Dental Codes- Auth Requirement UCSLS Codes

Procedure Need Authorisation

Category Code Description
(Yes/No)

UCSLS 11101 POLISHING One unit of time No

UCSLS 11109 POLISHING Each additional unit over two No
UCSLS 11111 SCALING One unit of time No
UCSLS 11119 SCALING Each additional unit over six No
UCSLS 12101 Fluoride Treatment, Topical Application No
NUTRITIONAL COUNSELING Including: recording and analysis up
UCSLS 13101 No
to seven day dietary intake and consultation One unit of time

NUTRITIONAL COUNSELING Including: recording and analysis up

to seven day dietary intake and consultationNUTRITIONAL
UCSLS 13109 No
COUNSELING Including: recording and analysis up to seven day
dietary intake and consultation Each additional unit over four
ORAL HYGIENE INSTRUCTION/PLAQUE CONTROL
To include: brushing and/or flossing and/or embrasure cleaning
UCSLS 13211 No
Individual Instruction (one instructor to one patient) - excluding
audio-visual timeOne unit of time
ORAL HYGIENE INSTRUCTION/PLAQUE CONTROL
To include: brushing and/or flossing and/or embrasure cleaning
UCSLS 13219 No
Individual Instruction (one instructor to one patient) - excluding
audio-visual time Each additional unit over four
SEALANTS, PIT AND FISSURE (Mechanical and/or chemical
UCSLS 13401 preparation included) SEALANTS, PIT AND FISSURE (Mechanical No
and/or chemical preparation included) First tooth
SEALANTS, PIT AND FISSURE (Mechanical and/or chemical
UCSLS 13409 No
preparation included) Each additional tooth same quadrant
Preventive Restorative Resin (procedure that involves some
UCSLS 13411 preparation of the pits and/or fissures in tooth enamel and may No
extend into dentin in limited areas) First tooth
Preventive Restorative Resin (procedure that involves some
preparation of the pits and/or fissures in tooth enamel and may
UCSLS 13419 No
extend into dentin in limited areas) Each additional tooth same
quadrant
CONTROL OF ORAL HABITS, MISCELLANEOUS Motivation of
UCSLS 14301 Patient - Psychological Approach (e.g. thumb sucking, lip biting, No
etc.) - per visit + L
UCSLS 15604 Removal of Fixed Space Maintainer Appliances by Second Dentist. No
ANATOMIC MODIFICATIONS (Reshaping, recontouring, or occlusal
modifications of a natural tooth or teeth, single or multiple
restorations, or the inter-articulation of the teeth) FINISHING
UCSLS 16101 RESTORATIONS (To include: polishing, removal of overhangs, No
refining marginal ridges and occusal surgaces, etc. (when
restorations were performed by another dentist or restorations are
over two years old). One unit of time
ANATOMIC MODIFICATIONS (Reshaping, recontouring, or occlusal
modifications of a natural tooth or teeth, single or multiple
restorations, or the inter-articulation of the teeth) FINISHING
UCSLS 16109 RESTORATIONS (To include: polishing, removal of overhangs, No
refining marginal ridges and occusal surgaces, etc. (when
restorations were performed by another dentist or restorations are
over two years old). Each additional unit over four
DISKING OF TEETH,
UCSLS 16201 No
Interproximal One unit of time
DISKING OF TEETH,
UCSLS 16209 No
Interproximal Each additional unit over three
RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS
UCSLS 16301 No
One unit of time
RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS
UCSLS 16309 No
Each additional unit of time
RECONTOURING OF TEETH FOR FUNCTIONAL REASONS
UCSLS 16401 (not associated with delivery of a single or multiple prosthesis) No
One unit of time
RECONTOURING OF TEETH FOR FUNCTIONAL REASONS
UCSLS 16409 (not associated with delivery of a single or multiple prosthesis) No
Each additional unit of time
UCSLS 16511 OCCLUSION One unit of time No
UCSLS 16519 OCCLUSION Each additional unit over four No

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 Caries/Trauma/Pain Control (removal of carious lesions or existing
restorations or gingivally attached tooth fragment and placement
UCSLS 20111 No
of sedative/protective dressings, includes pulp caps when
necessary, as a separate procedure) First tooth
Caries/Trauma/Pain Control (removal of carious lesions or existing
restorations or gingivally attached tooth fragment and placement
UCSLS 20119 of sedative/protective dressings, includes pulp caps when No
necessary, as a separate procedure) Each additional tooth same
quadrant
Caries/Trauma/Pain Control (removal of carious lesions or existing
restorations or gingivally attached tooth fragment and placement
UCSLS 20121 of sedative/protective dressings, includes pulp caps when No
necessary and the use of a band for retention and support, as a
separate procedure) First tooth
Caries/Trauma/Pain Control (removal of carious lesions or existing
restorations or gingivally attached tooth fragment and placement
UCSLS 20129 of sedative/protective dressings, includes pulp caps when No
necessary and the use of a band for retention and support, as a
separate procedure) Each additional tooth same quadrant
Trauma Control, Smoothing of Fractured Surfaces, per tooth First
UCSLS 20131 No
tooth
Trauma Control, Smoothing of Fractured Surfaces, per tooth Each
UCSLS 20139 No
additional tooth same quadrant
Pulp Capping Direct Performed in Conjunction with Permanent
UCSLS 20141 No
Restoration First tooth
Pulp Capping Direct Performed in Conjunction with Permanent
UCSLS 20149 No
Restoration Each additional tooth same quadrant
Restorations, Amalgam,
UCSLS 21111 No
Non-Bonded, Primary Teeth One surface
Restorations, Amalgam,
UCSLS 21112 No
Non-Bonded, Primary Teeth Two surfaces
Restorations, Amalgam,
UCSLS 21113 No
Non-Bonded, Primary Teeth Three surfaces
UCSLS 21114 Four surfaces No
UCSLS 21115 Five surfaces or maximum surfaces per tooth No
Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and
UCSLS 21211 No
Anteriors One surface
Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and
UCSLS 21212 No
Anteriors Two surfaces
Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and
UCSLS 21213 No
Anteriors Three surfaces
Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and
UCSLS 21214 No
Anteriors Four surfaces
Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and
UCSLS 21215 Anteriors Five surfaces or maximum No
surfaces per tooth
Restorations, Amalgam, Non-Bonded, Permanent Molars One
UCSLS 21221 No
surface
Restorations, Amalgam, Non-Bonded, Permanent Molars Two
UCSLS 21222 No
surfaces
Restorations, Amalgam, Non-Bonded, Permanent Molars Three
UCSLS 21223 No
surfaces
Restorations, Amalgam, Non-Bonded, Permanent Molars Four
UCSLS 21224 No
surfaces
Restorations, Amalgam, Non-Bonded, Permanent Molars Five
UCSLS 21225 No
surfaces or maximum surfaces per tooth
Restorations, Amalgam Core, Non-Bonded in conjunction with
UCSLS 21301 No
crown or Fixed Bridge Retainer
PINS, RETENTIVE
UCSLS 21401 per restoration (for amalgams and tooth coloured restorations) No
One pin
PINS, RETENTIVE
UCSLS 21402 per restoration (for amalgams and tooth coloured restorations) No
Two pins
PINS, RETENTIVE
UCSLS 21403 per restoration (for amalgams and tooth coloured restorations) No
Three pins
PINS, RETENTIVE
UCSLS 21404 per restoration (for amalgams and tooth coloured restorations) No
Four pins
PINS, RETENTIVE
UCSLS 21405 per restoration (for amalgams and tooth coloured restorations) No
Five pins or more
RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH
UCSLS 22211 No
Primary Posterior
RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH
UCSLS 22212 No
Primary Posterior - open face
RESTORATIONS PREFABRICATED, PLASTIC, PRIMARY TEETH
UCSLS 22401 No
Primary Anterior

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 RESTORATIONS PREFABRICATED, PLASTIC, PRIMARY TEETH
UCSLS 22411 No
Primary Posterior
RESTORATIONS PREFABRICATED, PLASTIC, PERMANENT TEETH
UCSLS 22501 No
Permanent Anterior
RESTORATIONS PREFABRICATED, PLASTIC, PERMANENT TEETH
UCSLS 22511 No
Permanent Posterior
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23101 SILVER FILINGS - RESTORATIONS, TOOTH COLOURED, No
PERMANENT ANTERIORS NON BONDED TECHNIQUE One surface
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS - RESTORATIONS, TOOTH COLOURED,
UCSLS 23102 No
PERMANENT ANTERIORS NON BONDED TECHNIQUE Two surfaces
(continuous)
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS - RESTORATIONS, TOOTH COLOURED,
UCSLS 23103 No
PERMANENT ANTERIORS NON BONDED TECHNIQUE Three
surfaces (continuous)
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS - RESTORATIONS, TOOTH COLOURED,
UCSLS 23104 No
PERMANENT ANTERIORS NON BONDED TECHNIQUE Four surfaces
(continuous)
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS - RESTORATIONS, TOOTH COLOURED,
UCSLS 23105 No
PERMANENT ANTERIORS NON BONDED TECHNIQUE Five surfaces
(continuous, maximum surfaces per tooth)
Restorations, Permanent Anteriors, Bonded Technique (not to be
UCSLS 23111 No
used for Veneer Applications or Diastema Closures) One surface
Restorations, Permanent Anteriors, Bonded Technique (not to be
UCSLS 23112 used for Veneer Applications or Diastema Closures) Two surfaces No
(continuous)
Restorations, Permanent Anteriors, Bonded Technique (not to be
UCSLS 23113 used for Veneer Applications or Diastema Closures) Three surfaces No
(continuous)
Restorations, Permanent Anteriors, Bonded Technique (not to be
UCSLS 23114 used for Veneer Applications or Diastema Closures) Four surfaces No
(continuous)
Restorations, Permanent Anteriors, Bonded Technique (not to be
UCSLS 23115 used for Veneer Applications or Diastema Closures) Five surfaces No
(continuous, maximum surfaces per tooth)
Tooth Coloured Veneer Application - Direct Chairside Prefabricated -
UCSLS 23121 No
Bonded
Tooth Coloured Veneer Application - Non Prefabricated Direct
UCSLS 23122 No
Buildup - Bonded
Tooth Coloured Veneer Application - Diastema Closure,
UCSLS 23123 No
Interproximal only, Bonded
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23211 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Bicuspids One surface
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23212 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Bicuspids Two surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23213 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Bicuspids Three surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23214 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Bicuspids Four surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23215 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Bicuspids Five surfaces or maximum surfaces per tooth
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23221 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Molars One surface
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23222 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Molars Two surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23223 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Molars Three surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23224 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Molars Four surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23225 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Molars Five surfaces or maximum surfaces per tooth
Restorations, Tooth Coloured, Permanent Bicuspids, Bonded
UCSLS 23311 No
Technique, One surface

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 Restorations, Tooth Coloured, Permanent Bicuspids, Bonded
UCSLS 23312 No
Technique, Two surfaces (continuous)
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23313 SILVER FILINGS, PERMANENT POSTERIORS NON BONDED No
Permanent Bicuspids Three surfaces
Restorations, Tooth Coloured, Permanent Bicuspids, Bonded
UCSLS 23314 No
Technique, Four surfaces (continuous)
Restorations, Tooth Coloured, Permanent Bicuspids, Bonded
UCSLS 23315 Technique, Five surfaces (continuous, maximum surfaces per No
tooth)
Restorations, Tooth Coloured, Permanent Posteriors - Bonded One
UCSLS 23321 No
surface
Restorations, Tooth Coloured, Permanent Posteriors - Bonded Two
UCSLS 23322 No
surfaces
Restorations, Tooth Coloured, Permanent Posteriors - Bonded
UCSLS 23323 No
Three surfaces
Restorations, Tooth Coloured, Permanent Posteriors - Bonded Four
UCSLS 23324 No
surfaces
Restorations, Tooth Coloured, Permanent Posteriors - Bonded Five
UCSLS 23325 No
surfaces or maximum surfaces per tooth
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON
UCSLS 23401 No
BONDED One surface
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON
UCSLS 23402 No
BONDED two surfaces (continuous)
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON
UCSLS 23403 No
BONDED three surfaces (continuous)
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON
UCSLS 23404 No
BONDED four surfaces (continuous)
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON
UCSLS 23405 BONDED Five surfaces (continuous or maximum surfaces per No
tooth)
Restorations, Tooth Coloured, Primary, Anterior Bonded Technique
UCSLS 23411 No
One surface
Restorations, Tooth Coloured, Primary, Anterior Bonded Technique
UCSLS 23412 No
Two surfaces (continuous)
Restorations, Tooth Coloured, Primary, Anterior Bonded Technique
UCSLS 23413 No
Three surfaces (continuous)
Restorations, Tooth Coloured, Primary, Anterior Bonded Technique
UCSLS 23414 No
Four surfaces (continuous)
Restorations, Tooth Coloured, Primary, Anterior Bonded Technique
UCSLS 23415 No
Five surfaces (continuous or maximum surfaces per tooth)
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23501 SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED One No
surface
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23502 SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED Two No
surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23503 SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED Three No
surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23504 SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED Four No
surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
UCSLS 23505 SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED Five No
surfaces (or maximum surfaces per tooth)
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED -
UCSLS 23511 No
Restorations, Tooth Coloured, Primary, Posterior, Bonded One
surface
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED -
UCSLS 23512 No
Restorations, Tooth Coloured, Primary, Posterior, Bonded Two
surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED -
UCSLS 23513 No
Restorations, Tooth Coloured, Primary, Posterior, Bonded Three
surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED -
UCSLS 23514 No
Restorations, Tooth Coloured, Primary, Posterior, Bonded Four
surfaces
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT
SILVER FILINGS, PRIMARY, POSTERIOR, NON BONDED -
UCSLS 23515 No
Restorations, Tooth Coloured, Primary, Posterior, Bonded Five
surfaces or maximum surfaces per tooth
Restoration, Tooth Coloured, Non-Bonded Core, in Conjunction
UCSLS 23601 No
with Crown or Fixed Bridge Retainer
Restoration, Tooth Coloured, Bonded, Core, in Conjunction with
UCSLS 23602 No
Crown or Fixed Bridge Retainer

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 UCSLS 25781 Post Removal Posts, Provisional One unit of time No
UCSLS 25789 Post Removal Posts, Provisional Each additional unit over four No
UCSLS 27801 RECONTOURING OF EXISTING CROWNS per tooth One unit of time No
RECONTOURING OF EXISTING CROWNS per tooth Each additional
UCSLS 27809 No
unit of time
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Natural
Tooth Preparation, Placement of Pulp Chamber Restoration
UCSLS 28101 No
(amalgam or composite) and Fluoride Application Endodontically
Treated Tooth
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Natural
UCSLS 28102 No
Tooth Preparation and Fluoride Application, Vital Tooth
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Pre-
fabricated Attachment, as an Internal or External Overdenture
UCSLS 28103 No
Retentive Device, Direct to a Natural Tooth + L and/or + E (used
with the appropriate denture code) per tooth
RECEMENTATION/REBONDING, INLAYS/ONLAYS/
UCSLS 29101 CROWNS/VENEERS/POSTS/ NATURAL TOOTH FRAGMENTS One No
unit of time +L +E
RECEMENTATION/REBONDING, INLAYS/ONLAYS/
UCSLS 29109 CROWNS/VENEERS/POSTS/ NATURAL TOOTH FRAGMENTS Each No
additional unit over four+L +E
Re-Insertion/Recementation Implant-supported Crown One unit of
UCSLS 29111 No
time +L +E
Re-Insertion/Recementation Implant-supported Crown Each
UCSLS 29119 No
additional unit over four +L +E
REMOVAL, INLAYS/ ONLAYS/CROWNS/ VENEERS
UCSLS 29301 NO
(single units only) One unit of time
REMOVAL, INLAYS/ ONLAYS/CROWNS/ VENEERS
UCSLS 29309 NO
(single units only) Each additional unit over four
Removal, Implant-supported Crowns (single units only) One unit
UCSLS 29311 NO
of time
Removal, Implant-supported Crowns (single units only) Each
UCSLS 29319 NO
additional unit over four
UCSLS 29321 Removal, Mesostructure (to be reseated) One unit of time NO
Removal, Mesostructure (to be reseated) Each additional unit over
UCSLS 29329 NO
four
Removal of Compromised Mesostructure
UCSLS 29331 NO
(to be replaced) One unit of time
Removal of Compromised Mesostructure
UCSLS 29339 NO
(to be replaced) Each additional unit over four
Removal, Fractured Implant-supported Crown Retaining Screw
UCSLS 29351 NO
One unit of time
Removal, Fractured Implant-supported Crown Retaining Screw
UCSLS 29359 NO
Each additional unit over four
Pulpotomy, Permanent Teeth
UCSLS 32221 No
(as a Separate Emergency Procedure) Anterior and Bicuspid Teeth
Pulpotomy, Permanent Teeth
UCSLS 32222 No
(as a Separate Emergency Procedure) Molar Teeth
UCSLS 32231 Pulpotomy Primary Tooth as a Separate Procedure No
Pulpotomy Primary Tooth, Concurrent with Restorations (but
UCSLS 32232 No
excluding final restoration)
PULPECTOMY
(An emergency procedure and/or as a pre-emptive phase to the
UCSLS 32311 No
preparation of the root canal system for obturation) Pulpectomy,
Permanent Teeth/Retained Primary Teeth One Canal

PULPECTOMY
(An emergency procedure and/or as a pre-emptive phase to the
UCSLS 32312 No
preparation of the root canal system for obturation) Pulpectomy,
Permanent Teeth/Retained Primary Teeth Two Canals

PULPECTOMY
(An emergency procedure and/or as a pre-emptive phase to the
UCSLS 32313 No
preparation of the root canal system for obturation) Pulpectomy,
Permanent Teeth/Retained Primary Teeth Three Canals

PULPECTOMY
(An emergency procedure and/or as a pre-emptive phase to the
UCSLS 32314 No
preparation of the root canal system for obturation) Pulpectomy,
Permanent Teeth/Retained Primary Teeth Four Canals or more
PULPECTOMY
(An emergency procedure and/or as a pre-emptive phase to the
UCSLS 32321 No
preparation of the root canal system for obturation) Pulpectomy,
Primary Teeth Anterior Tooth
PULPECTOMY
(An emergency procedure and/or as a pre-emptive phase to the
UCSLS 32322 No
preparation of the root canal system for obturation) Pulpectomy,
Primary Teeth Posterior Tooth

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 Root Canals, Permanent Teeth/Retained Primary Teeth, One Canal
UCSLS 33111 No
One canal
UCSLS 33115 Re-treatment of Previously Completed Therapy No
Continuing Treatment having been Aborted by Referring/Previous
UCSLS 33116 No
Dentist
Root Canals, Permanent Teeth/Retained Primary Teeth, Two
UCSLS 33121 No
Canals Two canals
Root Canals, Permanent Teeth/Retained Primary Teeth, Two
UCSLS 33125 No
Canals Re-treatment of Previously Completed Therapy
Root Canals, Permanent Teeth/Retained Primary Teeth, Two
UCSLS 33126 Canals Continuing Treatment having been Aborted by No
Referring/Previous Dentist
Root Canals, Permanent Teeth/Retained Primary Teeth, Three
UCSLS 33131 No
Canals Three canals
Root Canals, Permanent Teeth/Retained Primary Teeth, Three
UCSLS 33135 No
Canals Re-treatment of Previously Completed Therapy
Root Canals, Permanent Teeth/Retained Primary Teeth, Three
UCSLS 33136 Canals Continuing Treatment having been Aborted by Referring/ No
Previous Dentist
Root Canals, Permanent Teeth/Retained Primary Teeth, Four or
UCSLS 33141 No
More Canals Four or more canals
Root Canals, Permanent Teeth/Retained Primary Teeth, Four or
UCSLS 33145 No
More Canals Re-treatment of previously completed therapy
Root Canals, Permanent Teeth/Retained Primary Teeth, Four or
UCSLS 33146 More Canals Continuing Treatment having been aborted by No
Referring/ Previous Dentist
UCSLS 33401 ROOT CANALS, PRIMARY TEETH One canal No
UCSLS 33402 ROOT CANALS, PRIMARY TEETH Two canals No
UCSLS 33403 ROOT CANALS, PRIMARY TEETH Three canals or more No
APEXIFICATION/APEXOGENESIS/ INDUCTION OF HARD TISSUE
UCSLS 33601 REPAIR (to include biomechanical preparation and placement of No
dentogenic media) One canal
APEXIFICATION/APEXOGENESIS/ INDUCTION OF HARD TISSUE
UCSLS 33602 REPAIR (to include biomechanical preparation and placement of No
dentogenic media) Two canals
APEXIFICATION/APEXOGENESIS/ INDUCTION OF HARD TISSUE
UCSLS 33603 REPAIR (to include biomechanical preparation and placement of No
dentogenic media) Three canals
APEXIFICATION/APEXOGENESIS/ INDUCTION OF HARD TISSUE
UCSLS 33604 REPAIR (to include biomechanical preparation and placement of No
dentogenic media) Four canals or more
UCSLS 33611 Re-insertion of Dentogenic Media per visit One canal No
UCSLS 33612 Re-insertion of Dentogenic Media per visit Two canals No
UCSLS 33613 Re-insertion of Dentogenic Media per visit Three canals No
UCSLS 33614 Re-insertion of Dentogenic Media per visit Four canals or more No
UCSLS 33621 OBTURATION OF APEXIFIED CANAL One canal No
UCSLS 33622 OBTURATION OF APEXIFIED CANAL Two canals No
UCSLS 33623 OBTURATION OF APEXIFIED CANAL Three canals No
UCSLS 33624 OBTURATION OF APEXIFIED CANAL Four canals or more No
UCSLS 34111 APICOECTOMY/APICAL CURETTAGE Maxillary Anterior One root No
UCSLS 34112 APICOECTOMY/APICAL CURETTAGE Maxillary Anterior Two roots No

UCSLS 34121 APICOECTOMY/APICAL CURETTAGE Maxillary Bicuspid One root No

UCSLS 34122 APICOECTOMY/APICAL CURETTAGE Maxillary Bicuspid Two roots No

UCSLS 34123 APICOECTOMY/APICAL CURETTAGE Maxillary Bicuspid Three roots No

UCSLS 34131 APICOECTOMY/APICAL CURETTAGE Maxillary Molar One root No
UCSLS 34132 APICOECTOMY/APICAL CURETTAGE Maxillary Molar Two roots No

APICOECTOMY/APICAL CURETTAGE Maxillary Molar

UCSLS 34133 No
APICOECTOMY/APICAL CURETTAGE Maxillary Molar Three roots
APICOECTOMY/APICAL CURETTAGE Maxillary Molar Four or more
UCSLS 34134 No
roots
UCSLS 34141 APICOECTOMY/APICAL CURETTAGE Mandibular Anterior One root No
APICOECTOMY/APICAL CURETTAGE Mandibular Anterior Two or
UCSLS 34142 No
more roots
UCSLS 34151 APICOECTOMY/APICAL CURETTAGE Mandibular Bicuspid One root No
APICOECTOMY/APICAL CURETTAGE Mandibular Bicuspid Two
UCSLS 34152 No
roots
APICOECTOMY/APICAL CURETTAGE Mandibular Bicuspid Three or
UCSLS 34153 No
more roots
UCSLS 34161 APICOECTOMY/APICAL CURETTAGE Mandibular Molar One root No
UCSLS 34162 APICOECTOMY/APICAL CURETTAGE Mandibular Molar Two roots No

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 APICOECTOMY/APICAL CURETTAGE Mandibular
UCSLS 34163 MolarAPICOECTOMY/APICAL CURETTAGE Mandibular Molar Three No
roots
APICOECTOMY/APICAL CURETTAGE Mandibular Molar Four or
UCSLS 34164 No
more roots
UCSLS 34211 RETROFILLING Maxillary Anterior One canal No
UCSLS 34212 RETROFILLING Maxillary Anterior Two or more canals No
UCSLS 34221 RETROFILLING Maxillary Bicuspid One canal No
UCSLS 34222 RETROFILLING Maxillary Bicuspid Two canals No
UCSLS 34223 RETROFILLING Maxillary Bicuspid Three canals No
UCSLS 34224 RETROFILLING Maxillary Bicuspid Four or more canals No
UCSLS 34231 RETROFILLING Maxillary Molar One canal No
UCSLS 34232 RETROFILLING Maxillary Molar Two canals No
UCSLS 34233 RETROFILLING Maxillary Molar Three canals No
UCSLS 34234 RETROFILLING Maxillary Molar Four or more canals No
UCSLS 34241 RETROFILLING Mandibular Anterior One canal No
UCSLS 34242 RETROFILLING Mandibular Anterior Two or more canals No
UCSLS 34251 RETROFILLING Mandibular Bicuspid One canal No
UCSLS 34252 RETROFILLING Mandibular Bicuspid Two canals No
UCSLS 34253 RETROFILLING Mandibular Bicuspid Three canals No
UCSLS 34254 RETROFILLING Mandibular Bicuspid Four or more canals No
UCSLS 34261 RETROFILLING Mandibular Molar One canal No
UCSLS 34262 RETROFILLING Mandibular Molar Two canals No
UCSLS 34263 RETROFILLING Mandibular Molar Three canals No
UCSLS 34264 RETROFILLING Mandibular Molar Four or more canals No
Amputations, Root (includes recontouring tooth and furca) One
UCSLS 34411 No
root
Amputations, Root (includes recontouring tooth and furca) Two
UCSLS 34412 No
roots
UCSLS 34421 Hemisection Maxillary Bicuspid No
UCSLS 34422 Hemisection Maxillary Molar No
UCSLS 34423 Hemisection Mandibular Molar No
Perforations/Resorptive Defects, Pulp Chamber or Root Repair,
UCSLS 34511 No
Non-Surgical Per Tooth
Perforations/Resorptive Defect(s), Pulp Chamber Repair or Root
UCSLS 34521 No
Repair, Surgical Anterior Tooth
Perforations/Resorptive Defect(s), Pulp Chamber Repair or Root
UCSLS 34522 No
Repair, Surgical Bicuspid Tooth
Perforations/Resorptive Defect(s), Pulp Chamber Repair or Root
UCSLS 34523 No
Repair, Surgical Molar Tooth
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS
Banding and/or Coronal Buildup of Tooth/Teeth and/or Contouring
UCSLS 39101 No
of Tissue Surrounding Tooth/Teeth to Maintain Aseptic Operating
Field (per tooth)
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS, OPEN
UCSLS 39201 AND DRAIN (Separate Emergency Procedures)Anteriors and No
Bicuspids
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS, OPEN
UCSLS 39202 No
AND DRAIN (Separate Emergency Procedures)Molars
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS
UCSLS 39211 Opening Through Artificial Crown (In addition to Procedures) No
Anteriors and Bicuspids
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS
UCSLS 39212 Opening Through Artificial Crown (In addition to Procedures) No
Molars
UCSLS 39311 Bleaching Endodontically Treated Tooth/Teeth One unit of time No
Bleaching Endodontically Treated Tooth/Teeth Each additional unit
UCSLS 39319 No
over three
Oral Manifestations, Oral Mucosal Disorders, Mucocutaneous
disorders and diseases of localized mucosal conditions, e.g. lichen
planus, aphthous stomatitis, benign mucous membrane
UCSLS 41211 No
pemphigoid, pemphigus, salivary gland tumours, leukoplakia with
and without dysphasia, neoplasms, hairy leukoplakia, polyps,
verrucae, fibroma etc. One unit of time
Oral Manifestations, Oral Mucosal Disorders, Mucocutaneous
disorders and diseases of localized mucosal conditions, e.g. lichen
planus, aphthous stomatitis, benign mucous membrane
UCSLS 41219 No
pemphigoid, pemphigus, salivary gland tumours, leukoplakia with
and without dysphasia, neoplasms, hairy leukoplakia, polyps,
verrucae, fibroma etc. Each additional unit over four
Nervous and Muscular Disorders, Disorders of facial sensation and
motor dysfonction at the jaw, e.g. trigeminal neuralgia, atypical
UCSLS 41221 facial pain, atypical odontologia, burning mouth syndrome, No
dyskenesia, post injection trismus, muscular and joint pain
syndrome One unit of time
UCSLS 41229 Each additional unit over four No

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 Oral Manifestations of Systemic Disease or complications of
medical therapy e.g. complications of chemotherapy, radiation
therapy, post operative neuropathics, post surgical or radiation
UCSLS 41231 No
therapy, dysfunction, oral manifestations of lupus erythematosis
and systemic disease including leukemia, diabetes and bleeding
disorders (e.g. haemophilia) One unit of time

Oral Manifestations of Systemic Disease or complications of

medical therapy e.g. complications of chemotherapy, radiation
therapy, post operative neuropathics, post surgical or radiation
UCSLS 41239 No
therapy, dysfunction, oral manifestations of lupus erythematosis
and systemic disease including leukemia, diabetes and bleeding
disorders (e.g. haemophilia) Each additional unit over four
DESENSITIZATION (This may involve application and burnishing of
medicinal aids on the root or the use of a variety of therapeutic
UCSLS 41301 No
procedures. More than one appointment may be necessary.) One
unit of time
DESENSITIZATION (This may involve application and burnishing of
medicinal aids on the root or the use of a variety of therapeutic
procedures. More than one appointment may be
UCSLS 41309 necessary.)DESENSITIZATION (This may involve application and No
burnishing of medicinal aids on the root or the use of a variety of
therapeutic procedures. More than one appointment may be
necessary.) Each additional unit over two
UCSLS 42111 Surgical Curettage, to Include Definitive Root Planing Per sextant No
Surgical Curettage, to Include Definitive Debridement About an
UCSLS 42121 Implant - Affected by Peri-implant Inflammation or Infection Per No
Site
UCSLS 42201 PERIODONTAL SURGERY, GINGIVOPLASTY Per sextant No
UCSLS 42211 Periodontal Surgery, Gingivoplasty – Around an Implant Per Site No
UCSLS 42311 Gingivectomy, Uncomplicated Per sextant No
UCSLS 42331 Gingival Fiber Incision (Supra Crestal Fibrotomy) First tooth No
Gingival Fiber Incision (Supra Crestal Fibrotomy) Each additional
UCSLS 42339 No
tooth
Soft Tissue Re-contouring for Crown Lengthening Limited re-
UCSLS 42341 No
countouring of tissue per tooth
UCSLS 42411 PERIODONTAL SURGERY, FLAP APPROACH Per sextant No
PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with
UCSLS 42421 No
Curettage of Osseous Per sextant
PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with
UCSLS 42451 No
Osteoplasty/Ostoectomy for Crown Lengthening Per site
PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with
UCSLS 42461 No
Curettage of an Osseous Defect About a Failing Implant Per Site
PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with
Curettage of an Osseous Defect About a Failing Implant, and
UCSLS 42471 Including Removal of Exposed Threads or Retentive Surface No
Elements of the Implant and/or Detoxification of the Implant
Surface Per Site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42511 Soft Tissue, Pedicle (including apically or lateral sliding and rotated No
flaps) Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42521 No
Soft Tissue, Pedicle (Coronally Positioned)Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42531 No
Free Soft Tissu Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42541 Soft Tissue, Pedicle, with Free Graft Placed in Pedicle Donor Site No
Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42551 No
Free Connective Tissue (For root coverage) Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42561 No
Free Connective Tissue (For ridge augmentation) Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42571 Connective Tissue, Pedicle with Free Graft for Root Coverage Per No
site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts,
UCSLS 42581 No
Gingival Onlay, for Ridge Augmentation Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE
UCSLS 42611 Grafts, Osseous, Autograft (Including Flap Entry, Closure and Yes
Donor Site Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE
UCSLS 42621 Grafts, Osseous, Allograft (Including Flap Entry and Closure) Per Yes
site + E
PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE
UCSLS 42631 Grafts, Osseous, Xenograft (Including Flap Entry and Closure) Per Yes
site + E

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 Guided Tissue Regeneration – Non-resorbable Membrane - per site
UCSLS 42701 Yes
+ E.
UCSLS 42702 Guided Tissue Regeneration – Resorbable Membrane - per site +E. Yes
Guided Tissue Regeneration – Non-resorbable Membrane, Surgical
UCSLS 42703 Yes
Re-entry for Removal
Proximal Wedge Procedure (as a separate procedure) With Flap
UCSLS 42811 No
Curettage, per site
Proximal Wedge Procedure (as a separate procedure)Proximal
UCSLS 42819 Wedge Procedure (as a separate procedure) With Flap Curettage No
and Osteotomy/Osteoplasty per site
Post Surgical Periodontal Treatment Visit per Dressing Change
UCSLS 42821 No
One unit of time
Post Surgical Periodontal Treatment Visit per Dressing Change
UCSLS 42829 No
Each additional unit over three
Periodontal Abscess or Pericoronitis, includes any of the following
UCSLS 42831 procedures: Lancing, Scaling, Curettage, Surgery or Medication No
One unit of time
Periodontal Abscess or Pericoronitis, includes any of the following
UCSLS 42839 procedures: Lancing, Scaling, Curettage, Surgery or Medication No
Each additional unit over four
PERIODONTAL SPLINT OR LIGATION, PROVISIONAL, INTRA
CORONAL
UCSLS 43111 Note:This procedure is in addition to the usual code for the tooth No
preparation on either side "A" Splint (restorative material plus
wire, fibre ribbon or rope) Per joint + E
Bonded Joint Restorations (per joint) Per joint (may include
UCSLS 43211 No
reinforcement) +E
UCSLS 43221 Bonded, Interproximal Enamel Splint Per joint No
UCSLS 43231 Wire Ligation Per joint No
Cast/Soldered/Ceramic/Polymer Glass, Splint Bonded Per
UCSLS 43271 No
Abutment + L
UCSLS 43281 Removal of Fixed Periodontal Splints One unit of time No
UCSLS 43289 Removal of Fixed Periodontal Splints Each additional unit of time No
UCSLS 43421 Root Planing Root PlaningOne unit of time No
UCSLS 43429 Root Planing Each additional unit over six No
Chemotherapeutic and/or antimicrobial agents, topical application
UCSLS 43511 No
One unit of time
Chemotherapeutic and/or antimicrobial agents, topical application
UCSLS 43519 No
Each additional unit of time
PERIODONTAL RE-EVALUATION/EVALUATION
Note: This follow-up service applies to the evaluation of ongoing
UCSLS 49101 periodontal treatment or to a post-surgical re-evaluation No
performed more than one (1) month after surgery, or if performed
by another practitioner One unit of time
PERIODONTAL RE-EVALUATION/EVALUATION
Note: This follow-up service applies to the evaluation of ongoing
UCSLS 49109 periodontal treatment or to a post-surgical re-evaluation No
performed more than one (1) month after surgery, or if performed
by another practitioner Each additional unit over two
UCSLS 49211 Periodontal Irrigation, Subgingival + E One unit of time +E No
Periodontal Irrigation, Subgingival + E Each additional unit of time
UCSLS 49219 No
+E
Periodontal Irrigation about Implants, Subgingival + E One unit of
UCSLS 49221 No
time +E
Periodontal Irrigation about Implants, Subgingival + E Each
UCSLS 49229 No
additional unit of time +E
Removals, Erupted Teeth, Uncomplicated Single tooth,
UCSLS 71101 No
Uncomplicated
Removals, Erupted Teeth, Uncomplicated Each additional tooth,
UCSLS 71109 No
same quadrant, same appointment
Odontectomy, (extraction), Erupted Tooth, Surgical Approach,
UCSLS 71201 No
Requiring Surgical Flap and/or Sectioning of Tooth.
Odontectomy, (extraction), Erupted Tooth, Surgical Approach,
UCSLS 71209 Requiring Surgical Flap and/or Sectioning of Tooth. Each additional No
tooth, same quadrant
Requiring elevation of a Flap, Removal of Bone and/or Sectioning
UCSLS 71211 No
of Tooth for Removal of Tooth Single Tooth
Requiring elevation of a Flap, Removal of Bone and/or Sectioning
UCSLS 71219 of Tooth for Removal of Tooth Each additional Tooth same No
quadrant
Removals, Impactions, Requiring Incision of Overlying Soft Tissue
UCSLS 72111 No
and Removal of the Tooth. Single tooth
Removals, Impactions, Requiring Incision of Overlying Soft Tissue
UCSLS 72119 No
and Removal of the Tooth. Each additional tooth, same quadrant
Removals, Impaction, Requiring Incision of Overlying Soft Tissue,
UCSLS 72211 Elevation of a Flap and EITHER Removal of Bone and Tooth OR No
Sectioning and Removal of Tooth Single tooth

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 Removals, Impaction, Requiring Incision of Overlying Soft Tissue,
Elevation of a Flap and EITHER Removal of Bone and Tooth OR
UCSLS 72219 No
Sectioning and Removal of Tooth Each additional tooth, same
quadrant
Removals, Impaction, Requiring Incision of Overlying Soft Tissue,
UCSLS 72221 Elevation of a Flap, Removal of Bone AND Sectioning of Tooth for No
Removal Single tooth
Removals, Impaction, Requiring Incision of Overlying Soft Tissue,
UCSLS 72229 Elevation of a Flap, Removal of Bone AND Sectioning of Tooth for No
Removal Each additional tooth, same quadrant
Removals, Impactions, Requiring Incision of Overlying Soft Tissue,
Elevation of a Flap, Removal of Bone, AND/OR Sectioning of the
UCSLS 72231 No
Tooth for Removal AND/OR Presents Unusual Difficulties and
Circumstances. Single tooth
Removals, Impactions, Requiring Incision of Overlying Soft Tissue,
Elevation of a Flap, Removal of Bone, AND/OR Sectioning of the
UCSLS 72239 No
Tooth for Removal AND/OR Presents Unusual Difficulties and
Circumstances. Each additional tooth, same quadrant
UCSLS 72311 Removals, Residual Roots, Erupted First tooth No
Removals, Residual Roots, Erupted Each additional tooth, same
UCSLS 72319 No
quadrant
UCSLS 72321 Removals, Residual Roots, Soft Tissue Coverage First tooth No
Removals, Residual Roots, Soft Tissue Coverage Each additional
UCSLS 72329 No
tooth, same quadrant
UCSLS 72331 Removals, Residual Roots, Bone Tissue Coverage First tooth No
Removals, Residual Roots, Bone Tissue Coverage Each additional
UCSLS 72339 No
tooth, same quadrant
UCSLS 72411 Alveolar Bone Preservation – Autograft First tooth Yes
UCSLS 72419 Alveolar Bone Preservation – Autograft Each additional tooth Yes
UCSLS 72421 Alveolar Bone Preservation – Allograft First tooth + E Yes
UCSLS 72429 Alveolar Bone Preservation – Allograft Each additional tooth + E Yes
UCSLS 72431 Alveolar Bone Preservation – Xenograft First tooth + E Yes
UCSLS 72439 Alveolar Bone Preservation – Xenograft Each additional tooth + E Yes
Surgical Exposures, Unerupted, Uncomplicated, Soft Tissue
UCSLS 72511 No
Coverage (includes operculectomy). Single tooth
Surgical Exposures, Unerupted, Uncomplicated, Soft Tissue
UCSLS 72519 Coverage (includes operculectomy). Each additional tooth, same No
quadrant
UCSLS 72521 Surgical Exposures, Complex, Hard Tissue Coverage Single tooth No
Surgical Exposures, Complex, Hard Tissue Coverage Each
UCSLS 72529 No
additional tooth, same quadrant
Surgical Exposures, Unerupted Tooth, with Orthodontic
UCSLS 72531 No
Attachment. Single tooth
Surgical Exposures, Unerupted Tooth, with Orthodontic
UCSLS 72539 No
Attachment. Each additional tooth, same quadrant
Surgical Exposures, Unerupted Tooth, Soft Tissue Coverage with
UCSLS 72541 No
Positioning of Attached Gingivae, Single tooth
Surgical Exposures, Unerupted Tooth, Hard Tissue Coverage with
UCSLS 72551 No
Positioning of Attached Gingivae Single tooth
UCSLS 72711 Unerupted Tooth and Follicle First tooth No
UCSLS 72719 Unerupted Tooth and Follicle Each additional tooth, same quadrant No
UCSLS 73111 Alveoloplasty, in Conjunction with Extractions Per sextant No
UCSLS 73121 Alveoloplasty, Not in Conjunction with Extractions Per sextant No
UCSLS 73152 Torus Palatinus, Excision No
UCSLS 73153 Torus Mandibularis, Unilateral, Excision No
UCSLS 73154 Torus Mandibularis, Bilateral, Excision No
UCSLS 73161 Removal of Bone, Exostosis, MultiplePer quadrant No
UCSLS 73171 Reduction of Bone, Tuberosity Unilateral, Reduction No
UCSLS 73172 Reduction of Bone, Tuberosity Bilateral, Reduction No
UCSLS 73221 Gingivoplasty, in Conjunction with Tooth Removal No
UCSLS 73222 Excision of Vestibular Hyperplasia (per sextant) No
UCSLS 73223 Surgical Shaving of Papillary Hyperplasia of the Palate No
Excision of Pericoronal Gingiva (for retained tooth/implant) per
UCSLS 73224 No
tooth/implant
Removals, Tissue, Hyperplastic (includes the incision of the
mucous membrane, the dissection and removal of hyperplastic
UCSLS 73231 No
tissue, the replacing and adapting of the mucous membrane) Per
sextant
Removal, Mucosa, Excess (complete removal without dissection)
UCSLS 73241 No
Per sextant
UCSLS 73251 Excision of Scar or Pigmented Tissue Per site No
UCSLS 73421 Sulcus Deepening and Ridge Reconstruction Per sextant No
UCSLS 73431 Vestibuloplasty, with Secondary Epithelization Per sextant No
Vestibuloplasty – with Connective Tissue for Ridge Augmentation
UCSLS 73491 No
Per sextant

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 Reconstruction, Alveolar Ridge, with Autogenous Bone Per sextant
UCSLS 73511 Yes
+E
Reconstruction, Alveolar Ridge, with Alloplastic Material Per
UCSLS 73521 Yes
sextant + E
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
UCSLS 74111 No
of Soft Tissue of the Oral Cavity 1 cm and under
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
UCSLS 74112 No
of Soft Tissue of the Oral Cavity 1-2 cm
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
of Soft Tissue of the Oral CavityTumours, Benign, Scar Tissue,
UCSLS 74113 No
Inflammatory or Congenital Lesions of Soft Tissue of the Oral
Cavity 2-3 cm
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
UCSLS 74114 No
of Soft Tissue of the Oral Cavity 3-4 cm
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
of Soft Tissue of the Oral CavityTumours, Benign, Scar Tissue,
UCSLS 74115 No
Inflammatory or Congenital Lesions of Soft Tissue of the Oral
Cavity 4-6 cm
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
UCSLS 74116 No
of Soft Tissue of the Oral Cavity 6-9 cm
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
UCSLS 74117 No
of Soft Tissue of the Oral Cavity 9-15 cm
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions
UCSLS 74118 No
of Soft Tissue of the Oral Cavity 15 cm and over
UCSLS 74121 Tumours, Benign, Bone Tissue 1 cm and under No
UCSLS 74122 Tumours, Benign, Bone Tissuev 1-2 cm No
UCSLS 74123 Tumours, Benign, Bone Tissue 2-3 cm No
UCSLS 74124 Tumours, Benign, Bone Tissue 3-4 cm No
UCSLS 74125 Tumours, Benign, Bone Tissue 4-6 cm No
UCSLS 74126 Tumours, Benign, Bone Tissue 6-9 cm No
UCSLS 74127 Tumours, Benign, Bone Tissue 9-15 cm No
UCSLS 74128 Tumours, Benign, Bone Tissue 15 cm and over No
UCSLS 74211 Tumours, Malignant, Soft Tissue, Oral Cavity 1 cm and under No
UCSLS 74212 Tumours, Malignant, Soft Tissue, Oral Cavity 1-2 cm No
UCSLS 74213 Tumours, Malignant, Soft Tissue, Oral Cavity 2-3 cm No
UCSLS 74214 Tumours, Malignant, Soft Tissue, Oral Cavity 3-4 cm No
UCSLS 74215 Tumours, Malignant, Soft Tissue, Oral Cavity 4-6 cm No
UCSLS 74216 Tumours, Malignant, Soft Tissue, Oral Cavity 6-9 cm No
UCSLS 74217 Tumours, Malignant, Soft Tissue, Oral Cavity 9-15 cm No
UCSLS 74218 Tumours, Malignant, Soft Tissue, Oral Cavity 15 cm and over No
UCSLS 74221 Surgical Excision, Tumours, Malignant, Bone Tissue1 cm and under No
UCSLS 74222 Surgical Excision, Tumours, Malignant, Bone Tissue1-2 cm No
UCSLS 74223 Surgical Excision, Tumours, Malignant, Bone Tissue2-3 cm No
UCSLS 74224 Surgical Excision, Tumours, Malignant, Bone Tissue3-4 cm No
UCSLS 74225 Surgical Excision, Tumours, Malignant, Bone Tissue4-6 cm No
UCSLS 74226 Surgical Excision, Tumours, Malignant, Bone Tissue6-9 cm No
UCSLS 74227 Surgical Excision, Tumours, Malignant, Bone Tissue9-15 cm No
UCSLS 74228 Surgical Excision, Tumours, Malignant, Bone Tissue15 cm and over No
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74611 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 1 cm and under
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74612 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 1-2 cm
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74613 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 2-3 cm
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74614 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 3-4 cm
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74615 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 4-6 cm
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74616 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 6-9 cm
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74617 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 9-15 cm
Enucleation of Cyst/Granuloma, Odontogenic and Non-
UCSLS 74618 Odontogenic, Requiring Prior Removal of Bony Tissue and No
Subsequent Suture(s) 15 cm and over
UCSLS 74621 Cyst, Marsupialization No
UCSLS 74631 Excision of Cyst 1 cm and under No
UCSLS 74632 Excision of Cyst 1-2 cm No
UCSLS 74633 Excision of Cyst 2-3 cm No
UCSLS 74634 Excision of Cyst 3-4 cm No
UCSLS 74635 Excision of Cyst 4-6 cm No
UCSLS 74636 Excision of Cyst 6-9 cm No

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 UCSLS 74637 Excision of Cyst 9-15 cm No
UCSLS 74638 Excision of Cyst 15 cm and over No
UCSLS 75111 Intraoral, Surgical Exploration, Soft Tissue No
UCSLS 75112 Intraoral, Abscess, Soft Tissue No
UCSLS 75113 Intraoral, Abscess, In Major Anatomical area with Drain No
Surgical Incision and Drainage and/or Exploration, Intraoral Hard
UCSLS 75121 No
Tissue Intraoral, Abscess, Hard Tissue, Trephination and Drainage
Surgical Incision and Drainage and/or Exploration, Intraoral Hard
UCSLS 75122 No
Tissue Intraoral, Surgical Exploration, Hard Tissue
Surgical Incision and Drainage and/or Exploration, Intraoral Hard
UCSLS 75123 Tissue Intraoral, Abscess, Hard Tissue, Trephination and Drainage No
in a Major Anatomical Area
Surgical Incision and Drainage and/or Exploration, Extraoral, Soft
UCSLS 75211 No
Tissue Extraoral, Abscess, Superficial
Surgical Incision and Drainage and/or Exploration, Extraoral, Soft
UCSLS 75212 No
Tissue Extraoral, Abscess, Deep
Surgical Incision and Drainage and/or Exploration, Extraoral, Hard
UCSLS 75221 No
Tissue Extraoral, Surgical Exploration, Hard Tissue
UCSLS 75301 Removal, from Skin or Subcutaneous Alveolar Tissue No
UCSLS 75302 Removal, of Reaction Producing Foreign Bodies No
UCSLS 75303 Removal, of Needle from Musculo-skeletal System No
UCSLS 75401 Intraoral Sequestrectomy No
UCSLS 75402 Saucerization No
UCSLS 75403 Osteomyelitis, Non Surgical Treatment of No
UCSLS 76911 Fracture, Alveolar, Debridement, Teeth Removed 3 cm or less No
UCSLS 76912 Fracture, Alveolar, Debridement, Teeth Removed 3-6 cm No
UCSLS 76913 Fracture, Alveolar, Debridement, Teeth Removed 6 cm and over No
Reduction, Alveolar, Closed, with Teeth (fixation extra) 3 cm or
UCSLS 76921 No
less
UCSLS 76922 Reduction, Alveolar, Closed, with Teeth (fixation extra) 3-6 cm No
Reduction, Alveolar, Closed, with Teeth (fixation extra)Reduction,
UCSLS 76923 No
Alveolar, Closed, with Teeth (fixation extra) 6-9 cm
Reduction, Alveolar, Closed, with Teeth (fixation extra) 9 cm and
UCSLS 76924 No
over
Reduction, Alveolar, Open, with Teeth (fixation extra) 3 cm and
UCSLS 76931 No
less
UCSLS 76932 Reduction, Alveolar, Open, with Teeth (fixation extra) 3-6 cm No
UCSLS 76933 Reduction, Alveolar, Open, with Teeth (fixation extra) 6-9 cm No
Reduction, Alveolar, Open, with Teeth (fixation extra) 9 cm and
UCSLS 76934 No
over
Replantation, Avulsed Tooth/Teeth
UCSLS 76941 No
(including splinting) Replantation, first tooth
Replantation, Avulsed Tooth/Teeth
UCSLS 76949 No
(including splinting) Each additional tooth
UCSLS 76951 Repositioning of Traumatically Displaced Teeth One unit of time No
Repositioning of Traumatically Displaced Teeth Each additional unit
UCSLS 76959 No
over two
Repairs, Lacerations, Uncomplicated, Intraoral or Extraoral 2 cm
UCSLS 76961 No
or less
UCSLS 76962 Repairs, Lacerations, Uncomplicated, Intraoral or Extraoral 2-4 cm No
Osteotomy, Segmental, Anterior – for Distraction Osteogenesis-
UCSLS 77415 No
Maxillary
Osteotomy, Segmental, Posterior – for Distraction Osteogenesis-
UCSLS 77416 No
Maxillary
UCSLS 77417 Activation of Distraction Device-Maxillary No
UCSLS 77418 Removal of Segmental Maxillary Distraction Device No
Osteotomy, Segmental, Anterior – for Distraction Osteogenesis-
UCSLS 77426 No
Mandible
Osteotomy, Segmental, Posterior – for Distraction Osteogenesis-
UCSLS 77427 No
Mandible
UCSLS 77428 Activation of Distraction Device-Mandible No
UCSLS 77429 Removal of Segmental Mandibular Distraction Device No
Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique,
UCSLS 77604 Yes
Maxilla - per Sextant
Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique,
UCSLS 77605 Yes
Mandible - per Sextant
UCSLS 77801 Frenectomy, Upper Labial No
UCSLS 77802 Frenectomy, Lower Labial No
UCSLS 77803 Frenectomy, Lower Lingual or "Z" Plasty No
Frenectomy, Lower Lingual or "Z" Plasty with Myotomy of
UCSLS 77804 No
Genioglossus
UCSLS 77805 Frenoplasty, Upper "Z" No
UCSLS 77806 Frenoplasty, Lower "Z" No
UCSLS 78102 TMJ, Dislocation, Closed Reduction, Uncomplicated No
UCSLS 78103 TMJ, Dislocation, Closed Reduction, under General Anesthetic No
UCSLS 78104 TMJ, Luxation, Reduction without Anaesthesia No

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 UCSLS 78105 TMJ, Luxation, Reduction under Anesthesia No
UCSLS 78106 TMJ, Manipulation, under Anesthesia No
UCSLS 78601 TMJ Injection, with Anti-Inflammatory Drugs No
UCSLS 78602 TMJ Injection, with Sclerosing Agent No
UCSLS 79123 Excision of Mucocele No
UCSLS 79124 Excision of Ranula No
UCSLS 79125 Marsupialization of Ranula No
Antral Surgery, Immediate Recovery of a Dental Root or Foreign
UCSLS 79311 No
Body from the Antrum
Antral Surgery, Immediate Closure of Antrum by Another Dental
UCSLS 79312 No
Surgeon
Antral Surgery, Delayed Recovery of a Dental Root with Oral
UCSLS 79313 No
Antrostomy
Antral Surgery, Oro-Antral Fistula Closure, (same session) Oro-
UCSLS 79331 No
Antral Fistula Closure with Buccal Flap
Antral Surgery, Oro-Antral Fistula Closure, (same session) Oro-
UCSLS 79333 No
Antral Fistula Closure with Palatal Flap
Antral Surgery, Oro-Antral Fistula Closure, (subsequent session)
UCSLS 79341 No
Oro-Antral Fistula Closure with Buccal Flap
Antral Surgery, Oro-Antral Fistula Closure, (subsequent session)
UCSLS 79343 No
Oro-Antral Fistula Closure with Palatal Flap
Sinus Osseous Augmentation, Open Lateral Approach -Autograft
UCSLS 79351 Yes
+E
Sinus Osseous Augmentation, Open Lateral Approach-Allograft +
UCSLS 79352 Yes
E.
Sinus Osseous Augmentation, Open Lateral Approach -Xenograft +
UCSLS 79353 Yes
E.
Sinus Osseous Augmentation, Indirect Inferior Approach –
UCSLS 79354 Yes
Autograft +E
Sinus Osseous Augmentation, Indirect Inferior Approach –
UCSLS 79355 Yes
Allograft + E.
Sinus Osseous Augmentation, Indirect Inferior Approach –
UCSLS 79356 Yes
Xenograft + E.
UCSLS 79401 Primary Hemorrhage, Control No
UCSLS 79402 Secondary Hemorrhage, Control No
UCSLS 79403 Hemorrhage Control, using Compression and Hemostatic Agent No
Hemorrhage Control, using Hemostatic Substance and Sutures
UCSLS 79404 No
(including removal of bony tissue, if necessary)
UCSLS 79511 Harvesting of Intraoral Tissue for Grafting to Operative Site Bone No
Harvesting of Intraoral Tissue for Grafting to Operative Site
UCSLS 79514 No
Mucosa
UCSLS 79541 Harvesting and Preparation of Platelet Rich Plasma + E. No
Post Surgical Care, Subsequent to Initial Post Surgical Treatment,
UCSLS 79601 No
Minor, by Treating Dentist
UCSLS 79602 Post Surgical Care, Minor, by Other Than Treating Dentist No
UCSLS 79603 Post Surgical Care, Major, by Treating Dentist No
UCSLS 79604 Post Surgical Care, Major, by Other Than Treating Dentist No
UCSLS 79605 Post Surgical Care, Alveolitis, Treatment of (without Anaesthesia) No
UCSLS 79606 Post Surgical Care, Alveolitis, Treatment of (with Anaesthesia) No
Palliative (emergency) Treatment of Dental Pain, Minor Procedure
UCSLS 91111 No
One unit of time
Palliative (emergency) Treatment of Dental Pain, Minor Procedure
UCSLS 91119 No
Each additional unit over three
UCSLS 91231 Management of Exceptional Patient One unit of time No
UCSLS 91239 Management of Exceptional Patient Each additional unit over four No
Provision of facilities, equipment and support services for general
UCSLS 92222 anaesthesia when provided by a separate practioner Two units of No
time
Provision of facilities, equipment and support services for general
UCSLS 92229 anaesthesia when provided by a separate practioner Each No
additional unit over eight
Nitrous Oxide Time is measured from the placement of the
UCSLS 92411 inhalation device and terminates with the removal of the inhalation No
device One unit of time
Nitrous Oxide Time is measured from the placement of the
UCSLS 92419 inhalation device and terminates with the removal of the inhalation No
device Each additional unit over eight
Oral Sedation
Sedation sufficient to require monitored care. Time is to be
UCSLS 92421 No
measured from the start of patient monitoring to release from the
treatment/recovery room One unit of time
Oral Sedation
Sedation sufficient to require monitored care. Time is to be
UCSLS 92429 No
measured from the start of patient monitoring to release from the
treatment/recovery room Each additional unit over eight

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 Nitrous Oxide with Oral Sedation
Time is measured with the administration of nitrous oxide and
UCSLS 92431 No
terminates with the release of the patient from the
treatment/recovery room One unit of time
Nitrous Oxide with Oral Sedation
Time is measured with the administration of nitrous oxide and
UCSLS 92439 No
terminates with the release of the patient from the
treatment/recovery room Each additional unit over eight
Parenteral Conscious Sedation (regardless of method -IM or IV)
UCSLS 92441 No
One unit
Parenteral Conscious Sedation (regardless of method -IM or IV)
UCSLS 92449 No
Each additional unit over eight
Combined Techniques of Inhalation plus Intravenous and/or
UCSLS 92451 No
Intramuscular Injection One unit of time
Combined Techniques of Inhalation plus Intravenous and/or
UCSLS 92459 No
Intramuscular Injection Each additional unit over eight
A dental-legal report - a short factually written or verbal
communication given to any lay person (e.g. lawyer, insurance
UCSLS 93121 No
representative, local, municipal or government agency, etc.) in
relation to the patient with prior patient approval.
A dental-legal report - a comprehensive written report with patient
approval, on symptoms, history and records giving diagnosis,
UCSLS 93122 treatment, results and present condition. The report is a factual No
summary of all information available on the case and could contain
prognostic information regarding patient response.

A dental-legal opinion - a comprehensive written report primarily

in the field of expert opinion. The report may be an opinion
regarding the possible course of events (when these cannot be
UCSLS 93123 determined factually), with possible long term consequences and No
complications in the development of the conditions. The report will
require expert knowledge and judgement with respect to the facts
leading to a detailed prognosis.
Duplication and transfer of patient dental records at request of the
UCSLS 93211 No
patient + E
UCSLS 96201 Intramuscular Drug Injection + E No
UCSLS 96202 Intravenous Drug Injection + E No
UCSLS 97111 Bleaching, Vital, In Office One unit of time No
UCSLS 97119 Each additional unit over three No
Bleaching, Vital Home (Includes the fabrication of bleaching trays,
UCSLS 97121 dispensing the system and follow-up care) Maxillary Arch + L No
and/or E
Bleaching, Vital Home (Includes the fabrication of bleaching trays,
UCSLS 97122 dispensing the system and follow-up care) Mandibular Arch + L No
and/or E
Bleaching, Vital Home (Includes the fabrication of bleaching trays,
UCSLS 97123 dispensing the system and follow-up care) Maxillary plus No
Mandibular (combined) + L and/or E
UCSLS 97131 Micro-Abrasion One unit of time No
UCSLS 97139 Micro-Abrasion Each additional unit over four No
Examination and Diagnosis,
Limited, Oral, New Patient.
UCSLS 01201 Examination and Diagnosis of hard and soft tissues, including No
checking of occlusion and appliances, but not including specific
test/analysis as for 01100. (May include PSR)
Examination and Diagnosis, Complete, Primary Dentition, to
include:
UCSLS 01101 (a) Extended examination and diagnosis on primary dentition, No
recording history, charting, treatment planning and case
presentation, including above description as per 01100.
Examination and Diagnosis, Complete, Mixed Dentition, to include:
(a) Extended examination and diagnosis on mixed dentition,
UCSLS 01102 recording history, charting, treatment planning and case No
presentation, including above description as per 01100;
(b) Eruption sequence, tooth size -jaw size assessment
Examination and Diagnosis, Complete, Permanent Dentition to
include:
UCSLS 01103 (a) Extended examination on permanent dentition, recording No
history, charting, treatment planning and case presentation,
including above description as per 01100.

Examination and Diagnosis, Limited, Oral, Previous Patient (recall).

Examination of hard and soft tissues, including checking of
UCSLS 01202 No
occlusion and
appliances, but not including specific test/analysis, as for 01100

Examination and Diagnosis, Specific Examination and evaluation

UCSLS 01204 No
of a specific situation

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 Examination and Diagnosis, Emergency. Examination and
UCSLS 01205 Diagnosis for the investigation of discomfort and/or infection in a No
localized area.
UCSLS 01206 Analysis, Mixed Dentition. No
Examination and Diagnosis, Stomatognathic Dysfunctional,
Comprehensive, to include:
(a) History, Medical, Dental, Pain/ Dysfunction;
(b) Clinical Examination to include, general appraisal, examination
UCSLS 01301 of head and neck, musculoskeletal system (static and functional); No
Intraoral examination of hard and soft tissues, including occlusal
analysis; consultation with other health care professionals, review
of previous records, including radiographs, ordering of appropriate
test/analysis and consultations.
Examination and Diagnosis, Stomatognathic Dysfunctional,
UCSLS 01302 No
Limited.
Examination and Diagnosis, Oral Pathology, General, to include:
(a) History, Medical and Dental
(b) Clinical Examination including, in-depth analysis of medical
UCSLS 01401 No
status, initial consultation, with referring dentist or physician,
evaluation of the diagnosis and prognosis and formulation
of a treatment plan.
Examination and Diagnosis, Oral Pathology, Specific (or repeat
UCSLS 01402 No
examination and diagnosis within 90 days for the same illness)
Examination and Diagnosis, Periodontal, General Recording
History, Charting, Treatment Planning and Case Presentation:
(a) History, Medical and Dental;
(b) Clinical Examination includes evaluation of topography of the
gingiva and related structures; degree of gingival inflammation;
UCSLS 01501 No
location, extent, sulcular depth; furcation involvement, mobility of
teeth; tooth contact relationships; evaluation of occlusion; TMJ,
examination of oral soft tissue pathosis; evaluation of the existing
restorative and/or prosthetic appliances; caries and
pulpal vitality.

UCSLS 01502 Examination and Diagnosis, Periodontal, Limited (previous patient) No

Examination and Diagnosis, Surgical, General

(a) History, Medical and Dental
(b) Clinical Examination as above, may include in-depth analysis of
medical status, medication, anaesthetic and surgical risk, initial
UCSLS 01601 No
consultation with referring dentist or physician, parent or guardian,
evaluation of source of chief complaint, evaluation of pulpal
vitality, mobility of teeth, occlusal factors, TMJ, or where the
patient is to be admitted to hospital for dental procedures.
UCSLS 01602 Examination and Diagnosis, Surgical, Specific No
Examination and Diagnosis, Prosthodontic, Edentulous
(a) Extended Examination of the Edentulous Mouth, including
detailed Medical and Dental History (including Prosthetic history),
UCSLS 01701 visual and digital examination of the oral structures, head and No
neck (including TMJ), lips, oral mucosa, tongue, oral pharynx,
salivary glands and lymph nodes, and including evaluation for
implant-supported or retained prosthesis.
Examination and Diagnosis,
UCSLS 01702 No
Prosthodontic, Specific.
Examination and Diagnosis, Prosthodontic, Fixed Oral
Rehabilitation, to include:
(a) History, Medical and Dental;
(b) Clinical Examination of Hard and Soft Tissues, including carious
lesions, missing teeth, determination of sulcular depth, gingival
UCSLS 01703 contours, mobility of teeth, interproximal tooth contact No
relationships, occlusion of teeth, TMJ, pulp vitality test/analysis,
where necessary and any other pertinent factors;
(c) evaluation of specific sites for implant-supported or retained
prosthesis;
(d) Radiographs extra, as required

Examination and Diagnosis, Endodontic, Complete Endodontic

examination and
diagnosis and/or complicated diagnosis. Recording history,
charting treatment planning and case history.
Includes the following:
UCSLS 01801 No
(a) History, Medical and Dental;
(b) Clinical Examination and Diagnosis may include, vitality
test/analysis, thermal test/analysis, cracked tooth test/analysis,
occlusal exams, percussion, palpation, transillumination,
anaesthetic test/analysis and mobility test/analysis

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 Examination and Diagnosis, Endodontic, Specific. Endodontic
UCSLS 01802 examination and evaluation of a specific situation in a localized No
area and vitality test analysis.
Examination and Diagnosis,
UCSLS 01902 No
Orthodontic, Specific
Radiographs, Complete Series (minimum of 12 images incl.
UCSLS 02101 No
bitewings).
Radiographs, Complete Series (minimum of 16 images incl.
UCSLS 02102 No
bitewings).
UCSLS 02111 Radiographs, Intraoral, Periapical-Single film No
UCSLS 02131 Radiographs, Occlusal Single images No
UCSLS 02141 Radiographs, BitewingSingle image No
RADIOGRAPHS, EXTRAORAL (Deprecated, do not use codes in this
UCSLS 02201 No
series) Single film
RADIOGRAPHS, POSTERO-ANTERIOR AND LATERAL SKULL AND
UCSLS 02301 No
FACIAL BONE Single film
Sinus Examination and Diagnosis - Minimum four films identified
UCSLS 02304 No
as: 1) Waters 2) Caldwell 3) Lateral Skull 4) Basal
UCSLS 02401 RADIOGRAPHS, SIALOGRAPHY Single film No
RADIOGRAPHS, TEMPOROMANDIBULAR JOINTRADIOGRAPHS,
UCSLS 02501 No
TEMPOROMANDIBULAR JOINT Single film
RADIOGRAPHS, TEMPOROMANDIBULAR JOINT Four films
UCSLS 02504 No
(minimum examination and diagnosis closed and open each side)
RADIOGRAPHS, TEMPOROMANDIBULAR JOINT Each additional film
UCSLS 02509 No
over four
UCSLS 02601 RADIOGRAPHS, PANORAMIC Single film No
RADIOGRAPHS,
UCSLS 02701 No
CEPHALOMETRIC Single film
Radiographs, Cephalometric, Tracing and Interpretation One unit
UCSLS 02751 No
of time
Radiographs, Cephalometric, Tracing and Interpretation Each
UCSLS 02759 No
additional unit over two
RADIOGRAPHS, COMPUTERIZED AXIAL TOMOGRAMS (C.A.T.),
POSITRON EMISSION TOMOGRAPHY (P.E.T.), MAGNETIC
RESONANCE IMAGES (M.R.I.), INTERPRETATION (either the
UCSLS 02801 No
radiographs, CAT scans, PET scans, MRI scans, or the
interpretation must be received from another source) One unit of
time + E
RADIOGRAPHS, COMPUTERIZED AXIAL TOMOGRAMS (C.A.T.),
POSITRON EMISSION TOMOGRAPHY (P.E.T.), MAGNETIC
RESONANCE IMAGES (M.R.I.), INTERPRETATION (either the
UCSLS 02809 No
radiographs, CAT scans, PET scans, MRI scans, or the
interpretation must be received from another source) Each
additional unit over two + E
UCSLS 02911 Radiographs, Duplications Single film No
UCSLS 02931 Radiographs, Tomography Single view No
UCSLS 02934 Radiographs, Tomography Four views No
Radiographs, Hand and Wrist (as a diagnostic aid for dental
UCSLS 02941 No
treatment) per case
Radiographic Guide, (includes diagnostic wax-up, with radio-
opaque markers for pre-surgical assessment of alveolar bone and
UCSLS 02951 Yes
vital structures as potential osseo-integrated implant site(s))
Maxillary Guide + L + E
Radiographic Guide, (includes diagnostic wax-up, with radio-
opaque markers for pre-surgical assessment of alveolar bone and
UCSLS 02952 Yes
vital structures as potential osseo-integrated implant site(s))
Mandibular + L + E
Microbiological Test/Analysis for the Determination of Pathological
UCSLS 04101 No
Agents + L
Bacteriological Test/Analysis for the Determination of Dental Caries
UCSLS 04201 No
Susceptibility + L
UCSLS 04311 Biopsy, Soft Oral Tissue - by Puncture + L No
UCSLS 04312 Biopsy, Soft Oral Tissue - by Incision + L No
UCSLS 04313 Biopsy, Soft Oral Tissue - by Aspiration + L No
Test/Analysis, Histopathological, Biopsy, Hard Oral Tissue - by
UCSLS 04321 No
Puncture + L
Test/Analysis, Histopathological, Biopsy, Hard Oral Tissue - by
UCSLS 04322 No
Incision + L
Test/Analysis, Histopathological, Biopsy, Hard Oral Tissue - by
UCSLS 04323 No
Aspiration + L
TESTS/ANALYSIS, PULP VITALITY AND INTERPRETATION One unit
UCSLS 04501 No
of time
TESTS/ANALYSIS, PULP VITALITY AND INTERPRETATION Each
UCSLS 04509 No
additional unit
Interpretation and/or Report, Microbiological by Oral Microbiologist
UCSLS 04601 No
+L
Interpretation and/or Report, Histopathological by Oral Pathologist
UCSLS 04602 No
or Microbiologist + L
UCSLS 04603 Interpretation and/or Report, Cytological by Oral Pathologist +L No

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 UCSLS 04631 Radiological Report One unit of time No
UCSLS 04639 Radiological Report Each additional unit of time No
PHOTOGRAPHS, DIAGNOSTIC (technical procedure only) Single
UCSLS 04801 No
photograph
UCSLS 06201 RADIOGRAPHS, EXTRAORAL (technical procedure only) Single film No
RADIOGRAPHS, SKULL (Postero-Anterior, Lateral Skull, Submental
UCSLS 06301 No
vertex, Waters, Caldwell, Single film
RADIOGRAPHS, SIALOGRAPHY
UCSLS 06401 No
(technical procedure only) Single film
RADIOGRAPHS, TEMPOROMANDIBULAR JOINT (technical
UCSLS 06501 No
procedure only) Single film
RADIOGRAPHS, TEMPOROMANDIBULAR JOINT (technical
UCSLS 06504 procedure only) Four films (minimum examination and diagnosis No
closed and open each side)
UCSLS 06601 RADIOGRAPHS, PANORAMIC (technical procedure only) Single film No
RADIOGRAPHS, CEPHALOMETRIC (technical procedure only)
UCSLS 06701 No
Single film
Radiographs, Cephalometric (tracing and interpretation) One unit
UCSLS 06751 No
of time
Radiographs, Cephalometric (tracing and interpretation) Each
UCSLS 06759 No
additional unit over four
Radiographs, Computerized Axial Tomograms, Positron Emission
UCSLS 06811 Tomograms, Magnetic Resonance Images, Interpretation, Oral No
Radiologist One unit of time
Radiographs, Computerized Axial Tomograms, Positron Emission
UCSLS 06819 Tomograms, Magnetic Resonance Images, Interpretation, Oral No
Radiologist Each additional unit of time over four
Radiographs, Computerized Axial Tomograms, Positron Emission
UCSLS 06821 Tomograms, Magnetic Resonance Images, Interpretation, No
Specialist Other than Oral Radiologist One unit of time
Radiographs, Computerized Axial Tomograms, Positron Emission
Tomograms, Magnetic Resonance Images, Interpretation,
UCSLS 06829 No
Specialist Other than Oral Radiologist Each additional unit over
four
UCSLS 06931 Radiographs, Tomography (technical procedure only) Single view No

UCSLS 06934 Radiographs, Tomography (technical procedure only) Four views No

Radiographs, Hand and Wrist (as a diagnostic aid for dental
UCSLS 06941 No
treatment) Per case
Chemotherapeutic and/or antimicrobial therapy, intra-sulcular
UCSLS 43521 No
application One unit of time + E
Chemotherapeutic and/or antimicrobial therapy, intra-sulcular
UCSLS 43529 No
application Each additional unit of time + E
APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS Appliance,
UCSLS 14101 No
Maxillary + L
APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS Appliance,
UCSLS 14102 No
Mandibular + L
APPLIANCES, REMOVABLE, CONTROL OF ORAL
UCSLS 14103 HABITSAPPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS No
Appliances, Maxillary plus Mandibular + L
APPLIANCES, FIXED/ CEMENTED, CONTROL OF ORAL HABITS
UCSLS 14201 No
Appliance, Maxillary + L
APPLIANCES, FIXED/ CEMENTED, CONTROL OF ORAL HABITS
UCSLS 14202 No
Appliance, Mandibular + L
APPLIANCES, CONTROL OF ORAL HABITS -
UCSLS 14401 No
adjustments, repairs, maintenance One unit of time + L
APPLIANCES, CONTROL OF ORAL HABITS -
UCSLS 14409 adjustments, repairs, maintenance Each additional unit over three No
+L
UCSLS 14501 Appliance, Protective Mouth Guard, Preformed No
UCSLS 14502 Appliance, Protective Mouth Guard, Processed + L No
Appliances, Periodontal (including bruxism appliance); Includes
UCSLS 14611 Impression, Insertion and Insertion adjustment (no post-insertion No
adjustments) Maxillary Appliance + L
Appliances, Periodontal (including bruxism appliance); Includes
UCSLS 14612 Impression, Insertion and Insertion adjustment (no post-insertion No
adjustments) Mandibular Appliance + L
UCSLS 14621 Appliances, Adjustment, Repair One unit of time + L No
Appliances, Adjustment, Repair Each additional unit over three +
UCSLS 14629 No
L
UCSLS 14631 Appliances, Reline, Direct No
UCSLS 14632 Appliances, Reline, Processed + L No
Appliance, TMJ, Diagnostic and/or Therapeutic, includes
UCSLS 14711 impression, insertion and insertion adjustment (no post-insertion No
adjustments) Maxillary Appliance + L
Appliance, TMJ, Diagnostic and/or Therapeutic, includes
UCSLS 14712 impression, insertion and insertion adjustment (no post-insertion No
adjustments) Mandibular Appliance + L

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 Appliance, TMJ Intraoral Repositioning; includes impression,
UCSLS 14721 insertion and insertion adjustment (no post-insertion adjustments) No
Maxillary Appliance + L
Appliance, TMJ Intraoral Repositioning; includes impression,
UCSLS 14722 insertion and insertion adjustment (no post-insertion adjustments) No
Mandibular Appliance + L
Appliance, TMJ, Periodic Maintenance, Adjustment, Repair One unit
UCSLS 14731 No
of time + L
Appliance, TMJ, Periodic Maintenance, Adjustment, Repair Each
UCSLS 14739 No
additional unit over three
UCSLS 14741 Appliance, TMJ Reline, Direct No
UCSLS 14742 Appliance, TMJ Reline, Indirect + L No
Appliance, Myofascial Pain Dysfunction Syndrome, to include:
models, gnathological determinants) Appliance Construction only,
UCSLS 14811 No
and insertion adjustment (no post-insertion adjustments) Maxillary
Appliance + L
Appliance, Myofascial Pain Dysfunction Syndrome, to include:
models, gnathological determinants) Appliance Construction only,
UCSLS 14812 No
and insertion adjustment (no post-insertion adjustments)
Mandibular Appliance + L
Appliance, Myofascial Pain Dysfunction Syndrome, Periodic
UCSLS 14821 No
Maintenance, Adjustment and repairs One unit of time + L
Appliance, Myofascial Pain Dysfunction Syndrome, Periodic
UCSLS 14829 Maintenance, Adjustment and repairs Each additional unit of time No
+L
Appliance, Myofascial Pain Dysfunction Syndrome, Relines Reline
UCSLS 14831 No
direct
Appliance, Myofascial Pain Dysfunction Syndrome,
UCSLS 14832 RelinesAppliance, Myofascial Pain Dysfunction Syndrome, Relines No
Reline, Processed + L
UCSLS 15101 Space Maintainer, Band Type, Fixed, Unilateral + L No
Space Maintainer, Band Type, Fixed, Unilateral with Intra-alveolar
UCSLS 15102 No
Attachment + L
Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual
UCSLS 15103 No
arch) + L
Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual
UCSLS 15104 No
arch), with Teeth Attached + L
Space Maintainer, Band Type, Fixed, Bilateral Tubes and Locking
UCSLS 15105 No
Wires + L
UCSLS 15201 Space Maintainer, Stainless Steel Crown Type, Fixed + L No
Space Maintainer, Stainless Steel Crown Type, Fixed, with Intra
UCSLS 15202 No
Alveolar Attachment + L
UCSLS 15301 Space Maintainer, Cast Type, Fixed + L No
Space Maintainer, Cast Type, Fixed, with Intra Alveolar Attachment
UCSLS 15302 No
+L
Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining
UCSLS 15401 No
Wires + L
Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining
UCSLS 15402 No
Wires with Teeth + L
UCSLS 15403 Space Maintainer, Acrylic Removable, No Clasps + L No
UCSLS 15501 Space Maintainer, Bonded, Pontic Type + L No
Maintenance, Space Maintainer Appliance, to include: adjustment
UCSLS 15601 No
and/or recementation after 30 days from insertion
Maintenance, Space Maintainer Appliances, addition of clasps
UCSLS 15602 No
and/or activating wires + L
Repairs, Space Maintainer Appliances (includes recementation) +
UCSLS 15603 No
L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25111 Yes
RESTORATIONS, INLAYS Metal -One surface + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25112 Yes
RESTORATIONS, INLAYS Metal -Two surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25113 Yes
RESTORATIONS, INLAYS Metal - Three surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25114 Yes
RESTORATIONS, INLAYS Metal - Three surfaces, modified + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25121 RESTORATIONS, INLAYS --Inlays, Composite/Compomer, Indirect No
(Bonded) One surface + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25122 RESTORATIONS, INLAYS --Inlays, Composite/Compomer, Indirect No
(Bonded) Two surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25123 RESTORATIONS, INLAYS --Inlays, Composite/Compomer, Indirect No
(Bonded) Three surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25124 RESTORATIONS, INLAYS --Inlays, Composite/Compomer, Indirect No
(Bonded) Three surfaces, modified + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25141 RESTORATIONS, INLAYS -Inlays, Porcelain/Ceramic/Polymer Glass Yes
(Bonded) One surface + L

DAMAN CONFIDENTIAL

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 RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25142 RESTORATIONS, INLAYS -Inlays, Porcelain/Ceramic/Polymer Glass Yes
(Bonded) Two surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25143 RESTORATIONS, INLAYS -Inlays, Porcelain/Ceramic/Polymer Glass Yes
(Bonded) Three surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS
UCSLS 25144 RESTORATIONS, INLAYS -Inlays, Porcelain/Ceramic/Polymer Glass Yes
(Bonded) Three surfaces, modified + L
UCSLS 25511 Onlays, Cast Metal, Indirect + L Yes
UCSLS 25512 Onlays, Cast Metal, Indirect (Bonded external retention type) + L Yes
UCSLS 25521 Onlays, Composite/Compomer, Indirect (Bonded) + L No
UCSLS 25531 Onlays, Porcelain/Ceramic/Polymer Glass (Bonded) + L Yes
Posts, Cast Metal, (including core) as a Separate Procedure Single
UCSLS 25711 No
section + L
Posts, Cast Metal, (including core) as a Separate Procedure Two
UCSLS 25712 No
sections + L
Posts, Cast Metal, (including core) as a Separate Procedure Three
UCSLS 25713 No
sections + L
Posts, Cast Metal (including core) Concurrent with Impression for
UCSLS 25721 No
Crown Single section + L
Posts, Cast Metal (including core) Concurrent with Impression for
UCSLS 25722 No
Crown Two sections + L
Posts, Cast Metal (including core) Concurrent with Impression for
UCSLS 25723 No
Crown Three sections + L
UCSLS 25731 Posts, Prefabricated Retentive + E One post + E No
UCSLS 25732 Posts, Prefabricated Retentive + E Two posts same tooth + E No
UCSLS 25733 Posts, Prefabricated Retentive + E Three posts same tooth + E No
Posts, Prefabricated, with Non-Bonded Core for Crown Restoration
[including pin(s) where applicable] or Fixed Bridge Retainer +
EPosts, Prefabricated, with Non-Bonded Core for Crown
UCSLS 25751 No
Restoration [including pin(s) where applicable] or Fixed Bridge
Retainer + E One post, with Non-Bonded amalgam core and pin(s)
+E
Posts, Prefabricated, with Non-Bonded Core for Crown Restoration
[including pin(s) where applicable] or Fixed Bridge Retainer + E
UCSLS 25752 No
Two posts (same tooth), with Non-Bonded amalgam core and
pin(s) + E
Posts, Prefabricated, with Non-Bonded Core for Crown Restoration
[including pin(s) where applicable] or Fixed Bridge Retainer + E
UCSLS 25753 No
Three posts (same tooth), with Non-Bonded amalgam core and
pin(s) + E
Posts, Prefabricated, with Bonded Core for Crown Restoration
UCSLS 25761 (including pin(s) where applicable) or Fixed Bridge Retainer +E No
One post, with bonded amalgam core and pin(s) +E
Posts, Prefabricated, with Bonded Core for Crown Restoration
UCSLS 25762 (including pin(s) where applicable) or Fixed Bridge Retainer +E No
Two posts (same tooth), with bonded amalgam core and pin(s) +E
Posts, Prefabricated, with Bonded Core for Crown Restoration
(including pin(s) where applicable) or Fixed Bridge Retainer +E
UCSLS 25763 No
Three posts (same tooth), with bonded amalgam core and pin(s)
+E
Posts, Prefabricated, with Bonded Core for Crown Restoration
UCSLS 25764 (including pin(s) where applicable) or Fixed Bridge Retainer +E No
One post, with bonded composite/compomer core and pin(s) +E
Two posts, (same tooth) with bonded composite/compomer core
UCSLS 25765 No
and pin(s) +E
Posts, Prefabricated, with Bonded Core for Crown Restoration
(including pin(s) where applicable) or Fixed Bridge Retainer +E
UCSLS 25766 No
Three posts, (same tooth) with bonded composite/compomer core
and pin(s) +E
UCSLS 25771 Posts, Provisional Per Post + L and/or + E No
MESOSTRUCTURES
(a separate component positioned between the head of an implant
UCSLS 26101 and the final restoration, retained by either a cemented post or Yes
screw) Indirect, Angulated or transmucosal pre-fabricated
abutment, per implant + L + E
MESOSTRUCTURES
(a separate component positioned between the head of an implant
UCSLS 26102 Yes
and the final restoration, retained by either a cemented post or
screw) Indirect, Custom laboratory fabricated, per implant + L + E

MESOSTRUCTURES
(a separate component positioned between the head of an implant
UCSLS 26103 Yes
and the final restoration, retained by either a cemented post or
screw) Direct, (with intra-oral preparation), per implant site + E

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 Crown, Acrylic/Composite/
UCSLS 27111 No
Compomer, Indirect + L
Crown, Acrylic/Composite/Compomer, Provisional [Long Term],
UCSLS 27113 No
Indirect (lab fabricated/relined intra-orally) + L
Crowns, Acrylic/Composite/Compomer, Direct, Provisional
UCSLS 27121 No
(chairside) + E
Crowns, Acrylic/Composite/Compomer, Direct, Provisional Implant-
UCSLS 27125 Yes
supported + E
Crown, Acrylic/Composite/Compomer/Cast Metal Base, Indirect +
UCSLS 27131 No
L
Crown, Acrylic/Composite/Compomer Cast Metal Base, Implant-
UCSLS 27135 Yes
supported + L + E
Semi-Precision Rest (interlock) (in addition to
UCSLS 27137 No
Acrylic/Composite/Compomer, Cast Metal Base Crown) + L + E
Semi-Precision or Precision Attachment RPD Retainer (in addition
UCSLS 27138 No
to Acrylic/Composite/Compomer, Cast Metal Base Crown) + L + E
Crown, Acrylic/Composite/Compomer/ Pre-fabricated Metal Base,
UCSLS 27145 Yes
Provisional, Implant-supported, Direct + E
Crown, Acrylic/ Composite/Compomer/Pre-fabricated Metal Base,
UCSLS 27155 Yes
Provisional, Implant-supported, Indirect + L + E
UCSLS 27201 Crown, Porcelain/Ceramic/Polymer Glass + L Yes
Crown, Porcelain/Ceramic/Polymer Glass, Implant-supported + L
UCSLS 27205 Yes
+E
Crown, Porcelain/Ceramic/Polymer Glass, with Cast Ceramic Post
UCSLS 27206 Yes
Retention + L
UCSLS 27211 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base + L Yes
Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base,
UCSLS 27213 Yes
with Porcelain Margin + L
Crown, Porcelain/Ceramic Fused to Metal Base, Implant-supported
UCSLS 27215 Yes
+ L +E
Crown, Porcelain/Ceramic Fused to Metal Base with Cast Metal
UCSLS 27216 Yes
Post Retention + L
Semi-precision Rest (Interlock) (in addition to Porcelain/Ceramic
UCSLS 27217 Yes
Fused to Metal Base Crown) + L + E
Semi-precision or Precision Attachment RPD Retainer (in addition
UCSLS 27218 Yes
to Porcelain/Ceramic Fused to Metal Base Crown) + L + E
UCSLS 27221 Crown, ¾, Porcelain/Ceramic/Polymer Glass, + L Yes
UCSLS 27301 Crown, Full, Cast Metal + L Yes
UCSLS 27305 Crown, Full, Cast Metal, Implant-supported + L + E Yes
Semi-precision Rest (Interlock) (in addition to Full, Cast Metal
UCSLS 27307 Yes
Crown) + L + E
Semi-Precision or Precision Attachment RPD Retainer (in addition
UCSLS 27308 Yes
to Full, Cast Metal Crown) + L + E
UCSLS 27311 Crowns, ¾, Cast Metal + L Yes
CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP
UCSLS 27401 Yes
(additional to crown) One crown
CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP
UCSLS 27409 Yes
(additional to crown) Each additional crown
UCSLS 27601 Veneers, Acrylic/Composite/Compomer, Bonded + L No
UCSLS 27602 Veneers, Porcelain/Ceramic/Polymer Glass, Bonded + L Yes
UCSLS 27711 Repairs, Acrylic/Composite/Compomer, Direct No
Repairs, Inlays Onlays or Crowns, Porcelain/Ceramic/Polymer
UCSLS 27721 Glass, Porcelain/Ceramic/Polymer Glass/Fused to Metal base, NO
Direct
Repairs, Inlays Onlays or Crowns, Porcelain/Ceramic/Polymer
UCSLS 27722 Glass, Porcelain/Ceramic/Polymer Glass/Fused to Metal base, NO
Indirect +L
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Implant-
UCSLS 28105 supported Prefabricated Attachment as an Overdenture Retentive Yes
Device, Direct + L + E
RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping
UCSLS 28211 Yes
Crown, Cast Metal, No Attachments, Indirect + L
RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping
UCSLS 28215 Crown, Cast Metal, No Attachments, Implant-supported, Indirect + Yes
L+E
RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping
UCSLS 28221 Crown, Cast Metal, with Attachments, Indirect+ L + E Coping Yes
Crown, Metal Cast, with Attachment, Indirect + L and/or + E
RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping
UCSLS 28225 Crown, Cast Metal, with Attachments, Indirect+ L + E Coping Yes
Crown, Cast Metal, Implant-supported with Attachment + L + E
UCSLS 51101 DENTURES, COMPLETE, STANDARD Maxillary + L Yes
UCSLS 51102 DENTURES, COMPLETE, STANDARD Mandibular + L Yes
DENTURES, COMPLETE, STANDARD Maxillary plus Mandibular
UCSLS 51103 Yes
(combined) + L
DENTURES, COMPLETE, STANDARD Liners, Processed, Resilient, in
UCSLS 51104 No
addition to above

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 DENTURES, SURGICAL, STANDARD, (IMMEDIATE) (includes
UCSLS 51301 Yes
first tissue conditioner, but not a processed reline) Maxillary + L

DENTURES, SURGICAL, STANDARD, (IMMEDIATE) (includes

UCSLS 51302 Yes
first tissue conditioner, but not a processed reline) Mandibular + L
DENTURES, SURGICAL, STANDARD, (IMMEDIATE) (includes
UCSLS 51303 first tissue conditioner, but not a processed reline) Maxillary plus Yes
Mandibular (combined) + L
UCSLS 51601 DENTURES, COMPLETE, PROVISIONAL Maxillary + L Yes
UCSLS 51602 DENTURES, COMPLETE, PROVISIONAL Mandibular + L Yes
DENTURES, COMPLETE, PROVISIONAL Maxillary plus Mandibular
UCSLS 51603 Yes
(combined) + L
DENTURES, COMPLETE, SURGICAL (IMMEDIATE),
UCSLS 51611 PROVISIONAL(Includes first tissue conditioner, but not a Yes
processed reline) Maxillary +L.
DENTURES, COMPLETE, SURGICAL (IMMEDIATE),
UCSLS 51612 PROVISIONAL(Includes first tissue conditioner, but not a Yes
processed reline) Mandibular +L.
DENTURES, COMPLETE, SURGICAL (IMMEDIATE),
UCSLS 51613 PROVISIONAL(Includes first tissue conditioner, but not a Yes
processed reline) Maxillary plus Mandibular (combined) +L.
Dentures, Complete, Overdentures, Tissue Borne, Supported by
UCSLS 51711 Natural Teeth with or without Coping Crowns, no Attachments Yes
Maxillary + L
Dentures, Complete, Overdentures, Tissue Borne, Supported by
UCSLS 51712 Natural Teeth with or without Coping Crowns, no Attachments Yes
Mandibular + L
Dentures, Complete, Overdentures, Tissue Borne, Supported by
UCSLS 51713 Natural Teeth with or without Coping Crowns, no Attachments Yes
Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, Supported by
UCSLS 51721 Implants with or without Coping Crowns, no Attachments Maxillary Yes
+L
Dentures, Complete, Overdentures, Tissue Borne, Supported by
UCSLS 51722 Implants with or without Coping Crowns, no Attachments Yes
Mandibular + L
Dentures, Complete, Overdentures, Tissue Borne, Supported by
UCSLS 51723 Implants with or without Coping Crowns, no Attachments Maxillary Yes
plus Mandibular (combined) + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne,
Supported by Natural Teeth with or without Coping Crowns, no
UCSLS 51811 Yes
Attachments (includes first tissue conditioner, but not a processed
reline) Maxillary + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne,
Supported by Natural Teeth with or without Coping Crowns, no
UCSLS 51812 Yes
Attachments (includes first tissue conditioner, but not a processed
reline) Mandibular + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne,
Supported by Natural Teeth with or without Coping Crowns, no
UCSLS 51813 Yes
Attachments (includes first tissue conditioner, but not a processed
reline) Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne,
Supported by Implants with or without Coping Crowns, no
UCSLS 51821 Yes
Attachments (includes first tissue conditioner, but not a processed
reline) Maxillary + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne,
Supported by Implants with or without Coping Crowns, no
UCSLS 51822 Yes
Attachments (includes first tissue conditioner, but not a processed
reline) Mandibular + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne,
Supported by Implants with or without Coping Crowns, no
UCSLS 51823 Yes
Attachments (includes first tissue conditioner, but not a processed
reline) Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, with
UCSLS 51911 Independent Attachments Secured to Natural Teeth with or without Yes
Coping Crowns Maxillary + L
Dentures, Complete, Overdentures, Tissue Borne, with
UCSLS 51912 Independent Attachments Secured to Natural Teeth with or without Yes
Coping Crowns Mandibular + L
Dentures, Complete, Overdentures, Tissue Borne, with
UCSLS 51913 Independent Attachments Secured to Natural Teeth with or without Yes
Coping Crowns Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, with
UCSLS 51921 Independent Attachments Secured to Implants with or without Yes
Coping Crowns Maxillary + L

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 Dentures, Complete, Overdentures, Tissue Borne, with
Independent Attachments Secured to Implants with or without
UCSLS 51922 Coping CrownsDentures, Complete, Overdentures, Tissue Borne, Yes
with Independent Attachments Secured to Implants with or
without Coping Crowns Mandibular + L
Dentures, Complete, Overdentures, Tissue Borne, with
UCSLS 51923 Independent Attachments Secured to Implants with or without Yes
Coping Crowns Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, with Retention
UCSLS 51941 from a Retentive Bar, Secured to Coping Crowns Supported by Yes
Natural Teeth Maxillary + L
Dentures, Complete, Overdentures, Tissue Borne, with Retention
UCSLS 51942 from a Retentive Bar, Secured to Coping Crowns Supported by Yes
Natural Teeth Mandibular + L
Dentures, Complete, Overdentures, Tissue Borne, with Retention
UCSLS 51943 from a Retentive Bar, Secured to Coping Crowns Supported by Yes
Natural Teeth Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, with Retention
UCSLS 51951 from a Retentive Bar, Secured to Coping Crowns Supported by Yes
Implants Maxillary + L
Dentures, Complete, Overdentures, Tissue Borne, with Retention
UCSLS 51952 from a Retentive Bar, Secured to Coping Crowns Supported by Yes
Implants Mandibular + L
Dentures, Complete, Overdentures, Tissue Borne, with Retention
UCSLS 51953 from a Retentive Bar, Secured to Coping Crowns Supported by Yes
Implants Maxillary plus Mandibular (combined) + L
DENTURES, PARTIAL, ACRYLIC BASE (PROVISIONAL) (With or
UCSLS 52101 Yes
Without Clasps) Maxillary + L
DENTURES, PARTIAL, ACRYLIC BASE (PROVISIONAL) (With or
UCSLS 52102 Yes
Without Clasps) Mandibular + L
DENTURES, PARTIAL, ACRYLIC BASE (PROVISIONAL) (With or
UCSLS 52103 Yes
Without Clasps) Maxillary plus Mandibular (combined) + L
Dentures, Partial, Acrylic Base (Immediate) (includes first tissue
UCSLS 52111 Yes
conditioner, but not a processed reline) Maxillary + L
Dentures, Partial, Acrylic Base (Immediate) (includes first tissue
UCSLS 52112 Yes
conditioner, but not a processed reline) Mandibular + L
Dentures, Partial, Acrylic Base (Immediate) (includes first tissue
conditioner, but not a processed reline)Dentures, Partial, Acrylic
UCSLS 52113 Yes
Base (Immediate) (includes first tissue conditioner, but not a
processed reline) Maxillary plus Mandibular (combined) + L
DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST
UCSLS 52301 Yes
CLASPS AND/OR RESTS Maxillary + L
DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST
UCSLS 52302 Yes
CLASPS AND/OR RESTS Mandibular + L
DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST
UCSLS 52303 CLASPS AND/OR RESTS Maxillary plus Mandibular (combined) + Yes
L
UCSLS 52511 Dentures, Partial, (flexible, Non Metal, Non Acrylic) Maxillary + L Yes

UCSLS 52512 Dentures, Partial, (flexible, Non Metal, Non Acrylic) Mandibular + L Yes
Dentures, Partial, (flexible, Non Metal, Non Acrylic) Maxillary plus
UCSLS 52513 Yes
Mandibular + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
UCSLS 52711 and/or Rests supported by Natural Teeth with or without Coping Yes
Crowns, no attachments Maxillary + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
UCSLS 52712 and/or Rests supported by Natural Teeth with or without Coping Yes
Crowns, no attachments Mandibular + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests supported by Natural Teeth with or without Coping
UCSLS 52713 Yes
Crowns, no attachments Maxillary plus Mandibular (combined) +
L
Dentures, Partial, Overdentures, Acrylic, with Cast/ Wrought
UCSLS 52721 Clasps and/or Rests, Supported by Implants with or without Yes
Coping Crowns, No Attachments Maxillary + L
Dentures, Partial, Overdentures, Acrylic, with Cast/ Wrought
UCSLS 52722 Clasps and/or Rests, Supported by Implants with or without Yes
Coping Crowns, No Attachments Mandibular + L
Dentures, Partial, Overdentures, Acrylic, with Cast/ Wrought
Clasps and/or Rests, Supported by Implants with or without
UCSLS 52723 Yes
Coping Crowns, No Attachments Maxillary plus Mandibular
(combined) + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests with Independent Attachments Secured by
UCSLS 52911 Yes
Attachments to Natural Teeth with or without Coping Crowns
Maxillary + L

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 Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests with Independent Attachments Secured by
UCSLS 52912 Yes
Attachments to Natural Teeth with or without Coping Crowns
Mandibular + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests with Independent Attachments Secured by
UCSLS 52913 Yes
Attachments to Natural Teeth with or without Coping Crowns
Maxillary plus Mandibular (combined) + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
UCSLS 52921 and/or Rests, with Independent Attachments Secured to Implants Yes
with or without Coping Crowns Maxillary + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
UCSLS 52922 and/or Rests, with Independent Attachments Secured to Implants Yes
with or without Coping Crowns Mandibular + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests, with Independent Attachments Secured to Implants
UCSLS 52923 Yes
with or without Coping Crowns Maxillary plus Mandibular
(combined) + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests, with Retention from a Retentive Bar, Secured to
UCSLS 52941 Yes
Coping Crowns Supported by Natural Teeth (see 62104 for
Retentive Bar) Maxillary + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests, with Retention from a Retentive Bar, Secured to
UCSLS 52942 Yes
Coping Crowns Supported by Natural Teeth (see 62104 for
Retentive Bar) Mandibular + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests, with Retention from a Retentive Bar, Secured to
UCSLS 52943 Yes
Coping Crowns Supported by Natural Teeth (see 62104 for
Retentive Bar) Maxillary plus Mandibular (combined) + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests, with Retention from a Retentive Bar, Secured to
UCSLS 52951 Yes
Coping Crowns Supported by Implants (see 62105 for Retentive
Bar) Maxillary + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests, with Retention from a Retentive Bar, Secured to
UCSLS 52952 Yes
Coping Crowns Supported by Implants (see 62105 for Retentive
Bar) Mandibular + L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps
and/or Rests, with Retention from a Retentive Bar, Secured to
UCSLS 52953 Yes
Coping Crowns Supported by Implants (see 62105 for Retentive
Bar) Maxillary plus Mandibular (combined) + L
DENTURES, PARTIAL, FREE END, CAST FRAME/ CONNECTOR,
UCSLS 53101 Yes
CLASPS AND RESTS Maxillary + L
DENTURES, PARTIAL, FREE END, CAST FRAME/ CONNECTOR,
UCSLS 53102 Yes
CLASPS AND RESTSv Mandibular + L
DENTURES, PARTIAL, FREE END, CAST FRAME/ CONNECTOR,
UCSLS 53103 Yes
CLASPS AND RESTS Maxillary plus Mandibular (combined) + L
Dentures, Partial, Free End, Cast Frame/Connector, Clasps and
UCSLS 53111 Rests, (Immediate) (includes first tissue conditioner, but not a Yes
processed reline) Maxillary + L
Dentures, Partial, Free End, Cast Frame/Connector, Clasps and
UCSLS 53112 Rests, (Immediate) (includes first tissue conditioner, but not a Yes
processed reline) Mandibular + L
Dentures, Partial, Free End, Cast Frame/Connector, Clasps and
UCSLS 53113 Rests, (Immediate) (includes first tissue conditioner, but not a Yes
processed reline) Maxillary plus Mandibular (combined) + L
UCSLS 53121 Dentures, Partial Free End, Swing Lock/Connector Maxillary + L Yes
UCSLS 53122 Dentures, Partial Free End, Swing Lock/Connector Mandibular + L Yes
Dentures, Partial Free End, Swing Lock/Connector Maxillary plus
UCSLS 53123 Yes
Mandibular (combined) + L
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR,
UCSLS 53201 Yes
CLASPS AND RESTS Maxillary + L
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR,
UCSLS 53202 Yes
CLASPS AND RESTS Mandibular + L
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR,
UCSLS 53203 Yes
CLASPS AND RESTS Maxillary plus Mandibular (combined) + L
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR,
UCSLS 53205 CLASPS AND RESTS Unilateral, one piece casting, clasps and Yes
pontics + L
Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and
UCSLS 53211 Rests, (Immediate) (includes first tissue conditioner, but not a Yes
processed reline) Maxillary + L
Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and
UCSLS 53212 Rests, (Immediate) (includes first tissue conditioner, but not a Yes
processed reline) Mandibular + L

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 Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and
UCSLS 53213 Rests, (Immediate) (includes first tissue conditioner, but not a Yes
processed reline) Maxillary plus Mandibular (combined) + L
Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and
Rests, (Immediate) (includes first tissue conditioner, but not a
UCSLS 53215 Yes
processed reline) Unilateral, One Piece Casting, Clasps and Pontics
+L
DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS Maxillary
UCSLS 53401 Yes
+L
DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS
UCSLS 53402 Yes
Mandibular + L
DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS Maxillary
UCSLS 53403 Yes
plus Mandibular (combined) + L
DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS
UCSLS 53501 Yes
Maxillary + L
DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS
UCSLS 53502 Yes
Mandibular + L
DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS
UCSLS 53503 Yes
Maxillary plus Mandibular (combined) + L
Dentures, Partial, Cast, Overdentures, Supported by Natural Teeth
UCSLS 53711 Yes
with or without Coping Crowns, no Attachments Maxillary + L

Dentures, Partial, Cast, Overdentures, Supported by Natural Teeth

UCSLS 53712 Yes
with or without Coping Crowns, no Attachments Mandibular + L
Dentures, Partial, Cast, Overdentures, Supported by Natural Teeth
UCSLS 53713 with or without Coping Crowns, no Attachments Maxillary plus Yes
Mandibular (combined) + L
Dentures, Partial, Casts, Overdentures, Supported by Implants
UCSLS 53721 Yes
with or without Coping Crowns, No Attachments Maxillary + L
Dentures, Partial, Casts, Overdentures, Supported by Implants
UCSLS 53722 Yes
with or without Coping Crowns, No Attachments Mandibular + L
Dentures, Partial, Casts, Overdentures, Supported by Implants
UCSLS 53723 with or without Coping Crowns, No Attachments Maxillary plus Yes
Mandibular (combined) + L
Dentures, Partial, Cast, Overdentures (Immediate), Supported by
Natural Teeth with or without Coping Crowns, No Attachments
UCSLS 53811 Yes
(includes first tissue conditioner, but not a processed reline)
Maxillary + L
Dentures, Partial, Cast, Overdentures (Immediate), Supported by
Natural Teeth with or without Coping Crowns, No Attachments
UCSLS 53812 Yes
(includes first tissue conditioner, but not a processed reline)
Mandibular + L
Dentures, Partial, Cast, Overdentures (Immediate), Supported by
Natural Teeth with or without Coping Crowns, No Attachments
UCSLS 53813 Yes
(includes first tissue conditioner, but not a processed reline)
Maxillary plus Mandibular (combined) + L
Dentures, Partial, Cast, Overdentures (Immediate), Supported by
UCSLS 53821 Implants with or without Coping Crowns, No Attachments (includes Yes
first tissue conditioner, but not a processed reline) Maxillary + L

Dentures, Partial, Cast, Overdentures (Immediate), Supported by

UCSLS 53822 Implants with or without Coping Crowns, No Attachments (includes Yes
first tissue conditioner, but not a processed reline) Mandibular + L
Dentures, Partial, Cast, Overdentures (Immediate), Supported by
Implants with or without Coping Crowns, No Attachments (includes
UCSLS 53823 Yes
first tissue conditioner, but not a processed reline) Maxillary plus
Mandibular (combined) + L
Dentures, Partial, Cast, Overdentures, with Retention from a
UCSLS 53941 Retentive Bar, Secured to Coping Crowns Supported by Natural Yes
Teeth (see 62104 for Retentive Bar) Maxillary + L
Dentures, Partial, Cast, Overdentures, with Retention from a
UCSLS 53942 Retentive Bar, Secured to Coping Crowns Supported by Natural Yes
Teeth (see 62104 for Retentive Bar) Mandibular + L
Dentures, Partial, Cast, Overdentures, with Retention from a
Retentive Bar, Secured to Coping Crowns Supported by Natural
UCSLS 53943 Yes
Teeth (see 62104 for Retentive Bar) Maxillary plus Mandibular
(combined) + L
Dentures, Partial, Cast, Overdentures, with Retention from a
UCSLS 53951 Retentive Bar, Secured to Coping Crowns Supported by Implants Yes
(see 62105 for Retentive Bar) Maxillary + L
Dentures, Partial, Cast, Overdentures, with Retention from a
UCSLS 53952 Retentive Bar, Secured to Coping Crowns Supported by Implants Yes
(see 62105 for Retentive Bar) Mandibular + L
Dentures, Partial, Cast, Overdentures, with Retention from a
Retentive Bar, Secured to Coping Crowns Supported by Implants
UCSLS 53953 Yes
(see 62105 for Retentive Bar) Maxillary plus Mandibular
(combined) + L

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 DENTURES, ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE,
UCSLS 54201 No
MINOR One unit of time + L
DENTURES, ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE,
UCSLS 54209 No
MINOR Each additional unit over two
DENTURE, REPAIRS, COMPLETE DENTURE, NO IMPRESSION
UCSLS 55101 No
REQUIREDMaxillary + L
DENTURE, REPAIRS, COMPLETE DENTURE, NO IMPRESSION
UCSLS 55102 No
REQUIRED Mandibular + L
DENTURES, REPAIRS, COMPLETE DENTURE, IMPRESSION
UCSLS 55201 No
REQUIRED Maxillary + L
DENTURES, REPAIRS, COMPLETE DENTURE, IMPRESSION
UCSLS 55202 No
REQUIRED Mandibular + L
DENTURES, REPAIRS, COMPLETE DENTURE, IMPRESSION
UCSLS 55203 No
REQUIRED Maxillary plus Mandibular (combined) + L
DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE, NO
UCSLS 55301 No
IMPRESSION REQUIRED Maxillary + L
DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE, NO
UCSLS 55302 No
IMPRESSION REQUIRED Mandibular + L
DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE,
UCSLS 55401 No
IMPRESSION REQUIRED Maxillary + L
DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE,
UCSLS 55402 No
IMPRESSION REQUIRED Mandibular + L
DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE,
UCSLS 55403 IMPRESSION REQUIRED Maxillary plus Mandibular (combined) + No
L
DENTURES/IMPLANT RETAINED PROSTHESIS, PROPHYLAXIS AND
UCSLS 55501 No
POLISHING One unit of time + L
DENTURES/IMPLANT RETAINED PROSTHESIS, PROPHYLAXIS AND
UCSLS 55509 No
POLISHING Each additional unit of time
Dentures, Replication, Complete Denture, Provisional (No Intra-
UCSLS 56111 No
oral Impression Required) Maxillary + L
Dentures, Replication, Complete Denture, Provisional (No Intra-
UCSLS 56112 No
oral Impression Required) Mandibular + L
Dentures, Replication, Complete Denture, Provisional (No Intra-
UCSLS 56113 oral Impression Required) Maxillary plus Mandibular (combined) + No
L
Dentures, Replication, Partial Denture (Provisional) (No Intra-oral
UCSLS 56121 No
Impression Required) Maxillary + L
Dentures, Replication, Partial Denture (Provisional) (No Intra-oral
UCSLS 56122 No
Impression Required) Mandibular + L
Dentures, Replication, Partial Denture (Provisional) (No Intra-oral
UCSLS 56123 No
Impression Required) Maxillary plus Mandibular (combined) + L
UCSLS 56211 Denture, Reline, Direct, Complete Denture Maxillary No
UCSLS 56212 Denture, Reline, Direct, Complete Denture Mandibular No
Denture, Reline, Direct, Complete Denture Maxillary plus
UCSLS 56213 No
Mandibular (combined)
UCSLS 56221 Denture, Reline, Direct, Partial Denture Maxillary No
Denture, Reline, Direct, Partial DentureDenture, Reline, Direct,
UCSLS 56222 No
Partial Denture Mandibular
Denture, Reline, Direct, Partial Denture Maxillary plus Mandibular
UCSLS 56223 No
(combined)
Denture, Reline, Processed, Complete DentureDenture, Reline,
UCSLS 56231 No
Processed, Complete Denture Maxillary + L
UCSLS 56232 Denture, Reline, Processed, Complete Denture Mandibular + L No
Denture, Reline, Processed, Complete Denture Maxillary plus
UCSLS 56233 No
Mandibular (combined) + L
UCSLS 56241 Denture, Reline, Processed, Partial Denture Maxillary + L No
UCSLS 56242 Denture, Reline, Processed, Partial Denture Mandibular + L No
Denture, Reline, Processed, Partial Denture Maxillary plus
UCSLS 56243 No
Mandibular (combined) + L
UCSLS 56311 Denture, Rebase, Complete Denture Maxillary + L No
UCSLS 56312 Denture, Rebase, Complete Denture Mandibular + L No
Denture, Rebase, Complete Denture Maxillary plus Mandibular
UCSLS 56313 No
(combined) + L
UCSLS 56321 Denture, Rebase Partial Denture Maxillary + L No
UCSLS 56322 Denture, Rebase Partial Denture Mandibular + L No
Denture, Rebase Partial Denture Maxillary plus Mandibular
UCSLS 56323 No
(combined) + L
Denture, Therapeutic Tissue Conditioning, per appointment,
UCSLS 56511 No
Complete Denture Maxillary
Denture, Therapeutic Tissue Conditioning, per appointment,
UCSLS 56512 No
Complete Denture Mandibular
Denture, Therapeutic Tissue Conditioning, per appointment,
UCSLS 56513 No
Complete Denture Maxillary plus Mandibular (combined)
Denture, Therapeutic Tissue Conditioning, per appointment, Partial
UCSLS 56521 No
Denture Maxillary
Denture, Therapeutic Tissue Conditioning, per appointment, Partial
UCSLS 56522 No
Denture Mandibular
Denture, Therapeutic Tissue Conditioning, per appointment, Partial
UCSLS 56523 No
Denture Maxillary plus Mandibular (combined)

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 Dentures, Tissue Conditioning, per appointment, Complete
UCSLS 56531 No
Overdenture, Supported by Natural Teeth Maxillary
Dentures, Tissue Conditioning, per appointment, Complete
UCSLS 56532 No
Overdenture, Supported by Natural Teeth Mandibular
Dentures, Tissue Conditioning, per appointment, Complete
UCSLS 56533 Overdenture, Supported by Natural Teeth Maxillary plus No
Mandibular (combined)
Dentures, Tissue Conditioning, per appointment, Complete
UCSLS 56541 No
Overdenture, Implant Supported Maxillary
Dentures, Tissue Conditioning, per appointment, Complete
UCSLS 56542 No
Overdenture, Implant Supported Mandibular
Dentures, Tissue Conditioning, per appointment, Complete
UCSLS 56543 Overdenture, Implant Supported Maxillary plus Mandibular No
(combined)
Dentures, Tissue Conditioning, per appointment, Partial
UCSLS 56551 No
Overdenture, Supported by Natural Teeth Maxillary
Dentures, Tissue Conditioning, per appointment, Partial
UCSLS 56552 No
Overdenture, Supported by Natural Teeth Mandibular
Dentures, Tissue Conditioning, per appointment, Partial
UCSLS 56553 Overdenture, Supported by Natural Teeth Maxillary plus No
Mandibular (combined)
Dentures, Tissue Conditioning, per appointment, Partial
UCSLS 56561 No
Overdenture, Implant Supported Maxillary
Dentures, Tissue Conditioning, per appointment, Partial
UCSLS 56562 No
Overdenture, Implant Supported Mandibular
Dentures, Tissue Conditioning, per appointment, Partial
UCSLS 56563 Overdenture, Implant Supported Maxillary plus Mandibular No
(combined)
Attaching or re-attaching retention elements to a removable
UCSLS 56611 No
prosthesis, direct One unit of time + E
UCSLS 62101 Pontics, Cast Metal + L Yes
Pontics, Cast Metal Framework with Separate
UCSLS 62102 Yes
Porcelain/Ceramic/Polymer Glass Jacket Pontic + L
UCSLS 62103 Pontics, Prefabricated Attachable Facing + L Yes
Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader
UCSLS 62104 Yes
Bar) Attached to Retainer + L + E
Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader)
UCSLS 62105 Bar, Attached to Implant-supported Retainer, to Retain Removable Yes
Prosthesis, Each Bar +L + E
Semi-precision or Precision Rest (interlock) (in addition to Cast
UCSLS 62107 Yes
Metal Pontic) + L + E
Semi-precision or Precision Attachment, RPD Retainer (in addition
UCSLS 62108 Yes
to Cast Metal Pontic) + L + E
UCSLS 62501 Pontics, Porcelain/Ceramic/Polymer Glass, Fused to Metal + L Yes
UCSLS 62502 Pontics, Porcelain/Ceramic/Polymer Glass, Aluminous + L Yes
Semi-Precision Rest (Interlock) (in addition to Pontic,
UCSLS 62507 Yes
Porcelain/Ceramic/Polymer Glass Fused to Metal) + L + E
Semi-Precision or Precision Attachment, RPD, Retainer (in addition
UCSLS 62508 Yes
to Procelain/Ceramic/Polymer Glass Fused to Metal Pontic) + L + E
UCSLS 62701 Pontics, Acrylic/Composite/Compomer, Processed to Metal + L No
UCSLS 62702 Pontics, Acrylic/Composite/Compomer, Indirect (Provisional) + L No
Pontics, Acrylic/Composite/Compomer, Bonded to adjacent Teeth
UCSLS 62703 No
Direct (Provisional) + E
UCSLS 62704 Pontics, Acrylic/Composite/Compomer +L No
Semi-Precision or Precision Rest, RPD Retainer (in addition to
UCSLS 62707 Yes
Acylic/Composite/Compomer Processed to Metal Pontic) + L + E
Semi-Precision or Precision Attachement, RPD Retainer (in addition
UCSLS 62708 to Acrylique/Composite/Compomer Processed to Metal Pontic) + L Yes
+E
Pontics, Natural Tooth Crown, Direct, Bonded to Adjacent Teeth
UCSLS 62801 No
(Provisional)
Pontics, Natural Tooth Crown, Direct, Bonded to Adjacent Teeth,
UCSLS 62802 No
Long-term Provisional
RECONTOURING OF RETAINER/PONTICS,
UCSLS 63001 No
(of existing bridgework) One unit of time
RECONTOURING OF RETAINER/PONTICS,
UCSLS 63009 No
(of existing bridgework) Each additional unit of time
Master Cast Techniques, Arbitrary Terminal Hinge Axis Registration
UCSLS 64111 No
and Transfer One unit of time + L
Master Cast Techniques, Centric Registration Recording One unit of
UCSLS 64131 No
time + L
Master Cast Techniques, Three Dimensional Recordings of
UCSLS 64141 Mandibular Movement (Pantograph or Stereograph) One unit of No
time + L
UCSLS 64301 MASTER CAST GNATHOLOGICAL WAX-UP + L One unit of time + L No
MASTER CAST GNATHOLOGICAL WAX-UP + L Each additional unit
UCSLS 64309 No
of time + L

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 Repairs, Removal, Fixed Bridge/Prosthesis - To be re-cemented
UCSLS 66211 No
One unit of time
Repairs, Removal, Fixed Bridge/Prosthesis - To be re-cemented
UCSLS 66219 No
Each additional unit over four
Repairs, Removal of Fixed Bridge/Prosthesis, Implant-supported-to
UCSLS 66231 No
be re-inserted One unit of time
Repairs, Removal of Fixed Bridge/Prosthesis, Implant-supported-to
UCSLS 66239 No
be re-inserted Each additional unit over four
Repairs, Sectioning of an Abutment or a Pontic plus polishing
UCSLS 66251 No
remaining portion (existing bridge) One unit of time
Repairs, Sectioning of an Abutment or a Pontic plus polishing
UCSLS 66259 No
remaining portion (existing bridge) Each additional unit over four

REPARIS, RE-INSERTION/RECEMENTATION (+L where laboratory

UCSLS 66301 No
charges are incurred during repair of bridge) One unit of time
REPARIS, RE-INSERTION/RECEMENTATION (+L where laboratory
UCSLS 66309 charges are incurred during repair of bridge) Each additional unit No
over four
Repairs, Reinsertion/Recementation Implant-supported
UCSLS 66311 No
Bridge/Prosthesis One unit of time + L and/or + E
Repairs, Reinsertion/Recementation Implant-supported
UCSLS 66319 Bridge/Prosthesis Each additional unit of time over four + L and/or No
+E
Repairs, Fixed Bridge/Prosthesis, Porcelain/Ceramic/Polymer
UCSLS 66711 No
Glass/Acrylic/Composite/Compomer, Direct First tooth
Repairs, Fixed Bridge/Prosthesis, Porcelain/Ceramic/Polymer
UCSLS 66719 No
Glass/Acrylic/Composite/Compomer, Direct Each additional tooth
Repairs, Solder Indexing to Repair Broken Solder Joint One unit of
UCSLS 66721 No
time + L
Repairs, Solder Indexing to Repair Broken Solder Joint Each
UCSLS 66729 No
additional unit of time
Repairs, Fixed Bridge/Prosthesis, Implant-supported, Direct One
UCSLS 66741 No
unit of time + E
Repairs, Fixed Bridge/Prosthesis, Implant-supported, Direct Each
UCSLS 66749 No
additional unit of time over four + E
UCSLS 67111 Retainers, Acrylic, Composite/Compomer, Indirect + L No
Retainers, Acrylic, Composite/Compomer, Provisional, Indirect (lab
UCSLS 67113 No
fabricated/relined intra-orally) + L
Retainers, Acrylic, Composite/Compomer, Implant-supported
UCSLS 67115 Yes
Indirect + L
Retainers, Acrylic, Composite/Compomer, Direct (provisional
UCSLS 67121 No
during healing, done at chair-side ) +E
Retainers, Acrylic, Composite/Compomer, (provisional during
UCSLS 67125 Yes
healing, done at chair-side), Implant-supported, Direct + E
Retainer, Compomer/Composite Resin/Acrylic, Processed to Cast
UCSLS 67131 No
Metal, Indirect + L
Retainer, Compomer/Composite Resin/Acrylic, Processed to Metal,
UCSLS 67135 Yes
Indirect, Implant-supported + L + E
Semi-precision Rest (Interlock) (in addition to Retainer,
UCSLS 67137 Compomer/Composite Resin/Acrylic, Processed to Metal, Indirect) Yes
+L+E
Semi-precision or Precision Attachment, RPD Retainer (in addition
to retainer) + L + E, Retainers, Acrylic/Composite/ Compomer
UCSLS 67138 Yes
With, Or Without Cast Or Prefabricated Metal Bases (Retainers,
Acrylic, Composite/Compomer, Cast Metal Base, Indirect)
Retainers, Acrylic/Composite/Compomer, Pre-fabricated Metal
UCSLS 67145 Yes
Base, Provisional, Implant-supported, Direct + E
Retainers, Acrylic/Composite/Compomer, Pre-fabricated Metal
UCSLS 67155 Yes
Base, Implant-supported, Provisional, Indirect + L + E
Retainers, Acrylic/Composite/Compomer, Two surface Inlay,
UCSLS 67161 No
Bonded, Indirect, + L
Retainers, Acrylic/Composite/Compomer, Three surface Inlay,
UCSLS 67171 No
Bonded, Indirect, + L
Retainers, Acrylic/Composite/Compomer, Onlay, Bonded, Indirect,
UCSLS 67181 No
+L
UCSLS 67201 Retainer, Porcelain/Ceramic/Polymer Glass, Full Coverage + L Yes
Retainer, Porcelain/Ceramic/Polymer Glass, Full Coverage, Implant-
UCSLS 67205 Yes
supported + L + E
Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base
UCSLS 67211 Yes
+L
Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base
UCSLS 67213 Yes
with a Porcelain/Ceramic/Polymer Glass Margin + L
Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base,
UCSLS 67215 Yes
Implant-supported + L + E
UCSLS 67217 Semi-precision Rest (Interlock) (in addition to Retainer) + L + E Yes

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 Semi-precision or Precision Attachment, RPD Retainer (in addition
to retainer) + L + E, Retainer, Porcelain/Ceramic/Polymer Glass,
UCSLS 67218 Yes
Full Coverage (Retainers, Porcelain/Ceramic/Polymer Glass, Fused
To Metal Base)
Retainer, Porcelain/Ceramic/Polymer Glass, Partial Coverage,
UCSLS 67221 Yes
Bonded (External Retention- e.g. “Maryland Bridge”) + L
Retainers, Porcelain/Ceramic/Polymer Glass, Two surface Inlay,
UCSLS 67231 Yes
Bonded +L
Retainers, Porcelain/Ceramic/Polymer Glass, Three surface Inlay,
UCSLS 67241 Yes
Bonded + L
UCSLS 67251 Retainers, Porcelain/Ceramic/Polymer Glass, Onlay, Bonded +L Yes
UCSLS 67301 Retainers, Full, Cast Metal + L Yes
UCSLS 67305 Retainers, Full, Cast Metal, Implant-Supported + L + E Yes
UCSLS 67307 Semi-precision Rests (interlock)(in addition to retainer) + L + E Yes
Semi-precision or Precision Attachment, RPD Retainer (in addition
UCSLS 67308 Yes
to retainer) +L + E
UCSLS 67311 Retainers, ¾, Cast Metal + L Yes
Retainer, Cast Metal, Onlay, with or without Perforations, Bonded
UCSLS 67341 Yes
to Abutment Tooth, (Pontic extra) + L
FIXED PROSTHETICS, ABUTMENTS/RETAINERS, MISCELLANEOUS
UCSLS 67501 SERVICES Abutment Preparation Under Existing Partial Denture No
Clasp, in addition to retainer codes + L
FIXED PROSTHETICS, ABUTMENTS/RETAINERS, MISCELLANEOUS
UCSLS 67502 Yes
SERVICES Telescoping Crown Unit + L
Fixed Prosthesis, Porcelain, to Replace a Substantial Portion of the
UCSLS 69101 Yes
Alveolar Process (in addition to retainer and pontics) + L
Splinting, for Extensive or Complicated Restorative Dentistry (per
UCSLS 69201 No
tooth) + L
Fixed Prosthodontic Frameworks, Osseo-Integrated, Attached with
UCSLS 69811 Screws and Incorporating Teeth (denture teeth and acrylic) Yes
Maxillary + L
Fixed Prosthodontic Frameworks, Osseo-Integrated, Attached with
UCSLS 69812 Screws and Incorporating Teeth (denture teeth and acrylic) Yes
Mandibular + L
Fixed Prosthodontic Framework, Osseo-Integrated, Attached with
Screws Or Cement and Incorporating Teeth
(Porcelain/Ceramic/Polymer Glass Bonded to Metal,
Acrylic/Composite/Compomer Processed to Metal or Full Metal
UCSLS 69821 Crowns)Fixed Prosthodontic Framework, Osseo-Integrated, Yes
Attached with Screws Or Cement and Incorporating Teeth
(Porcelain/Ceramic/Polymer Glass Bonded to Metal,
Acrylic/Composite/Compomer Processed to Metal or Full Metal
Crowns) Maxillary + L
Fixed Prosthodontic Framework, Osseo-Integrated, Attached with
Screws Or Cement and Incorporating Teeth
UCSLS 69822 (Porcelain/Ceramic/Polymer Glass Bonded to Metal, Yes
Acrylic/Composite/Compomer Processed to Metal or Full Metal
Crowns) Mandibular + L
Surgical Installation of Implant with Cover Screw – per Implant +
UCSLS 79931 Yes
E.
Surgical Installation of Implant with Healing Transmucosal Element
UCSLS 79932 Yes
- per Implant + E.
Surgical Installation of Implant with Final Transmucosal Element –
UCSLS 79933 Yes
per Implant + E.
Surgical Re-entry, Removal of Healing Screw and Placement of
UCSLS 79934 Yes
Healing Transmucosal Element – per Implant + E.
Surgical Re-entry, Removal of Healing Screw and Placement of
UCSLS 79935 Yes
Final Standard Transmucosal Element – per Implant + E.
Surgical Re-entry, Removal of Healing Screw and Placement of
UCSLS 79936 Yes
Final Custom Transmucosal Element–per Implant + E. +L.
UCSLS 79941 Surgical Installation of Implant – per Implant + E. Yes
UCSLS 79951 Installation of Provisional Implant – per Implant + E. Yes
UCSLS 79952 Removal of Provisional Implant – per Implant +E No
UCSLS 79961 Implants, Removal of Implant Per implant, Uncomplicated Yes
UCSLS 79962 Implants, Removal of Implant Per implant, Complicated Yes
Orthodontic Observation - for Tooth Guidance (i.e. tooth position,
UCSLS 80601 eruption sequence, serial extraction supervision, etc.) per Yes
appointment
Orthodontic Observation and Adjustment - to Orthodontic
UCSLS 80602 Appliances and/or the Reduction of Proximal Surfaces of Teeth per Yes
appointment
Repairs to Removable or Fixed Appliances (not including removal
UCSLS 80631 No
and recementation) One unit of time + L
Repairs to Removable or Fixed Appliances (not including removal
UCSLS 80639 No
and recementation) Each additional unit over two + L
UCSLS 80641 Alterations to Removable or Fixed Appliances One unit of time+ L No
Alterations to Removable or Fixed Appliances Each additional unit
UCSLS 80649 No
over two + L
UCSLS 80651 Recementation of Fixed Appliances One unit of time No
UCSLS 80659 Recementation of Fixed Appliances Each additional unit No

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 Separation (except where included in the fabrication of an
UCSLS 80661 No
appliance) One unit of time
Separation (except where included in the fabrication of an
UCSLS 80669 No
appliance) Each additional unit
Removal of Fixed Orthodontic Appliances (by a practitioner other
UCSLS 80671 No
than the original treating Practice or Practitioner) One unit of time
Removal of Fixed Orthodontic Appliances (by a practitioner other
UCSLS 80679 than the original treating Practice or Practitioner) Each additional No
unit
Appliances, Removable, Space Regaining Appliance, Maxillary,
UCSLS 81111 Yes
Unilateral + L
Appliances, Removable, Space Regaining Appliance, Mandibular,
UCSLS 81112 Yes
Unilateral + L
Appliances, Removable, Space Regaining Appliance, Maxillary,
UCSLS 81113 Yes
Bilateral + L
Appliances, Removable, Space Regaining Appliance, Mandibular,
UCSLS 81114 Yes
Bilateral + L
Appliances, Removable, Space Regaining Appliance, Maxillary,
UCSLS 81115 Yes
Complex + L
UCSLS 81116 Appliance, Mandibular, Removable, Space Regaining, Complex Yes
Appliances, Removable, Cross-Bite Correction Appliance, Maxillary,
UCSLS 81121 Yes
Simple + L
Appliances, Removable, Cross-Bite Correction Appliance,
UCSLS 81122 Yes
Mandibular, Simple + L
Appliances, Removable, Cross-Bite Correction Appliance, Maxillary,
UCSLS 81123 Yes
Complex + L
Appliance, Removable, Cross-Bite Correction, Mandibular,
UCSLS 81124 Yes
Complex
Appliances, Removable, Dental Arch Expansion Appliance,
UCSLS 81131 Yes
Maxillary, simple + L
Appliances, Removable, Dental Arch ExpansionAppliances,
UCSLS 81132 Removable, Dental Arch Expansion Appliance, Mandibular, Simple Yes
+L
Appliances, Removable, Dental Arch Expansion Appliance,
UCSLS 81133 Yes
Maxillary, Complex + L
Appliances, Removable, Dental Arch Expansion Appliance,
UCSLS 81134 Yes
Mandibular, Complexe, + L
Appliances, Removable, Dental Arch Expansion Appliance,
UCSLS 81135 Yes
Maxillary, Rapid Expansion + L
Appliances, Removable, Closure of Diastemas Appliance, Maxillary,
UCSLS 81141 Yes
Simple + L
Appliances, Removable, Closure of Diastemas Appliance,
UCSLS 81142 Yes
Mandibular, Simple + L
Appliances, Removable, Closure of Diastemas Appliance, Maxillary,
UCSLS 81143 Yes
Complex + L
Appliances, Removable, Closure of Diastemas Appliance,
UCSLS 81144 Yes
Mandibular, Complex + L
Appliances, Removable, Alignment of Anterior Teeth Appliance,
UCSLS 81151 Yes
Maxillary, Simple + L
Appliances, Removable, Alignment of Anterior Teeth Appliance,
UCSLS 81152 Yes
Mandibular, Simple + L
Appliances, Removable, Alignment of Anterior Teeth Appliance,
UCSLS 81153 Yes
Maxillary, Complex + L
Appliances, Removable, Alignment of Anterior Teeth Appliance,
UCSLS 81154 Yes
Mandibular, Complex + L
Appliance, Fixed, Space Regaining (e.g. lingual or labial arch with
UCSLS 81211 Yes
molar bands, tubes, locks) Appliance, Maxillary + L
Appliance, Fixed, Space Regaining (e.g. lingual or labial arch with
UCSLS 81212 Yes
molar bands, tubes, locks) Appliance, Mandibular + L
Appliance, Fixed, Space Regaining, Unilateral Appliance, Maxillary
UCSLS 81221 Yes
+L
Appliance, Fixed, Space Regaining, Unilateral Appliance,
UCSLS 81222 Yes
Mandibular + L
Appliance, Fixed, Cross-Bite Correction - Anterior Appliance,
UCSLS 81231 Yes
Maxillary + L
Appliance, Fixed, Cross-Bite Correction - Anterior Appliance,
UCSLS 81232 Yes
Mandibular + L
Appliance, Fixed, Cross-Bite Correction - Posterior Appliance,
UCSLS 81241 Yes
Maxillary + L
Appliance, Fixed, Cross-Bite Correction - Posterior Appliance,
UCSLS 81242 Yes
Mandibular + L
Appliance, Fixed, Cross-Bite Correction - Posterior Appliance, Two-
UCSLS 81243 Yes
Molar Band, Hooked and Elastics + L
UCSLS 81251 Appliance, Fixed, Dental Arch Expansion Appliance, Maxillary + L Yes

UCSLS 81252 Appliance, Fixed, Dental Arch Expansion Appliance, Mandibular + L Yes
Appliance, Fixed, Dental Arch Expansion Appliance, Maxillary,
UCSLS 81253 Yes
Rapid Expansion + L

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 UCSLS 81254 Appliance, Fixed, Dental Arch Expansion Appliance, Headgear + L Yes
UCSLS 81261 Appliance, Maxillary, Simple + L Yes
UCSLS 81262 Appliance, Mandibular, Simple + L Yes
UCSLS 81263 Appliance, Maxillary, Complex + L Yes
UCSLS 81264 Appliance, Fixed, Closure of Diastemas, Mandibular, Complex Yes
Appliance, Fixed, Alignment of Incisor Teeth Appliance, Maxillary,
UCSLS 81271 Yes
Simple + L
Appliance, Fixed, Alignment of Incisor Teeth Appliance,
UCSLS 81272 Yes
Mandibular, Simple + L
Appliance, Fixed, Alignment of Incisor Teeth Appliance, Maxillary,
UCSLS 81273 Yes
Complex + L
Appliance, Fixed, Alignment of Incisor Teeth Appliance,
UCSLS 81274 Yes
Mandibular, Complex + L
UCSLS 81281 Grassline or Elastic Ligatures per visit + L No
Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance,
UCSLS 81291 Yes
Maxillary, Impaction + L
Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance,
UCSLS 81292 Yes
Mandibular, Impaction + L
Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance,
UCSLS 81293 Yes
Maxillary, Erupted + L
Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance,
UCSLS 81294 Yes
Mandibular, Erupted + L
UCSLS 83101 APPLIANCES, REMOVABLE, RETENTIONAppliance, Maxillary + L Yes
UCSLS 83102 APPLIANCES, REMOVABLE, RETENTION Appliance, Mandibular + L Yes
APPLIANCES, REMOVABLE, RETENTION Appliance, Tooth Positioner
UCSLS 83103 Yes
+L
APPLIANCES, FIXED/CEMENTED, RETENTION Appliance, Maxillary
UCSLS 83201 Yes
+L
APPLIANCES, FIXED/CEMENTED, RETENTION Appliance,
UCSLS 83202 Yes
Mandibular + L
Case Type, Fixed Appliance (includes:formal full banded treatment
UCSLS 84101 Yes
and retention), Class I Malocclusion, Permanent Dentition

Case Type, Fixed Appliance (includes:formal full banded treatment

UCSLS 84201 Yes
and retention), Class II Malocclusion , Permanent Dentition

Case Type, Fixed Appliance (includes:formal full banded treatment

UCSLS 84301 Yes
and retention), Class III Malocclusion , Permanent Dentition
UCSLS 84401 Malocclusion not Requiring Complete Banding + L Yes
Case Type, Fixed Appliance (includes:formal full banded treatment
UCSLS 85101 Yes
and retention), Class I Malocclusion, Mixed Dentition
Case Type, Fixed Appliance (includes:formal full banded treatment
UCSLS 85201 Yes
and retention), Class II Malocclusion, Mixed Dentition

Case Type, Fixed Appliance (includes:formal full banded treatment

UCSLS 86101 Yes
and retention), Class I Malocclusion, Primary Dentition
UCSLS 86201 PRIMARY DENTITION Class II Malocclusion + L Yes
Case Type, Fixed Appliance (includes:formal full banded treatment
UCSLS 86301 Yes
and retention), Class III Malocclusion, Primary Dentition

Case Type, Removable Appliances (includes: removable appliance

UCSLS 87101 Yes
therapy and retention), Class I Malocclusion ,Permanent Dentition
Case Type, Removable Appliances (includes: removable appliance
UCSLS 87201 therapy and retention), Class II Malocclusion , Permanent Yes
Dentition
Case Type, Removable Appliances (includes: removable appliance
UCSLS 87301 therapy and retention), Class III Malocclusion , Permanent Yes
Dentition
Case Type, Removable Appliances (includes: removable appliance
UCSLS 88101 Yes
therapy and retention), Class I Malocclusion , Mixed Dentition

Case Type, Removable Appliances (includes: removable appliance

UCSLS 88201 Yes
therapy and retention), Class II Malocclusion , Mixed Dentition

Case Type, Removable Appliances (includes: removable appliance

UCSLS 88301 Yes
therapy and retention), Class III Malocclusion , Mixed Dentition

Case Type, Removable Appliances (includes: removable appliance

UCSLS 89101 Yes
therapy and retention), Class I Malocclusion , Primary Dentition
Case Type, Removable Appliances (includes: removable appliance
UCSLS 89201 therapy and retention), Class II Yes
Malocclusion , Primary Dentition
Case Type, Removable Appliances (includes: removable appliance
UCSLS 89301 Yes
therapy and retention), Class III Malocclusion , Primary Dentition

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 NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive
UCSLS 89501 treatment for first six months of life) Expansion Appliance for Yes
Infants with Cleft Palate + L

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 NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive
UCSLS 89502 treatment for first six months of life) Extraoral Retraction Yes
Appliance for Infants with Cleft Palate + L
NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive
UCSLS 89503 treatment for first six months of life) Stage I - Initial Expansion + Yes
L
NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive
UCSLS 89504 treatment for first six months of life) Stage II - Anterior Alignment Yes
+L
NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive
UCSLS 89505 treatment for first six months of life) Stage III - Final Alignment Yes
(complete banding) + L
NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive
UCSLS 89506 treatment for first six months of life)v Stage III - Where Stage I Yes
and II were not provided for + L
UCSLS 93332 Monthly Payment/Instalment for treatment in progress Yes
Examination and Diagnosis, Orthodontic, General. To include:
(a) Diagnosis models, complete intraoral radiograph series, or
UCSLS 01901 Yes
panoramic film, cephalograms, facial and intraoral photographs,
consultation and case presentation.
TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to
UCSLS 03001 locate and orient osseo-integrated implants) Maxillary Template + Yes
L+E
TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to
UCSLS 03002 locate and orient osseo-integrated implants) Mandibular Template Yes
+L+E
Equilibration, Casts, Diagnostic (pilot equilibration) for extensive or
UCSLS 04711 No
complicated restorative dentistry + L One unit of time + L
Equilibration, Casts, Diagnostic (pilot equilibration) for extensive or
UCSLS 04719 complicated restorative dentistry + L Each additional unit over four No
+L
Wax-up, Diagnostic (to evaluate cosmetic and/or preparation
UCSLS 04721 design and/or occlusal considerations) (gnathological wax-up) + L No
One unit of time + L
Wax-up, Diagnostic (to evaluate cosmetic and/or preparation
UCSLS 04729 design and/or occlusal considerations) (gnathological wax-up) + L No
Each additional unit over four + L
UCSLS 04911 Cast, Diagnostic, Unmounted + L No
UCSLS 04912 Cast, Diagnostic, Unmounted, Duplicate + L No
UCSLS 04921 Casts, Diagnostic, Mounted + L No
UCSLS 04922 Casts, Diagnostic, Mounted, using face bow transfer + L No
UCSLS 04923 Casts, Diagnostic, Mounted, using face bow + occlusal records + L No
Casts, Diagnostic, Orthodontic (unmounted, angle trimmed and
UCSLS 04931 No
soaped) + L
Transverse Axis Location and Transfer, used in conjunction with
UCSLS 04941 No
04922, 04923, and 04924 + L
Case Type, Fixed Appliance (includes:formal full banded treatment
UCSLS 85301 Yes
and retention), Class III Malocclusion, Mixed Dentition
Resilient Liner, in Relined or Rebased Denture (in addition to reline
UCSLS 56601 No
or rebase of denture) + L
Attaching or re-attaching elements to a removable prosthesis,
UCSLS 56621 No
indirect + E + L
UCSLS 57209 PROSTHESIS, MAXILLOFACIAL, Speech Aid Prosthesis Yes
"+ L" Commercial Laboratory Procedures (A commercial laboratory
is defined as an independent business which performs laboratory
UCSLS 99111 Yes
services and bills the dental practice for these services on a case
by case basis).
UCSLS 1201 Examination and Diagnosis limited, new Patient 012 No
UCSLS 34431 Perforations/Resorptive defects, pulp chamber or r No
UCSLS 33114 RCT Perm./Retained Primary Tooth, 1 Canal, Calicif No
UCSLS 33112 RCT Perm./Retained Primary Tooth, 1 Canal, Difficu No
UCSLS 33113 RCT Perm./Retained Primary Tooth, 1 Canal, Excepti No
UCSLS 33124 RCT Perm./Retained Primary Tooth, 2 Canals, Calcif No
UCSLS 33122 RCT Perm./Retained Primary Tooth, 2 Canals, Diffic No
UCSLS 33123 RCT Perm./Retained Primary Tooth, 2 Canals, Except No
UCSLS 33134 RCT Perm./Retained Primary Tooth, 3 Canals, Calcif No
UCSLS 33132 RCT Perm./Retained Primary Tooth, 3 Canals, Diffic No
UCSLS 33133 RCT Perm./Retained Primary Tooth, 3 Canals, Except No
UCSLS 33144 RCT Perm./Retained Primary Tooth, 4 Canals, Calcif No
UCSLS 33142 RCT Perm./Retained Primary Tooth, 4 Canals, Diffic No
UCSLS 33143 RCT Perm./Retained Primary Tooth, 4 Canals, Except No
UCSLS 34444 Surg., Endodontic, Exploratory Mand. Ant 34444 No
UCSLS 34445 Surg., Endodontic, Exploratory Mand. Bicuspid 3444 No
UCSLS 34446 Surg., Endodontic, Exploratory Mand. Molar 34446 No
UCSLS 34441 Surg., Endodontic, Exploratory Max. Ant. 34441 No
UCSLS 34442 Surg., Endodontic, Exploratory Max. Bicuspid 34442 No
UCSLS 34443 Surg., Endodontic, Exploratory Max. Molar No

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