| Item Number | Description | Schedule Fee |
|---|---|---|
| 75621 | The fabrication and fitting of surgical splint or guide in conjunction with orthognathic surgical procedures and implant treatment, if provided in association with a service to which: (a) any item in the following series applies: (i) any of items 46150 to 46161 apply; or (ii) any of items 52342 to 52375 apply; or (b) item 52380 or 52382 applies; (c) item 75610 applies |
$270.15 |
| Total: | $270.15 | |