| Item Number | Description | Schedule Fee |
|---|---|---|
| 52122 | Mandible, hemi‑mandibular reconstruction of, or maxilla reconstruction of, with bone graft, plate, tray or alloplast, other than a service associated with a service to which item 52123 applies (H) (Anaes.) (Assist.) |
$965.10 |
| Total: | $965.10 | |