BRIGHTER WAY DENTAL WITH HCH AMD 4.PDF

CONTRACT NO: C-86-15-045-3-04 AMENDMENT NO: 4
AMENDMENT TO CONTRACT
Between
MARICOPA COUNTY
By and Through its
DEPARTMENT OF PUBLIC HEALTH
4041 N Central Avenue, Suite 1400, Phoenix, Arizona 85012
And
Brighter Way Institute aka Brighter Way Dental
(fka Central Arizona Shelter Services, Inc. (CASS))
I. The above named contract is hereby amended as specified below:
A. Replace Attachment A with the revised Attachment A. Healthcare for the Homeless
pays 1/3 of these fees. Brighter Way Dental does not utilize their own Sliding Fee
Scale.
B. Page 1, Paragraph 1.
Recognition of a change in Contractor's name from Central Arizona Shelter Services
Dental Services (CASS), to Brighter Way Institute aka Brighter Way Dental;
C. Page 1,3.
Contract amount is changed to an aggregate, not-to-exceed total amount from
$537,209 to $677,209,00 (increased $140,000.00 for the budget period
January 1,2017 to December 31, 2017).
D. Section IV, 1. COMPENSATION
A. Contractor will make available 11 new patient appointments weekly.
E. Section IV, 2. METHOD OF PAYMENT
B. Replace B. with this revised B.
Each quarter, subject to the availability of funds, County will process and remit to the
Contractor a warrant for payment up to the maximum total allowable for services
provided or work performed during the contract period. Should County make a
disallowance in the claim, the claim shall be processed for the reduced amount. If
the Contractor protests the amount or the reason for a disallowance, the protest shall
be construed a dispute concerning a question of fact within the meaning of the
"Disputes" clause of the Special Provisions of this Contract.
E. Monthly invoices will be submitted by hard copy or electronically to:
Healthcare for the Homeless Supervisor
Healthcare for the Homeless
220 South 12 th Avenue
Phoenix, AZ 85007
Phone: 602-372-2101
Fax: 602-372-2107
II. All other terms and conditions of the original contract and its amendments shall remain
in full force and effect.
I

IN WITNESS WHEREOF, the parties agree to the changes indicated herein:
FOR AND ON BEHALF OF
MARICOPA COUNTY
By: By:
Clint Hickman
Chairman, Board of Supervisors Kr Uoi c_
30 1n
/0/4 _V /LP
Date Date
ATTEST ATTEST
Clerk of the Board
Date Date
APPROVED AS TO FORM APPROVED AS TO FORM
Attorney for Maricopa County
Date Date
2

Office of Procurement Services
GOODS AND SERVICES
COMPETITION IMPRACTICABLE FORM
This form is to be used when an agency believes an acquisition is a single source and the acquisition dollar amount is above
$5,000. The Chief Procurement Officer can approve purchases up to $100,000. Board of Supervisors approval Is required if
the acquisition Is over $100,000. This form must be submitted for approval to: Office of Procurement Services I 320 W.
Lincoln I Phoenix, AZ 85003, Fax number; 602.258.15n The signed form must be retained in the purchasing fife.
DEPARTMENT NAME DEPARTMENT RX#
PROPOSED CONTRACT VENDOR NEED $DENTDEO Date; 10/29/ 16
Company: Brighter Way Institute REQUESTED DELIVERY
Address: 230 S, 12th Ave, Date:
City, State: Phoenix, AZ QUOTED PRICE: $140,000 for year 2
Zip/Postal Code: 85007
Phone: (602) 362-0744 Accounting string;
Fax
Contact Name: Nettie Chunn / Dr. Kris Volchek
DESCRIPTION OF GOODS OR SERVICE REQUIRED:
The estimated cost of this Procurement is: r ..c $ION (F.> $100k
Is this a Technology Procurement? r. Yes (:. No
The Health Care for the Homeless (HCH) grant requires that dental care be provided to homeless
patients. The dental provider is located on the Human Services Campus where Health Care for the
Homeless (HCH)is located, in very close proximity. Transportation is an issue among homeless
individuals as well as their transient lifestyle. The Public Health's HCH provides medical and dental
care to the homeless through a grant received by the Federal Health and Human Services Division.
SINGLE SOURCE CATEGORY (Check applicable box, attach documentation or provide explanation below.)
Maricopa County Procurement Code MC1-351 states: 'Single source" means an acquisition where, competition is impractical because
of standardization, warranty, or other factors as approved by the Board of Supervisors.
NOTE: The following are unlikely to be sufficient single _source Justifications:
• Personal or agency preference for a product or vendor
• Agency perception that the vendor is the best qualified (this should be determined through a competitive process)
• Lack of agency planning resulfing in limited time to conduct a competitive procurement
• special incentive or deal offered (can be assessed in open and competitive solicitation)
• Agency convenience
C...: Software license renew*, additions, or upgrades available
Grant specified (supporting documents attached) r: from only one source
r Brand compatibility available from only one source (no other
r Mailing lists, subscriptions or media advertising distributors)
C: Warranty voided if service provided by other contract vendor r Other proprietary situation
(": Other (Provide written explanation below)

THIS PROCURIVIENT IS A SINGLE SOURCE BECAUSE (attach additional page if needed):
Brighter Way Dental Institute operates on the Human Services Campus (HSC) next to HCH at 12th Ave.
and Madison, in downtown Phoenix. They are the only viable option for a provider, because of this and
due to lack of transportation for patients that stay on campus. The HSC acts as a one-stop shop for many
of the homeless individuals, the hours at Brighter Way Dental and HCH are the same, and are very
convenient for clients and staff. The dental provider would not only need to be in close proximity to the
homeless population on the HSC, but they also need to be culturally sensitive to the needs of the
homeless population. Many in the homeless population are not well-groomed or bathed, which makes
them less desirable in a private dental setting. The amount of time it would take to transfer patient
records to another provider would be detrimental to the current program.
SEARCH
A search was conducted consisting of: (check all that apply) RESULTS
E Market research EI Public notice given, ilst 0 no alternatives were Identified
0 Other vendors contacted [] Other r-i no alternatives were deemed acceptable
L- (explain below):
Describe the search from above in detail:
The Human Services Campus is the only on of its kind in downtown Phoenix.
PRICE
MC1-35243 states: The Using Agency requesting a Competition Impracticable Procurement shall provide written evidence
to support a Competition Impracticable determination containing an explanation of why the proposed procurement
• recess is Advantageous to the County; and the scope,durat'on, and estimated total dollar value of the procurement.
Price has been fairly and reasonably established by: • Comparison to public sector contract pricing
ri Comparison to previous comparable purchases 111 Discount off published catalog pricing
" from a different vendor in Market survey
E Independent estimate Eil Other, explain:
Describe methodology and results (attach any written supporting data, e.g., survey or market analysis):
This is the amount available from our grant funds.

CERTIFICATIONS
I certify:
1) I recognize that the Maricopa County Procurement Code requires the use of competitive solicitations unless
exempted by law. I have reviewed the information and materials relevant to this procurement of goods and services,
and am requesting approval of an exception to the competitive process for the reasons described;
21 the price to be paid to the proposed single source vendor is fair, reasonable, and provides the best value to Maricopa
County; and
3) this request for an exception to the competitive solicitation process is not the result of inadequate advance planning
or for purposes of securing the services of a preferred vendor.
Agency Head or Agency Head Delegate Signature (Required)
Diane Deionge-Ryan (b P-1-0,62.-z_____ 10/13/2016
Printed Name 'Signature Date
Office of Procurement Services
The CPO can approve procurements up to $100,000. This request is over $100,000 and must be submitted as an agenda
item to the Board of Supervisors for consideration.
d'Recommended
to BOS for approval
....----- 7-6 ,----- i-c\_ , ..... 7—...,_ _ dc
0 4 6. / V/
14.)-teg Name ture Date
ave

ATTACHMENT A
FEE SCHEDULE
Brighterway institute
Date: 10/14/2016 Page: 1
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
Cancelled Cancelled Appointment 0.00 0.00 0.00
D0001 Photo / Phone Call to Lab 0.00 0.00 0.00
d0002 RE -treatment plan 0.00 0.00 0.00
00003 Tx Plan Synopsis 0,00 0,00 0.00
D0120 Periodic Oral Evaluation 50.00 0.00 0.00
D0140 Emergency Exam 75.00 0.00 0.00
D0145 Child Exam - under 3 years old 66.00 0.00 0,00
D0150 Comprehensive Exam 86.00 0.00 0.00
00151 Pedo Exam 0,00 0.00 0,00
D0160 Detail/extensive oral eval, B/R 53.00 0.00 0.00
D0170 Limited re-evaluation estab pat 70.00 0.00 0.00
D0171 Re-eval - Post-op Office Visit 0.00 0.00 0.00
D0180 Perio Evaluation 93.00 0.00 0.00
D0210 FMX - Complete Set 132.00 0.00 0.00
D0220 1 FA X-ray 30.00 0.00 0.00
• D0230 Additional PA X-ray 24.00 0.00 0.00
D0240 Intraoral-occlusal film 41.00 0.00 0.00
D0250 Extraoral-first film 59.00 0.00 0.00
• D0260 Extraoral-each additional film 51.00 0.00 0.00
D0270 1 Bitewing 28.00 0.00 0.00
D0272 2 Bitewing X-rays 46.00 0.00 0.00
00273 3 Bitewings 55,00 0.00 0,00
00274 4 Bitewing X-rays 66.00 0.00 0.00
00277 Vertical Bitewings 97.00 0,00 0.00
D0290 Skull &facial bone survey film 127.00 0.00 0.00
D0310 Sialography 357,00 0,00 0.00
00320 TMJ arthrogram, incl injection 539.00 0.00 0.00
00321 Other TMJ films, by report 204.00 0.00 0.00
D0322 Tomographic survey 497.00 0,00 0.00
D0330 Panoramic X-ray 112.00 0.00 0.00
D0340 Cephalometric film 122.00 0.00 0.00
D0350 Oral/Facial Photographic Images 71.00 0.00 0.00
00351 3D Photographic Image 0.00 0.00 0.00
00415 Collection of microorg culture 173.00 0.00 0.00
00416 Viral Culture 163.00 0.00 0.00
00417 Collection of saliva sample 153.00 0.00 0.00
00418 Analysis of saliva sample 140.00 0.00 0,00
00421 Genetic test-suscept oral dis 148.00 0.00 0.00
00425 Caries susceptibility tests 88.00 0,00 0.00
D0431 Adjunc pre-diag test-detect muc 66.00 0.00 0.00
D0460 Pulp vitality tests 56.00 0.00 0.00
00470 Diagnostic casts 111.00 0.00 0.00
00502 Other oral path procedure, B/R 166.00 0.00 0.00
00999 Unspecified diag procedure, B/R 79.00 0.00 0,00
01110 Adult Cleaning- Prophy 92,00 0.00 0.00
01120 Child Cleaning (under 12) 68.00 0.00 0.00
01201 Prophylaxis with fluoride-child 80,00 0.00 0,00
01203 Fluoride - Child 29.00 0,00 0,00
D1204 Fluoride- Adult 29,00 0.00 0.00
D1205 Prophylaxis with fluoride-adult 101.00 0.00 0.00
D1206 Fluoride Varnish 39.00 0.00 0.00
D1310 Nutritional counseling 60.00 0.00 0.00
D1320 Tobacco counseling 75.00 0,00 0.00
DI 330 Ora/ hygiene instruction 52.00 0.00 0.00
01351 Sealant 56.00 0.00 0.00
01352 Preventive Restoration, Perm Th 95.00 0.00 0.00
D1353 Sealant repair - per tooth 0,00 0.00 0.00
01354 Interim caries arresting mods 0,00 0.00 0.00
01510 Space maint-fixed-unilateral 320.00 0,00 0,00
01515 Space maint-fixed.bilateral 426.00 0.00 0,00
01520 Space maint-remov-unilateral 391.00 0.00 0.00

FEE SCHEDULE
Brighterway Institute
Date: 10/14/2016 Page: 2
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
01525 Space maint-remov-bilateral 483.00 0.00 0.00
D1550 Recementation of space maint 82.00 0.00 0.00
01555 Removal of fixed space maint 79.00 0.00 0,00
02100 Final Impression 0.00 0.00 0,00
02101 Seat Crown 0.00 0.00 0.00
D2140 Amalgam- 1 Surface 142.00 0.00 0.00
02150 Amalgam -2 surface 177.00 0.00 0.00
02160 Amalgam -3 surface 216.00 0.00 0.00
02161 Amalgam - 4+ surface 255.00 0.00 0.00
02330 Composite Anterior 1 surface 156,00 0.00 0.00
02331 Composite - Anterior 2 surface 203.00 0.00 0.00
02332 Composite - Anterior 3 surface 249.00 0.00 0.00
02335 Composite - Anterior 4 surface 313.00 0.00 0.00
02390 Resin composite crown, anterior 452.00 0.00 0.00
02391 Composite -Posterior 1 surface 182.00 0.00 0.00
02392 Composite -Posterior 2 surface 234.00 0.00 0,00
02393 Composite -Posterior 3 surface 287.00 0.00 0.00
O2394 Composite -Posterior 4 surface 346.00 0.00 0.00
D2410 Gold foil-one surface 542.00 0.00 0.00
02420 Gold foil-two surfaces 653.00 0.00 0.00
D2430 Gold foil-three surfaces 775.00 0.00 0.00
D2510 Inlay-metallic-one surface 839,00 0.00 0.00
02520 Inlay-metallic-two surfaces 892,00 0.00 0.00
02530 Inlay-metallic-three + surfaces 954.00 0.00 0.00
02642 Onlay-metalfc-two surfaces 991.00 0.00 0.00
02543 Onlay-metallic-three surfaces 1018.00 0.00 0.00
O2544 Onlay-metallic-four + surfaces 1068.00 0.00 0.00
02610 Inlay-porcel/ceramic-1 surface 916.00 0.00 0.00
02620 Inlay-porcel/ceramic-2 surface 946.00 0.00 0.00
02630 Inlay-parcel/ceramic-3+ surface 1003.00 0.00 0.00
02642 Onlay-porcel/cerarn-2 surface 1018.00 0.00 0.00
02643 Onlay-porcel/ceram-3 surface 1058.00 0,00 0.00
02644 Onlay-porcel/ceram-4 + surface 1101.00 0,00 0.00
02650 Inlay-resin based composite-1s 859,00 0.00 0.00
02651 Inlay-resin based composite-2s 882.00 0.00 0.00
D2652 Inlay-resin based composite-3+s 922,00 0.00 0.00
02662 Onlay-resin based composite-2s 944.00 0.00 0.00
02663 Onlay-resin based composite-3s 979.00 0.00 0.00
02664 Onlay-resin based composite-4+s 1007.00 0.00 0.00
02710 Crown-resin composite(indirect) 916.00 0.00 0.00
02712 Crown-314 resin-based comp-ind 1008.00 0.00 0.00
D2720 Crown-resin w/high noble metal 1063.00 0.00 0.00
02721 Crown-resin w/ most base metal 998.00 0.00 0.00
02722 Crown-resin with noble metal 1025.00 0.00 0.00
02740 Crown-Zirconia/eMax 1140.00 0,00 0.00
02750 Crown -Porcelain Fused to Metal 1140.00 150.00 0.00
D2751 Crown-porc fused to base metal 1041,00 0.00 0.00
02752 Crown-porc fused noble metal 1084.00 0.00 0.00
02780 3/4 Gold Crown 1103.00 0.00 0.00
02781 Crown-3/4 cast most base metal 1022.00 0,00 0.00
O2762 Crown-3/4 cast noble metal 1057,00 0.00 0.00
02783 3/4 Porcelain Crown 1105.00 0.00 0.00
02790 Gold Crown 1156,00 150.00 0.00
02791 Crown-full cast base metal 1014.00 0.00 0.00
02792 Crown-full cast noble metal 1074.00 0.00 0.00
02794 Crown-titanium 1091.00 0.00 0.00
02799 Provisional crown 432.00 0.00 0.00
02910 Recement inlay/onlay/partial 110.00 0.00 0,00
O2915 Recernnt cast or prefab pst/cor 112.00 0.00 0.00
02920 Recement Crown 111 00 0.00 0.00
02929 Prefab Porcelain/C Crown-Prim 0.00 0.00 0.00

FEE SCHEDULE
Brig hterway Institute
Date: 10/14/2016 Page: 3
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
02930 Stainless Steel Crown- Baby Th 270.00 0.00 0,00
D2931 Stainless Steel Crown - Adult 321.00 0.00 0.00
02932 Prefabricated resin crown 356.00 0.00 0.00
D2933 Prefab stl crown w/resin window 305.00 0.00 0.00
D2934 Prefb esth cid sinl stl crn-prm 366.00 0.00 0.00
02940 Sedative filling 122,00 0.00 0.00
02941 Interim Therapeutic Rest - Prim 0.00 0.00 0.00
D2949 Foundation for Indirect Rest 0.00 0.00 0.00
02950 Core Build Up 275.00 0,00 0.00
02951 Pin retention-/tooth, (-1, rest) 73.00 0.00 0.00
02952 Cast post &core in add to crown 419.00 0.00 0.00
02953 Each addrIcast post-same tooth 306.00 0.00 0.00
02954 Prefab Post & Coro 342.00 0.00 0.00
D2955 Post removal (not with endo) 293.00 0,00 0.00
D2957 Each + prefab post-same tooth 198.00 0.00 0.00
D2960 Labial veneer(laminate)-chairsd 667.00 0.00 0.00
D2961 Labial veneer (resin larnin)-lab 956,00 0.00 0.00
02962 Veneer 1152.00 0.00 0.00
02970 Temporary crown (fractured th) 377.00 0.00 0.00
D2971 Adel prc-new cm undr exs dent 178.00 0.00 0.00
02975 Coping 605.00 0.00 0.00
D2980 Crown repair, by report 288.00 0.00 0.00
D2999 Unspecif restorative proced B/R 165.00 0.00 0.00
03110 Pulp cap-direct, (+rest) 83,00 0.00 0.00
03120 Pulp cap-indirect, (+ rest) 82.00 0.00 0.00
03220 Pulpotomy 200,00 0.00 0.00
D3221 Pulp Debridement (Start RCT) 228.00 0.00 0.00
D3222 Partial pulpototomy apexogen 288.00 0.00 0.00
D3230 Puipectomy - Front, Baby Tooth 275.00 0.00 0.00
D3240 Pulpectomy - Molar, Baby Tooth 305.00 0.00 0.00
03310 Finish Root Canal - Anterior 756.00 0.00 0.00
D3320 Finish Root Canal - Bicuspid 863.00 0.00 0.00
D3330 Finish Root Canal - Molar 1030.00 0.00 0.00
D3331 Treatmnt of root canal obstruct 563.00 0.00 0.00
D3332 Incompit endo ther-inopbl/unres 451.00 0.00 0,00
03333 Int root repair of pert defects 344.00 0.00 0.00
03346 Retreat, prey RCT - anterior 860,00 0.00 0.00
D3347 Retreat, prey RCT - bicuspid 973.00 0.00 0.00
03348 Retreat, prey RCT - molar 1155.00 0.00 0,00
D3351 Apexification/recalcif, initial 357.00 0.00 0.00
03352 Apexification/recalcif, interim 255.00 0.00 0.00
03353 Apexificationtrecalcif, final 532.00 0.00 0.00
03355 Pulpal Regeneration - 1st visit 0,00 0.00 0.00
D3356 Pulpal Rgn - interim med Replc 0.00 0.00 0.00
D3357 Pulpal Regen - completion 0.00 0.00 0.00
03410 Apicoectomy/Periradic surg-ant 697.00 0.00 0,00
03421 Apicoect/Perirad-bicus/1st root 784,00 0.00 0.00
03425 Apicoect/Perirad-molarhst root 890,00 0.00 0.00
03426 Apicoect/Perirad (each + root) 406.00 0.00 0.00
03427 Periradicular surg-no apicoect 0.00 0.00 0.00
03428 Bone Graft w/Perirdc Sig 1 Site 0.00 0,00 0.00
D3429 Bn Graft w/Berirdc Srg each add 0.00 0.00 0.00
03430 Retrograde filling-per root 280.00 0.00 0.00
03431 Bio Mtri to aid Reg w/Prcio Srg 0.00 0.00 0.00
03432 Guided TissRgn PerSite w/PrdSrg 0.00 0.00 0.00
03450 Root amputation-per root 482.00 0.00 0.00
03460 Endodontic endosseous implant 1462.00 0.00 0.00
03470 Intentional replant, inc splint 787.00 0.00 0.00
D3910 Surg isolation of th w/rub dam 229.00 0.00 0.00
03920 Hemisection, no root can ther 467.00 0.00 0.00
03950 Canal prep/fit of dowel/post 254.00 0.00 0.00

FEE SCHEDULE
Brighterway Institute
Date: 10/14/2016 Page: 4
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
D3999 Unspecified endo procedure, B/R 237,00 0.00 0.00
04210 Gingivectorny-4+ per quadrant 629.00 0.00 0.00
04211 Gingivectorny-1-3 contig th/quad 290.00 0,00 0.00
04212 Gingivectomy-Access/Restoration 0.00 0.00 0.00
D4230 Anatomical crwn exp,4+teeth/qu 692.00 0.00 0.00
04231 Anatomical crwn exp,1-3 th/quad 582.00 0.00 0.00
D4240 Ging flap,root pin, 4+ per quad 743.00 0.00 0.00
D4241 Ging flap rt pin 1-3 cntg th/qu 613.00 0.00 0.00
04245 Apically positioned flap 813,00 0.00 0.00
04249 Crown Lengthening 755.00 0.00 0.00
04260 Osseous Surgery Per/Tooth 1073.00 0.00 0.00
04261 Osseous surg- 1-3 contg th/quad 874.00 0.00 0.00
04263 Bone Grafting 647.00 0.00 0.00
04264 Bone replace graft-each add/qu 509.00 0.00 0.00
04265 Bio mat, sft&osseous liss regen 598.00 0,00 0.00
04266 Guided tiss regen-resorb-per 744.00 0.00 0.00
04267 Guided tiss regen-nonresorb-per 898.00 0.00 0,00
04268 Surg revision proc, per tooth 780.00 0.00 0.00
D4270 Pedicle soft tissue graft proc 834.00 0.00 0.00
04273 Subepithelial con tis graft/th 1049.00 0.00 0.00
04274 Distal/proximal wedge procedure 661.00 0.00 0.00
04275 Soft tissue allograft 960.00 0,00 0.00
D4276 Comb cnct tiss&dbl pedicle grft 1084.00 0.00 0.00
D4277 Soft Tissue Graft, 1st Tooth 0.00 0.00 0,00
04278 Soft Tissue Graft, Each Add'I 0.00 0.00 0.00
04320 Provisional splinting-intracor 516.00 0.00 0.00
04321 Provisional splinting-extracor 470.00 0,00 0.00
04341 SRP - per Quadrant 258.00 0,00 0.00
D4342 SRP - 1-3 teeth 187.00 0.00 0.00
04355 Full Mouth Debridemnt 183.00 0.00 0.00
D4381 Local deliv antimicrb ag-th B/R 72.00 0.00 0.00
04910 Periodontal Maintenance 137.00 0.00 0.00
04920 Unscheduled dressing change 102.00 0.00 0.00
04921 Gingival Irrigation-Per Quad 0.00 0.00 0.00
D4999 Unspecified perio proced, B/R 86.00 0.00 0.00
D5104 Overdenture Amalgam Cap 0.00 0.00 0,00
05105 Wax Bite Rims / Metal Framework 0.00 0.00 0.00
05106 Wax Try-in 0.00 0,00 0.00
05107 Deliver Denture 0.00 0,00 0.00
05108 Deliver Partial 0,00 0.00 0.00
D5110 Upper Denture - Initial Imp. 1728.00 250.00 0.00
D5120 Lower Denture - Initial imp. 1730.00 250.00 0,00
D5130 Immediate Upper Denture / Imp 1832.00 250.00 0.00
05140 Immediate Lower Denture / Imp 1836.00 250.00 0.00
D5211 Maxillary partial - Impression 1338.00 360.00 0.00
D5212 Mandibular partial - Impression 1338.00 350.00 0.00
05213 Upper Partial Denture - Imp 1781.00 350.00 0,00
05214 Lower Partial Denture - Imp 1816.00 350.00 0.00
05221 Immed maxii part' dent w/resin 0.00 0.00 0.00
05222 Immed mand partl dent w/resin 0,00 0.00 0.00
D5223 lmd Max part-cast met' w/resin 0.00 0.00 0.00
05224 Imd Mond part-cast met! w/resin 0.00 0,00 0.00
05225 Upper Vail)last 1577.00 0.00 0,00
05226 Valplast Lower 1569.00 0.00 0.00
05281 Removable unirat part denture 1001.00 0.00 0,00
05410 Adjust Upper Denture 90.00 0.00 0.00
05411 Adjust Lower Denture 90.00 0.00 0.00
05421 Adjust Upper Partial 90.00 0.00 0.00
05422 Adjust Lower Partial 90.00 0.00 0.00
05510 Repair Broken Denture 213.00 100.00 0,00
05520 Replace Tooth on Denture 188.00 100.00 0.00

FEE SCHEDULE
Brighterway Institute
Date: 10/14/2016 Page: 5
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
05610 Repair Chipped Denture 208.00 100.00 0.00
06620 Repair cast framework 292,00 100.00 0.00
D5630 Repair Broken Clasp on Partial 270,00 100.00 0.00
D5640 Replace tooth on Partial 189.00 100.00 0.00
D5650 Add tooth to exist part denture 229.00 100.00 0.00
D6660 Add clasp, exist part denture 271.00 100.00 0.00
05670 Replace all th&acrylic-maxil 714.00 0.00 0,00
05671 Replace all th&acryllc-rnand 734.00 0.00 0,00
05710 Rebase complete maxil denture 585,00 100.00 0.00
05711 Rebase complete mand denture 585.00 100.00 0.00
05720 Rebase maxil partial denture 570.00 100.00 0.00
D5721 Rebase mand partial denture 570.00 100,00 0,00
05730 Reline Upper Soft 378.00 0.00 0,00
05731 Reline Lower Soft 377.00 0.00 0.00
05740 Reline maxii partial-chairside 366.00 0.00 0.00
D5741 Reline mand partial-chairside 368,00 0.00 0.00
05750 Reline Upper Denture-Lab 474.00 100.00 0.00
D5751 Reline Lower Denture-Lab 478.00 100,00 0.00
05760 Reline Upper Partial 471.00 0.00 0.00
05761 Reline Lower Partial 471.00 100.00 0,00
05810 Larell Denture Max 856.00 100.00 0.00
D5811 Larell Denture Lower 869.00 100.00 0.00
D5820 Upper Flipper 692,00 100.00 0.00
05821 Lower Flipper 693.00 100.00 0.00
05850 Tissue condition - Upper 204.00 0,00 0.00
05851 Tissue condition - Lower 204.00 0.00 0.00
D5860 Overdenture- initial impression 712.00 350.00 0.00
D5861 Over - Partial 1900.00 0.00 0.00
D5862 Implant Attachment 450.00 100.00 0.00
05867 ERA/Zest Replacement 366.00 0,00 0,00
05875 Mod of remvble prosth-post surg 404,00 0.00 0.00
05899 Unspecified remove prosth, B/R 499.00 0.00 0.00
05911 Facial moulage (sectional) 320.00 0.00 0.00
05912 Facial moulage (complete) 508.00 0.00 0.00
05913 Nasal prosthesis 2595,00 0.00 0.00
D5914 Auricular prosthesis 2605.00 0.00 0.00
05937 Trismus appliance (not TMD) 672.00 0.00 0.00
05951 Feeding aid 883.00 0.00 0,00
05982 Surgical stent 433.00 0.00 0.00
D5986 Fluoride gel carrier 199.00 0.00 0,00
05987 Cornmissure splint 443,00 0.00 0.00
D5988 Surgical splint 743,00 0.00 0.00
05991 Topical medicament carrier 219.00 0.00 0.00
05992 Adj Max'facial Prosth, Report 0.00 0.00 0.00
05993 Maint Max'facial Prosth, Report 0.00 0.00 0.00
D5999 Unspec maxillofacial prosth B/R 705.00 0.00 0.00
06000 Seat Bridge 0.00 0.00 0.00
06010 Implant 1920.00 0.00 0,00
06011 Second stage implant surgery 0.00 0.00 0.00
06012 Plemnt of intrm impl: endosteal 1574.00 0.00 0,00
06040 Surgic place: eposteal implant 7619.00 0.00 0.00
06050 Surg place: transosteal implant 5404.00 0.00 0.00
D6051 Interim Abutment 0,00 0.00 0.00
06052 Semi-precision attchmt abutment 0.00 0.00 0.00
06053 Implant Overdenture 2500.00 0.00 0.00
06055 Dent implant sup connecting bar 2946.00 0.00 0.00
D6056 Abutment - Prefabricated Stock 748.00 0.00 0.00
06057 Abutment - Custom Fabricated 883.00 0.00 0.00
06058 Implant Crown - Porcelain 1425,00 0.00 0.00
06059 Implant Crown - PFM 1427.00 0,00 0.00
06060 Abtmt supp porc fused-base met1 1360.00 0.00 0,00

FEE SCHEDULE
Brighterway Institute
Date: 10/14/2016 Page: 6
,
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
06061 Abtmt supp porc fused-mil crown 1374.00 0.00 0.00
06062 Implant Crown - Gold 1426.00 0.00 0.00
D6063 Abtmt supp cast ml! crown-base 1333.00 0.00 0.00
06064 Abtmt supp cast mtl crown-noble 1369.00 0.00 0.00
06066 Implant supp porc fused ml! cmn 1506.00 0.00 0,00
06067 Implant supported metal crown 1626.00 0.00 0.00
06068 Abtmt supp ret for porc/cer FPD 1436.00 0.00 0.00
D6069 Abut sup ret-porc fsci ml! FPDhn 1444.00 0.00 0.00
D6070 Abut sup ret-porc fsd ml! FPDbm 1342.00 0.00 0.00
06071 Abut sup ret-porc fsd mtl FPDno 1356.00 0.00 0.00
06072 Abut sup ret-cast ml! FPD-hinob 1434.00 0.00 0.00
O6073 Abut sup ret-cast ml! FPD-base 1343.00 0.00 0.00
06074 Abut sup ret-cast ml! FPD-noble 1351.00 0.00 0.00
06075 Implant supp ret-ceramic FPD 1492.00 0.00 0.00
06076 Impint supp ret-pro fuse mtIFPD 1518.00 0.00 0.00
06077 Implant supp ret-cast metal FPD 1529.00 0.00 0.00
06079 Hybrid Valplast w/Cast frame 0.00 0.00 0.00
06080 Implant Maintenance 285,00 0.00 0,00
06090 Repair implant sup prosth, B/R 732,00 0,00 0.00
06091 Rpl Overdenture Insert/Attchmnt 582.00 0.00 0.00
D6092 Recement irnpl/abut sup crown 157,00 0.00 0.00
D6093 Recement impl/abut sup FPD 181.00 0.00 0.00
06094 Abutment supp crown - titanium 1269.00 0.00 0.00
06095 Repair implant abutment, B/R 726.00 0.00 0,00
• D6100 Implant removal, by report 749.00 0.00 0.00
06101 Debride Pen-Implant Defect 0.00 0.00 0.00
• 06102 Debride/Oss Peri-Implant Defect 0.00 0.00 0.00
06103 Bone Graft Rep Pen-Imp Defect 0.00 0.00 0.00
• 06104 Bone Graft, Implant Placement 0.00 0.00 0.00
06110 Imp/abt sup RD - ednt max 0.00 0.00 0,00
06111 Imp/abt sup RD - ednt mand 0.00 0.00 0.00
06112 Imp/abt sup RD - Part-ednt max 0.00 0.00 0.00
06113 Impiabt sup RD - Part-ednt mend 0.00 0.00 0.00
D6114 Imp/abt sup FD - edni max 0.00 0.00 0.00
06115 Imp/abt sup FD edni mand 0.00 0.00 0.00
O6116 Imp/abt sup FD - Part-ednt max 0.00 0.00 0.00
O6117 Imp/abt sup FD - Part-ednt rnand 0.00 0.00 0.00
06190 CT scan for implants 334.00 0.00 0.00
06194 Abut sup ret-cast mtl FPD-iitan 1369.00 0.00 0,00
06195 Healing Abutment 0.00 0.00 0.00
06199 Unspecified implant proced, B/R 392.00 0.00 0.00
06205 Pontic-Indirect res based comp 967.00 0,00 0.00
O6210 Pontic - Gold 1114.00 150.00 0.00
06211 Poniic-cast predominantly base 1018.00 0.00 0.00
06212 Poniic-cast noble metal 1059.00 0.00 0.00
06214 Ponilc-titanium 1068.00 0.00 0.00
06240 Pontic PFM 1119.00 150.00 0.00
06241 Pontic-porcelain fused to base 1043.00 0.00 0.00
06242 Pontic-porcelain fused to nob! 1074.00 0.00 0.00
06245 Pontic - Zirconia/eMAx 1136.00 0.00 0.00
D6250 Pontic-resin w/ high noble met 1079.00 0.00 0.00
08251 Pontic-resin WI predomnt base 1042.00 0.00 0.00
06252 Pontic-resin with noble metal 1047.00 0.00 0.00
06253 Provisional pontic 661,00 0.00 0.00
06254 Interim Pontic 0.00 0.00 0.00
06545 MARYLAND BRIDGE(metal wings) 814,00 0.00 0.00
06548 MARYLAND BRIDGE(pontic) 946.00 0.00 0.00
06549 Ret-res - Res bnd fxd pros 0.00 0.00 0.00
06600 Inlay-porcelain/ceramic, 2 surf 976.00 0.00 0.00
06601 Inlay-porcelain/ceramic, 3.4-surf 1034.00 0.00 0.00
D6602 Inlay-cast high noble met,2surf 1002.00 0,00 0.00

FEE SCHEDULE
Brig hterway Institute
Date: 10/14/2016 Page: 7
CODE DESCRIPTION UDR LAB EXPENSE MATERIAL
D6603 Inlay-cast high nob met, 3+surf 1035.00 0.00 0.00
O6604 inlay-cast predomni base, 2surf 968.00 0.00 0.00
D6605 Inlay-cast predomnt base,3+surf 1000.00 0.00 0.00
D6606 Inlay-cast noble metal, 2 surf 978.00 0.00 0.00
' D6607 Inlay-cast noble metal, 3+ surf 1032.00 0.00 0.00
D6608 Onlay-porcelain/ceramic, 2 surf 1040.00 0.00 0.00
' 06609 Onlay-porcelain/ceramic, 3+surf 1113,00 0.00 0.00
06610 Onlay-cast high noble met,2surf 1068.00 0.00 0.00
06611 Onlay-cast high nob met, 3+surf 1119.00 0.00 0.00
D6612 Onlay-cast preclomnt base, 2surf 1088.00 0.00 0.00
D6613 Onlay-cast predomnt base,34surf 1052.00 0.00 0.00
D6614 Onlay-cast noble metal, 2 surf 1036.00 0.00 0.00
06615 Onlay-cast noble metal, 3+ surf 1081.00 0.00 0.00
06624 Inlay-titanium 1057.00 0.00 0.00
O6634 Onfay-titanium 1104.00 0,00 0.00
D6710 Retainer orn-indir res-bas comp 992.00 0.00 0.00
D6720 Retainer crn-res w/ hi nob met 1068.00 0.00 0.00
D6721 Retainer cm-resin w/ base met 1019.00 0.00 0.00
06722 Retainer cm-resin w/ nob met 1052,00 0.00 0.00
06740 Bridge Abutment Zirconia/eMax 1142.00 0.00 0.00
06750 Bridge Abutment/Retainer - PPM 1145.00 150.00 0.00
06751 Retainer ern-pore fuse-base met 1043.00 0.00 0.00
05752 Retainer crn-porc fused-nob met 1083.00 0.00 0.00
06780 Retainer crn-3/4 cast h nob met 1092.00 0.00 0.00
06781 Crown-3/4 cast most base metal 1021.00 0.00 0.00
06782 Crown-3/4 cast noble metal 1066.00 0.00 0.00
06783 Crown-3/4 porcelain/ceramic 1103.00 0.00 0.00
06790 Bridge Abutment/Retainer - Gold 1119.00 150.00 0.00
06791 Retainer cm-full cast base 1034.00 0.00 0.00
06792 Retainer cm-full cast nob met 1068.00 0.00 0.00
06793 Provisional retainer crown 504,00 0.00 0.00
06794 Retainer crown-titanium 1054.00 0.00 0.00
06795 Interim Retainer Crown 0.00 0.00 0.00
D6920 Connector bar 1011.00 0.00 0.00
06930 Recement Bridge 173.00 0.00 0.00
D6940 Stress breaker 417.00 0,00 0.00
06950 Precision attachment 656.00 150.00 0.00
O6972 Prefab Post under Bridge 285.00 0.00 0.00
06973 Core Buildup Under Bridge 0.00 0.00 0.00
D6980 Fixed partial dent. repair, B/R 391.00 0.00 0.00
06985 Pediatric part'l denture, fixed 865.00 0.00 0.00
06999 Unspec fixed prosth proced, B/R 204.00 0.00 0.00
07111 Extraction crni remnts-decid th 133,00 0.00 0.00
07140 Extraction 176.00 0.00 0.00
07210 Extraction - Surgical 280.00 0.00 0.00
D7220 Extraction - Soft Tissue Impact 315.00 0.00 0.00
D7230 Extraction - Part Bony 397.00 0.00 0.00
07240 Extraction - Full Bony 483.00 0.00 0.00
07241 Extraction - Impacted/Complex 771.00 0.00 0.00
D7250 Extraction - Root Tip 305.00 0.00 0.00
D7251 Coronectomy-part tooth removal 401.00 0.00 0.00
D7257 Post-op 0.00 0.00 0.00
D7260 Oral antral fistula closure 931.00 0.00 0.00
D7261 Prim closure sinus perforation 745.00 0.00 0.00
D7270 ReimpIantation/stabilization 551.00 0.00 0.00
D7272 Tooth transplantation 698.00 0.00 0.00
D7280 Surgical access unreupted tooth 473.00 0.00 0.00
D7282 Mobifiz eruptimalpos th-erupt 489.00 0,00 0.00
D7283 Plcmnt of devc fo facil erup th 489.00 0.00 0.00
D7285 Biopsy of oral tissue-hard 418.00 0.00 0.00
07286 Biopsy of Soft Tissue 325.00 0.00 0.00

FEE SCHEDULE
Brig hterway Institute
Date: 10/14/2016 Page: 8
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
D7287 Exfotiative cyt sample collectn 178.00 0.00 0.00
D7288 Brush biopsy-transeplth sample 189.00 0,00 0.00
D7290 Surgical reposition of teeth 884.00 0.00 0.00
D7291 T/SC Fiberotomy, B/R 305.00 0.00 0.00
07292 Plcmnt: temp anch scrw rind pit 3016.00 0.00 0.00
07293 Plcmnt: temp anch w/ surg flap 2292.00 0.00 0.00
D7294 Plcmnt: temp anch w/o surg flap 1535.00 0.00 0.00
07295 Bone Harvest for Grafting 509.00 0.00 0.00
07310 Alveoloplasty w/ Extractions 300.00 0.00 0.00
07311 Alveoloplasty w/ext 1-3 th/quad 300.00 0.00 0.00
07320 Alveoloplasty without Exts 435,00 0.00 0.00
07321 Alveoloplsty w/o ex 1-3 th/quad 421.00 0.00 0.00
07340 Vestibuloplasty-ridge ext -2nd 1133.00 0.00 0.00
D7350 Vestiplasty-ridge ext (inc) 2255.00 0.00 0.00
07410 Excision benign lesion<=1.25crn 399.00 0.00 0.00
• D7411 Excision benign lesion>1,25 cm 390.00 0.00 0.00
07412 Excision benign lesion,complic 839,00 0.00 0.00
07413 Excision malig lesion<=1.25cm 717,00 0.00 0.00
D7414 Excision malig lesion>1.25cm 1079.00 0.00 0.00
• D7415 Excision maligiesion,complic 1209.00 0.00 0.00
07440 Ex matig tumor-diam <= 1.25 cm 963.00 0.00 0.00
D7441 Ex malig tumor-diarn > 1.25 cm 1226.00 0.00 0.00
07450 Rem benign odont-diam<=1,25cm 574,00 0.00 0.00
07451 Rem benign odont-diam>1.25 cm 785,00 0.00 0,00
• D7460 Rem benign nonodont-di<=1.25cm 561.00 0.00 0.00
D7461 Rem benign nonodont-diam>1.25cm 841.00 0,00 0.00
D7465 Destruct lesion-phys/chem B/R 302,00 0.00 0.00
07471 Rem at exostosis-maxil/mand 666.00 0.00 0.00
07472 Removal of torus palatinus 845,00 0.00 0.00
07473 Removal of torus mandibularis 784.00 0.00 0.00
07485 Surg reduc, osseous tuberosity 738.00 0.00 0.00
07490 Rad resectn-maxilla or mandible 7343.00 0.00 0.00
07510 Incise & Drain - Intraoral 240.00 0.00 0.00
07511 Incis&drain abscs-int soft comp 331.00 0.00 0.00
07520 incis&drain abscess-extra soft 438.00 0.00 0.00
07521 Incis&drain abscs-ext soft comp 585.00 0.00 0,00
D7530 Removal of Foreign Body -Tissue 356.00 0.00 0.00
D7540 Remove foreign body from bone 635.00 0.00 0,00
D7550 Partial ostect/sequestrectomy 544.00 0.00 0.00
D7560 Maxi11 sinusotomy-rem foreign 1311.00 0.00 0.00
07610 Maxilla-open red (teeth immob) 4274,00 0.00 0.00
07620 Maxilla-closed red(teeth immob) 3358.00 0.00 0.00
07630 Mandible-open red (teeth immob) 4559.00 0.00 0.00
D7640 Mandible-closed red (th immob) 3355.00 0.00 0.00
07650 Malar/zygomat arch-open reduc 3856.00 0.00 0.00
07660 Malar/zygo arch-closed reduc 3325.00 0.00 0.00
D7670 Alveolus-closed reduction 1628.00 0.00 0.00
07671 Alveolus-open reduction 1319.00 0.00 0.00
D7680 Facial bone-complicated reduct 6745.00 0.00 0.00
07710 Maxilla-open reduction 4499.00 0.00 0.00
D7720 Maxilla-closed reduction 3474.00 0.00 0.00
07730 Mandible-open reduction 4847.00 0.00 0.00
07740 Mandible-closed reduction 3617.00 0.00 0.00
07750 Malar/zygomatic arch-open red 4173.00 0,00 0.00
07760 Malar/zygomatic arch-close red 5779.00 0.00 0.00
07770 Alveolus-stabilize teeth, open 2805,00 0.00 0,00
07771 Alveolus-stabilize teeth,closed 1932.00 0.00 0.00
D7780 Facial bones-complicated reduc 8163.00 0.00 0.00
07810 Open reduction of dislocation 4128.00 0.00 0.00
07820 Closed reduction of dislocate 618.00 0.00 0,00
07830 Manipulation under anesthesia 931,00 0.00 0.00

FEE SCHEDULE
Brighterway Institute
Date: 10/14/2016 Page: 9
CODE DESCRIPTION OCR LAB EXPENSE MATERIAL
D7840 Condylectomy 5238.00 0.00 0.00
07850 Surgical discect:w/ w/o implant 5187.00 0.00 0.00
D7852 Disc repair 5607.00 0.00 0.00
D7854 Synovectomy 5267.00 0.00 0.00
D7856 Myotomy 5881.00 0.00 0.00
D7870 Arthrocentesis 535.00 0.00 0.00
D7880 Occlusal orthotic device 857.00 0.00 0.00
07910 Suture of small wounds to 5cm 299.00 0.00 0,00
07911 Complicated suture-up to 5 cm 451.00 0.00 0.00
07912 Complicated suture-over 5 cm 717.00 0.00 0.00
07920 Skin grafts, by report 2784.00 0.00 0.00
D7940 Osteoplasty-orthognathic defor 4008.00 0.00 0.00
D7941 Osteotorny-mandibular rami 9158.00 0.00 0.00
07943 Osteotomy-mand rami w/ graft 8789.00 0.00 0.00
07944 Osteotomy-segment/subap-s/quad 7040.00 0.00 0.00
07945 Osteotomy-body of mandible 6930.00 0.00 0,00
D7946 LeFort I (maxilla-total) 8425.00 0.00 0.00
D7947 LeFort I (maxilla-segmented) 8494.00 0.00 0.00
D7948 LeFort II/III-no bone graft 9768.00 0.00 0.00
07949 LeFort II/III-with bone grafi 11636.00 0.00 0.00
07950 Osseous/cartilage graft-mandB/R 2114.00 0.00 0.00
07951 Sinus augmentation w/bone 2748.00 0.00 0.00
07953 Bone repl grft ridge prsv/site 475.00 0.00 0.00
D7955 Rep maxillofacial sft/hrd tis 2111.00 0.00 0.00
07960 Frenulectomy-separate procectur 447.00 0.00 0.00
07963 Frenuloplasty 477.00 0.00 0.00
07970 Excision, hyperplast ties-arch 505.00 0.00 0,00
07971 Excision-pericoronal ging /arch 255,00 0.00 0.00
07972 Surg reduc, fibrous tuberosity 712.00 0.00 0.00
07980 Sialofithotomy 769.00 0.00 0.00
07982 Sialodochoplasty 1740,00 0.00 0.00
07983 Closure of salivary fistula 1566.00 0.00 0.00
D7990 Emergency tracheotomy 1451.00 0.00 0.00
07991 Coronoidectomy 3846.00 0.00 0.00
07997 Appliance removal-incl archbar 338.00 0,00 0.00
D7998 Plcmnt of devc w/o fracture 2479.00 0.00 0.00
D7999 Unspecified oral surg proc, B/R 170.00 0.00 0.00
08010 Limited ortho trt, primary dent 2112,00 0.00 0.00
D8020 Limited ortho trt, transitional 2400.00 0.00 0.00
08030 Limited ortho treat, adolescent 2798.00 0.00 0.00
D8040 Limited ortho treat, adult dent 2943.00 0.00 0.00
D8050 Intercep orth trt, primary dent 2443.00 0.00 0.00
D8060 'Mercer) orth trt, transitional 2720.00 0.00 0.00
08070 Comprehensive orth,transitional 5101.00 0.00 0.00
08080 Comprehensive ortho, adolescent 5160.00 0.00 0.00
08090 Orthodontics/Braces - Adult 5280.00 0.00 0,00
08210 Removable appliance therapy 848.00 0.00 0,00
D8220 Fixed appliance therapy 946 00 0.00 0.00
08660 Pre-orthodontic treatment visit 464.00 0.00 0.00
08680 Orthodontic Retention/Retainer 450,00 0.00 0.00
08690 Ortho treatment (bill/contract) 270,00 0.00 0.00
D8691 Repair of orthodontic appliance 214.00 0.00 0.00
D8692 Retainer replacemnt-lost/broken 305.00 0.00 0.00
D8693 Rebond/repair of fixed retainer 286.00 0.00 0.00
08999 Unspec ortho procedure, B/R 128.00 0.00 0.00
09110 Emergency Pallative Treatment 127.00 0.00 0.00
09120 Fixed partl denture sectioning 217.00 0.00 0.00
D9210 Local anesthesia not op/surg 71.00 0.00 0.00
D9211 Regional block anesthesia 92.00 0,00 0.00
D9212 Trigeminal division blk anesth 253.00 0.00 0.00
D9215 Local anesthesia 61,00 0.00 0.00

FEE SCHEDULE
Brighterway institute
Date: 10/14/2016 Page: 10
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
09219 Eval for deep sedat/gen anesth 0.00 0.00 0.00
D9220 Deep sedat/gen anesth-1st 30m 383,00 0.00 0.00
D9221 Deep sedat/gen anesth-ea+15m 163,00 0.00 0.00
D9223 Deep sedat/gen anesth-ea15m 0.00 0.00 0.00
D9230 Nitrous Oxide 72.00 0.00 0.00
D9241 lntravn cons sed/analg-1st 30m 342.00 0.00 0.00
09242 Intravn cons sedianalg-eal5m+ 153.00 0.00 0,00
09248 Non IV conscious sedation 305.00 0.00 0.00
09310 Consultation 127.00 0.00 0.00
09311 Consult with Dr. V 0.00 0.00 0.00
d9312 Implant Consult 0,00 0.00 0.00
09313 Consult with Harold/Dr, Scafaru 0.00 0,00 0,00
09315 Consult with Dr. Rushlo 0.00 0.00 0.00
09410 House/extended care facility 214.00 0.00 0,00
D9420 Professional hospital call 271.00 0,00 0.00
D9430 Office Visit 76.00 0.00 0.00
09440 Office visit-after regular nrs 170,00 0.00 0.00
09450 Treatment Plan Presentation 143.00 0.00 0.00
09610 Therapeutic drug injection, B/R 92.00 0.00 0.00
09612 Therap parenterai drugs, 2+ 168.00 0.00 0.00
09630 Other drugs/medicaments, B/R 30.00 0.00 0.00
09910 Application of desensitize med 59,00 0.00 0.00
D9911 Apply desensitiz' resin, per th 76.00 0.00 0.00
09920 Behavior management, by report 137.00 0,00 0.00
09930 Treat complications-postsurgic 127.00 0.00 0.00
D9931 Clean/insp of rmvb1 appliance 0.00 0.00 0.00
09932 Clean/insp of maxi comp denture 0.00 0.00 0.00
09933 Clean/insp of mend comp denture 0,00 0.00 0.00
09934 Clean/insp of maxl part denture 0.00 0.00 0.00
09935 Clean/insp of mend part denture 0.00 0.00 0,00
09940 Night Guard 583,00 0.00 0.00
09941 Fabricate athletic mouthguards 250.00 0.00 0.00
09942 Repair/Refine of occlusal guard 239.00 0.00 0.00
09943 Deliver Night Guard 0.00 0.00 0.00
09950 Occlusal analysis-mounted case 336.00 0.00 0.00
09951 Occlusal adjustment-limited 179.00 0,00 0.00
09952 Occlusal adjustment-complete 661.00 0,00 0.00
09970 Enamel microabrasion 203.00 0.00 0.00
D9971 Odontoplasty 1-2 teeth-rmv enam 168.00 0.00 0.00
09972 Custom Tray 285.00 0.00 0.00
09973 External bleaching-per tooth 214.00 0.00 0.00
109974 Internal bleaching-per tooth 286,00 0,00 0,00
09991 Oral Cancer ScreeningNelscope 0.00 0.00 0.00
09999 Unspecified adjunct. proced,B/R 70.00 0.00 0.00
Missed Missed Appointment 0.00 0.00 0.00
Reschedul Rescheduled Appointment 0.00 0.00 0.00
07110 Suture Removal 125.00 0.00 0.00
07120 Extraction Additional 120.00 0,00 0.00
12345 Supernumerary tooth 0.00 0.00 0.00
15000 Drifting - Mesial 0.00 0.00 0.00
15001 Drifting - Distal 0.00 0.00 0.00
15002 Impacted - Distal 0.00 0.00 0.00
15003 Impacted - Mesial 0,00 0.00 0.00
15004 Bleeding 0.00 0.00 0.00
15006 Gum Abscess 0.00 0.00 0.00
15009 VVatch Tooth 0.00 0.00 0.00
16011 Hypersensitivity 0.00 0.00 0.00
15012 Recession 0.00 0.00 0.00
15101 Missing tooth 0.00 0.00 0.00
15104 Cavity 0.00 0.00 0.00
15108 Failing Filling 0,00 0.00 0.00

FEE SCHEDULE
Brighterway Institute
Date: 10/14/2016 Page: 11
CODE DESCRIPTION UCR LAB EXPENSE MATERIAL
15110 Fractured Tooth 0.00 0.00 0.00
15111 Residual Root Tip 0.00 0.00 0.00
15114 Unerupted tooth 0.00 0.00 0.00
15115 Root Abscess 0.00 0.00 0.00
15116 Supereruption 0.00 0.00 0.00