Daman Standard Dental Pricelist (USCLS)

Daman Standard Dental Pricelist (USCLS)
Category Code Description Net Price

UCSLS 11101 POLISHING One unit of time 56
UCSLS 11109 POLISHING Each additional unit over two 35
UCSLS 11111 SCALING One unit of time 70
UCSLS 11119 SCALING Each additional unit over six 52.5
UCSLS 12101 Fluoride Treatment, Topical Application 105
NUTRITIONAL COUNSELING Including: recording and analysis up to seven day dietary intake and
UCSLS 13101 56
consultation One unit of time
NUTRITIONAL COUNSELING Including: recording and analysis up to seven day dietary intake and
UCSLS 13109 consultationNUTRITIONAL COUNSELING Including: recording and analysis up to seven day 35
dietary intake and consultation Each additional unit over four
ORAL HYGIENE INSTRUCTION/PLAQUE CONTROL
UCSLS 13211 To include: brushing and/or flossing and/or embrasure cleaning Individual Instruction (one 35
instructor to one patient) - excluding audio-visual timeOne unit of time
ORAL HYGIENE INSTRUCTION/PLAQUE CONTROL
UCSLS 13219 To include: brushing and/or flossing and/or embrasure cleaning Individual Instruction (one 21
instructor to one patient) - excluding audio-visual time Each additional unit over four
SEALANTS, PIT AND FISSURE (Mechanical and/or chemical preparation included) SEALANTS, PIT
UCSLS 13401 105
AND FISSURE (Mechanical and/or chemical preparation included) First tooth
SEALANTS, PIT AND FISSURE (Mechanical and/or chemical preparation included) Each additional
UCSLS 13409 87.5
tooth same quadrant
Preventive Restorative Resin (procedure that involves some preparation of the pits and/or fissures
UCSLS 13411 105
in tooth enamel and may extend into dentin in limited areas) First tooth
Preventive Restorative Resin (procedure that involves some preparation of the pits and/or fissures
UCSLS 13419 91
in tooth enamel and may extend into dentin in limited areas) Each additional tooth same quadrant
CONTROL OF ORAL HABITS, MISCELLANEOUS Motivation of Patient - Psychological Approach
UCSLS 14301 105
(e.g. thumb sucking, lip biting, etc.) - per visit + L
UCSLS 15604 Removal of Fixed Space Maintainer Appliances by Second Dentist. 70
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, refining marginal ridges and 84
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, refining marginal ridges and 84
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 70
Interproximal One unit of time
DISKING OF TEETH,
UCSLS 16209 70
Interproximal Each additional unit over three
UCSLS 16301 RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS One unit of time 70
UCSLS 16309 RECONTOURING OF NATURAL TEETH FOR AESTHETIC REASONS Each additional unit of time 70
RECONTOURING OF TEETH FOR FUNCTIONAL REASONS
UCSLS 16401 70
(not associated with delivery of a single or multiple prosthesis) One unit of time
RECONTOURING OF TEETH FOR FUNCTIONAL REASONS
UCSLS 16409 70
(not associated with delivery of a single or multiple prosthesis) Each additional unit of time
UCSLS 16511 OCCLUSION One unit of time 105
UCSLS 16519 OCCLUSION Each additional unit over four 105
Caries/Trauma/Pain Control (removal of carious lesions or existing restorations or gingivally
UCSLS 20111 attached tooth fragment and placement of sedative/protective dressings, includes pulp caps when 105
necessary, as a separate procedure) First tooth
necessary, as a separate procedure) Each additional tooth same quadrant

necessary and the use of a band for retention and support, as a separate procedure) First tooth
DAMAN CONFIDENTIAL
Doc. No.: EXH/428 Version No.: 1 Revision No.: 2 Date of Issue: 04.02.2018 1 of 28

attached tooth fragment and placement of sedative/protective dressings, includes pulp caps when
UCSLS 20129 91
necessary and the use of a band for retention and support, as a separate procedure) Each
additional tooth same quadrant
UCSLS 20131 Trauma Control, Smoothing of Fractured Surfaces, per tooth First tooth 56
UCSLS 20139 Trauma Control, Smoothing of Fractured Surfaces, per tooth Each additional tooth same quadrant 42
UCSLS 20141 Pulp Capping Direct Performed in Conjunction with Permanent Restoration First tooth 70
Pulp Capping Direct Performed in Conjunction with Permanent Restoration Each additional tooth
UCSLS 20149 63
same quadrant
Restorations, Amalgam,
UCSLS 21111 105
Non-Bonded, Primary Teeth One surface
UCSLS 21112 140
Non-Bonded, Primary Teeth Two surfaces
UCSLS 21113 175
Non-Bonded, Primary Teeth Three surfaces
UCSLS 21114 Four surfaces 245
UCSLS 21115 Five surfaces or maximum surfaces per tooth 262.5
UCSLS 21211 Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors One surface 105
UCSLS 21212 Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors Two surfaces 140
UCSLS 21213 Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors Three surfaces 175
UCSLS 21214 Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors Four surfaces 245
Restorations, Amalgam, Non-Bonded, Permanent Bicuspids and Anteriors Five surfaces or
UCSLS 21215 maximum 262.5
surfaces per tooth
UCSLS 21221 Restorations, Amalgam, Non-Bonded, Permanent Molars One surface 105
UCSLS 21222 Restorations, Amalgam, Non-Bonded, Permanent Molars Two surfaces 140
UCSLS 21223 Restorations, Amalgam, Non-Bonded, Permanent Molars Three surfaces 175
UCSLS 21224 Restorations, Amalgam, Non-Bonded, Permanent Molars Four surfaces 245
Restorations, Amalgam, Non-Bonded, Permanent Molars Five surfaces or maximum surfaces per
UCSLS 21225 262.5
tooth
UCSLS 21301 Restorations, Amalgam Core, Non-Bonded in conjunction with crown or Fixed Bridge Retainer 262.5
PINS, RETENTIVE
UCSLS 21401 35
per restoration (for amalgams and tooth coloured restorations) One pin
PINS, RETENTIVE
UCSLS 21402 52.5
per restoration (for amalgams and tooth coloured restorations) Two pins
PINS, RETENTIVE
UCSLS 21403 70
per restoration (for amalgams and tooth coloured restorations) Three pins
PINS, RETENTIVE
UCSLS 21404 87.5
per restoration (for amalgams and tooth coloured restorations) Four pins
PINS, RETENTIVE
UCSLS 21405 105
per restoration (for amalgams and tooth coloured restorations) Five pins or more
UCSLS 22211 RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH Primary Posterior 280
UCSLS 22212 RESTORATIONS, PREFABRICATED, METAL, PRIMARY TEETH Primary Posterior - open face 350
UCSLS 22401 RESTORATIONS PREFABRICATED, PLASTIC, PRIMARY TEETH Primary Anterior 350
UCSLS 22411 RESTORATIONS PREFABRICATED, PLASTIC, PRIMARY TEETH Primary Posterior 245
UCSLS 22501 RESTORATIONS PREFABRICATED, PLASTIC, PERMANENT TEETH Permanent Anterior 245
UCSLS 22511 RESTORATIONS PREFABRICATED, PLASTIC, PERMANENT TEETH Permanent Posterior 245
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS -
UCSLS 23101 RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS NON BONDED TECHNIQUE One 77
surface
UCSLS 23102 RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS NON BONDED TECHNIQUE Two 154
surfaces (continuous)
UCSLS 23103 RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS NON BONDED TECHNIQUE Three 192.5
UCSLS 23104 RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS NON BONDED TECHNIQUE Four 269.5
UCSLS 23105 RESTORATIONS, TOOTH COLOURED, PERMANENT ANTERIORS NON BONDED TECHNIQUE Five 288.75
surfaces (continuous, maximum surfaces per tooth)
DAMAN CONFIDENTIAL

Restorations, Permanent Anteriors, Bonded Technique (not to be used for Veneer Applications or
UCSLS 23111 192.5
Diastema Closures) One surface
UCSLS 23112 231
Diastema Closures) Two surfaces (continuous)
UCSLS 23113 269.5
Diastema Closures) Three surfaces (continuous)
UCSLS 23114 308
Diastema Closures) Four surfaces (continuous)
UCSLS 23115 346.5
Diastema Closures) Five surfaces (continuous, maximum surfaces per tooth)
UCSLS 23121 Tooth Coloured Veneer Application - Direct Chairside Prefabricated - Bonded 420
UCSLS 23122 Tooth Coloured Veneer Application - Non Prefabricated Direct Buildup - Bonded 385
UCSLS 23123 Tooth Coloured Veneer Application - Diastema Closure, Interproximal only, Bonded 231
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS, PERMANENT
UCSLS 23211 115.5
POSTERIORS NON BONDED Permanent Bicuspids One surface
UCSLS 23212 154
POSTERIORS NON BONDED Permanent Bicuspids Two surfaces
UCSLS 23213 192.5
POSTERIORS NON BONDED Permanent Bicuspids Three surfaces
UCSLS 23214 231
POSTERIORS NON BONDED Permanent Bicuspids Four surfaces
UCSLS 23215 269.5
POSTERIORS NON BONDED Permanent Bicuspids Five surfaces or maximum surfaces per tooth
UCSLS 23221 115.5
POSTERIORS NON BONDED Permanent Molars One surface
UCSLS 23222 154
POSTERIORS NON BONDED Permanent Molars Two surfaces
UCSLS 23223 192.5
POSTERIORS NON BONDED Permanent Molars Three surfaces
UCSLS 23224 231
POSTERIORS NON BONDED Permanent Molars Four surfaces
UCSLS 23225 269.5
POSTERIORS NON BONDED Permanent Molars Five surfaces or maximum surfaces per tooth
UCSLS 23311 Restorations, Tooth Coloured, Permanent Bicuspids, Bonded Technique, One surface 169.4
Restorations, Tooth Coloured, Permanent Bicuspids, Bonded Technique, Two surfaces
UCSLS 23312 207.9
(continuous)
UCSLS 23313 308
POSTERIORS NON BONDED Permanent Bicuspids Three surfaces
Restorations, Tooth Coloured, Permanent Bicuspids, Bonded Technique, Four surfaces
UCSLS 23314 346.5
(continuous)
Restorations, Tooth Coloured, Permanent Bicuspids, Bonded Technique, Five surfaces (continuous,
UCSLS 23315 385
maximum surfaces per tooth)
UCSLS 23321 Restorations, Tooth Coloured, Permanent Posteriors - Bonded One surface 192.5
UCSLS 23322 Restorations, Tooth Coloured, Permanent Posteriors - Bonded Two surfaces 231
UCSLS 23323 Restorations, Tooth Coloured, Permanent Posteriors - Bonded Three surfaces 308
UCSLS 23324 Restorations, Tooth Coloured, Permanent Posteriors - Bonded Four surfaces 385
Restorations, Tooth Coloured, Permanent Posteriors - Bonded Five surfaces or maximum surfaces
UCSLS 23325 423.5
per tooth
UCSLS 23401 RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON BONDED One surface 77
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON BONDED two surfaces
UCSLS 23402 154
(continuous)
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON BONDED three surfaces
UCSLS 23403 192.5
(continuous)
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON BONDED four surfaces
UCSLS 23404 231
(continuous)
RESTORATIONS, TOOTH COLOURED, PRIMARY, ANTERIOR, NON BONDED Five surfaces
UCSLS 23405 269.5
(continuous or maximum surfaces per tooth)
UCSLS 23411 Restorations, Tooth Coloured, Primary, Anterior Bonded Technique One surface 115.5
UCSLS 23412 Restorations, Tooth Coloured, Primary, Anterior Bonded Technique Two surfaces (continuous) 154
UCSLS 23413 Restorations, Tooth Coloured, Primary, Anterior Bonded Technique Three surfaces (continuous) 192.5
DAMAN CONFIDENTIAL

UCSLS 23414 Restorations, Tooth Coloured, Primary, Anterior Bonded Technique Four surfaces (continuous) 231
Restorations, Tooth Coloured, Primary, Anterior Bonded Technique Five surfaces (continuous or
UCSLS 23415 269.5
maximum surfaces per tooth)
RESTORATIONS, TOOTH COLOURED/PLASTIC WITH/WITHOUT SILVER FILINGS, PRIMARY,
UCSLS 23501 115.5
POSTERIOR, NON BONDED One surface
UCSLS 23502 154
POSTERIOR, NON BONDED Two surfaces
UCSLS 23503 231
POSTERIOR, NON BONDED Three surfaces
UCSLS 23504 269.5
POSTERIOR, NON BONDED Four surfaces
UCSLS 23505 308
POSTERIOR, NON BONDED Five surfaces (or maximum surfaces per tooth)
UCSLS 23511 POSTERIOR, NON BONDED - Restorations, Tooth Coloured, Primary, Posterior, Bonded One 115.5
surface
UCSLS 23512 POSTERIOR, NON BONDED - Restorations, Tooth Coloured, Primary, Posterior, Bonded Two 154
surfaces
UCSLS 23513 POSTERIOR, NON BONDED - Restorations, Tooth Coloured, Primary, Posterior, Bonded Three 192.5
surfaces
UCSLS 23514 POSTERIOR, NON BONDED - Restorations, Tooth Coloured, Primary, Posterior, Bonded Four 231
surfaces
UCSLS 23515 POSTERIOR, NON BONDED - Restorations, Tooth Coloured, Primary, Posterior, Bonded Five 269.5
surfaces or maximum surfaces per tooth
Restoration, Tooth Coloured, Non-Bonded Core, in Conjunction with Crown or Fixed Bridge
UCSLS 23601 308
Retainer
UCSLS 23602 Restoration, Tooth Coloured, Bonded, Core, in Conjunction with Crown or Fixed Bridge Retainer 385
UCSLS 25781 Post Removal Posts, Provisional One unit of time 105
UCSLS 25789 Post Removal Posts, Provisional Each additional unit over four 70
UCSLS 27801 RECONTOURING OF EXISTING CROWNS per tooth One unit of time 105
UCSLS 27809 RECONTOURING OF EXISTING CROWNS per tooth Each additional unit of time 84
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Natural Tooth Preparation, Placement of
UCSLS 28101 Pulp Chamber Restoration (amalgam or composite) and Fluoride Application Endodontically 210
Treated Tooth
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Natural Tooth Preparation and Fluoride
UCSLS 28102 175
Application, Vital Tooth
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Pre-fabricated Attachment, as an Internal
UCSLS 28103 or External Overdenture Retentive Device, Direct to a Natural Tooth + L and/or + E (used with 700
the appropriate denture code) per tooth
RECEMENTATION/REBONDING, INLAYS/ONLAYS/ CROWNS/VENEERS/POSTS/ NATURAL TOOTH
UCSLS 29101 105
FRAGMENTS One unit of time +L +E
RECEMENTATION/REBONDING, INLAYS/ONLAYS/ CROWNS/VENEERS/POSTS/ NATURAL TOOTH
UCSLS 29109 105
FRAGMENTS Each additional unit over four+L +E
UCSLS 29111 Re-Insertion/Recementation Implant-supported Crown One unit of time +L +E 140
UCSLS 29119 Re-Insertion/Recementation Implant-supported Crown Each additional unit over four +L +E 105
REMOVAL, INLAYS/ ONLAYS/CROWNS/ VENEERS
UCSLS 29301 105
(single units only) One unit of time
REMOVAL, INLAYS/ ONLAYS/CROWNS/ VENEERS
UCSLS 29309 70
(single units only) Each additional unit over four
UCSLS 29311 Removal, Implant-supported Crowns (single units only) One unit of time 70
UCSLS 29319 Removal, Implant-supported Crowns (single units only) Each additional unit over four 35
UCSLS 29321 Removal, Mesostructure (to be reseated) One unit of time 70
UCSLS 29329 Removal, Mesostructure (to be reseated) Each additional unit over four 35
Removal of Compromised Mesostructure
UCSLS 29331 140
(to be replaced) One unit of time
Removal of Compromised Mesostructure
UCSLS 29339 70
(to be replaced) Each additional unit over four
UCSLS 29351 Removal, Fractured Implant-supported Crown Retaining Screw One unit of time 140
DAMAN CONFIDENTIAL

UCSLS 29359 Removal, Fractured Implant-supported Crown Retaining Screw Each additional unit over four 70
Pulpotomy, Permanent Teeth
UCSLS 32221 210
(as a Separate Emergency Procedure) Anterior and Bicuspid Teeth
Pulpotomy, Permanent Teeth
UCSLS 32222 245
(as a Separate Emergency Procedure) Molar Teeth
UCSLS 32231 Pulpotomy Primary Tooth as a Separate Procedure 210
UCSLS 32232 Pulpotomy Primary Tooth, Concurrent with Restorations (but excluding final restoration) 122.5
PULPECTOMY
UCSLS 32311 (An emergency procedure and/or as a pre-emptive phase to the preparation of the root canal 140
system for obturation) Pulpectomy, Permanent Teeth/Retained Primary Teeth One Canal
PULPECTOMY
system for obturation) Pulpectomy, Permanent Teeth/Retained Primary Teeth Two Canals
PULPECTOMY
system for obturation) Pulpectomy, Permanent Teeth/Retained Primary Teeth Three Canals
PULPECTOMY
(An emergency procedure and/or as a pre-emptive phase to the preparation of the root canal
UCSLS 32314 280
system for obturation) Pulpectomy, Permanent Teeth/Retained Primary Teeth Four Canals or
more
PULPECTOMY
system for obturation) Pulpectomy, Primary Teeth Anterior Tooth
PULPECTOMY
system for obturation) Pulpectomy, Primary Teeth Posterior Tooth
UCSLS 33111 Root Canals, Permanent Teeth/Retained Primary Teeth, One Canal One canal 385
UCSLS 33115 Re-treatment of Previously Completed Therapy 455
UCSLS 33116 Continuing Treatment having been Aborted by Referring/Previous Dentist 434
UCSLS 33121 Root Canals, Permanent Teeth/Retained Primary Teeth, Two Canals Two canals 539
Root Canals, Permanent Teeth/Retained Primary Teeth, Two Canals Re-treatment of Previously
UCSLS 33125 654.5
Completed Therapy
Root Canals, Permanent Teeth/Retained Primary Teeth, Two Canals Continuing Treatment having
UCSLS 33126 595
been Aborted by Referring/Previous Dentist
UCSLS 33131 Root Canals, Permanent Teeth/Retained Primary Teeth, Three Canals Three canals 665
Root Canals, Permanent Teeth/Retained Primary Teeth, Three Canals Re-treatment of Previously
UCSLS 33135 924
Completed Therapy
Root Canals, Permanent Teeth/Retained Primary Teeth, Three Canals Continuing Treatment
UCSLS 33136 770
having been Aborted by Referring/ Previous Dentist
UCSLS 33141 Root Canals, Permanent Teeth/Retained Primary Teeth, Four or More Canals Four or more canals 875
Root Canals, Permanent Teeth/Retained Primary Teeth, Four or More Canals Re-treatment of
UCSLS 33145 980
previously completed therapy
Root Canals, Permanent Teeth/Retained Primary Teeth, Four or More Canals Continuing
UCSLS 33146 910
Treatment having been aborted by Referring/ Previous Dentist
UCSLS 33401 ROOT CANALS, PRIMARY TEETH One canal 280
UCSLS 33402 ROOT CANALS, PRIMARY TEETH Two canals 350
UCSLS 33403 ROOT CANALS, PRIMARY TEETH Three canals or more 420
APEXIFICATION/APEXOGENESIS/ INDUCTION OF HARD TISSUE REPAIR (to include
UCSLS 33601 315
biomechanical preparation and placement of dentogenic media) One canal
UCSLS 33602 385
biomechanical preparation and placement of dentogenic media) Two canals
UCSLS 33603 490
biomechanical preparation and placement of dentogenic media) Three canals
UCSLS 33604 560
biomechanical preparation and placement of dentogenic media) Four canals or more
UCSLS 33611 Re-insertion of Dentogenic Media per visit One canal 175
UCSLS 33612 Re-insertion of Dentogenic Media per visit Two canals 210
UCSLS 33613 Re-insertion of Dentogenic Media per visit Three canals 245
UCSLS 33614 Re-insertion of Dentogenic Media per visit Four canals or more 280
UCSLS 33621 OBTURATION OF APEXIFIED CANAL One canal 420
DAMAN CONFIDENTIAL

UCSLS 33622 OBTURATION OF APEXIFIED CANAL Two canals 455
UCSLS 33623 OBTURATION OF APEXIFIED CANAL Three canals 560
UCSLS 33624 OBTURATION OF APEXIFIED CANAL Four canals or more 770
UCSLS 34111 APICOECTOMY/APICAL CURETTAGE Maxillary Anterior One root 910
UCSLS 34112 APICOECTOMY/APICAL CURETTAGE Maxillary Anterior Two roots 1120
UCSLS 34121 APICOECTOMY/APICAL CURETTAGE Maxillary Bicuspid One root 910
UCSLS 34122 APICOECTOMY/APICAL CURETTAGE Maxillary Bicuspid Two roots 1120
UCSLS 34123 APICOECTOMY/APICAL CURETTAGE Maxillary Bicuspid Three roots 1330
UCSLS 34131 APICOECTOMY/APICAL CURETTAGE Maxillary Molar One root 910
UCSLS 34132 APICOECTOMY/APICAL CURETTAGE Maxillary Molar Two roots 1120
APICOECTOMY/APICAL CURETTAGE Maxillary Molar APICOECTOMY/APICAL CURETTAGE
UCSLS 34133 1330
Maxillary Molar Three roots
UCSLS 34134 APICOECTOMY/APICAL CURETTAGE Maxillary Molar Four or more roots 1400
UCSLS 34141 APICOECTOMY/APICAL CURETTAGE Mandibular Anterior One root 910
UCSLS 34142 APICOECTOMY/APICAL CURETTAGE Mandibular Anterior Two or more roots 1120
UCSLS 34151 APICOECTOMY/APICAL CURETTAGE Mandibular Bicuspid One root 910
UCSLS 34152 APICOECTOMY/APICAL CURETTAGE Mandibular Bicuspid Two roots 1120
UCSLS 34153 APICOECTOMY/APICAL CURETTAGE Mandibular Bicuspid Three or more roots 1330
UCSLS 34161 APICOECTOMY/APICAL CURETTAGE Mandibular Molar One root 910
UCSLS 34162 APICOECTOMY/APICAL CURETTAGE Mandibular Molar Two roots 1120
APICOECTOMY/APICAL CURETTAGE Mandibular MolarAPICOECTOMY/APICAL CURETTAGE
UCSLS 34163 1330
Mandibular Molar Three roots
UCSLS 34164 APICOECTOMY/APICAL CURETTAGE Mandibular Molar Four or more roots 1400
UCSLS 34211 RETROFILLING Maxillary Anterior One canal 105
UCSLS 34212 RETROFILLING Maxillary Anterior Two or more canals 175
UCSLS 34221 RETROFILLING Maxillary Bicuspid One canal 140
UCSLS 34222 RETROFILLING Maxillary Bicuspid Two canals 175
UCSLS 34223 RETROFILLING Maxillary Bicuspid Three canals 210
UCSLS 34224 RETROFILLING Maxillary Bicuspid Four or more canals 245
UCSLS 34231 RETROFILLING Maxillary Molar One canal 175
UCSLS 34232 RETROFILLING Maxillary Molar Two canals 210
UCSLS 34233 RETROFILLING Maxillary Molar Three canals 245
UCSLS 34234 RETROFILLING Maxillary Molar Four or more canals 280
UCSLS 34241 RETROFILLING Mandibular Anterior One canal 140
UCSLS 34242 RETROFILLING Mandibular Anterior Two or more canals 175
UCSLS 34251 RETROFILLING Mandibular Bicuspid One canal 175
UCSLS 34252 RETROFILLING Mandibular Bicuspid Two canals 210
UCSLS 34253 RETROFILLING Mandibular Bicuspid Three canals 210
UCSLS 34254 RETROFILLING Mandibular Bicuspid Four or more canals 280
UCSLS 34261 RETROFILLING Mandibular Molar One canal 175
UCSLS 34262 RETROFILLING Mandibular Molar Two canals 210
UCSLS 34263 RETROFILLING Mandibular Molar Three canals 280
UCSLS 34264 RETROFILLING Mandibular Molar Four or more canals 350
UCSLS 34411 Amputations, Root (includes recontouring tooth and furca) One root 700
UCSLS 34412 Amputations, Root (includes recontouring tooth and furca) Two roots 840
UCSLS 34421 Hemisection Maxillary Bicuspid 420
UCSLS 34422 Hemisection Maxillary Molar 560
UCSLS 34423 Hemisection Mandibular Molar 700
UCSLS 34511 Perforations/Resorptive Defects, Pulp Chamber or Root Repair, Non-Surgical Per Tooth 280
UCSLS 34521 Perforations/Resorptive Defect(s), Pulp Chamber Repair or Root Repair, Surgical Anterior Tooth 770
UCSLS 34522 Perforations/Resorptive Defect(s), Pulp Chamber Repair or Root Repair, Surgical Bicuspid Tooth 1050
UCSLS 34523 Perforations/Resorptive Defect(s), Pulp Chamber Repair or Root Repair, Surgical Molar Tooth 1190
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS Banding and/or Coronal Buildup of
UCSLS 39101 Tooth/Teeth and/or Contouring of Tissue Surrounding Tooth/Teeth to Maintain Aseptic Operating 140
Field (per tooth)
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS, OPEN AND DRAIN (Separate
UCSLS 39201 105
Emergency Procedures)Anteriors and Bicuspids
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS, OPEN AND DRAIN (Separate
UCSLS 39202 140
Emergency Procedures)Molars
ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS Opening Through Artificial Crown (In
UCSLS 39211 105
addition to Procedures) Anteriors and Bicuspids
DAMAN CONFIDENTIAL

ISOLATION OF ENDODONTIC TOOTH/ TEETH FOR ASEPSIS Opening Through Artificial Crown (In
UCSLS 39212 126
addition to Procedures) Molars
UCSLS 39311 Bleaching Endodontically Treated Tooth/Teeth One unit of time 210
UCSLS 39319 Bleaching Endodontically Treated Tooth/Teeth Each additional unit over three 140
Oral Manifestations, Oral Mucosal Disorders, Mucocutaneous disorders and diseases of localized
mucosal conditions, e.g. lichen planus, aphthous stomatitis, benign mucous membrane
UCSLS 41211 126
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 105
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,
UCSLS 41221 e.g. trigeminal neuralgia, atypical facial pain, atypical odontologia, burning mouth syndrome, 126
dyskenesia, post injection trismus, muscular and joint pain syndrome One unit of time
UCSLS 41229 Each additional unit over four 105
Oral Manifestations of Systemic Disease or complications of medical therapy e.g. complications of
chemotherapy, radiation therapy, post operative neuropathics, post surgical or radiation therapy,
UCSLS 41231 126
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 therapy,
UCSLS 41239 105
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
UCSLS 41301 the use of a variety of therapeutic procedures. More than one appointment may be necessary.) 140
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 burnishing of medicinal aids on 84
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 420
Surgical Curettage, to Include Definitive Debridement About an Implant - Affected by Peri-implant
UCSLS 42121 420
Inflammation or Infection Per Site
UCSLS 42201 PERIODONTAL SURGERY, GINGIVOPLASTY Per sextant 560
UCSLS 42211 Periodontal Surgery, Gingivoplasty – Around an Implant Per Site 560
UCSLS 42311 Gingivectomy, Uncomplicated Per sextant 560
UCSLS 42331 Gingival Fiber Incision (Supra Crestal Fibrotomy) First tooth 490
UCSLS 42339 Gingival Fiber Incision (Supra Crestal Fibrotomy) Each additional tooth 315
UCSLS 42341 Soft Tissue Re-contouring for Crown Lengthening Limited re-countouring of tissue per tooth 140
UCSLS 42411 PERIODONTAL SURGERY, FLAP APPROACH Per sextant 1050
UCSLS 42421 PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with Curettage of Osseous Per sextant 1050
PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with Osteoplasty/Ostoectomy for
UCSLS 42451 1050
Crown Lengthening Per site
PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with Curettage of an Osseous Defect
UCSLS 42461 1050
About a Failing Implant Per Site
PERIODONTAL SURGERY, FLAP APPROACH Flap Approach, with Curettage of an Osseous Defect
UCSLS 42471 About a Failing Implant, and Including Removal of Exposed Threads or Retentive Surface 1120
Elements of the Implant and/or Detoxification of the Implant Surface Per Site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Soft Tissue, Pedicle (including
UCSLS 42511 1050
apically or lateral sliding and rotated flaps) Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Soft Tissue, Pedicle (Coronally
UCSLS 42521 1050
Positioned)Per site
UCSLS 42531 PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Free Soft Tissu Per site 1050
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Soft Tissue, Pedicle, with Free
UCSLS 42541 1260
Graft Placed in Pedicle Donor Site Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Free Connective Tissue (For root
UCSLS 42551 1050
coverage) Per site
DAMAN CONFIDENTIAL

PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Free Connective Tissue (For ridge
UCSLS 42561 1190
augmentation) Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Connective Tissue, Pedicle with
UCSLS 42571 1260
Free Graft for Root Coverage Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, SOFT TISSUE Grafts, Gingival Onlay, for Ridge
UCSLS 42581 1190
Augmentation Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE Grafts, Osseous, Autograft
UCSLS 42611 1750
(Including Flap Entry, Closure and Donor Site Per site
PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE Grafts, Osseous, Allograft (Including
UCSLS 42621 1540
Flap Entry and Closure) Per site + E
PERIODONTAL SURGERY, FLAPS, GRAFTS, OSSEOUS TISSUE Grafts, Osseous, Xenograft
UCSLS 42631 1540
(Including Flap Entry and Closure) Per site + E
UCSLS 42701 Guided Tissue Regeneration – Non-resorbable Membrane - per site + E. 1470
UCSLS 42702 Guided Tissue Regeneration – Resorbable Membrane - per site +E. 1470
UCSLS 42703 Guided Tissue Regeneration – Non-resorbable Membrane, Surgical Re-entry for Removal 770
UCSLS 42811 Proximal Wedge Procedure (as a separate procedure) With Flap Curettage, per site 700
Proximal Wedge Procedure (as a separate procedure)Proximal Wedge Procedure (as a separate
UCSLS 42819 875
procedure) With Flap Curettage and Osteotomy/Osteoplasty per site
UCSLS 42821 Post Surgical Periodontal Treatment Visit per Dressing Change One unit of time 70
UCSLS 42829 Post Surgical Periodontal Treatment Visit per Dressing Change Each additional unit over three 56
Periodontal Abscess or Pericoronitis, includes any of the following procedures: Lancing, Scaling,
UCSLS 42831 140
Curettage, Surgery or Medication One unit of time
Periodontal Abscess or Pericoronitis, includes any of the following procedures: Lancing, Scaling,
UCSLS 42839 105
Curettage, Surgery or Medication 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 preparation on either side "A" 140
Splint (restorative material plus wire, fibre ribbon or rope) Per joint + E
UCSLS 43211 Bonded Joint Restorations (per joint) Per joint (may include reinforcement) +E 105
UCSLS 43221 Bonded, Interproximal Enamel Splint Per joint 105
UCSLS 43231 Wire Ligation Per joint 105
UCSLS 43271 Cast/Soldered/Ceramic/Polymer Glass, Splint Bonded Per Abutment + L 280
UCSLS 43281 Removal of Fixed Periodontal Splints One unit of time 105
UCSLS 43289 Removal of Fixed Periodontal Splints Each additional unit of time 84
UCSLS 43421 Root Planing Root PlaningOne unit of time 105
UCSLS 43429 Root Planing Each additional unit over six 84
UCSLS 43511 Chemotherapeutic and/or antimicrobial agents, topical application One unit of time 105
UCSLS 43519 Chemotherapeutic and/or antimicrobial agents, topical application Each additional unit of time 84
PERIODONTAL RE-EVALUATION/EVALUATION
Note: This follow-up service applies to the evaluation of ongoing periodontal treatment or to a
UCSLS 49101 105
post-surgical re-evaluation 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 periodontal treatment or to a
UCSLS 49109 84
post-surgical re-evaluation 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 105
UCSLS 49219 Periodontal Irrigation, Subgingival + E Each additional unit of time +E 84
UCSLS 49221 Periodontal Irrigation about Implants, Subgingival + E One unit of time +E 105
UCSLS 49229 Periodontal Irrigation about Implants, Subgingival + E Each additional unit of time +E 84
UCSLS 71101 Removals, Erupted Teeth, Uncomplicated Single tooth, Uncomplicated 115.5
Removals, Erupted Teeth, Uncomplicated Each additional tooth, same quadrant, same
UCSLS 71109 77
appointment
Odontectomy, (extraction), Erupted Tooth, Surgical Approach, Requiring Surgical Flap and/or
UCSLS 71201 455
Sectioning of Tooth.
Odontectomy, (extraction), Erupted Tooth, Surgical Approach, Requiring Surgical Flap and/or
UCSLS 71209 269.5
Sectioning of Tooth. Each additional tooth, same quadrant
Requiring elevation of a Flap, Removal of Bone and/or Sectioning of Tooth for Removal of Tooth
UCSLS 71211 595
Single Tooth
Requiring elevation of a Flap, Removal of Bone and/or Sectioning of Tooth for Removal of Tooth
UCSLS 71219 420
Each additional Tooth same quadrant
Removals, Impactions, Requiring Incision of Overlying Soft Tissue and Removal of the Tooth.
UCSLS 72111 700
Single tooth
DAMAN CONFIDENTIAL

Removals, Impactions, Requiring Incision of Overlying Soft Tissue and Removal of the Tooth.
UCSLS 72119 700
Each additional tooth, same quadrant
Removals, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap and EITHER
UCSLS 72211 1050
Removal of Bone and Tooth OR Sectioning and Removal of Tooth Single tooth
Removals, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap and EITHER
UCSLS 72219 Removal of Bone and Tooth OR Sectioning and Removal of Tooth Each additional tooth, same 1050
quadrant
Removals, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap, Removal of
UCSLS 72221 1050
Bone AND Sectioning of Tooth for Removal Single tooth
Removals, Impaction, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap, Removal of
UCSLS 72229 770
Bone AND Sectioning of Tooth for Removal Each additional tooth, same quadrant
Removals, Impactions, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap, Removal of
UCSLS 72231 Bone, AND/OR Sectioning of the Tooth for Removal AND/OR Presents Unusual Difficulties and 1190
Circumstances. Single tooth
Removals, Impactions, Requiring Incision of Overlying Soft Tissue, Elevation of a Flap, Removal of
UCSLS 72239 Bone, AND/OR Sectioning of the Tooth for Removal AND/OR Presents Unusual Difficulties and 700
Circumstances. Each additional tooth, same quadrant
UCSLS 72311 Removals, Residual Roots, Erupted First tooth 140
UCSLS 72319 Removals, Residual Roots, Erupted Each additional tooth, same quadrant 84
UCSLS 72321 Removals, Residual Roots, Soft Tissue Coverage First tooth 210
UCSLS 72329 Removals, Residual Roots, Soft Tissue Coverage Each additional tooth, same quadrant 175
UCSLS 72331 Removals, Residual Roots, Bone Tissue Coverage First tooth 700
UCSLS 72339 Removals, Residual Roots, Bone Tissue Coverage Each additional tooth, same quadrant 280
UCSLS 72411 Alveolar Bone Preservation – Autograft First tooth 455
UCSLS 72419 Alveolar Bone Preservation – Autograft Each additional tooth 280
UCSLS 72421 Alveolar Bone Preservation – Allograft First tooth + E 455
UCSLS 72429 Alveolar Bone Preservation – Allograft Each additional tooth + E 280
UCSLS 72431 Alveolar Bone Preservation – Xenograft First tooth + E 455
UCSLS 72439 Alveolar Bone Preservation – Xenograft Each additional tooth + E 280
Surgical Exposures, Unerupted, Uncomplicated, Soft Tissue Coverage (includes operculectomy).
UCSLS 72511 280
Single tooth
Surgical Exposures, Unerupted, Uncomplicated, Soft Tissue Coverage (includes operculectomy).
UCSLS 72519 210
Each additional tooth, same quadrant
UCSLS 72521 Surgical Exposures, Complex, Hard Tissue Coverage Single tooth 700
UCSLS 72529 Surgical Exposures, Complex, Hard Tissue Coverage Each additional tooth, same quadrant 420
UCSLS 72531 Surgical Exposures, Unerupted Tooth, with Orthodontic Attachment. Single tooth 840
Surgical Exposures, Unerupted Tooth, with Orthodontic Attachment. Each additional tooth, same
UCSLS 72539 420
quadrant
Surgical Exposures, Unerupted Tooth, Soft Tissue Coverage with Positioning of Attached Gingivae,
UCSLS 72541 910
Single tooth
Surgical Exposures, Unerupted Tooth, Hard Tissue Coverage with Positioning of Attached Gingivae
UCSLS 72551 1050
Single tooth
UCSLS 72711 Unerupted Tooth and Follicle First tooth 630
UCSLS 72719 Unerupted Tooth and Follicle Each additional tooth, same quadrant 420
UCSLS 73111 Alveoloplasty, in Conjunction with Extractions Per sextant 350
UCSLS 73121 Alveoloplasty, Not in Conjunction with Extractions Per sextant 700
UCSLS 73152 Torus Palatinus, Excision 1050
UCSLS 73153 Torus Mandibularis, Unilateral, Excision 1050
UCSLS 73154 Torus Mandibularis, Bilateral, Excision 1400
UCSLS 73161 Removal of Bone, Exostosis, MultiplePer quadrant 875
UCSLS 73171 Reduction of Bone, Tuberosity Unilateral, Reduction 875
UCSLS 73172 Reduction of Bone, Tuberosity Bilateral, Reduction 1400
UCSLS 73221 Gingivoplasty, in Conjunction with Tooth Removal 140
UCSLS 73222 Excision of Vestibular Hyperplasia (per sextant) 630
UCSLS 73223 Surgical Shaving of Papillary Hyperplasia of the Palate 525
UCSLS 73224 Excision of Pericoronal Gingiva (for retained tooth/implant) per tooth/implant 280
Removals, Tissue, Hyperplastic (includes the incision of the mucous membrane, the dissection and
UCSLS 73231 945
removal of hyperplastic tissue, the replacing and adapting of the mucous membrane) Per sextant
UCSLS 73241 Removal, Mucosa, Excess (complete removal without dissection) Per sextant 420
UCSLS 73251 Excision of Scar or Pigmented Tissue Per site 315
UCSLS 73421 Sulcus Deepening and Ridge Reconstruction Per sextant 945
UCSLS 73431 Vestibuloplasty, with Secondary Epithelization Per sextant 700
UCSLS 73491 Vestibuloplasty – with Connective Tissue for Ridge Augmentation Per sextant 1050
DAMAN CONFIDENTIAL

UCSLS 73511 Reconstruction, Alveolar Ridge, with Autogenous Bone Per sextant + E 1470
UCSLS 73521 Reconstruction, Alveolar Ridge, with Alloplastic Material Per sextant + E 1750
Tumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions of Soft Tissue of the Oral
UCSLS 74111 840
Cavity 1 cm and under
UCSLS 74112 840
Cavity 1-2 cm
UCSLS 74113 CavityTumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions of Soft Tissue of the 980
Oral Cavity 2-3 cm
UCSLS 74114 1190
Cavity 3-4 cm
UCSLS 74115 CavityTumours, Benign, Scar Tissue, Inflammatory or Congenital Lesions of Soft Tissue of the 1400
Oral Cavity 4-6 cm
UCSLS 74116 1750
Cavity 6-9 cm
UCSLS 74117 2100
Cavity 9-15 cm
UCSLS 74118 2450
Cavity 15 cm and over
UCSLS 74121 Tumours, Benign, Bone Tissue 1 cm and under 910
UCSLS 74122 Tumours, Benign, Bone Tissuev 1-2 cm 1190
UCSLS 74123 Tumours, Benign, Bone Tissue 2-3 cm 1680
UCSLS 74128 Tumours, Benign, Bone Tissue 15 cm and over 3500
UCSLS 74211 Tumours, Malignant, Soft Tissue, Oral Cavity 1 cm and under 1400
UCSLS 74212 Tumours, Malignant, Soft Tissue, Oral Cavity 1-2 cm 1575
UCSLS 74218 Tumours, Malignant, Soft Tissue, Oral Cavity 15 cm and over 3150
UCSLS 74221 Surgical Excision, Tumours, Malignant, Bone Tissue1 cm and under 1400
UCSLS 74222 Surgical Excision, Tumours, Malignant, Bone Tissue1-2 cm 1750
UCSLS 74228 Surgical Excision, Tumours, Malignant, Bone Tissue15 cm and over 4900
Enucleation of Cyst/Granuloma, Odontogenic and Non-Odontogenic, Requiring Prior Removal of
UCSLS 74611 875
Bony Tissue and Subsequent Suture(s) 1 cm and under
UCSLS 74612 1050
Bony Tissue and Subsequent Suture(s) 1-2 cm
UCSLS 74613 1400
UCSLS 74614 1750
UCSLS 74615 2240
UCSLS 74616 2590
UCSLS 74617 3150
UCSLS 74618 3850
Bony Tissue and Subsequent Suture(s) 15 cm and over
UCSLS 74621 Cyst, Marsupialization 1400
UCSLS 74631 Excision of Cyst 1 cm and under 700
UCSLS 74632 Excision of Cyst 1-2 cm 840
DAMAN CONFIDENTIAL

UCSLS 74638 Excision of Cyst 15 cm and over 3850
UCSLS 75111 Intraoral, Surgical Exploration, Soft Tissue 350
UCSLS 75112 Intraoral, Abscess, Soft Tissue 210
UCSLS 75113 Intraoral, Abscess, In Major Anatomical area with Drain 350
Surgical Incision and Drainage and/or Exploration, Intraoral Hard Tissue Intraoral, Abscess, Hard
UCSLS 75121 700
Tissue, Trephination and Drainage
Surgical Incision and Drainage and/or Exploration, Intraoral Hard Tissue Intraoral, Surgical
UCSLS 75122 700
Exploration, Hard Tissue
Surgical Incision and Drainage and/or Exploration, Intraoral Hard Tissue Intraoral, Abscess, Hard
UCSLS 75123 910
Tissue, Trephination and Drainage in a Major Anatomical Area
Surgical Incision and Drainage and/or Exploration, Extraoral, Soft Tissue Extraoral, Abscess,
UCSLS 75211 910
Superficial
UCSLS 75212 Surgical Incision and Drainage and/or Exploration, Extraoral, Soft Tissue Extraoral, Abscess, Deep 1260
Surgical Incision and Drainage and/or Exploration, Extraoral, Hard Tissue Extraoral, Surgical
UCSLS 75221 1470
Exploration, Hard Tissue
UCSLS 75301 Removal, from Skin or Subcutaneous Alveolar Tissue 1260
UCSLS 75302 Removal, of Reaction Producing Foreign Bodies 1260
UCSLS 75303 Removal, of Needle from Musculo-skeletal System 1260
UCSLS 75401 Intraoral Sequestrectomy 910
UCSLS 75402 Saucerization 1260
UCSLS 75403 Osteomyelitis, Non Surgical Treatment of 630
UCSLS 76911 Fracture, Alveolar, Debridement, Teeth Removed 3 cm or less 840
UCSLS 76912 Fracture, Alveolar, Debridement, Teeth Removed 3-6 cm 1260
UCSLS 76913 Fracture, Alveolar, Debridement, Teeth Removed 6 cm and over 1470
UCSLS 76921 Reduction, Alveolar, Closed, with Teeth (fixation extra) 3 cm or less 910
UCSLS 76922 Reduction, Alveolar, Closed, with Teeth (fixation extra) 3-6 cm 1190
Reduction, Alveolar, Closed, with Teeth (fixation extra)Reduction, Alveolar, Closed, with Teeth
UCSLS 76923 1470
(fixation extra) 6-9 cm
UCSLS 76924 Reduction, Alveolar, Closed, with Teeth (fixation extra) 9 cm and over 1750
UCSLS 76931 Reduction, Alveolar, Open, with Teeth (fixation extra) 3 cm and less 1190
UCSLS 76932 Reduction, Alveolar, Open, with Teeth (fixation extra) 3-6 cm 1470
UCSLS 76933 Reduction, Alveolar, Open, with Teeth (fixation extra) 6-9 cm 1750
UCSLS 76934 Reduction, Alveolar, Open, with Teeth (fixation extra) 9 cm and over 2450
Replantation, Avulsed Tooth/Teeth
UCSLS 76941 315
(including splinting) Replantation, first tooth
Replantation, Avulsed Tooth/Teeth
UCSLS 76949 280
(including splinting) Each additional tooth
UCSLS 76951 Repositioning of Traumatically Displaced Teeth One unit of time 210
UCSLS 76959 Repositioning of Traumatically Displaced Teeth Each additional unit over two 175
UCSLS 76961 v 2 cm or less 245
UCSLS 76962 Repairs, Lacerations, Uncomplicated, Intraoral or Extraoral 2-4 cm 490
UCSLS 77415 Osteotomy, Segmental, Anterior – for Distraction Osteogenesis-Maxillary 1190
UCSLS 77416 Osteotomy, Segmental, Posterior – for Distraction Osteogenesis-Maxillary 1470
UCSLS 77417 Activation of Distraction Device-Maxillary 140
UCSLS 77418 Removal of Segmental Maxillary Distraction Device 350
UCSLS 77426 Osteotomy, Segmental, Anterior – for Distraction Osteogenesis-Mandible 1190
UCSLS 77427 Osteotomy, Segmental, Posterior – for Distraction Osteogenesis-Mandible 1470
UCSLS 77428 Activation of Distraction Device-Mandible 154
UCSLS 77429 Removal of Segmental Mandibular Distraction Device 350
UCSLS 77604 Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique, Maxilla - per Sextant 560
UCSLS 77605 Surgical Expansion of Alveolar Ridge – Ridge Splitting Technique, Mandible - per Sextant 560
UCSLS 77801 Frenectomy, Upper Labial 525
UCSLS 77802 Frenectomy, Lower Labial 525
UCSLS 77803 Frenectomy, Lower Lingual or "Z" Plasty 525
UCSLS 77804 Frenectomy, Lower Lingual or "Z" Plasty with Myotomy of Genioglossus 910
UCSLS 77805 Frenoplasty, Upper "Z" 700
UCSLS 77806 Frenoplasty, Lower "Z" 700
UCSLS 78102 TMJ, Dislocation, Closed Reduction, Uncomplicated 350
UCSLS 78103 TMJ, Dislocation, Closed Reduction, under General Anesthetic 1190
UCSLS 78104 TMJ, Luxation, Reduction without Anaesthesia 630
UCSLS 78105 TMJ, Luxation, Reduction under Anesthesia 770
DAMAN CONFIDENTIAL

UCSLS 78106 TMJ, Manipulation, under Anesthesia 910
UCSLS 78601 TMJ Injection, with Anti-Inflammatory Drugs 175
UCSLS 78602 TMJ Injection, with Sclerosing Agent 175
UCSLS 79123 Excision of Mucocele 350
UCSLS 79124 Excision of Ranula 490
UCSLS 79125 Marsupialization of Ranula 490
UCSLS 79311 Antral Surgery, Immediate Recovery of a Dental Root or Foreign Body from the Antrum 1190
UCSLS 79312 Antral Surgery, Immediate Closure of Antrum by Another Dental Surgeon 910
UCSLS 79313 Antral Surgery, Delayed Recovery of a Dental Root with Oral Antrostomy 1470
Antral Surgery, Oro-Antral Fistula Closure, (same session) Oro-Antral Fistula Closure with Buccal
UCSLS 79331 1050
Flap
Antral Surgery, Oro-Antral Fistula Closure, (same session) Oro-Antral Fistula Closure with Palatal
UCSLS 79333 1050
Flap
Antral Surgery, Oro-Antral Fistula Closure, (subsequent session) Oro-Antral Fistula Closure with
UCSLS 79341 840
Buccal Flap
Antral Surgery, Oro-Antral Fistula Closure, (subsequent session) Oro-Antral Fistula Closure with
UCSLS 79343 910
Palatal Flap
UCSLS 79351 Sinus Osseous Augmentation, Open Lateral Approach -Autograft +E 1400
UCSLS 79352 Sinus Osseous Augmentation, Open Lateral Approach-Allograft + E. 1750
UCSLS 79353 Sinus Osseous Augmentation, Open Lateral Approach -Xenograft + E. 1470
UCSLS 79354 Sinus Osseous Augmentation, Indirect Inferior Approach – Autograft +E 770
UCSLS 79355 Sinus Osseous Augmentation, Indirect Inferior Approach – Allograft + E. 1050
UCSLS 79356 Sinus Osseous Augmentation, Indirect Inferior Approach – Xenograft + E. 1050
UCSLS 79401 Primary Hemorrhage, Control 154
UCSLS 79402 Secondary Hemorrhage, Control 210
UCSLS 79403 Hemorrhage Control, using Compression and Hemostatic Agent 140
Hemorrhage Control, using Hemostatic Substance and Sutures (including removal of bony tissue,
UCSLS 79404 525
if necessary)
UCSLS 79511 Harvesting of Intraoral Tissue for Grafting to Operative Site Bone 1470
UCSLS 79514 Harvesting of Intraoral Tissue for Grafting to Operative Site Mucosa 630
UCSLS 79541 Harvesting and Preparation of Platelet Rich Plasma + E. 910
UCSLS 79601 Post Surgical Care, Subsequent to Initial Post Surgical Treatment, Minor, by Treating Dentist 140
UCSLS 79602 Post Surgical Care, Minor, by Other Than Treating Dentist 140
UCSLS 79603 Post Surgical Care, Major, by Treating Dentist 350
UCSLS 79604 Post Surgical Care, Major, by Other Than Treating Dentist 350
UCSLS 79605 Post Surgical Care, Alveolitis, Treatment of (without Anaesthesia) 140
UCSLS 79606 Post Surgical Care, Alveolitis, Treatment of (with Anaesthesia) 210
UCSLS 91111 Palliative (emergency) Treatment of Dental Pain, Minor Procedure One unit of time 140
UCSLS 91119 Palliative (emergency) Treatment of Dental Pain, Minor Procedure Each additional unit over three 84
UCSLS 91231 Management of Exceptional Patient One unit of time 105
UCSLS 91239 Management of Exceptional Patient Each additional unit over four 84
Provision of facilities, equipment and support services for general anaesthesia when provided by a
UCSLS 92222 350
separate practioner Two units of time
Provision of facilities, equipment and support services for general anaesthesia when provided by a
UCSLS 92229 175
separate practioner Each additional unit over eight
Nitrous Oxide Time is measured from the placement of the inhalation device and terminates with
UCSLS 92411 140
the removal of the inhalation device One unit of time
Nitrous Oxide Time is measured from the placement of the inhalation device and terminates with
UCSLS 92419 105
the removal of the inhalation device Each additional unit over eight
Oral Sedation
UCSLS 92421 Sedation sufficient to require monitored care. Time is to be measured from the start of patient 175
monitoring to release from the treatment/recovery room One unit of time
Oral Sedation
UCSLS 92429 Sedation sufficient to require monitored care. Time is to be measured from the start of patient 140
monitoring to release from the treatment/recovery room Each additional unit over eight
Nitrous Oxide with Oral Sedation
UCSLS 92431 Time is measured with the administration of nitrous oxide and terminates with the release of the 315
patient from the treatment/recovery room One unit of time
Nitrous Oxide with Oral Sedation
UCSLS 92439 Time is measured with the administration of nitrous oxide and terminates with the release of the 210
patient from the treatment/recovery room Each additional unit over eight
UCSLS 92441 Parenteral Conscious Sedation (regardless of method -IM or IV) One unit 280
DAMAN CONFIDENTIAL

UCSLS 92449 Parenteral Conscious Sedation (regardless of method -IM or IV) Each additional unit over eight 210
Combined Techniques of Inhalation plus Intravenous and/or Intramuscular Injection One unit of
UCSLS 92451 350
time
Combined Techniques of Inhalation plus Intravenous and/or Intramuscular Injection Each
UCSLS 92459 315
additional unit over eight
A dental-legal report - a short factually written or verbal communication given to any lay person
UCSLS 93121 (e.g. lawyer, insurance representative, local, municipal or government agency, etc.) in relation to 84
the patient with prior patient approval.
A dental-legal report - a comprehensive written report with patient approval, on symptoms,
history and records giving diagnosis, treatment, results and present condition. The report is a
UCSLS 93122 140
factual 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 complications in the 210
development of the conditions. The report will require expert knowledge and judgement with
respect to the facts leading to a detailed prognosis.
UCSLS 93211 Duplication and transfer of patient dental records at request of the patient + E 315
UCSLS 96201 Intramuscular Drug Injection + E 10.5
UCSLS 96202 Intravenous Drug Injection + E 17.5
UCSLS 97111 Bleaching, Vital, In Office One unit of time 630
UCSLS 97119 Each additional unit over three 455
Bleaching, Vital Home (Includes the fabrication of bleaching trays, dispensing the system and
UCSLS 97121 770
follow-up care) Maxillary Arch + L and/or E
UCSLS 97122 770
follow-up care) Mandibular Arch + L and/or E
UCSLS 97123 1330
follow-up care) Maxillary plus Mandibular (combined) + L and/or E
UCSLS 97131 Micro-Abrasion One unit of time 140
UCSLS 97139 Micro-Abrasion Each additional unit over four 84
Examination and Diagnosis,
Limited, Oral, New Patient.
UCSLS 01201 70
Examination and Diagnosis of hard and soft tissues, including 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, recording history, charting, 70
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, recording history, charting,
UCSLS 01102 70
treatment planning and case 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 history, charting, treatment planning 70
and case presentation, including above description as per 01100.
Examination and Diagnosis, Limited, Oral, Previous Patient (recall).
UCSLS 01202 Examination of hard and soft tissues, including checking of occlusion and 56
appliances, but not including specific test/analysis, as for 01100
UCSLS 01204 Examination and Diagnosis, Specific Examination and evaluation of a specific situation 70
Examination and Diagnosis, Emergency. Examination and Diagnosis for the investigation of
UCSLS 01205 70
discomfort and/or infection in a localized area.
UCSLS 01206 Analysis, Mixed Dentition. 105
Examination and Diagnosis, Stomatognathic Dysfunctional, Comprehensive, to include:
(a) History, Medical, Dental, Pain/ Dysfunction;
(b) Clinical Examination to include, general appraisal, examination of head and neck,
UCSLS 01301 175
musculoskeletal system (static and functional); 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.
UCSLS 01302 Examination and Diagnosis, Stomatognathic Dysfunctional, Limited. 56
DAMAN CONFIDENTIAL

Examination and Diagnosis, Oral Pathology, General, to include:
(a) History, Medical and Dental
UCSLS 01401 (b) Clinical Examination including, in-depth analysis of medical status, initial consultation, with 175
referring dentist or physician, evaluation of the diagnosis and prognosis and formulation
of a treatment plan.
Examination and Diagnosis, Oral Pathology, Specific (or repeat examination and diagnosis within
UCSLS 01402 70
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;
UCSLS 01501 175
degree of gingival inflammation; 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) 56
Examination and Diagnosis, Surgical, General
(a) History, Medical and Dental
(b) Clinical Examination as above, may include in-depth analysis of medical status, medication,
UCSLS 01601 175
anaesthetic and surgical risk, initial 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 70
Examination and Diagnosis, Prosthodontic, Edentulous
(a) Extended Examination of the Edentulous Mouth, including detailed Medical and Dental History
UCSLS 01701 (including Prosthetic history), visual and digital examination of the oral structures, head and neck 175
(including TMJ), lips, oral mucosa, tongue, oral pharynx, salivary glands and lymph nodes, and
including evaluation for implant-supported or retained prosthesis.
UCSLS 01702 70
Prosthodontic, Specific.
Examination and Diagnosis, Prosthodontic, Fixed Oral Rehabilitation, to include:
(b) Clinical Examination of Hard and Soft Tissues, including carious lesions, missing teeth,
determination of sulcular depth, gingival contours, mobility of teeth, interproximal tooth contact
UCSLS 01703 175
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 175
(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
Examination and Diagnosis, Endodontic, Specific. Endodontic examination and evaluation of a
UCSLS 01802 70
specific situation in a localized area and vitality test analysis.
UCSLS 01902 140
Orthodontic, Specific
UCSLS 02101 Radiographs, Complete Series (minimum of 12 images incl. bitewings). 140
UCSLS 02102 Radiographs, Complete Series (minimum of 16 images incl. bitewings). 175
UCSLS 02111 Radiographs, Intraoral, Periapical-Single film 35
UCSLS 02131 Radiographs, Occlusal Single images 35
UCSLS 02141 Radiographs, BitewingSingle image 35
UCSLS 02201 RADIOGRAPHS, EXTRAORAL (Deprecated, do not use codes in this series) Single film 70
UCSLS 02301 RADIOGRAPHS, POSTERO-ANTERIOR AND LATERAL SKULL AND FACIAL BONE Single film 70
Sinus Examination and Diagnosis - Minimum four films identified as: 1) Waters 2) Caldwell 3)
UCSLS 02304 175
Lateral Skull 4) Basal
UCSLS 02401 RADIOGRAPHS, SIALOGRAPHY Single film 126
RADIOGRAPHS, TEMPOROMANDIBULAR JOINTRADIOGRAPHS, TEMPOROMANDIBULAR JOINT
UCSLS 02501 70
Single film
DAMAN CONFIDENTIAL

RADIOGRAPHS, TEMPOROMANDIBULAR JOINT Four films (minimum examination and diagnosis
UCSLS 02504 175
closed and open each side)
UCSLS 02509 RADIOGRAPHS, TEMPOROMANDIBULAR JOINT Each additional film over four 35
UCSLS 02601 RADIOGRAPHS, PANORAMIC Single film 105
RADIOGRAPHS,
UCSLS 02701 105
CEPHALOMETRIC Single film
UCSLS 02751 Radiographs, Cephalometric, Tracing and Interpretation One unit of time 140
UCSLS 02759 Radiographs, Cephalometric, Tracing and Interpretation Each additional unit over two 56
RADIOGRAPHS, COMPUTERIZED AXIAL TOMOGRAMS (C.A.T.), POSITRON EMISSION
TOMOGRAPHY (P.E.T.), MAGNETIC RESONANCE IMAGES (M.R.I.), INTERPRETATION (either the
UCSLS 02801 70
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 56
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 35
UCSLS 02931 Radiographs, Tomography Single view 140
UCSLS 02934 Radiographs, Tomography Four views 420
UCSLS 02941 Radiographs, Hand and Wrist (as a diagnostic aid for dental treatment) per case 84
Radiographic Guide, (includes diagnostic wax-up, with radio-opaque markers for pre-surgical
UCSLS 02951 assessment of alveolar bone and vital structures as potential osseo-integrated implant site(s)) 350
Maxillary Guide + L + E
Radiographic Guide, (includes diagnostic wax-up, with radio-opaque markers for pre-surgical
UCSLS 02952 assessment of alveolar bone and vital structures as potential osseo-integrated implant site(s)) 350
Mandibular + L + E
UCSLS 04101 Microbiological Test/Analysis for the Determination of Pathological Agents + L 84
UCSLS 04201 Bacteriological Test/Analysis for the Determination of Dental Caries Susceptibility + L 84
UCSLS 04311 Biopsy, Soft Oral Tissue - by Puncture + L 140
UCSLS 04312 Biopsy, Soft Oral Tissue - by Incision + L 140
UCSLS 04313 Biopsy, Soft Oral Tissue - by Aspiration + L 140
UCSLS 04321 Test/Analysis, Histopathological, Biopsy, Hard Oral Tissue - by Puncture + L 280
UCSLS 04322 Test/Analysis, Histopathological, Biopsy, Hard Oral Tissue - by Incision + L 280
UCSLS 04323 Test/Analysis, Histopathological, Biopsy, Hard Oral Tissue - by Aspiration + L 280
UCSLS 04501 TESTS/ANALYSIS, PULP VITALITY AND INTERPRETATION One unit of time 70
UCSLS 04509 TESTS/ANALYSIS, PULP VITALITY AND INTERPRETATION Each additional unit 56
UCSLS 04601 Interpretation and/or Report, Microbiological by Oral Microbiologist + L 154
UCSLS 04602 Interpretation and/or Report, Histopathological by Oral Pathologist or Microbiologist + L 154
UCSLS 04603 Interpretation and/or Report, Cytological by Oral Pathologist +L 154
UCSLS 04631 Radiological Report One unit of time 70
UCSLS 04639 Radiological Report Each additional unit of time 56
UCSLS 04801 PHOTOGRAPHS, DIAGNOSTIC (technical procedure only) Single photograph 35
UCSLS 06201 RADIOGRAPHS, EXTRAORAL (technical procedure only) Single film 56
RADIOGRAPHS, SKULL (Postero-Anterior, Lateral Skull, Submental vertex, Waters, Caldwell,
UCSLS 06301 56
Single film
RADIOGRAPHS, SIALOGRAPHY
UCSLS 06401 119
(technical procedure only) Single film
UCSLS 06501 RADIOGRAPHS, TEMPOROMANDIBULAR JOINT (technical procedure only) Single film 56
RADIOGRAPHS, TEMPOROMANDIBULAR JOINT (technical procedure only) Four films (minimum
UCSLS 06504 175
examination and diagnosis closed and open each side)
UCSLS 06601 RADIOGRAPHS, PANORAMIC (technical procedure only) Single film 84
UCSLS 06701 RADIOGRAPHS, CEPHALOMETRIC (technical procedure only) Single film 77
UCSLS 06751 Radiographs, Cephalometric (tracing and interpretation) One unit of time 126
UCSLS 06759 Radiographs, Cephalometric (tracing and interpretation) Each additional unit over four 105
Radiographs, Computerized Axial Tomograms, Positron Emission Tomograms, Magnetic
UCSLS 06811 126
Resonance Images, Interpretation, Oral Radiologist One unit of time
UCSLS 06819 105
Resonance Images, Interpretation, Oral Radiologist Each additional unit of time over four
UCSLS 06821 126
Resonance Images, Interpretation, Specialist Other than Oral Radiologist One unit of time
UCSLS 06829 Resonance Images, Interpretation, Specialist Other than Oral Radiologist Each additional unit over 105
four
UCSLS 06931 Radiographs, Tomography (technical procedure only) Single view 126
UCSLS 06934 Radiographs, Tomography (technical procedure only) Four views 350
DAMAN CONFIDENTIAL

UCSLS 06941 Radiographs, Hand and Wrist (as a diagnostic aid for dental treatment) Per case 56
UCSLS 43521 Chemotherapeutic and/or antimicrobial therapy, intra-sulcular application One unit of time + E 105
Chemotherapeutic and/or antimicrobial therapy, intra-sulcular application Each additional unit of
UCSLS 43529 84
time + E
UCSLS 14101 APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS Appliance, Maxillary + L 595
UCSLS 14102 APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITS Appliance, Mandibular + L 595
APPLIANCES, REMOVABLE, CONTROL OF ORAL HABITSAPPLIANCES, REMOVABLE, CONTROL OF
UCSLS 14103 910
ORAL HABITS Appliances, Maxillary plus Mandibular + L
UCSLS 14201 APPLIANCES, FIXED/ CEMENTED, CONTROL OF ORAL HABITS Appliance, Maxillary + L 700
UCSLS 14202 APPLIANCES, FIXED/ CEMENTED, CONTROL OF ORAL HABITS Appliance, Mandibular + L 700
APPLIANCES, CONTROL OF ORAL HABITS -
UCSLS 14401 175
adjustments, repairs, maintenance One unit of time + L
APPLIANCES, CONTROL OF ORAL HABITS -
UCSLS 14409 77
adjustments, repairs, maintenance Each additional unit over three + L
UCSLS 14501 Appliance, Protective Mouth Guard, Preformed 280
UCSLS 14502 Appliance, Protective Mouth Guard, Processed + L 560
Appliances, Periodontal (including bruxism appliance); Includes Impression, Insertion and
UCSLS 14611 490
Insertion adjustment (no post-insertion adjustments) Maxillary Appliance + L
Appliances, Periodontal (including bruxism appliance); Includes Impression, Insertion and
UCSLS 14612 560
Insertion adjustment (no post-insertion adjustments) Mandibular Appliance + L
UCSLS 14621 Appliances, Adjustment, Repair One unit of time + L 175
UCSLS 14629 Appliances, Adjustment, Repair Each additional unit over three + L 84
UCSLS 14631 Appliances, Reline, Direct 210
UCSLS 14632 Appliances, Reline, Processed + L 315
Appliance, TMJ, Diagnostic and/or Therapeutic, includes impression, insertion and insertion
UCSLS 14711 525
adjustment (no post-insertion adjustments) Maxillary Appliance + L
Appliance, TMJ, Diagnostic and/or Therapeutic, includes impression, insertion and insertion
UCSLS 14712 525
adjustment (no post-insertion adjustments) Mandibular Appliance + L
Appliance, TMJ Intraoral Repositioning; includes impression, insertion and insertion adjustment
UCSLS 14721 525
(no post-insertion adjustments) Maxillary Appliance + L
Appliance, TMJ Intraoral Repositioning; includes impression, insertion and insertion adjustment
UCSLS 14722 525
(no post-insertion adjustments) Mandibular Appliance + L
UCSLS 14731 Appliance, TMJ, Periodic Maintenance, Adjustment, Repair One unit of time + L 175
UCSLS 14739 Appliance, TMJ, Periodic Maintenance, Adjustment, Repair Each additional unit over three 84
UCSLS 14741 Appliance, TMJ Reline, Direct 210
UCSLS 14742 Appliance, TMJ Reline, Indirect + L 315
Appliance, Myofascial Pain Dysfunction Syndrome, to include: models, gnathological
UCSLS 14811 determinants) Appliance Construction only, and insertion adjustment (no post-insertion 700
adjustments) Maxillary Appliance + L
Appliance, Myofascial Pain Dysfunction Syndrome, to include: models, gnathological
UCSLS 14812 determinants) Appliance Construction only, and insertion adjustment (no post-insertion 700
adjustments) Mandibular Appliance + L
Appliance, Myofascial Pain Dysfunction Syndrome, Periodic Maintenance, Adjustment and repairs
UCSLS 14821 175
One unit of time + L
Appliance, Myofascial Pain Dysfunction Syndrome, Periodic Maintenance, Adjustment and repairs
UCSLS 14829 84
Each additional unit of time + L
UCSLS 14831 Appliance, Myofascial Pain Dysfunction Syndrome, Relines Reline direct 210
Appliance, Myofascial Pain Dysfunction Syndrome, RelinesAppliance, Myofascial Pain Dysfunction
UCSLS 14832 315
Syndrome, Relines Reline, Processed + L
UCSLS 15101 Space Maintainer, Band Type, Fixed, Unilateral + L 350
UCSLS 15102 Space Maintainer, Band Type, Fixed, Unilateral with Intra-alveolar Attachment + L 525
UCSLS 15103 Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch) + L 630
UCSLS 15104 Space Maintainer, Band Type, Fixed, Bilateral (soldered lingual arch), with Teeth Attached + L 840
UCSLS 15105 Space Maintainer, Band Type, Fixed, Bilateral Tubes and Locking Wires + L 630
UCSLS 15201 Space Maintainer, Stainless Steel Crown Type, Fixed + L 630
UCSLS 15202 Space Maintainer, Stainless Steel Crown Type, Fixed, with Intra Alveolar Attachment + L 875
UCSLS 15301 Space Maintainer, Cast Type, Fixed + L 630
UCSLS 15302 Space Maintainer, Cast Type, Fixed, with Intra Alveolar Attachment + L 840
UCSLS 15401 Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining Wires + L 455
UCSLS 15402 Space Maintainer, Acrylic, Removable, Bilateral Clasps, Retaining Wires with Teeth + L 560
UCSLS 15403 Space Maintainer, Acrylic Removable, No Clasps + L 455
UCSLS 15501 Space Maintainer, Bonded, Pontic Type + L 525
DAMAN CONFIDENTIAL

Maintenance, Space Maintainer Appliance, to include: adjustment and/or recementation after 30
UCSLS 15601 105
days from insertion
UCSLS 15602 Maintenance, Space Maintainer Appliances, addition of clasps and/or activating wires + L 175
UCSLS 15603 Repairs, Space Maintainer Appliances (includes recementation) + L 105
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS RESTORATIONS, INLAYS Metal -One
UCSLS 25111 630
surface + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS RESTORATIONS, INLAYS Metal -Two
UCSLS 25112 840
surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS RESTORATIONS, INLAYS Metal - Three
UCSLS 25113 945
surfaces + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS RESTORATIONS, INLAYS Metal - Three
UCSLS 25114 1120
surfaces, modified + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS RESTORATIONS, INLAYS --Inlays,
UCSLS 25121 665
Composite/Compomer, Indirect (Bonded) One surface + L
UCSLS 25122 875
Composite/Compomer, Indirect (Bonded) Two surfaces + L
UCSLS 25123 945
Composite/Compomer, Indirect (Bonded) Three surfaces + L
UCSLS 25124 1120
Composite/Compomer, Indirect (Bonded) Three surfaces, modified + L
RESTORATIONS, INLAYS, ONLAYS, PINS AND POSTS RESTORATIONS, INLAYS -Inlays,
UCSLS 25141 840
Porcelain/Ceramic/Polymer Glass (Bonded) One surface + L
UCSLS 25142 1050
Porcelain/Ceramic/Polymer Glass (Bonded) Two surfaces + L
UCSLS 25143 1260
Porcelain/Ceramic/Polymer Glass (Bonded) Three surfaces + L
UCSLS 25144 1400
Porcelain/Ceramic/Polymer Glass (Bonded) Three surfaces, modified + L
UCSLS 25511 Onlays, Cast Metal, Indirect + L 1050
UCSLS 25512 Onlays, Cast Metal, Indirect (Bonded external retention type) + L 1120
UCSLS 25521 Onlays, Composite/Compomer, Indirect (Bonded) + L 1050
UCSLS 25531 Onlays, Porcelain/Ceramic/Polymer Glass (Bonded) + L 1190
UCSLS 25711 Posts, Cast Metal, (including core) as a Separate Procedure Single section + L 560
UCSLS 25712 Posts, Cast Metal, (including core) as a Separate Procedure Two sections + L 700
UCSLS 25713 Posts, Cast Metal, (including core) as a Separate Procedure Three sections + L 770
UCSLS 25721 Posts, Cast Metal (including core) Concurrent with Impression for Crown Single section + L 420
UCSLS 25722 Posts, Cast Metal (including core) Concurrent with Impression for Crown Two sections + L 560
UCSLS 25723 Posts, Cast Metal (including core) Concurrent with Impression for Crown Three sections + L 630
UCSLS 25731 Posts, Prefabricated Retentive + E One post + E 175
UCSLS 25732 Posts, Prefabricated Retentive + E Two posts same tooth + E 210
UCSLS 25733 Posts, Prefabricated Retentive + E Three posts same tooth + E 280
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 385
Restoration [including pin(s) where applicable] or Fixed Bridge Retainer + E One post, with Non-
Bonded amalgam core and pin(s) + E
UCSLS 25752 applicable] or Fixed Bridge Retainer + E Two posts (same tooth), with Non-Bonded amalgam core 455
and pin(s) + E
UCSLS 25753 applicable] or Fixed Bridge Retainer + E Three posts (same tooth), with Non-Bonded amalgam 525
core and pin(s) + E
Posts, Prefabricated, with Bonded Core for Crown Restoration (including pin(s) where applicable)
UCSLS 25761 385
or Fixed Bridge Retainer +E One post, with bonded amalgam core and pin(s) +E
UCSLS 25762 455
or Fixed Bridge Retainer +E Two posts (same tooth), with bonded amalgam core and pin(s) +E
UCSLS 25763 525
or Fixed Bridge Retainer +E Three posts (same tooth), with bonded amalgam core and pin(s) +E
UCSLS 25764 385
or Fixed Bridge Retainer +E One post, with bonded composite/compomer core and pin(s) +E
DAMAN CONFIDENTIAL

UCSLS 25765 Two posts, (same tooth) with bonded composite/compomer core and pin(s) +E 455
UCSLS 25766 or Fixed Bridge Retainer +E Three posts, (same tooth) with bonded composite/compomer core 525
and pin(s) +E
UCSLS 25771 Posts, Provisional Per Post + L and/or + E 140
MESOSTRUCTURES
(a separate component positioned between the head of an implant and the final restoration,
UCSLS 26101 1050
retained by either a cemented post or screw) Indirect, Angulated or transmucosal pre-fabricated
abutment, per implant + L + E
MESOSTRUCTURES
UCSLS 26102 1050
retained by either a cemented post or screw) Indirect, Custom laboratory fabricated, per implant
+L+E
MESOSTRUCTURES
UCSLS 26103 1050
retained by either a cemented post or screw) Direct, (with intra-oral preparation), per implant site
+E
Crown, Acrylic/Composite/
UCSLS 27111 385
Compomer, Indirect + L
Crown, Acrylic/Composite/Compomer, Provisional [Long Term], Indirect (lab fabricated/relined
UCSLS 27113 350
intra-orally) + L
UCSLS 27121 Crowns, Acrylic/Composite/Compomer, Direct, Provisional (chairside) + E 231
UCSLS 27125 Crowns, Acrylic/Composite/Compomer, Direct, Provisional Implant-supported + E 308
UCSLS 27131 Crown, Acrylic/Composite/Compomer/Cast Metal Base, Indirect + L 840
UCSLS 27135 Crown, Acrylic/Composite/Compomer Cast Metal Base, Implant-supported + L + E 1050
Semi-Precision Rest (interlock) (in addition to Acrylic/Composite/Compomer, Cast Metal Base
UCSLS 27137 630
Crown) + L + E
Semi-Precision or Precision Attachment RPD Retainer (in addition to
UCSLS 27138 770
Acrylic/Composite/Compomer, Cast Metal Base Crown) + L + E
Crown, Acrylic/Composite/Compomer/ Pre-fabricated Metal Base, Provisional, Implant-supported,
UCSLS 27145 245
Direct + E
Crown, Acrylic/ Composite/Compomer/Pre-fabricated Metal Base, Provisional, Implant-supported,
UCSLS 27155 315
Indirect + L + E
UCSLS 27201 Crown, Porcelain/Ceramic/Polymer Glass + L 1540
UCSLS 27205 Crown, Porcelain/Ceramic/Polymer Glass, Implant-supported + L + E 1540
UCSLS 27206 Crown, Porcelain/Ceramic/Polymer Glass, with Cast Ceramic Post Retention + L 1925
UCSLS 27211 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base + L 924
UCSLS 27213 Crown, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, with Porcelain Margin + L 1155
UCSLS 27215 Crown, Porcelain/Ceramic Fused to Metal Base, Implant-supported + L +E 1540
UCSLS 27216 Crown, Porcelain/Ceramic Fused to Metal Base with Cast Metal Post Retention + L 1232
Semi-precision Rest (Interlock) (in addition to Porcelain/Ceramic Fused to Metal Base Crown) + L
UCSLS 27217 595
+E
Semi-precision or Precision Attachment RPD Retainer (in addition to Porcelain/Ceramic Fused to
UCSLS 27218 700
Metal Base Crown) + L + E
UCSLS 27221 Crown, ¾, Porcelain/Ceramic/Polymer Glass, + L 1190
UCSLS 27301 Crown, Full, Cast Metal + L 770
UCSLS 27305 Crown, Full, Cast Metal, Implant-supported + L + E 1540
UCSLS 27307 Semi-precision Rest (Interlock) (in addition to Full, Cast Metal Crown) + L + E 595
Semi-Precision or Precision Attachment RPD Retainer (in addition to Full, Cast Metal Crown) + L +
UCSLS 27308 700
E
UCSLS 27311 Crowns, ¾, Cast Metal + L 805
UCSLS 27401 CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP (additional to crown) One crown 280
CROWNS MADE TO AN EXISTING PARTIAL DENTURE CLASP (additional to crown) Each additional
UCSLS 27409 280
crown
UCSLS 27601 Veneers, Acrylic/Composite/Compomer, Bonded + L 700
UCSLS 27602 Veneers, Porcelain/Ceramic/Polymer Glass, Bonded + L 1540
UCSLS 27711 Repairs, Acrylic/Composite/Compomer, Direct 140
Repairs, Inlays Onlays or Crowns, Porcelain/Ceramic/Polymer Glass, Porcelain/Ceramic/Polymer
UCSLS 27721 175
Glass/Fused to Metal base, Direct
Repairs, Inlays Onlays or Crowns, Porcelain/Ceramic/Polymer Glass, Porcelain/Ceramic/Polymer
UCSLS 27722 455
Glass/Fused to Metal base, Indirect +L
RESTORATIVE PROCEDURES, OVERDENTURES, DIRECT Implant-supported Prefabricated
UCSLS 28105 700
Attachment as an Overdenture Retentive Device, Direct + L + E
DAMAN CONFIDENTIAL

RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping Crown, Cast Metal, No
UCSLS 28211 770
Attachments, Indirect + L
RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping Crown, Cast Metal, No
UCSLS 28215 840
Attachments, Implant-supported, Indirect + L + E
RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping Crown, Cast Metal, with
UCSLS 28221 Attachments, Indirect+ L + E Coping Crown, Metal Cast, with Attachment, Indirect + L and/or + 1050
E
RESTORATIVE PROCEDURES, OVERDENTURES, INDIRECT Coping Crown, Cast Metal, with
UCSLS 28225 Attachments, Indirect+ L + E Coping Crown, Cast Metal, Implant-supported with Attachment + L 1050
+E
UCSLS 51101 DENTURES, COMPLETE, STANDARD Maxillary + L 1120
UCSLS 51102 DENTURES, COMPLETE, STANDARD Mandibular + L 1330
UCSLS 51103 DENTURES, COMPLETE, STANDARD Maxillary plus Mandibular (combined) + L 2240
UCSLS 51104 DENTURES, COMPLETE, STANDARD Liners, Processed, Resilient, in addition to above 280
DENTURES, SURGICAL, STANDARD, (IMMEDIATE) (includes first tissue conditioner, but not a
UCSLS 51301 700
processed reline) Maxillary + L
UCSLS 51302 840
processed reline) Mandibular + L
UCSLS 51303 1540
processed reline) Maxillary plus Mandibular (combined) + L
UCSLS 51601 DENTURES, COMPLETE, PROVISIONAL Maxillary + L 700
UCSLS 51602 DENTURES, COMPLETE, PROVISIONAL Mandibular + L 840
UCSLS 51603 DENTURES, COMPLETE, PROVISIONAL Maxillary plus Mandibular (combined) + L 1540
DENTURES, COMPLETE, SURGICAL (IMMEDIATE), PROVISIONAL(Includes first tissue conditioner,
UCSLS 51611 1330
but not a processed reline) Maxillary +L.
UCSLS 51612 1610
but not a processed reline) Mandibular +L.
UCSLS 51613 2450
but not a processed reline) Maxillary plus Mandibular (combined) +L.
Dentures, Complete, Overdentures, Tissue Borne, Supported by Natural Teeth with or without
UCSLS 51711 1400
Coping Crowns, no Attachments Maxillary + L
UCSLS 51712 1750
Coping Crowns, no Attachments Mandibular + L
UCSLS 51713 2800
Coping Crowns, no Attachments Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, Supported by Implants with or without Coping
UCSLS 51721 2100
Crowns, no Attachments Maxillary + L
UCSLS 51722 2800
Crowns, no Attachments Mandibular + L
UCSLS 51723 4200
Crowns, no Attachments Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne, Supported by Natural Teeth with
UCSLS 51811 or without Coping Crowns, no Attachments (includes first tissue conditioner, but not a processed 1750
reline) Maxillary + L
reline) Mandibular + L
reline) Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures (Immediate), Tissue Borne, Supported by Implants with or
UCSLS 51821 without Coping Crowns, no Attachments (includes first tissue conditioner, but not a processed 2450
reline) Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, with Independent Attachments Secured to
UCSLS 51911 1890
Natural Teeth with or without Coping Crowns Maxillary + L
UCSLS 51912 2100
Natural Teeth with or without Coping Crowns Mandibular + L
UCSLS 51913 3150
Natural Teeth with or without Coping Crowns Maxillary plus Mandibular (combined) + L
DAMAN CONFIDENTIAL

UCSLS 51921 2590
Implants with or without Coping Crowns Maxillary + L
UCSLS 51922 Implants with or without Coping CrownsDentures, Complete, Overdentures, Tissue Borne, with 2800
Independent Attachments Secured to Implants with or without Coping Crowns Mandibular + L
UCSLS 51923 3500
Implants with or without Coping Crowns Maxillary plus Mandibular (combined) + L
Dentures, Complete, Overdentures, Tissue Borne, with Retention from a Retentive Bar, Secured to
UCSLS 51941 2450
Coping Crowns Supported by Natural Teeth Maxillary + L
UCSLS 51942 2590
Coping Crowns Supported by Natural Teeth Mandibular + L
UCSLS 51943 3850
Coping Crowns Supported by Natural Teeth Maxillary plus Mandibular (combined) + L
UCSLS 51951 2590
Coping Crowns Supported by Implants Maxillary + L
UCSLS 51952 2800
Coping Crowns Supported by Implants Mandibular + L
UCSLS 51953 4200
Coping Crowns Supported by Implants Maxillary plus Mandibular (combined) + L
UCSLS 52101 DENTURES, PARTIAL, ACRYLIC BASE (PROVISIONAL) (With or Without Clasps) Maxillary + L 700
UCSLS 52102 DENTURES, PARTIAL, ACRYLIC BASE (PROVISIONAL) (With or Without Clasps) Mandibular + L 700
DENTURES, PARTIAL, ACRYLIC BASE (PROVISIONAL) (With or Without Clasps) Maxillary plus
UCSLS 52103 1225
Mandibular (combined) + L
Dentures, Partial, Acrylic Base (Immediate) (includes first tissue conditioner, but not a processed
UCSLS 52111 840
UCSLS 52112 840
UCSLS 52113 reline)Dentures, Partial, Acrylic Base (Immediate) (includes first tissue conditioner, but not a 1400
processed reline) Maxillary plus Mandibular (combined) + L
DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS Maxillary
UCSLS 52301 1050
+L
DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS
UCSLS 52302 1050
Mandibular + L
DENTURES, PARTIAL, ACRYLIC, WITH METAL WROUGHT/CAST CLASPS AND/OR RESTS Maxillary
UCSLS 52303 1400
plus Mandibular (combined) + L
UCSLS 52511 Dentures, Partial, (flexible, Non Metal, Non Acrylic) Maxillary + L 1050
UCSLS 52512 Dentures, Partial, (flexible, Non Metal, Non Acrylic) Mandibular + L 1050
UCSLS 52513 Dentures, Partial, (flexible, Non Metal, Non Acrylic) Maxillary plus Mandibular + L 1750
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests supported by
UCSLS 52711 1890
Natural Teeth with or without Coping Crowns, no attachments Maxillary + L
UCSLS 52712 2100
Natural Teeth with or without Coping Crowns, no attachments Mandibular + L
UCSLS 52713 Natural Teeth with or without Coping Crowns, no attachments Maxillary plus Mandibular 2800
(combined) + L
Dentures, Partial, Overdentures, Acrylic, with Cast/ Wrought Clasps and/or Rests, Supported by
UCSLS 52721 2450
Implants with or without Coping Crowns, No Attachments Maxillary + L
UCSLS 52722 2800
Implants with or without Coping Crowns, No Attachments Mandibular + L
UCSLS 52723 Implants with or without Coping Crowns, No Attachments Maxillary plus Mandibular (combined) 3850
+L
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests with Independent
UCSLS 52911 Attachments Secured by Attachments to Natural Teeth with or without Coping Crowns Maxillary + 3150
L
UCSLS 52912 Attachments Secured by Attachments to Natural Teeth with or without Coping Crowns Mandibular 3500
+L
DAMAN CONFIDENTIAL

UCSLS 52913 Attachments Secured by Attachments to Natural Teeth with or without Coping Crowns Maxillary 4900
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with
UCSLS 52921 3150
Independent Attachments Secured to Implants with or without Coping Crowns Maxillary + L
UCSLS 52922 3500
Independent Attachments Secured to Implants with or without Coping Crowns Mandibular + L
UCSLS 52923 Independent Attachments Secured to Implants with or without Coping Crowns Maxillary plus 4900
Dentures, Partial, Overdentures, Acrylic, with Cast/Wrought Clasps and/or Rests, with Retention
UCSLS 52941 from a Retentive Bar, Secured to Coping Crowns Supported by Natural Teeth (see 62104 for 3150
Retentive Bar) Maxillary + L
Retentive Bar) Mandibular + L
Retentive Bar) Maxillary plus Mandibular (combined) + L
UCSLS 52951 from a Retentive Bar, Secured to Coping Crowns Supported by Implants (see 62105 for Retentive 3150
Bar) Maxillary + L
Bar) Mandibular + L
Bar) Maxillary plus Mandibular (combined) + L
UCSLS 53101 DENTURES, PARTIAL, FREE END, CAST FRAME/ CONNECTOR, CLASPS AND RESTS Maxillary + L 1400
DENTURES, PARTIAL, FREE END, CAST FRAME/ CONNECTOR, CLASPS AND RESTSv Mandibular +
UCSLS 53102 1400
L
DENTURES, PARTIAL, FREE END, CAST FRAME/ CONNECTOR, CLASPS AND RESTS Maxillary plus
UCSLS 53103 2800
Dentures, Partial, Free End, Cast Frame/Connector, Clasps and Rests, (Immediate) (includes first
UCSLS 53111 1540
tissue conditioner, but not a processed reline) Maxillary + L
UCSLS 53112 1540
tissue conditioner, but not a processed reline) Mandibular + L
UCSLS 53113 2800
tissue conditioner, but not a processed reline) Maxillary plus Mandibular (combined) + L
UCSLS 53121 Dentures, Partial Free End, Swing Lock/Connector Maxillary + L 2450
UCSLS 53122 Dentures, Partial Free End, Swing Lock/Connector Mandibular + L 2450
UCSLS 53123 Dentures, Partial Free End, Swing Lock/Connector Maxillary plus Mandibular (combined) + L 3500
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR, CLASPS AND RESTS Maxillary +
UCSLS 53201 1400
L
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR, CLASPS AND RESTS
UCSLS 53202 1400
Mandibular + L
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR, CLASPS AND RESTS Maxillary
UCSLS 53203 2450
DENTURES, PARTIAL, TOOTH BORNE, CAST FRAME/CONNECTOR, CLASPS AND RESTS Unilateral,
UCSLS 53205 910
one piece casting, clasps and pontics + L
Dentures, Partial, Tooth Borne, Cast Frame/Connector, Clasps and Rests, (Immediate) (includes
UCSLS 53211 1750
first tissue conditioner, but not a processed reline) Maxillary + L
UCSLS 53212 1750
first tissue conditioner, but not a processed reline) Mandibular + L
UCSLS 53213 2800
first tissue conditioner, but not a processed reline) Maxillary plus Mandibular (combined) + L
UCSLS 53215 first tissue conditioner, but not a processed reline) Unilateral, One Piece Casting, Clasps and 1050
Pontics + L
DAMAN CONFIDENTIAL

UCSLS 53401 DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS Maxillary + L 2100
UCSLS 53402 DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS Mandibular + L 2100
DENTURES, PARTIAL, CAST, PRECISION ATTACHMENTS Maxillary plus Mandibular (combined) +
UCSLS 53403 3850
L
UCSLS 53501 DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS Maxillary + L 2100
UCSLS 53502 DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS Mandibular + L 2100
DENTURES, PARTIAL, CAST, SEMI-PRECISION ATTACHMENTS Maxillary plus Mandibular
UCSLS 53503 3500
(combined) + L
Dentures, Partial, Cast, Overdentures, Supported by Natural Teeth with or without Coping
UCSLS 53711 2100
Crowns, no Attachments Maxillary + L
UCSLS 53712 2100
Crowns, no Attachments Mandibular + L
UCSLS 53713 3500
Crowns, no Attachments Maxillary plus Mandibular (combined) + L
Dentures, Partial, Casts, Overdentures, Supported by Implants with or without Coping Crowns, No
UCSLS 53721 2100
Attachments Maxillary + L
UCSLS 53722 2100
Attachments Mandibular + L
UCSLS 53723 3150
Attachments Maxillary plus Mandibular (combined) + L
Dentures, Partial, Cast, Overdentures (Immediate), Supported by Natural Teeth with or without
UCSLS 53811 Coping Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) 2450
Maxillary + L
Mandibular + L
Maxillary plus Mandibular (combined) + L
Dentures, Partial, Cast, Overdentures (Immediate), Supported by Implants with or without Coping
UCSLS 53821 Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary + 2800
L
UCSLS 53822 Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Mandibular 2800
+L
UCSLS 53823 Crowns, No Attachments (includes first tissue conditioner, but not a processed reline) Maxillary 3850
Dentures, Partial, Cast, Overdentures, with Retention from a Retentive Bar, Secured to Coping
UCSLS 53941 3150
Crowns Supported by Natural Teeth (see 62104 for Retentive Bar) Maxillary + L
UCSLS 53942 3150
Crowns Supported by Natural Teeth (see 62104 for Retentive Bar) Mandibular + L
UCSLS 53943 Crowns Supported by Natural Teeth (see 62104 for Retentive Bar) Maxillary plus Mandibular 4200
(combined) + L
UCSLS 53951 3150
Crowns Supported by Implants (see 62105 for Retentive Bar) Maxillary + L
UCSLS 53952 3150
Crowns Supported by Implants (see 62105 for Retentive Bar) Mandibular + L
UCSLS 53953 Crowns Supported by Implants (see 62105 for Retentive Bar) Maxillary plus Mandibular 4550
(combined) + L
UCSLS 54201 DENTURES, ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE, MINOR One unit of time + L 70
DENTURES, ADJUSTMENTS, PARTIAL OR COMPLETE DENTURE, MINOR Each additional unit over
UCSLS 54209 52.5
two
UCSLS 55101 DENTURE, REPAIRS, COMPLETE DENTURE, NO IMPRESSION REQUIREDMaxillary + L 105
UCSLS 55102 DENTURE, REPAIRS, COMPLETE DENTURE, NO IMPRESSION REQUIRED Mandibular + L 105
UCSLS 55201 DENTURES, REPAIRS, COMPLETE DENTURE, IMPRESSION REQUIRED Maxillary + L 105
UCSLS 55202 DENTURES, REPAIRS, COMPLETE DENTURE, IMPRESSION REQUIRED Mandibular + L 140
DENTURES, REPAIRS, COMPLETE DENTURE, IMPRESSION REQUIRED Maxillary plus Mandibular
UCSLS 55203 245
(combined) + L
UCSLS 55301 DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE, NO IMPRESSION REQUIRED Maxillary + L 105
DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE, NO IMPRESSION REQUIRED Mandibular +
UCSLS 55302 140
L
DAMAN CONFIDENTIAL

UCSLS 55401 DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE, IMPRESSION REQUIRED Maxillary + L 175
UCSLS 55402 DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE, IMPRESSION REQUIRED Mandibular + L 175
DENTURES, REPAIRS/ ADDITIONS, PARTIAL DENTURE, IMPRESSION REQUIRED Maxillary plus
UCSLS 55403 350
DENTURES/IMPLANT RETAINED PROSTHESIS, PROPHYLAXIS AND POLISHING One unit of time +
UCSLS 55501 70
L
DENTURES/IMPLANT RETAINED PROSTHESIS, PROPHYLAXIS AND POLISHING Each additional
UCSLS 55509 52.5
unit of time
Dentures, Replication, Complete Denture, Provisional (No Intra-oral Impression Required)
UCSLS 56111 525
Maxillary + L
UCSLS 56112 525
Mandibular + L
UCSLS 56113 1050
Maxillary plus Mandibular (combined) + L
Dentures, Replication, Partial Denture (Provisional) (No Intra-oral Impression Required) Maxillary
UCSLS 56121 525
+L
Dentures, Replication, Partial Denture (Provisional) (No Intra-oral Impression Required)
UCSLS 56122 525
Mandibular + L
Dentures, Replication, Partial Denture (Provisional) (No Intra-oral Impression Required) Maxillary
UCSLS 56123 1050
UCSLS 56211 Denture, Reline, Direct, Complete Denture Maxillary 140
UCSLS 56212 Denture, Reline, Direct, Complete Denture Mandibular 140
UCSLS 56213 Denture, Reline, Direct, Complete Denture Maxillary plus Mandibular (combined) 280
UCSLS 56221 Denture, Reline, Direct, Partial Denture Maxillary 140
UCSLS 56222 Denture, Reline, Direct, Partial DentureDenture, Reline, Direct, Partial Denture Mandibular 140
UCSLS 56223 Denture, Reline, Direct, Partial Denture Maxillary plus Mandibular (combined) 280
Denture, Reline, Processed, Complete DentureDenture, Reline, Processed, Complete Denture
UCSLS 56231 315
Maxillary + L
UCSLS 56232 Denture, Reline, Processed, Complete Denture Mandibular + L 385
UCSLS 56233 Denture, Reline, Processed, Complete Denture Maxillary plus Mandibular (combined) + L 700
UCSLS 56241 Denture, Reline, Processed, Partial Denture Maxillary + L 315
UCSLS 56242 Denture, Reline, Processed, Partial Denture Mandibular + L 385
UCSLS 56243 Denture, Reline, Processed, Partial Denture Maxillary plus Mandibular (combined) + L 700
UCSLS 56311 Denture, Rebase, Complete Denture Maxillary + L 420
UCSLS 56312 Denture, Rebase, Complete Denture Mandibular + L 420
UCSLS 56313 Denture, Rebase, Complete Denture Maxillary plus Mandibular (combined) + L 840
UCSLS 56321 Denture, Rebase Partial Denture Maxillary + L 350
UCSLS 56322 Denture, Rebase Partial Denture Mandibular + L 350
UCSLS 56323 Denture, Rebase Partial Denture Maxillary plus Mandibular (combined) + L 700
UCSLS 56511 Denture, Therapeutic Tissue Conditioning, per appointment, Complete Denture Maxillary 140
UCSLS 56512 Denture, Therapeutic Tissue Conditioning, per appointment, Complete Denture Mandibular 140
Denture, Therapeutic Tissue Conditioning, per appointment, Complete Denture Maxillary plus
UCSLS 56513 280
Mandibular (combined)
UCSLS 56521 Denture, Therapeutic Tissue Conditioning, per appointment, Partial Denture Maxillary 140
UCSLS 56522 Denture, Therapeutic Tissue Conditioning, per appointment, Partial Denture Mandibular 140
Denture, Therapeutic Tissue Conditioning, per appointment, Partial Denture Maxillary plus
UCSLS 56523 280
Mandibular (combined)
Dentures, Tissue Conditioning, per appointment, Complete Overdenture, Supported by Natural
UCSLS 56531 140
Teeth Maxillary
UCSLS 56532 140
Teeth Mandibular
UCSLS 56533 280
Teeth Maxillary plus Mandibular (combined)
Dentures, Tissue Conditioning, per appointment, Complete Overdenture, Implant Supported
UCSLS 56541 140
Maxillary
UCSLS 56542 140
Mandibular
UCSLS 56543 280
Maxillary plus Mandibular (combined)
Dentures, Tissue Conditioning, per appointment, Partial Overdenture, Supported by Natural Teeth
UCSLS 56551 140
Maxillary
UCSLS 56552 140
Mandibular
DAMAN CONFIDENTIAL

UCSLS 56553 280
Maxillary plus Mandibular (combined)
UCSLS 56561 Dentures, Tissue Conditioning, per appointment, Partial Overdenture, Implant Supported Maxillary 140
UCSLS 56562 v Mandibular 140
Dentures, Tissue Conditioning, per appointment, Partial Overdenture, Implant Supported Maxillary
UCSLS 56563 280
plus Mandibular (combined)
Attaching or re-attaching retention elements to a removable prosthesis, direct One unit of time +
UCSLS 56611 245
E
UCSLS 62101 Pontics, Cast Metal + L 693
UCSLS 62102 Pontics, Cast Metal Framework with Separate Porcelain/Ceramic/Polymer Glass Jacket Pontic + L 980
UCSLS 62103 Pontics, Prefabricated Attachable Facing + L 700
Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader Bar) Attached to Retainer + L
UCSLS 62104 1750
+E
Pontics, Retentive Bar, Pre-fabricated or Custom (Dolder or Hader) Bar, Attached to Implant-
UCSLS 62105 1750
supported Retainer, to Retain Removable Prosthesis, Each Bar +L + E
UCSLS 62107 Semi-precision or Precision Rest (interlock) (in addition to Cast Metal Pontic) + L + E 560
UCSLS 62108 Semi-precision or Precision Attachment, RPD Retainer (in addition to Cast Metal Pontic) + L + E 700
UCSLS 62501 Pontics, Porcelain/Ceramic/Polymer Glass, Fused to Metal + L 924
UCSLS 62502 Pontics, Porcelain/Ceramic/Polymer Glass, Aluminous + L 1540
Semi-Precision Rest (Interlock) (in addition to Pontic, Porcelain/Ceramic/Polymer Glass Fused to
UCSLS 62507 560
Metal) + L + E
Semi-Precision or Precision Attachment, RPD, Retainer (in addition to Procelain/Ceramic/Polymer
UCSLS 62508 700
Glass Fused to Metal Pontic) + L + E
UCSLS 62701 Pontics, Acrylic/Composite/Compomer, Processed to Metal + L 770
UCSLS 62702 Pontics, Acrylic/Composite/Compomer, Indirect (Provisional) + L 192.5
UCSLS 62703 Pontics, Acrylic/Composite/Compomer, Bonded to adjacent Teeth Direct (Provisional) + E 269.5
UCSLS 62704 Pontics, Acrylic/Composite/Compomer +L 693
Semi-Precision or Precision Rest, RPD Retainer (in addition to Acylic/Composite/Compomer
UCSLS 62707 560
Processed to Metal Pontic) + L + E
Semi-Precision or Precision Attachement, RPD Retainer (in addition to
UCSLS 62708 700
Acrylique/Composite/Compomer Processed to Metal Pontic) + L + E
UCSLS 62801 Pontics, Natural Tooth Crown, Direct, Bonded to Adjacent Teeth (Provisional) 315
UCSLS 62802 Pontics, Natural Tooth Crown, Direct, Bonded to Adjacent Teeth, Long-term Provisional 350
RECONTOURING OF RETAINER/PONTICS,
UCSLS 63001 105
(of existing bridgework) One unit of time
RECONTOURING OF RETAINER/PONTICS,
UCSLS 63009 84
(of existing bridgework) Each additional unit of time
Master Cast Techniques, Arbitrary Terminal Hinge Axis Registration and Transfer One unit of time
UCSLS 64111 175
+L
UCSLS 64131 Master Cast Techniques, Centric Registration Recording One unit of time + L 140
Master Cast Techniques, Three Dimensional Recordings of Mandibular Movement (Pantograph or
UCSLS 64141 280
Stereograph) One unit of time + L
UCSLS 64301 MASTER CAST GNATHOLOGICAL WAX-UP + L One unit of time + L 210
UCSLS 64309 MASTER CAST GNATHOLOGICAL WAX-UP + L Each additional unit of time + L 210
UCSLS 66211 Repairs, Removal, Fixed Bridge/Prosthesis - To be re-cemented One unit of time 105
UCSLS 66219 Repairs, Removal, Fixed Bridge/Prosthesis - To be re-cemented Each additional unit over four 84
Repairs, Removal of Fixed Bridge/Prosthesis, Implant-supported-to be re-inserted One unit of
UCSLS 66231 105
time
Repairs, Removal of Fixed Bridge/Prosthesis, Implant-supported-to be re-inserted Each additional
UCSLS 66239 84
unit over four
Repairs, Sectioning of an Abutment or a Pontic plus polishing remaining portion (existing bridge)
UCSLS 66251 105
One unit of time
Repairs, Sectioning of an Abutment or a Pontic plus polishing remaining portion (existing bridge)
UCSLS 66259 84
Each additional unit over four
REPARIS, RE-INSERTION/RECEMENTATION (+L where laboratory charges are incurred during
UCSLS 66301 105
repair of bridge) One unit of time
REPARIS, RE-INSERTION/RECEMENTATION (+L where laboratory charges are incurred during
UCSLS 66309 84
repair of bridge) Each additional unit over four
Repairs, Reinsertion/Recementation Implant-supported Bridge/Prosthesis One unit of time + L
UCSLS 66311 105
and/or + E
DAMAN CONFIDENTIAL

Repairs, Reinsertion/Recementation Implant-supported Bridge/Prosthesis Each additional unit of
UCSLS 66319 84
time over four + L and/or + E
Repairs, Fixed Bridge/Prosthesis, Porcelain/Ceramic/Polymer Glass/Acrylic/Composite/Compomer,
UCSLS 66711 140
Direct First tooth
Repairs, Fixed Bridge/Prosthesis, Porcelain/Ceramic/Polymer Glass/Acrylic/Composite/Compomer,
UCSLS 66719 140
Direct Each additional tooth
UCSLS 66721 Repairs, Solder Indexing to Repair Broken Solder Joint One unit of time + L 245
UCSLS 66729 Repairs, Solder Indexing to Repair Broken Solder Joint Each additional unit of time 119
UCSLS 66741 Repairs, Fixed Bridge/Prosthesis, Implant-supported, Direct One unit of time + E 189
Repairs, Fixed Bridge/Prosthesis, Implant-supported, Direct Each additional unit of time over four
UCSLS 66749 112
+E
UCSLS 67111 Retainers, Acrylic, Composite/Compomer, Indirect + L 693
Retainers, Acrylic, Composite/Compomer, Provisional, Indirect (lab fabricated/relined intra-orally)
UCSLS 67113 346.5
+L
UCSLS 67115 Retainers, Acrylic, Composite/Compomer, Implant-supported Indirect + L 924
Retainers, Acrylic, Composite/Compomer, Direct (provisional during healing, done at chair-side )
UCSLS 67121 192.5
+E
Retainers, Acrylic, Composite/Compomer, (provisional during healing, done at chair-side), Implant-
UCSLS 67125 231
supported, Direct + E
UCSLS 67131 Retainer, Compomer/Composite Resin/Acrylic, Processed to Cast Metal, Indirect + L 847
Retainer, Compomer/Composite Resin/Acrylic, Processed to Metal, Indirect, Implant-supported +
UCSLS 67135 1078
L+E
Semi-precision Rest (Interlock) (in addition to Retainer, Compomer/Composite Resin/Acrylic,
UCSLS 67137 490
Processed to Metal, Indirect) + L + E
Semi-precision or Precision Attachment, RPD Retainer (in addition to retainer) + L + E, Retainers,
UCSLS 67138 Acrylic/Composite/ Compomer With, Or Without Cast Or Prefabricated Metal Bases (Retainers, 560
Acrylic, Composite/Compomer, Cast Metal Base, Indirect)
Retainers, Acrylic/Composite/Compomer, Pre-fabricated Metal Base, Provisional, Implant-
UCSLS 67145 840
supported, Direct + E
Retainers, Acrylic/Composite/Compomer, Pre-fabricated Metal Base, Implant-supported,
UCSLS 67155 1190
Provisional, Indirect + L + E
UCSLS 67161 Retainers, Acrylic/Composite/Compomer, Two surface Inlay, Bonded, Indirect, + L 770
UCSLS 67171 Retainers, Acrylic/Composite/Compomer, Three surface Inlay, Bonded, Indirect, + L 885.5
UCSLS 67181 Retainers, Acrylic/Composite/Compomer, Onlay, Bonded, Indirect, + L 1078
UCSLS 67201 Retainer, Porcelain/Ceramic/Polymer Glass, Full Coverage + L 1400
UCSLS 67205 Retainer, Porcelain/Ceramic/Polymer Glass, Full Coverage, Implant-supported + L + E 1540
UCSLS 67211 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base + L 1386
Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base with a
UCSLS 67213 1078
Porcelain/Ceramic/Polymer Glass Margin + L
UCSLS 67215 Retainers, Porcelain/Ceramic/Polymer Glass, Fused to Metal Base, Implant-supported + L + E 1540
UCSLS 67217 Semi-precision Rest (Interlock) (in addition to Retainer) + L + E 490
Semi-precision or Precision Attachment, RPD Retainer (in addition to retainer) + L + E, Retainer,
UCSLS 67218 Porcelain/Ceramic/Polymer Glass, Full Coverage (Retainers, Porcelain/Ceramic/Polymer Glass, 560
Fused To Metal Base)
Retainer, Porcelain/Ceramic/Polymer Glass, Partial Coverage, Bonded (External Retention- e.g.
UCSLS 67221 462
“Maryland Bridge”) + L
UCSLS 67231 Retainers, Porcelain/Ceramic/Polymer Glass, Two surface Inlay, Bonded +L 1001
UCSLS 67241 Retainers, Porcelain/Ceramic/Polymer Glass, Three surface Inlay, Bonded + L 1078
UCSLS 67251 Retainers, Porcelain/Ceramic/Polymer Glass, Onlay, Bonded +L 1155
UCSLS 67301 Retainers, Full, Cast Metal + L 885.5
UCSLS 67305 Retainers, Full, Cast Metal, Implant-Supported + L + E 1078
UCSLS 67307 Semi-precision Rests (interlock)(in addition to retainer) + L + E 490
UCSLS 67308 Semi-precision or Precision Attachment, RPD Retainer (in addition to retainer) +L + E 665
UCSLS 67311 Retainers, ¾, Cast Metal + L 910
Retainer, Cast Metal, Onlay, with or without Perforations, Bonded to Abutment Tooth, (Pontic
UCSLS 67341 500.5
extra) + L
FIXED PROSTHETICS, ABUTMENTS/RETAINERS, MISCELLANEOUS SERVICES Abutment
UCSLS 67501 315
Preparation Under Existing Partial Denture Clasp, in addition to retainer codes + L
FIXED PROSTHETICS, ABUTMENTS/RETAINERS, MISCELLANEOUS SERVICES Telescoping Crown
UCSLS 67502 805
Unit + L
Fixed Prosthesis, Porcelain, to Replace a Substantial Portion of the Alveolar Process (in addition to
UCSLS 69101 490
retainer and pontics) + L
UCSLS 69201 Splinting, for Extensive or Complicated Restorative Dentistry (per tooth) + L 105
DAMAN CONFIDENTIAL

Fixed Prosthodontic Frameworks, Osseo-Integrated, Attached with Screws and Incorporating
UCSLS 69811 12600
Teeth (denture teeth and acrylic) Maxillary + L
Fixed Prosthodontic Frameworks, Osseo-Integrated, Attached with Screws and Incorporating
UCSLS 69812 12600
Teeth (denture teeth and acrylic) 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 Crowns)Fixed Prosthodontic
UCSLS 69821 17500
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 Crowns) Maxillary + L
Fixed Prosthodontic Framework, Osseo-Integrated, Attached with Screws Or Cement and
UCSLS 69822 Incorporating Teeth (Porcelain/Ceramic/Polymer Glass Bonded to Metal, 17500
Acrylic/Composite/Compomer Processed to Metal or Full Metal Crowns) Mandibular + L
UCSLS 79931 Surgical Installation of Implant with Cover Screw – per Implant + E. 2100
UCSLS 79932 Surgical Installation of Implant with Healing Transmucosal Element - per Implant + E. 2450
UCSLS 79933 Surgical Installation of Implant with Final Transmucosal Element – per Implant + E. 3500
Surgical Re-entry, Removal of Healing Screw and Placement of Healing Transmucosal Element –
UCSLS 79934 700
per Implant + E.
Surgical Re-entry, Removal of Healing Screw and Placement of Final Standard Transmucosal
UCSLS 79935 980
Element – per Implant + E.
Surgical Re-entry, Removal of Healing Screw and Placement of Final Custom Transmucosal
UCSLS 79936 980
Element–per Implant + E. +L.
UCSLS 79941 Surgical Installation of Implant – per Implant + E. 3150
UCSLS 79951 Installation of Provisional Implant – per Implant + E. 1050
UCSLS 79952 Removal of Provisional Implant – per Implant +E 140
UCSLS 79961 Implants, Removal of Implant Per implant, Uncomplicated 280
UCSLS 79962 Implants, Removal of Implant Per implant, Complicated 630
Orthodontic Observation - for Tooth Guidance (i.e. tooth position, eruption sequence, serial
UCSLS 80601 140
extraction supervision, etc.) per appointment
Orthodontic Observation and Adjustment - to Orthodontic Appliances and/or the Reduction of
UCSLS 80602 280
Proximal Surfaces of Teeth per appointment
Repairs to Removable or Fixed Appliances (not including removal and recementation) One unit of
UCSLS 80631 140
time + L
Repairs to Removable or Fixed Appliances (not including removal and recementation) Each
UCSLS 80639 140
additional unit over two + L
UCSLS 80641 Alterations to Removable or Fixed Appliances One unit of time+ L 210
UCSLS 80649 Alterations to Removable or Fixed Appliances Each additional unit over two + L 140
UCSLS 80651 Recementation of Fixed Appliances One unit of time 210
UCSLS 80659 Recementation of Fixed Appliances Each additional unit 140
UCSLS 80661 Separation (except where included in the fabrication of an appliance) One unit of time 210
UCSLS 80669 Separation (except where included in the fabrication of an appliance) Each additional unit 140
Removal of Fixed Orthodontic Appliances (by a practitioner other than the original treating
UCSLS 80671 210
Practice or Practitioner) One unit of time
Removal of Fixed Orthodontic Appliances (by a practitioner other than the original treating
UCSLS 80679 119
Practice or Practitioner) Each additional unit
UCSLS 81111 Appliances, Removable, Space Regaining Appliance, Maxillary, Unilateral + L 1225
UCSLS 81112 Appliances, Removable, Space Regaining Appliance, Mandibular, Unilateral + L 1225
UCSLS 81113 Appliances, Removable, Space Regaining Appliance, Maxillary, Bilateral + L 1365
UCSLS 81114 Appliances, Removable, Space Regaining Appliance, Mandibular, Bilateral + L 1365
UCSLS 81115 Appliances, Removable, Space Regaining Appliance, Maxillary, Complex + L 1050
UCSLS 81116 Appliance, Mandibular, Removable, Space Regaining, Complex 1050
UCSLS 81121 Appliances, Removable, Cross-Bite Correction Appliance, Maxillary, Simple + L 770
UCSLS 81122 Appliances, Removable, Cross-Bite Correction Appliance, Mandibular, Simple + L 770
UCSLS 81123 Appliances, Removable, Cross-Bite Correction Appliance, Maxillary, Complex + L 1050
UCSLS 81124 Appliance, Removable, Cross-Bite Correction, Mandibular, Complex 1050
UCSLS 81131 Appliances, Removable, Dental Arch Expansion Appliance, Maxillary, simple + L 1225
Appliances, Removable, Dental Arch ExpansionAppliances, Removable, Dental Arch Expansion
UCSLS 81132 1225
Appliance, Mandibular, Simple + L
UCSLS 81133 Appliances, Removable, Dental Arch Expansion Appliance, Maxillary, Complex + L 1260
UCSLS 81134 Appliances, Removable, Dental Arch Expansion Appliance, Mandibular, Complexe, + L 1260
UCSLS 81135 Appliances, Removable, Dental Arch Expansion Appliance, Maxillary, Rapid Expansion + L 1645
UCSLS 81141 Appliances, Removable, Closure of Diastemas Appliance, Maxillary, Simple + L 1225
UCSLS 81142 Appliances, Removable, Closure of Diastemas Appliance, Mandibular, Simple + L 1225
UCSLS 81143 Appliances, Removable, Closure of Diastemas Appliance, Maxillary, Complex + L 1050
UCSLS 81144 Appliances, Removable, Closure of Diastemas Appliance, Mandibular, Complex + L 1050
DAMAN CONFIDENTIAL

UCSLS 81151 Appliances, Removable, Alignment of Anterior Teeth Appliance, Maxillary, Simple + L 1225
UCSLS 81152 Appliances, Removable, Alignment of Anterior Teeth Appliance, Mandibular, Simple + L 1225
UCSLS 81153 Appliances, Removable, Alignment of Anterior Teeth Appliance, Maxillary, Complex + L 1050
UCSLS 81154 Appliances, Removable, Alignment of Anterior Teeth Appliance, Mandibular, Complex + L 1050
Appliance, Fixed, Space Regaining (e.g. lingual or labial arch with molar bands, tubes, locks)
UCSLS 81211 1470
Appliance, Maxillary + L
Appliance, Fixed, Space Regaining (e.g. lingual or labial arch with molar bands, tubes, locks)
UCSLS 81212 1470
Appliance, Mandibular + L
UCSLS 81221 Appliance, Fixed, Space Regaining, Unilateral Appliance, Maxillary + L 1470
UCSLS 81222 Appliance, Fixed, Space Regaining, Unilateral Appliance, Mandibular + L 1470
UCSLS 81231 Appliance, Fixed, Cross-Bite Correction - Anterior Appliance, Maxillary + L 1470
UCSLS 81232 Appliance, Fixed, Cross-Bite Correction - Anterior Appliance, Mandibular + L 1470
UCSLS 81241 Appliance, Fixed, Cross-Bite Correction - Posterior Appliance, Maxillary + L 1470
UCSLS 81242 Appliance, Fixed, Cross-Bite Correction - Posterior Appliance, Mandibular + L 1470
Appliance, Fixed, Cross-Bite Correction - Posterior Appliance, Two-Molar Band, Hooked and
UCSLS 81243 1470
Elastics + L
UCSLS 81251 Appliance, Fixed, Dental Arch Expansion Appliance, Maxillary + L 1470
UCSLS 81252 Appliance, Fixed, Dental Arch Expansion Appliance, Mandibular + L 1470
UCSLS 81253 Appliance, Fixed, Dental Arch Expansion Appliance, Maxillary, Rapid Expansion + L 1645
UCSLS 81254 Appliance, Fixed, Dental Arch Expansion Appliance, Headgear + L 1750
UCSLS 81261 Appliance, Maxillary, Simple + L 840
UCSLS 81262 Appliance, Mandibular, Simple + L 1470
UCSLS 81263 Appliance, Maxillary, Complex + L 980
UCSLS 81264 Appliance, Fixed, Closure of Diastemas, Mandibular, Complex 980
UCSLS 81271 Appliance, Fixed, Alignment of Incisor Teeth Appliance, Maxillary, Simple + L 1470
UCSLS 81272 Appliance, Fixed, Alignment of Incisor Teeth Appliance, Mandibular, Simple + L 1470
UCSLS 81273 Appliance, Fixed, Alignment of Incisor Teeth Appliance, Maxillary, Complex + L 1540
UCSLS 81274 Appliance, Fixed, Alignment of Incisor Teeth Appliance, Mandibular, Complex + L 1540
UCSLS 81281 Grassline or Elastic Ligatures per visit + L 210
UCSLS 81291 Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance, Maxillary, Impaction + L 2415
UCSLS 81292 Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance, Mandibular, Impaction + L 2415
UCSLS 81293 Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance, Maxillary, Erupted + L 2415
UCSLS 81294 Appliances, Fixed, Mechanical Eruption of Tooth/Teeth Appliance, Mandibular, Erupted + L 2415
UCSLS 83101 APPLIANCES, REMOVABLE, RETENTIONAppliance, Maxillary + L 840
UCSLS 83102 APPLIANCES, REMOVABLE, RETENTION Appliance, Mandibular + L 840
UCSLS 83103 APPLIANCES, REMOVABLE, RETENTION Appliance, Tooth Positioner + L 1190
UCSLS 83201 APPLIANCES, FIXED/CEMENTED, RETENTION Appliance, Maxillary + L 560
UCSLS 83202 APPLIANCES, FIXED/CEMENTED, RETENTION Appliance, Mandibular + L 560
Case Type, Fixed Appliance (includes:formal full banded treatment and retention), Class I
UCSLS 84101 4200
Malocclusion, Permanent Dentition
Case Type, Fixed Appliance (includes:formal full banded treatment and retention), Class II
UCSLS 84201 4340
Malocclusion , Permanent Dentition
Case Type, Fixed Appliance (includes:formal full banded treatment and retention), Class III
UCSLS 84301 4550
UCSLS 84401 Malocclusion not Requiring Complete Banding + L 3150
UCSLS 85101 3500
Malocclusion, Mixed Dentition
Case Type, Fixed Appliance (includes:formal full banded treatment and retention), Class II
UCSLS 85201 3640
UCSLS 86101 3150
Malocclusion, Primary Dentition
UCSLS 86201 PRIMARY DENTITION Class II Malocclusion + L 3500
UCSLS 86301 3640
Malocclusion, Primary Dentition
Case Type, Removable Appliances (includes: removable appliance therapy and retention), Class I
UCSLS 87101 3850
Malocclusion ,Permanent Dentition
Case Type, Removable Appliances (includes: removable appliance therapy and retention), Class II
UCSLS 87201 4060
Case Type, Removable Appliances (includes: removable appliance therapy and retention), Class
UCSLS 87301 4550
III Malocclusion , Permanent Dentition
UCSLS 88101 3850
Malocclusion , Mixed Dentition
Case Type, Removable Appliances (includes: removable appliance therapy and retention), Class II
UCSLS 88201 4060
Malocclusion , Mixed Dentition
DAMAN CONFIDENTIAL

UCSLS 88301 4340
III Malocclusion , Mixed Dentition
UCSLS 89101 3640
Malocclusion , Primary Dentition
UCSLS 89201 3850
UCSLS 89301 3850
III Malocclusion , Primary Dentition
NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive treatment for first six months of life)
UCSLS 89501 3500
Expansion Appliance for Infants with Cleft Palate + L
UCSLS 89502 3500
Extraoral Retraction Appliance for Infants with Cleft Palate + L
UCSLS 89503 3850
Stage I - Initial Expansion + L
UCSLS 89504 4200
Stage II - Anterior Alignment + L
UCSLS 89505 5250
Stage III - Final Alignment (complete banding) + L
NEONATAL DENTO-FACIAL ORTHOPEDICS (comprehensive treatment for first six months of life)v
UCSLS 89506 5600
Stage III - Where Stage I and II were not provided for + L
UCSLS 93332 Monthly Payment/Instalment for treatment in progress 420
Examination and Diagnosis, Orthodontic, General. To include:
UCSLS 01901 (a) Diagnosis models, complete intraoral radiograph series, or panoramic film, cephalograms, 525
facial and intraoral photographs, consultation and case presentation.
TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to locate and orient osseo-
UCSLS 03001 350
integrated implants) Maxillary Template + L + E
TEMPLATE, SURGICAL (includes diagnostic wax-up. Also used to locate and orient osseo-
UCSLS 03002 350
integrated implants) Mandibular Template + L + E
Equilibration, Casts, Diagnostic (pilot equilibration) for extensive or complicated restorative
UCSLS 04711 210
dentistry + L One unit of time + L
Equilibration, Casts, Diagnostic (pilot equilibration) for extensive or complicated restorative
UCSLS 04719 70
dentistry + L Each additional unit over four + L
Wax-up, Diagnostic (to evaluate cosmetic and/or preparation design and/or occlusal
UCSLS 04721 105
considerations) (gnathological wax-up) + L One unit of time + L
Wax-up, Diagnostic (to evaluate cosmetic and/or preparation design and/or occlusal
UCSLS 04729 84
considerations) (gnathological wax-up) + L Each additional unit over four + L
UCSLS 04911 Cast, Diagnostic, Unmounted + L 70
UCSLS 04912 Cast, Diagnostic, Unmounted, Duplicate + L 35
UCSLS 04921 Casts, Diagnostic, Mounted + L 84
UCSLS 04922 Casts, Diagnostic, Mounted, using face bow transfer + L 140
UCSLS 04923 Casts, Diagnostic, Mounted, using face bow + occlusal records + L 175
UCSLS 04931 Casts, Diagnostic, Orthodontic (unmounted, angle trimmed and soaped) + L 105
UCSLS 04941 Transverse Axis Location and Transfer, used in conjunction with 04922, 04923, and 04924 + L 175
UCSLS 85301 3850
UCSLS 56601 Resilient Liner, in Relined or Rebased Denture (in addition to reline or rebase of denture) + L 175
UCSLS 56621 Attaching or re-attaching elements to a removable prosthesis, indirect + E + L 245
UCSLS 57209 PROSTHESIS, MAXILLOFACIAL, Speech Aid Prosthesis 700
"+ L" Commercial Laboratory Procedures (A commercial laboratory is defined as an independent
UCSLS 99111 business which performs laboratory services and bills the dental practice for these services on a 350
case by case basis).
DAMAN CONFIDENTIAL

Daman Standard Dental Pricelist (USCLS)

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