7854      Synovectomy
         D 7856      Myotomy
         D 7858      Joint reconstruction
         D 7860      Arthrotomy
         D 7865      Arthroplasty
         D 7870      Arthrocentesis
         D 7871      Non-arthoscopic lysis and lavage
         D 7872      Arthroscopy - diagnosis, with or without biopsy
         D 7873      Arthroscopy - surgical, lavage and lysis of adhesions
         D 7874      Arthroscopy - surgical, disk repositioning and stabilization
         D 7875      Arthroscopy - surgical, synovectomy
         D 7876      Arthroscopy - surgical, discectomy
         D 7877      Arthroscopy - surgical, debridement
         D 7880      Occlusal orthotic device, by report




                                                                                             Page 34 of 123
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CDT CODE DESCRIPTION
         D 7899      Unspecified TMD therapy, by report
            Repair of Traumatic Wounds
         D 7910      Suture of recent small wounds up to 5 cm
            Complicated Suturing
         D 7911      Complicated suture - up to 5 cm
         D 7912      Complicated suture - greater than 5 cm
            Other Repair Procedures
         D 7920      Skin graft
         D 7940      Osteoplasty - for orthognathic deformities
         D 7941      Osteotomy - ramus, closed
         D 7943      Osteotomy - ramus, open with bone graft
         D 7944      Osteotomy - segmented or subapical, per sextant or quadrant
         D 7945      Osteotomy - body of mandible
         D 7946      LeFort I (maxilla - total)
         D 7947      LeFort I (maxilla - segmented)
         D 7948      LeFort II or LeFort III - without bone graft




                                                                                             Page 35 of 123
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Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 7949      LeFort II or LeFort III - with bone graft
            Other Repair Procedures (continued)
         D 7950      Osseous, osteoperiosteal, or cartilage graft of mandible or facial bones
         D 7951      Sinus augmentation with bone or bone substitutes
         D 7953      Bone replacement graft for ridge preservation - per site
         D 7955      Repair of maxillofacial soft and hard tissue defect
         D 7960      Frenulectomy (frenectomy or frenotomy) - separate procedure
         D 7963      Frenuloplasty
         D 7970      Excision of hyperplastic tissue - per arch
         D 7971      Excision of pericoronal gingiva
         D 7972      Surgical reduction of fibrous tuberosity
         D 7980      Sialolithotomy
         D 7981      Excision of salivary gland, by report
         D 7982      Sialodochoplasty
         D 7983      Closure of salivary fistula
         D 7990      Emergency tracheotomy




                                                                                             Page 36 of 123
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Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 7991      Coronoidectomy
         D 7995      Synthetic graft - mandible or facial bones, by report
         D 7996      Implant - mandible for augmentation purposes (excl. alveolar ridge), by report
         D 7997      Appliance removal(not by dds who placed appliance)includes archbar removal
         D 7998      Untraoral placement of fixation device not in conjunction with a fracture
         D 7999      Unspecified oral surgery procedure, by report
         D Limited Orthodontic Treatment
         D 8010      Limited orthodontic treatment of the primary dentition
         D 8020      Limited orthodontic treatment of the transitional dentition
         D 8030      Limited orthodontic treatment of the adolescent dentition
         D 8040      Limited orthodontic treatment of the adult dentition
         D Interceptive Orthodontic Treatment
         D 8050      Interceptive orthodontic treatment of the primary dentition
         D 8060      Interceptive orthodontic treatment of the transitional dentition
         D Comprehensive Orthodontic Treatment
         D 8070      Comprehensive orthodontic teratment of the transitional dentition




                                                                                             Page 37 of 123
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CDT CODE DESCRIPTION
         D 8080      Comprehensive orthodontic treatment of the adolescent dentition
         D 8090      Comprehensive orthodontic treatment of the adult dentition
         D Minor Treatment to Control Harmful Habits
         D 8210      Removable appliance therapy
         D 8220      Fixed appliance therapy
         D Other Orthodontic Services
         D 8660      Pre-orthodontic treatment visit
         D 8670      Periodic orthodontic treatment visit (as part of contract)
         D 8680      Orthodontic retention (removal of appliances, construction &
                       replacement of retainers
         D 8690      Orthodontic treatment (alternative billing to contract fee)
         D 8691      Repair of orthodontic appliance
         D 8693      Rebonding or recementing; and/or repair, as required, of fixed retainers
         D 8999      Unspecified orthodontic procedure, by report
            Unclassified Treatment
         D 9110      Palliative (emergency) treatment of dental pain - minor procedure




                                                                                             Page 38 of 123
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CDT CODE DESCRIPTION
         D 9120      Fixed partial denture sectioning
            Anesthesia
         D 9210      Local anesthesia, not w/ operative or surgical procedures
         D 9211      Regional block anesthesia
         D 9212      Trigeminal division block anesthesia
         D 9215      Local anesthesia
         D 9220      General anesthesia - first 30 minutes
         D 9221      General anesthesia - each additional 15 minutes
         D 9230      Analgesia
         D 9241      Intravenous conscious sedation-first 30 minutes
         D 9242      Intravenous conscious sedation-each add'l 15 minutes
         D 9248      Non-intravenous conscious sedation
            Professional Consultation
         D 9310      Consultation (by dentist or physician other than requesting dentist or physician)
            Professional Visits
         D 9410      House call




                                                                                             Page 39 of 123
                                                                                       2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 9420      Hospital call
         D 9430      Office visit for observation - during regularly scheduled hours
         D 9440      Office visit - after regularly scheduled hours
         D 9450      Case presentation, detailed and extensive treatment planning
            Drugs
         D 9610      Therapeutic parenteral drug single administration
         D 9612      Therapeutic parenteral drugs, two or more administrations, different medications
         D 9630      Other drugs and/or medicaments, by report
            Miscellaneous Services
         D 9910      Application of desensitizing medicament
         D 9911      Application of desensitizing resin for cevicl and/or root surface, per tooth
         D 9920      Behavior management, by report
         D 9930      Treatment of complications (post surgical) - unusual circumstances, by report
         D 9940      Occlusal guard, by report
         D 9941      Fabrication of athletic mouthguard
         D 9942      Repair and/or reline of occlusal




                                                                                               Page 40 of 123
                                                                                      2010 SVA Dental Fee Survey




                                                                                                              Please Fill In your Contact Information Below
                                                                                                              Practice Name:
                                                                                                              Practice Specialty: (click here, then select arrow on right for drop down list)
                                                                                                              Contact Person:
                                                                                                              Email Address:
                                                                                                              Mailing Address:
                                                                                                              City:   State:      Zip:
                     After completing the survey, please email Ashley Dobbs at dobbsa@sva.com


Note: If you perform a service less than 10 times a year, exclude entering fees for that particular service
CDT CODE DESCRIPTION
         D 9950      Occlusion analysis - mounted case
         D 9951      Occlusal adjustment - limited
         D 9952      Occlusal adjustment - complete
         D 9970      Enamel microabrasion
         D 9971      Odontoplasty 1 -2 teeth; includes removal of enamel projections
         D 9972      External bleaching - per arch
         D 9973      External bleaching - per tooth
         D 9974      internal bleaching - per tooth
         D 9999      Unspecified adjunctive procedure, by report




                                                                                             Page 41 of 123
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                             Endodontist
                             Oral Surgeon
                             Orthodontist
                             Periodontist
                             Prosthodontist
                             Pediatric Dentist
                             General Dentist




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Orthodontist


Prosthodontist
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General Dentist




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Orthodontist


Prosthodontist
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General Dentist




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Orthodontist


Prosthodontist
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General Dentist




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Orthodontist


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Oral Surgeon
Orthodontist


Prosthodontist
Pediatric Dentist
General Dentist




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Orthodontist


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General Dentist




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Orthodontist


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General Dentist




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Orthodontist


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Orthodontist


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Orthodontist


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Orthodontist


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Orthodontist


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Orthodontist


Prosthodontist
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Orthodontist


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Pediatric Dentist
General Dentist




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Orthodontist


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General Dentist




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Orthodontist


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General Dentist




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Orthodontist


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General Dentist




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Orthodontist


Prosthodontist
Pediatric Dentist
General Dentist




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Orthodontist


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Pediatric Dentist
General Dentist




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Orthodontist


Prosthodontist
Pediatric Dentist
General Dentist




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Orthodontist


Prosthodontist
Pediatric Dentist
General Dentist




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Orthodontist


Prosthodontist
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General Dentist




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Orthodontist


Prosthodontist
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Orthodontist


Prosthodontist
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Orthodontist


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General Dentist




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Orthodontist


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Orthodontist


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Orthodontist


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