CDT DENTAL CODES



TABLE OF CONTENTSIntroductionPageiiDefinitionsPage iiElements of CDT CodingPage iiiCDT DENTAL CODESI.DiagnosticPage 1II.PreventivePage 8III.RestorativePage 12IV.EndodonticsPage 18V.PeriodonticsPage 21VI.Prosthodontics, RemovablePage 25VII. Maxillofacial ProstheticsPage 30VIIIImplant Services……………………………………………………………………………………………………… Page 32IX.Prosthodontics, FixedPage 36X.Oral and Maxillofacial SurgeryPage 39XI.OrthodonticsPage 50XII.Adjunctive General ServicesPage 52INTRODUCTION-482718124754Eff. 7/1/1400Eff. 7/1/14Approximately once a year, the American Dental Association issues new Current Dental Terminology (CDT) dental procedure codes which includes additions to and deletions from this schedule of codes. Providers will be notified of all such additions and deletions through the list serve, by a revised Allowances for Dental Services or by revised billing instructions.Providers are requested to bill their usual and customary charge for all dental services. In accordance with policy, the MaineCare Program will continue to pay the lowest of the following:1.The fee established by MaineCare and noted in the “Maximum Allowance” column of the fee schedule;2.The lowest amount allowed by Medicare; or3.The provider's usual and customary charge.DEFINITIONSThe following are definitions for several terms that are frequently used throughout this publication.By Report:This notation in the Maximum Allowances column indicates that the fee for the procedure is to be determined based upon an operative report. Such a procedure would be one that is rarely provided, unusual, variable, or newly developed. Pertinent information contained in the report, which must accompany the claim, should include an adequate definition or description of the nature, extent, need for the procedure, time, effort, and equipment necessary to provide the service. Additional information, such as complexity of the symptoms, final diagnosis, pertinent physical findings, diagnostic and therapeutic procedures, concurrent problems, and follow-up care may also be included. If there is a maximum amount listed, then reimbursement is not to exceed the maximum amount listed.Consultation:Consultation is an opinion rendered by a dentist whose advice is requested by another dentist or physician for the further DEFINITIONS (cont.)evaluation and/or management of the patient. When the consulting dentists assumes responsibility for the continuing care of the patient, any subsequent service rendered by him/her will cease to be a consultation. The Department requires a written report to be sent to the requesting practitioner.Referral:A referral is the transfer of the total or specific care of a patient from one dentist to another and does not constitute a consultation.ELEMENTS OF HCPCS/CDT CODINGCodes for services are arranged in tabular form. Specific information regarding each code is given under the following headings:1.Procedure code:The actual CDT procedure code will be listed in this column.2.CDT Description:The narrative description of the procedure code will be listed in this column.-6417936985Eff. 7/1/1400Eff. 7/1/143.Covered Service:This column identifies whether a particular service is covered under the MaineCare program, indicated by a "YES," or not covered, indicated by a "NO." It is further divided into two (2) sub columns indicating services for those under 21 and all ICF-IID residents (with the exception of orthodontics which is not covered for residents of an ICF-IID) and the second column, indicating coverage for adults 21 and over when allowed under Section 25, Dental Services, of the MaineCare Benefits Manual (MBM), Chapter II, 25.04, Special Requirements for Adult Services.4.Prior AuthorizationSome procedures require authorization prior to the performance of a service in order for MaineCare toRequired:allow reimbursement. If prior authorization is required, it will be indicated by the message "YES" in these columns. MaineCare will not reimburse a provider for a service that requires prior authorization if the service is providedELEMENTS OF HCPCS/CDT CODING (cont.)before authorization is granted. Again this column is subdivided into requirements for the same two populations as column 3.-546144238125Eff. 7/1/1400Eff. 7/1/145.Additional Limits:This column lists any additional limitations affecting reimbursement for services. Examples include medically necessary criteria, prior authorization criteria, reimbursement frequency or the passage of time required before further reimbursement. This column is intended to parallel restrictions also described in Section 25, Dental Services, of the MBM, Chapter II. Codes also reimbursable to denturists and hygienists will be indicated in this column. If reimbursement is not available for a particular procedure "Not covered" will be listed in this column. MaineCare will not reimburse for non-covered services. Providers may bill members for non-covered services only if, prior to the provision of the service, the provider has clearly explained to the member that MaineCare does not cover the service and that the member will be responsible for the payment. Providers must document in the member’s record that the member was told, prior to provision, that the service was not a MaineCare covered service and that the member is responsible for the payment.6.Maximum Allowance:This column will show the maximum reimbursement that MaineCare will allow for a particular procedure. MaineCare will pay the lowest of this allowance, or the dentist's/denturist’s usual and customary fee, or the lowest amount allowed by Medicare.Some procedures are manually priced, or priced using a specific report for the service rendered. If a service is priced this way, the message "BY REPORT" will appear in the Maximum Allowance column. All BY REPORT codes suspend for a review, which interrupts the automatic claims processing and slows payment to the provider. A complete report must accompany any claim using a BY REPORT code. Please note that occasionally a description will include the term “by report.” Such a designation is part of the code description and does not indicate how MaineCare will reimburse the procedure.Every effort should be made to utilize the correct code. Billing should be done in accordance with the CDT guidelines and Chapter II and Chapter III, Section 25.Covered ServiceAge/ICF-IIDPrior AuthorizationrequiredProc.-418922173355Eff. 7/1/1400Eff. 7/1/14CodeDescriptionunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Additional LimitsMaxAllow I. DIAGNOSTIC CLINICAL ORAL EXAMINATIONS -41910092872Eff. 7/1/1400Eff. 7/1/14D0120Periodic Oral EvaluationYESNONO Twice per calendar year, but no more than once every 150 days.$30.00D0140Limited Oral Evaluation(Problem Focused) YESYESNONOOnce per episode per provider. Denturists may also use this code.$20.00-36957045262Eff. 7/1/1400Eff. 7/1/14D0145Oral Evaluation for a Patient Under Three Years of Ageand Counseling with Primary CaregiverYESNONO For members under age 3, twice per calendar year. Code may not be used for members age 3 and over.$20.00D0150Comprehensive Oral EvaluationYESNONO$55.00-365125-2998Eff. 7/1/1400Eff. 7/1/14D0160Detailed and Extensive Oral Evaluation - Problem FocusedYESNONO$25.00D0170Re-evaluation – Limited, Problem Focused, (established patient, not post-operative visit)YESNONO$20.00D0180Comprehensive Periodontal Evaluation – New or Established PatientNONONot Covered-419454128314Eff. 7/1/1400Eff. 7/1/14PRE-DIAGNOSTIC SERVICESD0190Screening of PatientNONONot CoveredD0191Assessment of a PatientNONONot CoveredCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredProc.-408305131017Eff. 7/1/1400Eff. 7/1/14CodeDescriptionunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Additional LimitsMaxAllowIMAGE CAPTURE WITH INTERPRETATIOND0210Intraoral - Complete Series of Radiographic ImagesYESYESNONOMust include 12 periapical plus 2 posterior bitewings, allowed only once every 3 years, except as part of approved orthodontics. IPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$43.50D0220Intraoral - Periapical, First Radiographic ImageYESYESNONOIPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$8.00D0230Intraoral - Periapical, Each Additional Radiographic ImageYESYESNONOIPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$6.50D0240Intraoral - Occlusal Radiographic ImageYESYESNONOIPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$10.00D0250Extraoral - First Radiographic ImageYESYESNONOIPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$9.00D0260Extraoral - Each Additional Radiographic ImageYESYESNONOIPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$9.00-41211556515Eff. 7/1/1400Eff. 7/1/14Covered ServiceAge/ICF-IIDPrior AuthorizationrequiredProc.CodeDescriptionunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Additional LimitsMaxAllowD0270Bitewing-Single Radiographic ImageYESYESNONOPosterior bitewings alone are once per calendar year. IDDHs$8.00D0272Bitewings - Two Radiographic ImagesYESYESNONOPosterior bitewings alone are once per calendar year. IPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$15.00D0273Bitewings - Three Radiographic ImagesYESYESNONOPosterior bitewings alone are once per calendar year. IPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$17.50D0274Bitewings - Four Radiographic ImagesYESYESNONOPosterior bitewings alone are once per calendar year. IPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$20.00D0277Vertical Bitewings – 7-8 Radiographic ImagesYESYESNONO. IPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$30.00D0290Posterior-Anterior or Lateral Skull and Facial Bones, Survey Radiographic ImageYESYESNONO$25.00D0310SialographyYESYESNONOFor gland or duct, not allowed for salivary stone$30.00Covered ServiceAge/ICF-IIDPrior AuthorizationrequiredProc.-373380137795Eff. 7/1/1400Eff. 7/1/14CodeDescriptionunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Additional LimitsMaxAllowD0320Temporomandibular Joint Arthrogram, Including InjectionYESYESNONORight and left trans-cranial films in open, closed, and rest required$35.00-48289631750Eff. 7/1/1400Eff. 7/1/14D0321Other Temporomandibular Joint Radiographic Images YESYESYESYES$43.00D0322Tomographic SurveyNONONot Covered-41945457032Eff. 7/1/1400Eff. 7/1/14D0330Panoramic Radiographic ImageYESYESNONOReimbursable: (1) for interceptive orthodontics; (2) for oral surgery. (3) once per five (5) years for either Preventive Services or Diagnostic Services . IPDHs may use this code subject to the guidelines and limitations in MBM Chap II.$43.00D0340Cephalometric Radiographic ImageNONOIncluded as part of “records” in comprehensive orthodontics, not covered separatelyD0350Oral/Facial Photographic Images Obtained Intraorally or ExtraorallyNONONot CoveredD0364Cone Beam - CT capture and interpretation with limited field of view – less than one whole jawNONONot CoveredD0365Cone Beam - CT capture and interpretation with field of view of one full dental arch – MandibleNONONot CoveredCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredProc.-408822227063Eff. 7/1/1400Eff. 7/1/14CodeDescriptionunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Additional LimitsMaxAllowD0366Cone Beam - CT capture and interpretation with field of view of one full dental arch – maxilla, with or without craniumNONONot CoveredD0367Cone Beam - CT capture and interpretation with field of view of both jaws; with or without craniumNONONot CoveredD0368Cone Beam - CT capture and interpretation for TMJ series including two or more exposuresNONONot CoveredD0369Maxillofacial MRI capture and interpretationNONONot CoveredD0370Maxillofacial ultrasound capture and interpretationNONONot CoveredD0371Sialoendoscopy capture and interpretationNONONot Covered IMAGE CAPTURE ONLY INTERPRETATION AND REPORT PERFORMED BY A PRACTIONER NOT ASSOCIATED WITH THE CAPTURED0380Cone Beam - CT image capture with limited field of view – less than one whole jawNONONot CoveredD0381Cone Beam - CT image capture with field of view of one full dental arch – mandibleNONONot CoveredD0382Cone Beam - CT image capture with field of view of one full dental arch – maxilla, with or without craniumNONONot CoveredD0383Cone Beam - CT image capture with field of view of both jaws, with or without craniumNONONot CoveredCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredProc.-440720216432Eff. 7/1/1400Eff. 7/1/14CodeDescriptionunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Additional LimitsMaxAllowD0384Cone Beam - CT image capture for TMJ series including two or more exposuresNONONot CoveredD0385Maxillofacial MRI image captureNONONot CoveredD0386Maxillofacial ultrasound image captureNONONot Covered IMAGE CAPTURE PERFORMED BY A PRACTITIONER NOT ASSOCIATED WITH INTERPRETATION AND REPORTD0391Interpretation of diagnostic image by a practitioner not associated with capture of the image, including reportNONONot CoveredTEST AND EXAMINATIONSD0415Collection of Microorganisms for Culture and SensitivityNONONot CoveredD0416Viral CultureNONONot CoveredD0417Collection and preparation of saliva sampleNONONot CoveredD0418Analysis of saliva sampleNONONot CoveredD0421Genetic Test for Susceptibility to Oral DiseasesNONONot CoveredD0425Caries Susceptibility TestNONONot CoveredD0431Adjunctive Pre-diagnostic Test that Aids in Detection of Mucosal Abnormalities including Premalignant and Malignant Lesions, not to include Cytology or Biopsy ProceduresNONONot CoveredD0460Pulp Vitality TestYESYESNONORequires documentation in member's chart of the vitality of the tooth$10.00Covered ServiceAge/ICF-IIDPrior AuthorizationrequiredProc.-33528048895Eff. 7/1/1400Eff. 7/1/14CodeDescriptionunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Additional LimitsMaxAllowCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredD0470Diagnostic CastsYESNONO$32.00ORAL PATHOLOGY LABORATORY CODES D0472Accession of Tissue, Gross Examination, Preparation and Transmission of Written ReportNONONot CoveredD0473Accession of Tissue, Gross and Microscopic Examination, Preparation and Transmission of Written ReportNONONot CoveredD0474Accession of Tissue, Gross and Microscopic Examination, Including Assessment of Surgical Margins for Presence of Disease, Preparation and Transmission of Written ReportNONONot CoveredD0475Decalcification ProcedureNONONot CoveredD0476Special Stains for MicroorganismsNONONot CoveredD0477Special Stains, not for MicroorganismsNONONot CoveredD0478Immunohistochemical StainsNONONot CoveredD0479Tissue in-situ Hybridization, including InterpretationNONONot CoveredD0480Accession of Exfoliative Cytologic Smears, Microscopic Examination, Preparation and Transmission of Written ReportNONONot CoveredD0481Electron Microscopy-DiagnosticNONONot CoveredD0482Direct ImmunofluorescenceNONONot CoveredD0483Indirect ImmunofluorescenceNONONot CoveredD0484Consultation on Slides Prepared ElsewhereNONONot CoveredProc.-440055247650Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04-440690287212Eff. 7/1/1400Eff. 7/1/14D0485Consultation, Including Preparation of Slides from Biopsy Material Supplied by Referring SourceNONONot CoveredD0486Accession of Transepithelial Cytologic Sample, Microscopic ExaminationNONONot CoveredD0502Other Oral Pathology Procedures, by ReportNONONot CoveredD0999Unspecified Diagnostic Procedure, by ReportNONONot CoveredII. PREVENTIVE DENTAL PROPHYLAXIS -436880142875Eff. 7/1/1400Eff. 7/1/14D1110Prophylaxis – AdultYESYESNOYES Limited to age 13 and over. Twice per calendar year, but no more than once every 150 days. Prior Authorization necessary for greater frequency. Includes oral hygiene instruction. Dental Hygienists practicing under PHS, IPDHs practicing under PHS may use this code for all ages. IPDHs may use this code only for members up to age 21.$40.00Proc.-41945496358Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D1120Prophylaxis – ChildYESNONO Twice per calendar year, but no more than once every 150 days. Prior Authorization necessary for greater frequency. Includes oral hygiene instruction. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code.$30.00TOPICAL FLUORIDE TREATMENTS (Office Procedure)D1206Topical Application of Fluoride Varnish YESNONOMembers under age 3: twice per calendar year, and a third treatment per calendar year is permitted for Members who either have a high caries rate or the Member has had new restorations placed in the previous eighteen (18) months. Members age 3 through age 20, twice per calendar year, but no more than once every 150 days, and a third treatment per calendar year is permitted for $12.00Proc.-398189245212Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Members who either have a high caries rate or the Member has had new restorations placed in the previous eighteen (18) months. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code.D1208Topical Application of FluorideYESNONOMembers under age 3: twice per calendar year, and a third treatment per calendar year is permitted for Members who either have a high caries rate or the Member has had new restorations placed in the previous eighteen (18) months. Members age 3 through age 20, twice per calendar year, but no more than once every 150 days, and a third treatment per calendar year is permitted for Members who either have a high caries rate or the Member has had new restorations placed in the previous eighteen (18) $12.00-461985143909Eff. 7/1/1400Eff. 7/1/14months. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code.Proc.CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04Other Preventive Services D1310Nutritional Counseling for Control of Dental DiseaseNONONot CoveredD1320Tobacco Counseling for the Control and Prevention of Oral DiseaseYESYESNONO$20.00D1330Oral Hygiene Instructions YESNONOThree times per calendar year. Not billable the same day as prophylaxis. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code.$13.00D1351Sealant – Per Tooth YESNONOPermanent teeth: once every three calendar years per provider per tooth. Primary teeth: once per lifetime of tooth unless documented good cause. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code.$16.00Proc.-430087117622Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D1352Preventive Resin Restoration in a Moderate to High Caries Risk Patient-permanent toothNONONot CoveredSPACE MAINTENANCE (PASSIVE APPLIANCES) D1510Space Maintainer, Fixed UnilateralYESNONO$95.00D1515Space Maintainer, Fixed BilateralYESNONO$220.00D1520Space Maintainer, Removable UnilateralNONONot CoveredD1525Space Maintainer, Removable BilateralYESNONO$110.00D1550Re-cementation of Space MaintainerYESNONO$22.50D1555Removal of Fixed Space MaintainerYESNONO$50.00III. RESTORATIVE AMALGAM RESTORATIONS (INCLUDING POLISHING)D2140Amalgam - One Surfaces, Primary or PermanentYESYESNONO$38.00D2150Amalgam - Two Surfaces, Primary or PermanentYESYESNONO$48.00D2160Amalgam - Three Surfaces, Primary or PermanentYESYESNONO$81.00D2161Amalgam - Four or More Surfaces, Primary or PermanentYESYESNONO$97.00Proc.-335280152400Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04RESIN-BASED COMPOSITE RESTORATIONS – DIRECTD2330Resin-Based Composite - One Surface, AnteriorYESYESNONO$68.00D2331Resin-Based Composite - Two Surfaces, AnteriorYESYESNONO$91.00D2332Resin-Based Composite - Three Surfaces, AnteriorYESYESNONO$109.00D2335Resin-Based Composite, - Four or More Surfaces or Involving Incisal Angle (Anterior)YESYESNONO$111.00D2390Resin-Based Composite Crown, AnteriorYESYESNONO$300.00D2391Resin-Based Composite – One Surface, PosteriorYESYESNONO$68.00D2392Resin-Based Composite – Two Surfaces, PosteriorYESYESNONO$90.00D2393Resin-Based Composite – Three Surfaces, PosteriorYESYESNONO$103.00D2394Resin-Based Composite – Four or More Surfaces, PosteriorYESYESNONO$111.00 GOLD FOIL RESTORATIONS D2410Gold Foil - One SurfaceNONONot CoveredD2420Gold Foil - Two SurfacesNONONot CoveredD2430Gold Foil - Three SurfacesNONONot CoveredProc.-40882296359Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04INLAY/ONLAY RESTORATIONSD2510Inlay - Metallic-One SurfaceNONONot CoveredD2520Inlay - Metallic-Two SurfacesNONONot CoveredD2530Inlay - Metallic-Three or More SurfacesNONONot CoveredD2542Onlay - Metallic-Two SurfacesNONONot CoveredD2543Onlay - Metallic – Three SurfacesNONONot CoveredD2544Onlay - Metallic - Four or More SurfacesNONONot CoveredD2610Inlay - Porcelain/Ceramic - One SurfaceNONONot CoveredD2620Inlay - Porcelain/Ceramic - Two SurfacesNONONot CoveredD2630Inlay - Porcelain/Ceramic - Three or More SurfacesNONONot CoveredD2642Onlay - Porcelain/Ceramic - Two SurfacesNONONot CoveredD2643Onlay - Porcelain/Ceramic - Three SurfacesNONONot CoveredD2644Onlay - Porcelain/Ceramic - Four or More SurfacesNONONot CoveredD2650Inlay - Resin-Based Composite - One SurfaceNONONot CoveredD2651Inlay - Resin-Based Composite - Two SurfacesNONONot CoveredD2652Inlay - Resin-Based Composite - Three or More SurfacesNONONot CoveredD2662Onlay - Resin-Based Composite - Two SurfacesNONONot CoveredD2663Onlay - Resin-Based Composite - Three Surfaces NONONot CoveredD2664Onlay - Resin-Based Composite - Four or More SurfacesNONONot CoveredProc.-408556159710Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04CROWNS - SINGLE RESTORATIONS ONLYD2710Crown - Resin Based Composite (indirect)YESYESNONO$300.00D2712Crown-3/4 Resin-Based Composite (indirect)NONONot CoveredD2720Crown - Resin with High Noble MetalNONONot CoveredD2721Crown - Resin with Predominantly Base MetalNONONot CoveredD2722Crown - Resin with Noble MetalNONONot CoveredD2740Crown – Porcelain/Ceramic SubstrateNONONot CoveredD2750Crown – Porcelain Fused to High Noble MetalNONONot CoveredD2751Crown - Porcelain Fused to Predominantly Base MetalNONONot CoveredD2752Crown – Porcelain Fused to Noble MetalNONONot CoveredD2780Crown - 3/4 Cast High Noble MetalNONONot CoveredD2781Crown-3/4 Cast Predominantly Base MetalNONONot CoveredD2782Crown - 3/4 Cast Noble MetalNONONot CoveredD2783Crown - 3/4 Porcelain/CeramicNONONot CoveredD2790Crown - Full Cast High Noble MetalNONONot CoveredD2791Crown - Full Cast Predominantly Base MetalNONONot CoveredD2792Crown - Full Cast Noble MetalNONONot Covered-471805143510Eff. 7/1/1400Eff. 7/1/14D2794Crown - TitaniumNONONot CoveredD2799Provisional Crown - further treatment or completion of diagnosis necessary prior to final impressionNONONot CoveredProc.-447276258844Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04OTHER RESTORATIVE SERVICESD2910Recement Inlay, Onlay, or Partial Coverage RestorationNONONot CoveredD2915Recement Cast or Prefabricated Post and CoreYESYESNONO$30.00-45085034792Eff. 7/1/1400Eff. 7/1/14D2920Recement CrownYESYESNONO$30.00 D2929Prefabricated Porcelain/Ceramic Crown – Primary Tooth NONONot CoveredD2930Prefabricated Stainless Steel Crown - Primary ToothYESNONO$120.00D2931Prefabricated Stainless Steel Crown - Permanent ToothYESYESNONO$120.00D2932Prefabricated Resin CrownYESYESNONOLimited to Primary and Permanent Anteriors $120.00D2933Prefabricated Stainless Steel Crown with Resin WindowNONONot Covered-451485186690Eff. 7/1/1400Eff. 7/1/14D2934Prefabricated Esthetic Coated Stainless Steel Crown –Primary ToothNONONot CoveredD2940Protective RestorationYESYESNONONot covered with Pulpotomy. IPDHs?may use this code subject to the guidelines and limitations in MBM Chap II.$30.00D2950Core Buildup, Including Any Pins when requiredYESYESNONO$150.00D2951Pin Retention - Per Tooth, in Addition to RestorationYESYESNONO$19.00D2952Post & Core in Addition to Crown, Indirectly FabricatedNONONot CoveredD2953Each Additional Indirectly Fabricated Post - Same ToothNONONot CoveredD2954Prefabricated Post & Core in Addition to CrownYESYESNONOPermanent tooth only$95.00Proc.-387557340906Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D2955Post Removal NONONot CoveredD2957Each Additional Prefabricated Post-Same Tooth, Use with D2954YESYESNONOPermanent tooth only$47.50D2960Labial Veneer (resin laminate)-ChairsideNONONot CoveredD2961Labial Veneer (resin laminate)-LaboratoryNONONot CoveredD2962Labial Veneer (porcelain laminate)-LaboratoryNONONot CoveredD2970Temporary Crown (Fractured Tooth)YESYESNONO$40.00D2971Additional Procedures to Construct New Crown under Existing Partial Denture FrameworkNONONot CoveredD2975CopingNONONot Covered-47261745262Eff. 7/1/1400Eff. 7/1/14D2980Crown Repair Necessitated By Restorative Material FailureYESYesNONO$34.00D2981Inlay Repair Necessitated By Restorative Material FailureNONONot CoveredD2982Onlay Repair Necessitated By Restorative Material FailureNONONot CoveredD2983Veneer Repair Necessitated By Restorative Material FailureNONONot CoveredD2990Resin Infiltration of Incipient Smooth Surface LesionsNONONot CoveredD2999Unspecified Restorative Procedure, by ReportYESYESYESYESEx: Temp. crown – fractured toothBy ReportIV. ENDODONTICS PULP CAPPINGProc.-392430139700Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D3110Pulp Cap - Direct (excluding final restoration)YESYESNONONot covered on primary teeth with more than 2/3 of root structure reabsorbed$7.00D3120Pulp Cap – Indirect (excluding final restoration)YESYESNONO$19.00PULPOTOMYD3220Therapeutic Pulpotomy (excluding final restoration) – Removal of Pulp Coronal to the Dentinocemental Junction and Application of MedicamentYESYESNONONot separately reimbursable to same provider as part of root canal in same period of treatment$50.00D3221Pulpal Debridement, Primary and Permanent TeethNONO Not CoveredD3222Partial pulpotomy for apexogenesis-permanent tooth with incomplete root developmentYESYESNot separately reimbursable to same provider as part of root canal in same period of treatment$50.00Proc.-401955333375Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04ENDODONTIC THERAPY ON PRIMARY TEETHD3230Pulpal Therapy (resorbable filling) - Anterior, Primary Tooth (excluding final restoration)YESNO Not separately reimbursable to same provider as part of root canal in same period of treatment$50.00D3240Pulpal Therapy (resorbable filling) - Posterior, Primary Tooth (excluding final restoration) YESNO Not separately reimbursable to same provider as part of root canal in same period of treatment$50.00ENDODONTIC THERAPY (including TREATMENT PLAN, CLINICAL PROCEDURES AND FOLLOW-UP CARE)D3310Anterior (excluding final restoration)YESYESNONOOnly on permanent teeth with favorable prognosis for dentition$220.00D3320Bicuspid (excluding final restoration)YESYESNONO$251.00D3330Molar (excluding final restoration)YESYESNONO$338.00D3331Treatment of Root Canal Obstruction; Non-Surgical AccessNONONot CoveredD3332Incomplete Endodontic Therapy; Inoperable, unrestorable or Fractured ToothNONONot CoveredD3333Internal Root Repair of Perforation DefectsNONONot CoveredProc.-468630109219Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D3346Retreatment of Previous Root Canal Therapy – AnteriorYESYESNONO$220.00D3347Retreatment of Previous Root Canal Therapy – BicuspidYESYESNONO$240.00D3348Retreatment of Previous Root Canal Therapy – MolarYESYESNONO$320.00APEXIFICATION/RECALCIFICATION PROCEDURES-472617138888Eff. 7/1/1400Eff. 7/1/14D3351Apexification/Recalcification-Initial Visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)YESYESNONO$56.00D3352Apexification/Recalcification-Interim Medication Replacement YESYESNONO$56.00D3353Apexification/Recalcification-Final Visit (includes completed root canal therapy-apical closure/calcific repair of perforations, root resorption, etc.)YESYESNONO$56.00APICOECTOMY/PERIRADICULAR SERVICES-472617105617Eff. 7/1/1400Eff. 7/1/14D3410Apicoectomy - AnteriorYESYESNONO$170.00D3421Apicoectomy - Bicuspid (first root)NONONot CoveredD3425Apicoectomy– Molar (first root)NONONot CoveredD3426Apicoectomy (each additional root)NONONONONot CoveredD3430Retrograde Filling – Per RootYESYESNONO$43.00D3450Root Amputation - Per RootNONONot CoveredProc.-363855180974Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D3460Endodontic Endosseous ImplantNONONot CoveredD3470Intentional Reimplantation (including necessary splinting)NONONot CoveredOTHER ENDODONTIC PROCEDURES D3910Surgical Procedure for Isolation of Tooth with Rubber DamNONoNot CoveredD3920Hemisection (including any root removal), Not Including Root Canal TherapyNONONot CoveredD3950Canal Preparation and Fitting or Preformed Dowel or PostNoNoNot CoveredD3999Unspecified Endodontic Procedure, by ReportYesYesYesYesBy ReportV. PERIODONTICS SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE CARE) -36639525400Eff. 7/1/1400Eff. 7/1/14D4210Gingivectomy or Gingivoplasty – Four or More Con- tiguous Teeth or Tooth Bounded Spaces Per QuadrantYesNONOMember must have medication enduced gingival hyperplasia with clinical pockets greater than 4mm.$162.00D4211Gingivectomy or Gingivoplasty – One to Three Teeth contiguous or Tooth bounded spaces, Per QuadrantYesNoYes$56.00Proc.-249555266700Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D4212Gingivectomy or gingivoplasty to allow access for restorative procedure, per toothYESNOYES$25.00D4230Anatomical Crown Exposure - Four or More Contiguous Teeth per QuadrantNONONot CoveredD4231Anatomical Crown Exposure - One to Three Teeth per QuadrantNONONot CoveredD4240Gingival Flap Procedure, Including Root Planing Four or More Contiguous Teeth or Bounded Teeth Spaces Per QuadrantYESNOYESNO$250.00D4241Gingival Flap Procedure, Including Root Planing – One to Three Contiguous Teeth or Bounded Teeth Spaces Per QuadrantYESnoYESNO$150.00D4245Apically Positioned FlapYesNoYES$162.00D4249Clinical Crown Lengthening-Hard TissueNONONot Covered-39420216511Eff. 7/1/1400Eff. 7/1/14D4260Osseous Surgery (including flap entry and closure) – Four or More Contiguous Teeth or Tooth Bounded Spaces Per QuadrantYesNoYes$280.00D4261Osseous Surgery (including flap entry and closure) – One to Three Contiguous Teeth or Tooth Bounded Spaces Per QuadrantYESNOYES$140.00D4263Bone Replacement Graft - First Site in QuadrantYesNoYes$330.00D4264Bone Replacement Graft - Each Additional Site in QuadrantYesNoYes$66.00D4265Biologic Materials to Aid in Soft and Osseous Tissue RegenerationNONONot CoveredProc.-287655171450Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D4266Guided Tissue Regeneration – Resorbable Barrier, Per SiteNoNoNot CoveredD4267Guided Tissue Regeneration – Nonresorbable Barrier, Per Site (includes membrane removal)NoNoNot CoveredD4268Surgical Revision Procedure, Per ToothYesYesYesYes$200.00D4270Pedicle Soft Tissue Graft ProcedureYesNoYes$250.00D4273Subepithelial Connective Tissue Graft Procedures Per ToothNoNoNot CoveredD4274Distal or Proximal Wedge Procedure (when not performed in conjunction with surgical procedures in the same anatomical area)NoNoNot CoveredD4275Soft Tissue AllograftnonoNot CoveredD4276Combined Connective Tissue and Double Pedicle Graft, Per ToothnonoNot Covered-372937-473Eff. 7/1/1400Eff. 7/1/14D4277Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graftsYESNOYES$250.00D4278Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in the same graft siteYESNOYESMust be reported in conjunction with D4277$125.00NON-SURGICAL PERIODONTAL SERVICES D4320Provisional Splinting - IntracoronalNONONot CoveredD4321Provisional Splinting – ExtracoronalNoNoNot CoveredProc.-411480152399Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D4341Periodontal Scaling and Root Planing – Four or More Teeth Per QuadrantYesYesYesYesNo PA required for diagnosis code 101 and the Department may authorize payment for Diagnosis Code 101 retroactively. $40.00D4342Periodontal Scaling and Root Planing – One to Three Teeth, Per QuadrantNonoNot Covered-47261738617Eff. 7/1/1400Eff. 7/1/14D4355Full Mouth Debridement to Enable Comprehensive Evaluation and DiagnosisYesYesYESYESOnce per year per provider. Dental Hygienists practicing under PHS and IPDHs practicing under PHS may use this code.$100.00D4381Localized Delivery of Antimicrobial Agents Via a Controlled Release Vehicle into Diseased Crevicular Tissue, Per ToothNoNONot CoveredOTHER PERIODONTAL SERVICES -47117059513Eff. 7/1/1400Eff. 7/1/14D4910Periodontal Maintenance YesNOYES$39.00D4920Unscheduled Dressing Change (by someone other than treating dentist or their staff)YesNoNo$27.00D4999Unspecified Periodontal Procedure, by ReportYesYesYesYesBy ReportVI. PROSTHODONTICS, REMOVABLE COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE) -45910573025Eff. 7/1/1400Eff. 7/1/14Proc.CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D5110Complete Denture - MaxillaryYesYesYesYesEvery 5 years, Denturists may also use this code $393.00D5120Complete Denture - MandibularYesYesYesYesEvery 5 years, Denturists may also use this code $393.00D5130Immediate Denture - MaxillaryYesYesYesYesEvery 5 years, Denturists may also use code$423.00D5140Immediate Denture - MandibularYesYesYesYesEvery 5 years, Denturists may also use this code$423.00PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE) -45135243534Eff. 7/1/1400Eff. 7/1/14D5211Maxillary Partial Denture-Resin Base (including any conventional clasps, rests and teeth)YesYESYesYESEvery 5 years. Denturists may also use this code.$280.00D5212Mandibular Partial Denture-Resin Base (including any conventional clasps, rests and teeth)YesYESYesYESEvery 5 years. Denturists may also use this code.$280.00D5213Maxillary Partial Denture-Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)YesYESYesYESEvery 5 years. Denturists may also use this code.$423.00Proc.-478155152400Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04-42601124042Eff. 7/1/1400Eff. 7/1/14D5214Mandibular Partial Denture-Cast Metal Framework with Resin Denture Bases (including any conventional clasps, rests and teeth)YesYESYesYESEvery 5 years. Denturists may also use this code.$423.00D5225Maxillary Partial Denture-Flexible Base (including any clasps, rests and teeth)NONONot CoveredD5226Mandibular Partial Denture-Flexible Base (including any clasps, rests and teeth)NONONot CoveredD5281Removable Unilateral Partial Denture - One Piece Case Metal (including clasps and teeth)NoNoNot CoveredADJUSTMENTS TO DENTURES D5410Adjust Complete Denture - MaxillaryYesYesNoNoDenturists may also use this code$26.00D5411Adjust Complete Denture - MandibularYesYesNoNoDenturists may also use this code$26.00-483058-8890Eff. 7/1/1400Eff. 7/1/14D5421Adjust Partial Denture - MaxillaryYesYesNoNoDenturists may also use this code.$25.00D5422Adjust Partial Denture - MandibularYesYesNoNoDenturists may also use this code.$25.00REPAIRS TO COMPLETE DENTURES D5510Repair Broken Complete Denture BaseYesYesNoNoDenturists may also use this code$57.00-478155136524Eff. 7/1/1400Eff. 7/1/14Proc.CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D5520Replace Missing or Broken Teeth-Complete Denture (each tooth)YesYesNoNoDenturists may also use this code$50.00REPAIRS TO PARTIAL DENTURES -48325020305Eff. 7/1/1400Eff. 7/1/14D5610Repair Resin Denture BaseYesYesNoNoDenturists may also use this code.$56.00D5620Repair Cast FrameworkYesYesNoNoDenturists may also use this code.$85.00D5630Repair or Replace Broken ClaspYesYesNoNoDenturists may also use this code.$85.00D5640Replace Broken Teeth - Per ToothYesYesNoNoDenturists may also use this code.$50.00D5650Add Tooth to Existing Partial DentureYesYesNoNoDenturists may also use this code.$55.00D5660Add Clasp to Existing Partial DentureYesYesNoNoDenturists may also use this code.$65.00D5670Replace All Teeth and Acrylic on Cast Metal Framework (maxillary)NoNONot CoveredD5671Replace All Teeth and Acrylic on Cast Metal Framework (mandibular)nonoNot CoveredDENTURE REBASE PROCEDURES Proc.-38290519050Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D5710Rebase Complete Maxillary DentureYesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$150.00D5711Rebase Complete Mandibular DentureYesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$150.00-44072028723Eff. 7/1/1400Eff. 7/1/14D5720Rebase Maxillary Partial DentureYesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$150.00 D5721Rebase Mandibular Partial DentureYesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$150.00DENTURE RELINE PROCEDURESD5730Reline Complete Maxillary Denture (chairside)YesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$78.00D5731Reline Complete Mandibular Denture (chairside)YesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$78.00D5740Reline Maxillary Partial Denture (chairside)NoNoNot CoveredD5741Reline Mandibular Partial Denture (chairside)NoNoNot CoveredProc.-41148066674Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D5750Reline Complete Maxillary Denture (laboratory)YesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$150.00D5751Reline Complete Mandibular Denture (laboratory)YesYesNoNoRefer to Chapter II, 25.03. Denturists may also use this code.$150.00D5760Reline Maxillary Partial Denture (laboratory)NoNoNot CoveredD5761Reline Mandibular Partial Denture (laboratory)NoNoNot CoveredINTERIM PROSTHESIS D5810Interim Complete Denture (maxillary)NoNoNot CoveredD5811Interim Complete Denture (mandibular)NoNoNot CoveredD5820Interim Partial Denture (maxillary)NoNoNot CoveredD5821Interim Partial Denture (mandibular)NoNoNot CoveredOTHER REMOVABLE PROSTHETIC SERVICESD5850Tissue Conditioning, MaxillaryNONONot CoveredD5851Tissue Conditioning, MandibularNONONot Covered-504515128595Eff. 7/1/1400Eff. 7/1/14D5862Precision Attachment, by ReportNoNoNot CoveredD5863Overdenture – complete maxillaryYESNOYES$473.00D5864Overdenture – partial maxillaryYESNOYES$473.00Proc.-421005142875Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D5865Overdenture – complete mandibularYESNOYES$473.00D5866Overdenture – partial mandibularYESNOYES$473.00D5867Replacement of Replaceable Part of Semi-Precision or Precision Attachment (male or female component)NoNoNot CoveredD5875Modification of Removable Prosthesis Following Implant SurgeryNoNoNot CoveredD5899Unspecified Removable Prosthodontic Procedure, by ReportNONONot CoveredVII. MAXILLOFACIAL PROSTHETICS D5911Facial Moulage (sectional)YesYesYesYesBy ReportD5912Facial Moulage (complete)YesYesYesYesBy ReportD5913Nasal ProsthesisYesYesYesYesBy ReportD5914Auricular ProsthesisYesYesYesYesBy ReportD5915Orbital ProsthesisYesYesYesYesBy ReportD5916Ocular ProsthesisYesYesYesYesBy ReportD5919Facial ProsthesisYesYesYesYesBy ReportD5922Nasal Septal ProsthesisYESYesYesYesBy ReportD5923Ocular Prosthesis, InterimYesYesYesYesBy ReportD5924Cranial ProsthesisYesYesYesYesBy ReportD5925Facial Augmentation Implant ProsthesisYesYesYesYesBy ReportD5926Nasal Prosthesis, ReplacementYesYesYesYesBy ReportD5927Auricular Prosthesis, ReplacementYesYesYesYesBy ReportProc.-401955171449Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D5928Orbital Prosthesis, ReplacementYesYESYESYESBy ReportD5929Facial Prosthesis, ReplacementYESYesYesYesBy ReportD5931Obturator Prosthesis, SurgicalYesYesNoNo$1,494.43D5932Obturator Prosthesis, DefinitiveYesYesNoNo$1,693.82D5933Obturator Prosthesis, ModificationYesYesNoNoBy ReportD5934Mandibular Resection Prosthesis with Guide FlangeYesYesYesYesBy ReportD5935Mandibular Resection Prosthesis without Guide FlangeYesYesYesYesBy ReportD5936 Obturator Prosthesis, InterimYESYESYESYESBy ReportD5937Trismus Appliance (not for TMD treatment)NoNoNot CoveredD5951Feeding AidYesYesNoNo$433.00D5952Speech Aid Prosthesis, PediatricYesNONOBy ReportD5953Speech Aid Prosthesis, AdultYesYesYesYesBy ReportD5954Palatal Augmentation ProsthesisYesYesYesYesBy ReportD5955Palatal Lift Prosthesis, DefinitiveYesYesYesYesBy ReportD5958Palatal Lift Prosthesis, InterimYesYesYesYesBy ReportD5959Palatal Lift Prosthesis, ModificationYesYesYesYesBy ReportD5960Speech Aid Prosthesis, ModificationYesYesYesYesBy ReportD5982Surgical StentYesYesYesYes$175.00D5983Radiation CarrierYesYesYesYesBy ReportD5984Radiation ShieldYesYesYesYesBy ReportD5985Radiation Cone LocatorYesYesYesYesBy ReportD5986Fluoride Gel CarrierYesYesYesYesBy ReportD5987Commissure SplintNONONot CoveredD5988Surgical SplintNoNoNot CoveredProc.-430087372804Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D5991Vesiculobullous disease medicament carrierNONONot CoveredD5992Adjustment of Maxillofacial Prostehtic ApplianceYESYESYESYESBy ReportD5993Maintenance and cleaning of Maxillofacial Prosthesis (extra or intraoral) other than required adjustmentsYESYESYESYESBy ReportD5999Unspecified Maxillofacial Prosthesis, by ReportYesYesYesYesBy ReportVIII. IMPLANT SERVICESD6010Surgical Placement of Implant Body: Endosteal ImplantNONONot CoveredD6012Surgical Placement of Interim Implant Body for Transitional Prosthesis: Endosteal ImplantNONONot CoveredD6040Surgical Placement: Eposteal ImplantNoNoNot Covered-429555109855Eff. 7/1/1400Eff. 7/1/14D6050Surgical Placement: Transosteal ImplantNoNoNot CoveredD6051Interim AbutmentNONONot CoveredIMPLANT SUPPORTED PROSTHETICSD6053Implant/Abutment Supported Removable Denture for Completely Edentulous ArchNONONot CoveredD6054Implant/Abutment Supported Removable Denture for Partially Edentulous ArchNONONot Covered-432730-1905Eff. 7/1/1400Eff. 7/1/14D6055Connecting Bar Implant Supported Abutment SupportedNONONot CoveredD6056Prefabricated Abutment - Includes Modification and PlacementNoNoNot CoveredProc.-430087394069Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D6057Custom Fabricated Abutment - Includes PlacementNoNoNot CoveredD6058Abutment Supported Porcelain/Ceramic CrownNoNoNot CoveredD6059Abutment Supported Porcelain Fused to Metal Crown (high noble metal)NoNoNot CoveredD6060Abutment Supported Porcelain Fused to Metal Crown (predominantly base mental)NoNoNot CoveredD6061Abutment Supported Porcelain Fused to Metal Crown (noble metal)NoNoNot CoveredD6062Abutment Supported Cast Metal Crown (high noble metal)NoNoNot CoveredD6063Abutment Supported Cast Metal Crown (predominantly base metal)NoNoNot CoveredD6064Abutment Supported Cast Metal Crown (noble metal)NoNoNot CoveredD6065Implant Supported Porcelain/Ceramic CrownNoNoNot CoveredD6066Implant Supported Porcelain Fused to Metal Crown (titanium, titanium alloy, high noble metal)NoNoNot CoveredD6067Implant Supported Metal Crown (titanium, titanium alloy, high noble metal)NoNoNot CoveredD6068Abutment Supported Retainer for Porcelain/Ceramic FPDNoNoNot CoveredD6069Abutment Supported Retainer for Porcelain Fused to Metal FPD (high noble mental)NoNoNot CoveredD6070Abutment Supported Retainer for Porcelain Fused to Metal FPD (predominantly base metal)NoNoNot CoveredProc.-382905190500Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D6071Abutment Supported Retainer for Porcelain Fused to Metal FPD (noble metal)NoNoNot CoveredD6072Abutment Supported Retainer for Cast Metal FPD (high noble metal)NoNoNot CoveredD6073Abutment Supported Retainer for Cast Metal FPD (predominantly base metal)NoNoNot CoveredD6074Abutment Supported Retainer for Cast Metal FPD (noble metal)NoNoNot CoveredD6075Implant Supported Retainer for Ceramic FPDNoNoNot CoveredD6076Implant Supported Retainer for Porcelain Fused to Metal FPD (titanium, titanium alloy, or high noble metal)NoNoNot CoveredD6077Implant Supported Retainer for Cast Metal FPD (titanium, titanium alloy, or high noble metal)NoNoNot CoveredD6078Implant/Abutment Supported Fixed Denture for Completely Edentulous ArchNoNoNot CoveredD6079Implant/Abutment Supported Fixture Denture for Partially Edentulous ArchNONONot CoveredOTHER IMPLANT SERVICES-43310029402Eff. 7/1/1400Eff. 7/1/14D6080Implant Maintenance Procedures, when Prostheses are Removed and Reinserted, Including Cleansing of Prostheses and Abutments NoNoNot CoveredD6090Repair Implant Supported Prosthesis, by ReportNoNoNot CoveredProc.-373380190500Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D6091Replacement of Semi-precision or Precision Attachment (male or female component) of Implant/Abutment Supported Prosthesis, per AttachmentNONONot CoveredD6092Recement Implant/Abutment Supported CrownNONONot CoveredD6093Recement Implant/Abutment Supported Fixed Partial DentureNONONot CoveredD6094Abutment Supported Crown - (titanium)NONONot CoveredD6095Repair Implant Abutment, by ReportNoNoNot Covered-462280128270Eff. 7/1/1400Eff. 7/1/14D6100Implant Removal, by ReportNoNoNot CoveredD6101Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closureNONONot CoveredD6102Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and closureNONONot CoveredD6103Bone graft for repair of periimplant defect – not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regenerationNONONot CoveredD6104Bone graft at time of implant placement. Placement of a barrier membrane or biologic materialsNONONot CoveredD6190Radiographic/Surgical Implant Index, by ReportNONONot CoveredD6194Abutment Supported Retainer Crown for FPD - (titanium)NONONot CoveredD6199Unspecified Implant Procedure, by ReportNoNoNot CoveredIX. PROSTHODONTICS, FIXEDFIXED BRIDGES (EACH ABUTMENT AND EACH PONTIC CONSTITUTES A UNIT)FIXED PARTIAL DENTURE PONTICS -4686303174Eff. 7/1/1400Eff. 7/1/14Proc.CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D6205Pontic - Indirect Resin Based CompositeNONONot CoveredD6210Pontic - Cast High Noble MetalNoNoNot CoveredD6211Pontic - Cast Predominantly Base MetalNoNoNot CoveredD6212Pontic - Cast Noble MetalNoNoNot CoveredD6214Pontic - TitaniumNONONot CoveredD6240Pontic - Porcelain Fused to High Noble MetalNoNoNot CoveredD6241Pontic - Porcelain Fused to Predominantly Base MetalYesNoYes$325.00D6242Pontic - Porcelain Fused to Noble MetalYesNoYes$344.00D6245Pontic - Porcelain/CeramicNoNoNot CoveredD6250Pontic - Resin with High Noble MetalNoNoNot CoveredD6251Pontic - Resin with Predominantly Base MetalYesNoYes$276.00-45402593980Eff. 7/1/1400Eff. 7/1/14D6252Pontic - Resin with Noble MetalYesNoYes$314.00D6253Provisional Pontic - Further Treatment Or Completion Of Diagnosis Necessary Prior To Final ImpressionNONONot CoveredFIXED PARTIAL DENTURE RETAINERS – INLAYS/ONLAYSD6545Retainer-Cast Metal for Resin Bonded Fixed ProsthesisYesNoYes$150.00Proc.-421005152399Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D6548Retainer-Porcelain/Ceramic for Resin Bonded Fixed ProsthesisNONONot CoveredD6600Inlay – Porcelain/Ceramic, Two SurfacesNONONot CoveredD6601Inlay – Porcelain/Ceramic, Three or More SurfacesNONONot CoveredD6602Inlay – Cast High Noble Metal, Two SurfacesNONONot CoveredD6603Inlay – Cast High Noble Metal, Three or More SurfacesNONONot CoveredD6604Inlay – Cast Predominantly Base Metal, Two SurfacesNONONot CoveredD6605Inlay – Cast Predominantly Base Metal, Three or More SurfacesNONONot CoveredD6606Inlay – Cast Noble Metal, Two SurfacesNONONot CoveredD6607Inlay – Cast Noble Metal, Three or More SurfacesNONONot CoveredD6608Onlay – Porcelain/Ceramic, Two SurfacesNONONot CoveredD6609Onlay – Porcelain/Ceramic, Three or More SurfacesNONONot CoveredD6610Onlay – Cast High Noble Metal, Two SurfacesNONONot CoveredD6611Onlay - Cast High Noble Metal, Three or More SurfacesNONONot CoveredD6612Onlay - Cast Predominantly Base Metal, Two SurfacesNONONot CoveredD6613Onlay - Cast Predominantly Base Metal, Three or More SurfacesNONONot CoveredD6614Onlay - Cast Noble Metal, Two SurfacesNONONot CoveredD6615Onlay - Cast Noble Metal, Three or More SurfacesNONONot CoveredD6624Inlay - TitaniumNONONot CoveredD6634Onlay - TitaniumNONONot CoveredFIXED PARTIAL DENTURE RETAINERS - CROWNSProc.-401955104775Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D6710Crown - Indirect Resin Based CompositeNONONot CoveredD6720Crown - Resin with High Noble MetalNoNoNot CoveredD6721Crown - Resin with Predominantly Base MetalNoNoNot CoveredD6722Crown - Resin with Noble MetalNoNoNot CoveredD6740Crown - Porcelain/CeramicNoNONot CoveredD6750Crown - Porcelain Fused to High Noble MetalNoNoNot CoveredD6751Crown - Porcelain Fused to Predominantly Base MetalNoNoNot CoveredD6752Crown - Porcelain Fused to Noble MetalNoNoNot CoveredD6780Crown - 3/4 Cast High Noble MetalNoNoNot CoveredD6781Crown - 3/4 Cast Predominantly Base MetalNoNoNot CoveredD6782Crown - 3/4 Cast Noble MetalNoNoNot CoveredD6783Crown - 3/4 Porcelain/CeramicNoNoNot CoveredD6790Crown - Full Cast High Noble MetalNoNoNot CoveredD6791Crown - Full Cast Predominantly Base MetalNoNoNot CoveredD6792Crown - Full Cast Noble MetalNoNoNot Covered-40120221133Eff. 7/1/1400Eff. 7/1/14D6793Provisional Retainer Crown - Further Treatment or Completion of Diagnosis Necessary Prior to Final ImpressionNoNONot CoveredD6794Crown - TitaniumNONONot CoveredProc.-363855171450Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04OTHER FIXED PARTIAL DENTURE SERVICESD6920Connector BarNoNoNot CoveredD6930Recement Fixed Partial DentureNoNoNot CoveredD6940Stress BreakerNoNoNot CoveredD6950Precision AttachmentNoNoNot Covered-43008717499Eff. 7/1/1400Eff. 7/1/14D6975Coping NoNoNot CoveredD6980Fixed Partial Denture Repair Necessitated By Restorative Material FailureNoNoNot CoveredD6985Pediatric Partial Denture, FixedNOnoNot CoveredD6999Unspecified Fixed Prosthodontic Procedure, by ReportNoNoNot CoveredX. ORAL and Maxillofacial SURGERY EXTRACTIONS - INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED & ROUTINE POSTOPERATIVE CARED7111Extraction, Coronal Remnants – Deciduous ToothYESYESNONO$55.00D7140Extraction, Erupted Tooth or exposed Root (elevation and/or forceps removal)YESYESNONO$91.00Proc.-461985362172Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04SURGICAL EXTRACTIONS – (INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED, & ROUTINE POSTOPERATIVE CARE) D7210Surgical Removal of Erupted Tooth Requiring Removal of Bone and/or Sectioning YesYesNoNoDocumented need demonstrated by X-rays$110.00D7220Removal of Impacted Tooth - Soft TissueYesYesNoNoDocumented need demonstrated by X-rays$95.00D7230Removal of Impacted Tooth - Partially BonyYesYesNoNoDocumented need demonstrated by X-rays$155.00D7240Removal of Impacted Tooth – Completely BonyYesYesNoNoDocumented need demonstrated by X-rays$185.00D7241Removal of Impacted Tooth – Completely Bony, with Unusual Surgical ComplicationsYesYesNoNoDocumented need demonstrated by X - rays$215.00-493882177475Eff. 7/1/1400Eff. 7/1/14D7250Surgical Removal of Residual Tooth Roots (cutting procedure)YesYesNoNoDocumented need demonstrated by X - rays$130.00D7251Coronectomy – Intentional Partial Tooth RemovalYESYESNONO$110.00OTHER SURGICAL PROCEDURESD7260Oroantral Fistula ClosureYesYesNoNo$250.00D7261Primary Closure of a Sinus PerforationYesYesnono$250.00D7270Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced ToothYesYesNoNo$175.00D7272Tooth Transplantation (includes reimplantation from one site to another and splinting and/or stabilization)NoNoNot CoveredProc.-421005171449Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7280Surgical Access of an Unerupted ToothYesNoNo$220.00D7282Mobilization of Erupted or Malpositioned Tooth to Aid EruptionnonoNot CoveredD7283Placement of Device to Facilitate Eruption of Impacted ToothYESNONO$225.00D7285Biopsy of Oral Tissue – Hard (bone, tooth)YesYesNoNo$110.00D7286Biopsy of Oral Tissue – Soft YesYesNoNo$85.00D7287Exfoliative Cytological Sample CollectionNONONot CoveredD7288Brush Biopsy-Transepithelial Sample CollectionYESYESBy Report-47625061595Eff. 7/1/1400Eff. 7/1/14D7290Surgical Repositioning of TeethYesYesNoNo$175.00D7291Transseptal Fiberotomy/Supra Crestal FiberotomyYesNoNO$45.00D7292Surgical Placement: Temporary Anchorage Device (screw retained plate) Requiring Surgical FlapNONONot CoveredD7293Surgical Placement: Temporary Anchorage Device Requiring Surgical FlapNONONot CoveredD7294Surgical Placement: Temporary Anchorage Device Without Surgical FlapNONONot Covered-475630-281Eff. 7/1/1400Eff. 7/1/14D7295Harvest of Bone for use in Autogenous Grafing ProcedureYESYESNOYESOnly reimbursable when necessary for bone graft for reconstruction of alveolar defect.$225.00Proc.-468630152399Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04ALVEOLOPLASTY - SURGICAL PREPARATION OF RIDGE FOR DENTURES D7310Alveoloplasty in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per QuadrantYesYesNONO$64.00D7311Alveoloplasty in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per QuadrantNONONot Covered-46198530199Eff. 7/1/1400Eff. 7/1/14D7320Alveoloplasty not in Conjunction with Extractions - Four or More Teeth or Tooth Spaces, Per QuadrantYesYesNONO Only reimbursable for members who have alveolar segment irregularity preventing denture placement.$94.00D7321Alveoloplasty not in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per QuadrantYESYESNONO Only reimbursable for members who have alveolar segment irregularity preventing denture placement.$47.00VESTIBULOPLASTYD7340Vestibuloplasty - Ridge Extension (secondary epithelialization)NoNoNot CoveredD7350Vestibuloplasty - Ridge Extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment, and management of hypertrophied and hyperplastic tissue)NoNoNot CoveredSURGICAL EXCISION OF SOFT TISSUE LESIONS -468630127000Eff. 7/1/1400Eff. 7/1/14Proc.CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7410Excision of Benign Lesion Up to 1.25 CmYesYesNoNo$75.00D7411Excision of Benign Lesion Greater Than 1.25 CmYesYesnono$120.00D7412Excision of Benign Lesion, Complicatedyesyesnono$200.00D7413Excision of Malignant Lesion up to 1.25 Cmyesyesnono$350.00D7414Excision of Malignant Lesion Greater Than 1.25 CmyesyesNONO$750.00-483250110387Eff. 7/1/1400Eff. 7/1/14D7415Excision of Malignant Lesion, ComplicatedyesyesNONO$750.00D7465Destruction of Lesion(s) by Physical or Chemical MethodYesYesNoNo$75.00SURGICAL EXCISION OF INTRA-OSSEOUS LESIONSD7440Excision of Malignant Tumor - Lesion Diameter Up to 1.25 CmYesYesNoNo$350.00D7441Excision of Malignant Tumor - Lesion Diameter Greater Than 1.25 CmYesYesNoNo$750.00D7450Removal of Benign Odontogenic Cyst or Tumor - Lesion Diameter Up to 1.25 CmYesYesNoNo$220.00D7451Removal of Benign Odontogenic Cyst or Tumor - Lesion Diameter Greater Than 1.25 CmYesYesNoNo$400.00D7460Removal of Benign Nonodontogenic Cyst or Tumor - Lesion Diameter up to 1.25 CmYesYesNoNo$200.00D7461Removal of Benign Nonodontogenic Cyst or Tumor - Lesion Diameter Greater Than 1.25 CmYesYesNoNo$400.00EXCISION OF BONE TISSUEProc.-451352273567Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7471Removal of Lateral Exostosis (maxilla or mandible)YesYesNONOOnly reimbursable when Lateral Exostosis prevents denture placement.$300.00D7472Removal of Torus PalatinusYESYESNONOOnly reimbursable when Torus Palatinus prevents denture placement.By ReportD7473Removal of Torus MandibularisYESYESNONOOnly reimbursable when Torus Manibulus prevents denture placement.By ReportD7485Surgical Reduction of Osseous TuberosityNoNONot CoveredD7490Radical Resection of Maxilla or MandibleNONONot CoveredSURGICAL INCISION D7510Incision and Drainage of Abscess – Intraoral Soft TissueYesYesNoNo$75.00D7511Incision and Drainage of Abscess - Intraoral Soft Tissue Complicated (includes drainage of multiple fascial spaces)YESYESNONO$90.00D7520Incision and Drainage of Abscess – Extraoral Soft TissueYesYesNoNo$150.00D7521Incision and Drainage of Abscess - Extraoral Soft Tissue-Complicated (includes drainage of multiple fascial spaces)YESYESNONO$165.00D7530Removal of Foreign Body from Mucosa, Skin, or Subcutaneous Alveolar TissueYesYesNoNo$100.00Proc.-46863047624Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7540Removal of Reaction Producing Foreign Bodies, Musculoskeletal SystemYESYESNONOBy ReportD7550Partial Ostectomy/Sequestrectomy for Removal of Non-Vital BoneYesYesNONOBy ReportD7560Maxillary Sinusotomy for Removal of Tooth Fragment or Foreign BodyYesYesNoNo$350.00TREATMENT OF FRACTURES - SIMPLE D7610Maxilla - Open Reduction (teeth immobilized, if present)YesYesNoNo$900.00D7620Maxilla - Closed Reduction (teeth immobilized, if present)YesYesNoNo$450.00D7630Mandible - Open Reduction (teeth immobilized, if present)YesYesNoNo$900.00D7640Mandible - Closed Reduction (teeth immobilized, if present)YesYesNoNo$450.00D7650Malar and/or Zygomatic Arch - Open ReductionYesYesNoNo$750.00D7660Malar and/or Zygomatic Arch - Closed ReductionYesYesNoNo$300.00D7670Alveolus – Closed Reduction, May Include Stabilization of TeethYesYesNoNo$400.00D7671Alveolus – Open Reduction, May Include Stabilization of TeethNONONot CoveredD7680Facial Bones - Complicated Reduction with Fixation and Multiple Surgical ApproachesYesYesNoNo$1,383.00TREATMENT OF FRACTURES - COMPOUND Proc.-392430101600Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7710Maxilla - Open ReductionYesYesNoNo$900.00D7720Maxilla - Closed ReductionYesYesNoNo$450.00D7730Mandible - Open ReductionYesYesNoNo$900.00D7740Mandible - Closed ReductionYesYesNoNo$450.00D7750Malar and/or Zygomatic Arch - Open ReductionYesYesNoNo$750.00D7760Malar and/or Zygomatic Arch - Closed ReductionYesYesNoNo$300.00D7770Alveolus – Open Reduction Stabilization of TeethYesYesNoNo$400.00D7771Alveolus, Closed Reduction Stabilization of Teethyesyesnono$400.00D7780Facial Bones - Complicated Reduction with Fixation and Multiple Surgical ApproachesYesYesNoNo$1,383.00REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHER TEMPOROMANDIBULAR JOINT DYSFUNCTIONS D7810Open Reduction of DislocationNONONot CoveredD7820Closed Reduction of DislocationNONONot CoveredD7830Manipulation Under AnesthesiaNONONot CoveredD7840CondylectomyNoNoNot CoveredD7850Surgical Discectomy, with/without ImplantYesYesYesYes$1,185.50D7852Disc RepairNoNoNot CoveredD7854SynovectomyNoNoNot CoveredD7856MyotomyNoNoNot CoveredD7858Joint ReconstructionNoNoNot CoveredProc.-430530123825Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7860ArthrotomyYesYesYesYes$1,185.50D7865ArthroplastyNONoNot CoveredD7870ArthrocentesisNONONot CoveredD7871Non-arthroscopic Lysis and LavageNONONot CoveredD7872Arthroscopy - Diagnosis, with or without BiopsyNONONot CoveredD7873Arthroscopy - Surgical; Lavage and Lysis of AdhesionsNONONot CoveredD7874Arthroscopy – Surgical; Disc Repositioning and StabilizationNONONot CoveredD7875Arthroscopy – Surgical; SynovectomyNONONot CoveredD7876Arthroscopy – Surgical; DiscectomyNONONot Covered-430087120177Eff. 7/1/1400Eff. 7/1/14D7877Arthroscopy – Surgical; DebridementNONONot CoveredD7880Occlusal Orthotic DeviceYesYesYesYes$250.00D7899Unspecified TMD Therapy, by ReportNONONot CoveredREPAIR OF TRAUMATIC WOUNDS D7910Suture of Recent Small Wounds Up to 5 cmYESYesNoNo$84.75COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE)D7911Complicated Suture - Up to 5 cmYesYesNoNo$193.00D7912Complicated Suture – Greater Than 5 cmYesYesNoNo$263.50Proc.-46863066675Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04OTHER REPAIR PROCEDURES-433705269240Eff. 7/1/1400Eff. 7/1/14D7920Skin Grafts (identify defect covered, location, and type of graft)NONONot CoveredD7921Collection and Application of Autologous Blood Concentrate ProductNONONot CoveredD7940Osteoplasty for Orthognathic DeformitiesYESYESYESYESBy ReportD7941Osteotomy – Mandibular RamiYESYESYESYESBy ReportD7943Osteotomy – Mandibular Rami with Bone Graft; Includes Obtaining The GraftYesYesYesYes$2,529.00D7944Osteotomy - Segmented or SubapicalYesYesYesYes$2,213.00D7945Osteotomy - Body of The MandibleYesYesYesYes$2,213.00D7946LeFort I (maxilla - total)YesYesYesYes$2,213.00D7947LeFort I (maxilla - segmented)YesYesYesYes$2,213.00D7948LeFort II or LeFort III (Osteoplasty of Facial Bones for Midface Hypoplasia or Retrusion) - without Bone GraftYesYesYesYes$2,213.00D7949LeFort II or LeFort III – with Bone GraftYesYesYesYES$2,529.00-419454363250Eff. 7/1/1400Eff. 7/1/14D7950Osseous, Osteoperiosteal, or Cartilage Graft of The Mandible or Maxilla - Autogenous or Nonautogenous, by ReportYesYesYesYesBy ReportD7951Sinus Augmentation with Bone or Bone Substitutes via a Lateral Open ApproachNONONot CoveredD7952Sinus Augmentation via a Vertical ApproachNONONot CoveredProc.-408822404701Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7953Bone Replacement Graft for Ridge Preservation - Per SiteYESYESNONOOnly reimbursable when necessary for bone graft for reconstruction of alveolar defect.$325.00D7955Repair of Maxillofacial Soft and/or Hard Tissue Defect YesYesNoNo$412.00-471347635Eff. 7/1/1400Eff. 7/1/14D7960Frenulectomy (Frenectomy or Frenotomy) - Separate Procedure Not Incidental to AnotherYesYesNoNO$97.00D7963FrenuloplastyYESYESNONO$125.00D7970Excision of Hyperplastic Tissue - Per ArchYesYesNONOOnly reimbursable when Hyperplastic Tissue prevents denture placement.$356.00D7971Excision of Pericoronal GingivaYesYesNONOOnly reimbursable when necessary to prevent chronic infection.$ 58.00D7972Surgical Reduction of Fibrous TuberosityYESyesyesyes$70.00D7980SialolithotomyYesYesNONOOnly reimbursable if removal of salivary stone is interfering with normal salivary gland function.$263.50D7981Excision of Salivary Gland, by ReportYesYesYesYesBy ReportD7982SialodochoplastyYesYesYesYesBy Report-474980-11105Eff. 7/1/1400Eff. 7/1/14D7983Closure of Salivary FistulaYesYesNONOOnly reimbursable for repair of draining salivary fistula.By ReportD7990Emergency TracheotomyYesYesNoNo $159.50-47117080335Eff. 7/1/1400Eff. 7/1/14D7991CoronoidectomyYesYesYesYesBy ReportD7995Synthetic Graft - Mandible or Facial BonesYesYesYesYes$1,106.50Proc.-373380114300Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D7996Implant - Mandible for Augmentation Purposes (Excluding Alveolar Ridge), by ReportNoNoNot CoveredD7997Appliance Removal (not by dentist who placed appliance), Includes Removal of ArchbarYESNoYESBy ReportD7998Intraoral Placement of a Fixation Device Not in Conjunction with a FractureNONONot CoveredD7999Unspecified Oral Surgery Procedure, by ReportYesYesYesYesBy Report-430530132080Eff. 7/1/1400Eff. 7/1/14XI. ORTHODONTICS (Orthodontics are not covered services for residents of ICF-IID facilities)LIMITED ORTHODONTIC TREATMENTD8010Limited Orthodontic Treatment of The Primary DentitionYesNoYes$332.50D8020Limited Orthodontic Treatment of The Transitional DentitionYesNoYes$332.50D8030Limited Orthodontic Treatment of The Adolescent DentitionYesNoYes$332.50D8040Limited Orthodontic Treatment of The Adult DentitionNoNoNot CoveredINTERCEPTIVE ORTHODONTIC TREATMENTD8050Interceptive Orthodontic Treatment of The Primary DentitionYesNoYes$592.00Proc.-392430104774Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D8060Interceptive Orthodontic Treatment of The Transitional DentitionYesNoYes$592.00COMPREHENSIVE ORTHODONTIC TREATMENT-39056969378Eff. 7/1/1400Eff. 7/1/14D8070Comprehensive Orthodontic Treatment of The Transitional DentitionYesNoYesThe Department will reimburse for one comprehensive orthodontic treatment per member per lifetime. D8070, D8080 and D8090 - all inclusive fee includes $2,725.00D8080Comprehensive Orthodontic Treatment of The Adolescent DentitionYesNoYesappliances, brackets, treatment visits, one appliance repair or$2,725.00D8090Comprehensive Orthodontic Treatment of The Adult DentitionYesNoYESreplacement, and one retainer repair or replacement. Covered to age 21$2,725.00MINOR TREATMENT TO CONTROL HARMFUL HABITSD8210Removable Appliance TherapyYesNoYes$375.00D8220Fixed Appliance TherapyYesNoYes$375.00OTHER ORTHODONTIC SERVICESD8660Pre-Orthodontic Treatment VisitYesNoNo$22.50Proc.-468630123824Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D8670Periodic Orthodontic Treatment Visit (as part of contract)YESNoYESCannot be billed in conjunction with D8070, D8080, D8090$66.00D8680Orthodontic Retention (removal of appliances, construction and placement of retainer(s))NoNoNot CoveredD8690Orthodontic Treatment (alternative billing to a contract fee)NoNoNot CoveredD8691Repair of Orthodontic ApplianceYESNOYES$75.00-48325040729Eff. 7/1/1400Eff. 7/1/14D8692Replacement of Lost or Broken RetainerYESNONO$125.00D8693Rebonding or Recementing of Fixed RetainersYESNONO$50.00D8999Unspecified Orthodontic Procedure, by ReportYesNoYesBy ReportXII. ADJUNCTIVE GENERAL SERVICESUNCLASSIFIED TREATMENTD9110Palliative (emergency) Treatment of Dental Pain - Minor ProcedureYesYesNoNo$35.00D9120Fixed Partial Denture SectioningNONONot CoveredANESTHESIAD9210Local Anesthesia not in Conjunction with Operative or Surgical ProceduresNoNoNot CoveredProc.-430530200024Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D9211Regional Block AnesthesiaNoNoNot Covered-432435119380Eff. 7/1/1400Eff. 7/1/14D9212Trigeminal Division Block AnesthesiaNoNoNot CoveredD9215Local Anesthesia in Conjunction with Operative or Surgical ProceduresNoNoNot CoveredD9220Deep Sedation/General Anesthesia – First 30 MinutesYesYesNONO$150.00-438785182275Eff. 7/1/1400Eff. 7/1/14D9221Deep Sedation/General Anesthesia - Each Additional 15 MinutesYesYesNONO$50.00D9230Inhalation of Nitrous Oxide/ Analgesia AnxiolysisYesYesNoNo$19.00D9241Intravenous Conscious Sedation/Analgesia - First 30 MinutesYesYES$150.00D9242Intravenous Conscious Sedation/Analgesia - Each Additional 15 MinutesYESYES$50.00D9248Non-Intravenous Conscious SedationNoNoNot CoveredPROFESSIONAL CONSULTATIOND9310Consultation - diagnostic service provided by dentist or physician other than Requesting Dentist or PhysicianYesYesNoNoDenturists may also use this code $31.00PROFESSIONAL VISITSProc.-459105123825Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04-461925449743Eff. 7/1/1400Eff. 7/1/14D9410House/Extended Care Facility CallYesYesNoNoLimited to dentist/denturist, only if medically necessary and providing a covered service under this policy $60.00D9420Hospital or Ambulatory Surgical Call CenterYesYesNoNoUse for emergency room trauma care $100.00D9430Office Visit for Observation (during regularly scheduled hours) - No Other Services PerformedYesYesNoNo $18.00D9440Office Visit - After Regularly Scheduled HoursYesYesNoNo $38.00D9450Case Presentation, Detailed and Extensive Treatment PlanningYesNOnoLimited to orthodontia$127.50DRUGSD9610Therapeutic Parenteral Drug, Single AdministrationYESYESNONOAcquisition cost only By ReportD9612Therapeutic Parenteral Drugs, Two or More Administrations, Different MedicationsYESYESNONOAcquisition cost only. Not to be reported in addition to D9610.By ReportD9630Other Drugs and/or Medications, by ReportYESYESNONOAcquisition cost onlyBy ReportMISCELLANEOUS SERVICESD9910Application of Desensitizing MedicamentNoNoNot CoveredProc.-440055200025Eff. 7/1/1400Eff. 7/1/14CodeDescriptionCovered ServiceAge/ICF-IIDPrior AuthorizationrequiredAdditional LimitsMaxAllowunder age 21 & all ICF-IID residents*age 21 & over when allowed under 25.04under age 21 & all ICF-IID residentsage 21 & over when allowed under 25.04D9911Application of Desensitizing Resin for Cervical and/or Root Surface, Per ToothNoNoNot Covered-45135228131Eff. 7/1/1400Eff. 7/1/14D9920Behavior ManagementYesNoNoLimit 3 visits per member per provider. Limited to dentist.$13.00 D9930Treatment of Complications (post-surgical) - Unusual CircumstancesYesYesNoNo$25.00D9940Occlusal GuardYesYesNONOOnly reimbursable when used in conjunction with bruxism and other occlusal habits to protect the dentition from parafunctional habits.$110.00D9941Fabrication of Athletic MouthguardNoNoNot CoveredD9942Repair and/or Reline of Occlusal GuardNONONot CoveredD9950Occlusion Analysis - Mounted CaseNoNoNot CoveredD9951Occlusal Adjustment - LimitedNoNoNot CoveredD9952Occlusal Adjustment - CompleteNoNoNot CoveredD9970Enamel MicroabrasionNoNoNot Covered-440218247015Eff. 7/1/1400Eff. 7/1/14D9971Odontoplasty 1-2 Teeth; Includes Removal of Enamel ProjectionsNoNoNot CoveredD9972External Bleaching – Per Arch Performed In OfficeNoNONot CoveredD9973External Bleaching – Per ToothNoNoNot Covered-439420118745Eff. 7/1/1400Eff. 7/1/14D9974Internal Bleaching – Per ToothNoNoNot CoveredD9975External Bleaching For Home Application, Per Arch; Includes Materials And Fabrication Of Custom TraysNONONot CoveredD9999Unspecified Adjunctive Procedure, by ReportYESYESYESYESBy Report ................
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