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Commonwealth of MassachusettsExecutive Office of Health and Human Services Office of MedicaidmasshealthMassHealthTransmittal Letter DEN-93 May 2015TO:Dental Providers Participating in MassHealthFROM:Daniel Tsai, Assistant Secretary and Director of MassHealthRE:Dental Manual (Revised Service Codes)This letter transmits an updated Subchapter 6 of the Dental Manual regarding coverage of dentures for MassHealth members. MassHealth currently covers dentures for members under age 21 when medically necessary, pursuant to federal Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirements. Effective for dates of service beginning May 15, 2015, and notwithstanding the descriptions and limitations in 130 CMR 420.428, MassHealth will also pay for certain prosthodontic services (full and partial dentures, including repairs) for members age 21 and older.The corresponding service codes in Subchapter 6 of the Dental Manual have been updated to reflect this additional coverage. Service codes affected by the addition of these prosthodontic services for members age 21 and older are listed below. The revised Subchapter 6 also includes several technical corrections.Current Dental Terminology (CDT) Codes Affected by UpdateD5110Complete denture - maxillary D5120Complete denture - mandibularD5211Maxillary partial denture – resin base(including any conventional clasps, rests and teeth)D5212Mandibular partial denture – resin base(including any conventional clasps, rests and teeth) D5510Repair broken complete denture baseD5520Replace missing or broken teeth – complete denture (each tooth) D5610Repairs to partial denturesD5620 Repairs to partial dentures D5630 Repairs to partial dentures D5640 Repairs to partial dentures D5650 Repairs to partial dentures D5660 Repairs to partial denturesD5710Rebase complete maxillary denture D5711Rebase complete mandibular dentureD5730Reline complete maxillary denture (chairside) D5731Reline complete mandibular denture (chairside) D5750LaboratoryD5751LaboratoryMassHealthTransmittal Letter DEN 93 May 2015Page 2MassHealth WebsiteThis transmittal letter and attached pages are available on the MassHealth website at masshealth.QuestionsIf you have any questions about the information in this transmittal letter, please contact the MassHealth Customer Services Center at 1-800-841-2900, e-mail your inquiry to providersupport@, or fax your inquiry to 617-988-8974.NEW MATERIAL(The pages listed here contain new or revised language.) Dental ManualPages 6-1 through 6-24OBSOLETE MATERIAL(The pages listed here are no longer in effect.) Dental ManualPages 6-1 through 6-6 — transmitted by Transmittal Letter DEN-92 Pages 6-7 through 6-24 — transmitted by Transmittal Letter DEN-90Commonwealth of Massachusetts MassHealthProvider Manual SeriesSubchapter Number and Title6. Service CodesPage6-1Dental ManualTransmittal LetterDEN-93Date05/15/15601IntroductionDental providers who bill using Current Dental Terminology (CDT) codes must refer to the current version of the American Dental Association’s (ADA) code book for the service descriptions for codes listed in Subchapter 6 of the Dental Manual. Dentists who are specialists in oral surgery in accordance with 130 CMR 420.405(A)(7) must refer to the current version of the American Medical Association’s (AMA) Current Procedural Terminology (CPT) code book for the service descriptions for codes listed in Subchapter 6 of the Dental Manual.MassHealth pays for dental services as described in MassHealth regulations at 130 CMR 420.000 and 450.000. A dental provider may request prior authorization for any medically necessary service payable in accordance with the Early and Periodic Screening, Diagnosis and Treatment(EPSDT) provisions set forth in 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member under the age of 21. This applies even if the service is not listed in Subchapter 6 of the Dental Manual. For each dental service code, the description indicates any limitations, such as age and frequency, and if prior authorization is required for the member.Dentists Who Are Specialists in Oral SurgeryA dentist who is a specialist in oral surgery in accordance with 130 CMR 420.405(A)(7) must submit all requests for prior authorization and claims containing Current Procedural Terminology (CPT) codes directly to MassHealth rather than to any third-party administrator or other MassHealth vendor, as described in 130 CMR 420.000.When billing for multiple surgeries performed during the same operative session or on the same day, dental providers who are specialists in oral surgery in accordance with 130 CMR 420.405(A)(7), are reminded that Modifier 51 must be added to the second, third, and subsequent lines as appropriate. The primary procedure must be on line 1.ModifiersThe following modifiers are for Provider Preventable Conditions (PPCs) that are National Coverage Determinations.PASurgical or other invasive procedure on wrong body part PBSurgical or other invasive procedure on wrong patient PCWrong surgery or other invasive procedure on patientFor more information on the use of these modifiers, see Appendix V of your provider manual. Public Health Dental HygienistsPublic health dental hygienists may claim payment for Service Codes D0220, D0272, D0273, D0274, D1110, D1120, D1206, D1208, D1351, D4341, D4342, D9110, and D9410.602Explanation of Abbreviations and Service Code RequirementsThe following abbreviations are used in Subchapter 6 with certain services that may require special reporting, as described below.Prior Authorization.“PA” indicates that service-specific prior authorization is required (see 130 CMR 420.410). The provider must include in any request for prior authorization sufficiently detailed, clear information documenting the medical necessity of the service requested and, where specified, the information described in this Subchapter 6.The MassHealth agency may require any additional information it deems necessary. If prior authorization is not required, the provider must maintain in the member’s dental record, all information necessary to disclose the medical necessity for the services provided. Pursuant to 130 CMR 420.410(B)(3), prior authorization may be requested for any exception to a limitation on a service otherwise covered for that member. (For example, MassHealth limits prophylaxis to two per member per calendar year, but pays for additional prophylaxis for a member within a calendar year if medically necessary.)Individual Consideration. “IC” indicates that the claim will receive individual consideration to determine payment. A descriptive report must accompany the claim (see 130 CMR 420.412) and be sufficiently detailed to enable the MassHealth agency to assess the extent and nature of the services provided. The reports must include the following where applicable:amount of time required to perform the service;degree of skill required to perform the service;severity and complexity of the member’s disease, disorder, or disability; andany extenuating circumstances or complications.603Service Codes: Diagnostic ServicesSee 130 CMR 420.422 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD0120Twice per calendar yearYesYesYesD0140Twice per calendar yearYesYesYesD0145Twice per calendar yearYes (IC)NoNoSee 602(B) above.D0150Once per member per dentistYesYesYesD0160YesYesYes604Service Codes: RadiographsSee 130 CMR 420.423 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD0210(FMx) (including bitewings)(once every three calendar years)YesYesYesD0220YesYesYesD0230YesYesYesD0270YesYesYesD0272Twice per calendar yearYesYesYesD0273Twice per calendar yearYes (IC)Yes (IC)Yes (IC)See 602(B) above.D0274Twice per calendar yearYesYesYesD0330YesYesYesD0340YesYesYes605Service Codes: Preventive ServicesSee 130 CMR 420.424 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD1110Twice per calendar year – permanent dentitionYes (Use this code for ages 14-21.)YesYesD1120Twice per calendar year – primary or mixed dentitionYes (Use this code forages up to14.)NoNo605Service Codes: Preventive Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD1206YesNoNoD1208YesNo*No** Exception for members who have a medical or dental condition that significantly interrupts the flow of saliva?(PA). See 602(A)above and 130 CMR 420.424(B)(1)(b).Other Preventive ServicesD1351Permanent first, second, and third noncarious, nonrestoredmolarsYesNoNoSpace Maintenance (Passive Appliances)D1510YesNoNoD1515YesNoNoD1520YesNoNoD1525YesNoNoD1550YesNoNo606Service Codes: Restorative ServicesSee 130 CMR 420.425 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsAmalgam Restorations (Including Polishing)D2140YesYesYesD2150YesYesYesD2160YesYesYesD2161YesYesYesResin-Based Composite RestorationsD2330YesYesYesD2331YesYesYesD2332YesYesYesD2335YesYesYes606Service Codes: Restorative Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD2390YesNoNoD2391YesYesYesD2392YesYesYesD2393YesYesYesD2394YesYesYesCrowns – Single Restoration OnlyD2710IndirectYesNoNoD2740YesNoNoD2750YesNoNoD2751YesYes (PA)NoInclude periapical film of the tooth. See 602(A) above and130 CMR 420.425(C)(2).D2752YesNoNoD2790YesNoNoOther Restorative ServicesD2910YesYesNoD2920YesYesNoD2930YesNoNoD2931YesNo*No* Exception for members with undue medical risk. See130 CMR 420.425(C)(2).D2932Primary anterior teeth onlyYesNoNoD2934YesNoNoD2951YesYesNoD2954YesYes (PA)NoInclude periapical film of the tooth. See602(A) above and130 CMR 420.425(C)(1)(c)D2980ChairsideYesYesNoD2999Outside laboratoryYes (PA) (IC)Yes (PA)(IC)NoInclude documentation to substantiate why the repair could not be done chairside. See 602(A) and(B) above and130 CMR 420.425(E).607Service Codes: Endodontic ServicesSee 130 CMR 420.426 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsPulpotomyD3220YesNoNoRoot Canal Therapy (Including Pre- and Post-Treatment Radiographs and Follow-up Care)D3310Excluding final restorationYesYesNoD3320Excluding final restorationYesNo*No* Exception for members with undue medical risk. See130 CMR 420.426(B)(3).PA required.D3330Excluding final restorationYesNo*No* Exception for members with undue medical risk. See130 CMR 420.426(B)(3).PA required.D3346YesYesNoD3347YesNo*No* Exception for members with undue medical risk or with one or more medical conditions listed in130 CMR 420.425(C)(2).See130 CMR 420.426(C)(2).PA required.Endodontic RetreatmentD3348YesNo*No* Exception for members with undue medical risk or with one or more medical conditions listed in130 CMR 420.425(C)(2).See130 CMR 420.426(C)(2).PA required.607 Service Codes: Endodontic Services (cont.)Service Code and LimitationsCoveredCoveredCoveredPrior-AuthorizationUnderDDSAged 21Requirements, ReportAge 21?Clientsand Older?Requirements, andAged 21NotationsandOlder?Apicoectomy/Periradicular ServicesD3410(per tooth) (includesYesYesNoInclude periapical filmretrograde filling)(PA)of the tooth and date ofthe original root canaltreatment. See 602(A)above and130 CMR 420.426(D).D3421First rootYesYesNoInclude periapical film(PA)of the tooth and date ofthe original root canaltreatment. See 602(A)above and130 CMR 420.426(D).D3425First rootYesYesNoInclude periapical film(PA)of the tooth and date ofthe original root canaltreatment. See 602(A)above and130 CMR 420.426(D).D3426Each additional rootYesYesNoInclude periapical film(PA)of the tooth and date ofthe original root canaltreatment. See 602(A)above and130 CMR 420.426(D).608 Service Codes: Periodontic ServicesSee 130 CMR 420.427 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsSurgical Services (Including Usual Postoperative Services)D4210Once per quadrant per three-YesYesNoInclude completeyear period(PA)periodontal charting,periapical films,documentation ofprevious periodontaltreatment, and astatement concerningthe member’speriodontal condition.See 602(A) above and130 CMR 420.427(A).D4211Once per quadrant per three-YesYesNoInclude completeyear period(PA)periodontal charting,periapical films,documentation ofprevious periodontaltreatment, and astatement concerningthe member’speriodontal condition.See 602(A) above and130 CMR 420.427(A).608 Service Codes: Periodontic Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD4341Once per quadrant per three-YesYesNoInclude completeyear period(PA)periodontal charting,periapical films,documentation ofprevious periodontaltreatment, and astatement concerningthe member’speriodontal condition.See 602(A) above and130 CMR 420.427(B).D4342YesYesNoInclude complete(PA)periodontal charting,periapical films,documentation ofprevious periodontaltreatment, and astatement concerningthe member’speriodontal condition.See 602(A) above and130 CMR 420.427(B).609 Service Codes: Prosthodontic (Removable) ServicesSee 130 CMR 420.428 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsComplete Dentures (Including Routine Post-Delivery Care)D5110YesYesYesD5120YesYesYesD5130YesNoNoD5140YesNoNoCommonwealth of Massachusetts MassHealthProvider Manual SeriesSubchapter Number and Title6. Service CodesPage6-10Dental ManualTransmittal LetterDEN-93Date05/15/15Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsPartial Dentures (Including Routine Post-Delivery Care)D5211YesYesYesD5212YesYesYesD5213YesNoNoD5214YesNoNoD5225YesNoNoD5226YesNoNoRepairs to Complete DenturesD5510YesYesYesD5520YesYesYesRepairs to Partial DenturesD5610YesYesYesD5620YesYesYesD5630YesYesYesD5640YesYesYesD5650YesYesYesD5660YesYesYesDenture Rebase ProceduresD5710YesYesYesD5711YesYesYesD5720YesNoNoD5721YesNoNoCommonwealth of Massachusetts MassHealthProvider Manual SeriesSubchapter Number and Title6. Service CodesPage6-11Dental ManualTransmittal LetterDEN-93Date05/15/15Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsDenture Reline ProceduresD5730YesYesYesD5731YesYesYesD5740YesNoNoD5741YesNoNoD5750YesYesYesD5751YesYesYesD5760YesNoNoD5761YesNoNo610 Service Codes: Prosthodontic (Fixed) ServicesSee 130 CMR 420.429 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsFixed Partial Denture PonticsD6241YesNoNoD6751YesNoNoOther Fixed Partial Denture ServicesD6930YesNoNoD6980YesNoNoSee 602 (D) above.611 Service Codes: Exodontic ServicesSee 130 CMR 420.430 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD6999Yes (PA) (IC)Yes (PA)NoInclude documentation to substantiate why the repair could not be done chairside. See 602(A), (B), and (D)above and130 CMR 420.429(B).Extractions (Includes Local Anesthesia and Routine Postoperative Care)D7111YesYesYesD7140YesYesYesD7210YesYesYesD7220YesYesYesD7230YesYesYesD7240Yes (PA)Yes (PA)Yes (PA)Include Panorex film. See 602(A) above and130 CMR 420.430(D).D7250YesYesYesD7270YesYesYesD7280Including orthodonticattachmentsYesNoNoD7283YesNoNo611 Service Codes: Exodontic Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsSurgical ProceduresD7310YesYesNoD7311YesYesNoD7320YesYesNoD7321YesYesNoD7340Yes (PA)Yes (PA)NoInclude justification of the surgical procedure designed to increase alveolar ridge height. See 602(A) aboveand 130 CMR 420.430(F).D7350?Yes (PA)Yes (PA)No? Payable only to a dental provider with a specialty in oral surgery. In accordance with130 CMR 420.405(A)(7).See 602(A) above and 130 CMR 420.430(F).D7410YesYesNoD7411YesYesNoD7450YesYesNoD7451YesYesNoD7460YesYesNoD7461YesYesNoD7471?Yes (PA)Yes (PA)No? Payable only to a dental provider with a specialty in oral surgery in accordance with130 CMR 420.405(A)(7).See 602(A) above.D7960YesYesNoSee 602(C) above.611 Service Codes: Exodontic Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD7963YesYesNoD7970YesYes (PA)NoInclude a narrative documenting the medical necessity for the procedure and documentation of the planned prosthesis. See 602(A) above and130 CMR 420.430(H).D7999Yes (PA) (IC)Yes (PA)(IC)NoSee 602(A), (B), and(D) above.612 Service Codes: Orthodontic ServicesSee 130 CMR 420.431 for service descriptions and limitations.Service Code and LimitationsCoveredCoveredCoveredPrior-AuthorizationUnderDDSAged 21Requirements,Age 21?ClientsAged 21and Older?Report Requirements,and NotationsandOlder?Orthodontic Diagnosis and Full Orthodontic TreatmentD8050Yes (PA)NoNoInclude the number of(IC)adjustment visitsrequired in conjunctionwith the type ofinterceptive appliance.See 602(A) and (B)above and130 CMR 420.431.612 Service Codes: Orthodontic Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements,Report Requirements, and NotationsD8060Yes (PA) (IC)NoNoInclude the number of adjustment visits required in conjunction with the type of interceptive appliance.See 602(A) and (B) above and130 CMR 420.431.D8080?Yes (PA)NoNoInclude the X-ray, photographic prints, and a completed copy of the Handicapping Labio- Lingual Deviations Form (HLD) (Dental Manual Appendix D). See 602(A) above and130 CMR 420.431.? Payable only to a dental provider who is a specialist in orthodontics in accordance with130 CMR 420.405(A)(6).Other Orthodontic ServicesD8660?Consultation - once per six monthsYesNoNo? Payable only to a dental provider who is a specialist in orthodontics in accordance with130 CMR 420.405(A)(6).612 Service Codes: Orthodontic Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements, and NotationsD8670?As part of contract; billedYesNo*No*Submit separate priorquarterly(PA)authorization request foryear 1, year 2, and year 3(up to 6 months), ifnecessary. For years 2 and 3only, include originalphotographic prints,intraoral photographicprints, documentation thatall restorative services werecompleted, and a copy ofthe initially submittedorthodontics prior-authorization form withPart IV completed withprogress to date. See602(A) above.* Exception for memberswhose comprehensiveorthodontic treatmentbegan by age 21. See130 CMR 420.431(A)(1).? Payable only to a dentalprovider who is a specialistin orthodontics inaccordance with130 CMR 420.405(A)(6).612 Service Codes: Orthodontic Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements,Report Requirements, and NotationsD8680?YesNo*No** Exception for members whose comprehensive orthodontic treatment began by age 21. PA required.See130 CMR 420.431(A)(1).? Payable only to a dental provider who is a specialist in orthodontics in accordance with130 CMR 420.405(A)(6)Include the date of the initial banding and a narrative of the reason(s) for removal of the orthodontic appliance. See 602(A) above.D8690?Yes (PA)NoNo? Payable only to a dental provider who is a specialist in orthodontics in accordance with130 CMR 420.405(A)(6)See 602(A) above.612 Service: Orthodontic Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements,Report Requirements, and NotationsD8692?Yes (PA)No*No*Include a statement regarding the date of the onset of retention. See 602(A) above.* Exception for members whose comprehensive orthodontic treatment began by age 21. PA required. See130 CMR 420.431(A)(1).? Payable only to a dental provider who is a specialist in orthodontics in accordance with130 CMR 420.405(A)(6).D8999?Yes (PA) (IC)No*No** Exception for members whose comprehensive orthodontic treatment began by age 21. PA required. See130 CMR 420.431(A)(1).? Payable only to a dental provider who is a specialist in orthodontics in accordance with130 CMR 420.405(A)(6) See 602(A), (B), and (D)above.613 Service Codes: General Anesthesia and IV Sedation ServicesSee 130 CMR 420.452 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements,and NotationsD9220YesYesYesD9221YesYesYesD9230YesYesYesD9241YesYesYesD9242YesYesYesD9248YesYesYes614 Service Codes: Other ServicesSee 130 CMR 420.456 for service descriptions and limitations.Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements,and NotationsUnclassified TreatmentD9110Other nonemergency medically necessary treatment may be provided during the same visit – that is, nonemergency codes may be billed in conjunction withD9110.YesYesYes614 Service Codes: Other Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements,Report Requirements, and NotationsProfessional VisitsD9410YesYesYesA visit to a nursing facility, chronic disease and rehabilitation hospital, hospice facility, school, or other licensed educational facility, once per facility per day. Bill in addition to any medically necessary MassHealth-covered service provided during the same visit. Code may be billed once per facility per day. See130 CMR 420.456(G).Treatment of Physically or Developmentally Disabled MembersD9920Once per member per dayYes (PA)Yes (PA)Yes (PA)Include a description of the member’s illness or disability, and types of services to be furnished. See 602(A) and (D) above and130 CMR 420.456(C).614 Service Codes: Other Services (cont.)Service Code and LimitationsCovered Under Age 21?Covered DDSClients Aged 21 andOlder?Covered Aged 21 and Older?Prior-Authorization Requirements, Report Requirements,and NotationsMiscellaneous ServicesD9930Yes (IC)Yes (IC)Yes (IC)Include with the claim the date, the location of the original surgery, and the type of procedure. See602(A) above.D9940Yes (PA)NoNoInclude documented evidence of the need for the appliance.See 602(A) and (D)above.D9941YesNoNoD9999Yes (PA)(IC)Yes (PA)(IC)NoSee 602(A), (B), and(D) above.615 Service Codes: Oral and Maxillofacial Surgery ServicesSee 130 CMR 420.453 and 420.455 for service descriptions and limitations.The following all-numeric service codes may be used only by dental providers who are specialists in oral surgery, in accordance with 130 CMR 420.405(A)(7).CPT Service Codes1006011045114461201513131100611104611640120161313210120111001164112017131331012111101116421201813150101401131011643120201315110160113111164412021131521018011312116461205113153110101131311960120521316011011114401197012053140001101211441119711205414001110421144212011120551402011043114431201312056140211104411444120141205714301615 Service Codes: Oral and Maxillofacial Surgery Services (cont.)14302170002102521155 (PA)2133614040170032102621159 (PA)2133714041170042102921160 (PA)2133814060171062103021172 (PA)2133914061172802103121175 (PA)21340151201728121032211812134315121172822103421182213441524017283210402118321345152411728421044211842134615260172862104521188 (PA)213471526117999 (IC)2104621193 (PA)2134815271200052104721194 (PA)2135515272202002104821195 (PA)2135615273202052104921196 (PA)2136015274202062105021198 (PA)2136515275202202106021206 (PA)2136615276202402107021208 (PA)2138515277202252107621209 (PA)2138615278202452107721210 (PA)2138715570205202107921215 (PA)2139015572205252108021230 (PA)2139515574205262108121235 (PA)2140015576206052108221240 (PA)2140115620206152108321242 (PA)2140615630206702108421243 (PA)2140715732206802108521244 (PA)2140815734206902108621247 (PA)2142115740206922108721255 (PA)21422157502069321088 (IC)2126021423157562069421089 (IC)21261214311575720900211002126321432157582090221110212672143315760209102111621268214351577020912211202127021436158192092021137 (PA)212752144015820 (PA)2092221138 (PA)212802144515821 (PA)2092421139 (PA)212822145015822 (PA)2092621141212952145115823 (PA)2095521142212962145215840209562114321299 (PA), (IC)214531584120962211452131021454158422096921146 (PA)2131521461158452097021147 (PA)21320214621585220999 (IC)21150 (PA)2132521465158602101021151 (PA)2133021470160002101521154 (PA)2133521480615 Service Codes: Oral and Maxillofacial Surgery Services (cont.)214853152540805412514231021490315754080641252423202149531600408084150042330214973160340810415104233521499 (IC)3160540812415204234029800 (PA)316104081441599 (IC)4240029804 (PA)3161540816418004240529999 (IC)31622408184180542408300003550040819418064240930020355724082041820 (IC), (PA)4241030124356814083041821 (IC)424153012535682408314182242420301303570140840 (PA)4182342425301403580040842 (PA)4182542440301503587540843 (PA)4182642450301603587640844 (PA)4182742500305203760940845 (PA)4182842505305803854240899 (IC)418304250730600385504100041850 (IC)42508309013855541005418744250930903387004100641899 (IC)425103090538720410074200042550309063872441008421004260030999 (IC)38790410094210442650310003879241010421064266031020385004101542107426653103038505410164212042699 (IC)310323851041017421404270031200404904101842145427203120140500411004216042725312054051041105421804280031225405204110842182428023123140525411104220042804312334052741112422054280631256405304111342210428083126740650411144221542809312904065241115422204281031292406544111642225428153129340700411204222642820312944070141130422274289431299 (IC)40702411354223542842314204072041140422604284431500407614114542280 (PA)428453150240799 (IC)4115042281 (PA)4286031505408004115342299 (IC)4287031510408014115542300429003151540804412504230542950615 Service Codes: Oral and Maxillofacial Surgery Services (cont.)4295362143648687022099215429606214564872702409922142961621466487470328992224296264400648857033099223429706460064999 (IC)70360992314297164612688017038099232429726461368810992019923342999 (IC)647226881199202992816158064727699909920399282615816473270100992049928361582647347011099205992846158464736701409921199285615866473870150992126160064740701609921362142648647021099214 ................
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