Attachment 01- Dental Codes-Fee Schedule .pdf

Attachment 01: Dental Codes/Fee Schedule – 720-5228-115358 Dental Services

Section #1- Basic care pre-approved dental codes (basic care and sedation paid at the fixed rate amounts)

D0120 Periodic oral evaluation established patient D0140 Limited oral evaluation-problem focused

D0150 Comprehensive oral evaluation new or established patient D0160 DTL and EXT oral eval problem focused report

D0170 Re-evaluation, limited problem focused

D0171 Re-eval post op office visit D0180 Comp perio eval

D0190 Screening of a patient D0191 Assessment of a patient D0210 Intra-oral complete series of radiographs D0220 Intraoral - periapical first radiographic image D0230 Intraoral - periapical each additional radiographic image

D0240 Intraoral - occlusal radiographic image D0250 Extraoral – first film D0251 Extraoral posterior

D0270 Bitewing - single radiographic image D0272 Bitewings - two radiographic images D0274 Bitewings - four radiographic images D0277 Vertical Bitewings 7-8 films

D0330 Panoramic radiographic image D0350 Oral facial photo image intra/extra oral D0419 Assessment of salivary flow by measurement D0425 Caries susceptibility test D0460 Pulp Vitality Test

D0470 Diagnostic casts D0601-0603 Caries Risk Assessment low to high risk D0604 Antigen test public health related D0605 Antibody test for public health related incl. coronavirus

D1110 Prophylaxis - adult D1206 Topical application of fluoride varnish D1208 Topical application of fluoride D1310 Nutritional counseling control of dental disease D1320 Tobacco counseling control and prevention D1321 Counseling for control and prevention of oral disease

D1330 Oral Hygiene Instruction

D1351 Sealant-per tooth D1354 Interim caries arresting medicament application(SDF) per quadrant unless otherwise pre-approved by DBHDS dental program lead

D2140 Amalgam - one surface D2150 Amalgam - two surfaces D2160 Amalgam - three surfaces

D2161 Amalgam - four or more surfaces

D2330 Resin-based composite - one surface, anterior

D2331 Resin-based composite - two surfaces, anterior

D2332 Resin-based composite - three surfaces, anterior D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior)

D2390 Resin-based composite crown anterior

D2391 Resin-based composite - one surface, posterior

D2392 Resin-based composite - two surfaces, posterior D2393 Resin-based composite - three surfaces, posterior D2394 Resin-based composite - four or more surfaces, posterior

D2940 Sedative filling

D4341 Periodontal scaling and root planing - four or more teeth per quadrant

D4342 Periodontal scaling and root planing - one to three teeth per quadrant

D4346 Scaling in presence of generalized moderate or severe gingival inflammation– full mouth, after oral evaluation

D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit

D4910 Periodontal maintenance procedures D9230 Analgesia nitrous D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes

D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15minute increment

D9248 Non-intravenous moderate (conscious) sedation/ per appointment D9986 Missed Appointment

*for individuals who have not provided the 24 hours notice.

After the second missed appointment individuals will need to reapply to the program.

$50.00 Paid to provider

D9986.01 Missed Sedation appointment *for individuals who have not provided the 24 hours notice.

After the second missed appointment individuals will need to reapply to the program.

$250.00 Paid to provider

D9995 Tele-dentistry – synchronous; real-time encounter

D9996 Tele-dentistry – asynchronous; information stored and forwarded to dentist for subsequent review

D9997 Dental Case Mgmt-sp healthcare concerns D9999 unspecified adjunctive procedure, by report

#2 Dental Extraction codes-

Code Description DBHDS Rate

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

$92.39

D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

$171.39

D7220 Removal of impacted tooth-soft tissue $206.21 D7230 Removal of impacted tooth-partially bony $285.21 D7240 Removal of impacted tooth-completely bony $330.73 D7241 Removal of impacted tooth-completely bony, with unusual surgical complications $356.17

D7250 Surgical removal of residual tooth roots (cutting procedure) $171.39

#3 DBHDS complete fee schedule to be used for anything considered to be outside of the DBHDS dental program or additional basic dental appointments beyond the two full-service visit required by contract.

Code Description DBHDS Rate

D0120 periodic oral evaluation established patient $26.99

D0140 limited oral evaluation-problem focused $33.25

D0150 Comprehensive oral evaluation new or established patient

*1 time per year

$41.92

D0160 DTL and EXT oral eval problem focused report $40.70

D0170 re-evaluation, limited problem focused $33.25

D0171 re-eval post op office visit $40.56

D0180 Comp perio eval

*1 time per year instead of the D0150 code

$41.92

D0190 Screening of a patient

*1 time per year or otherwise accompanied by documentation

$33.25

D0191 Assessment of a patient

*1 time per year or otherwise accompanied by documentation

$33.25

D0210 Intra-oral complete series of radiographs

*1 time every 3 years or as per patient necessity with documentation as per ADA recommendations

$96.28

D0220 intraoral - periapical first radiographic image $14.97

D0230 intraoral - periapical each additional radiographic image $14.97

D0240 intraoral - occlusal radiographic image $16.43

D0250 extraoral – first film $63.19

D0251 extraoral posterior $63.19

D0270 bitewing - single radiographic image $14.97

D0272 bitewings - two radiographic images

*1 time per year or as indicated

$26.99

D0274 bitewings - four radiographic images

*1 time per year or as indicated

$36.96

D0277 Vertical Bitewings 7-8 films $63.44

D0330 panoramic radiographic image

*1 time per 3 years or as per patient necessity with documentation as per ADA recommendations

$72.30

D0350 Oral facial photo image intra/extra oral $72.30

D0419 Assessment of salivary flow by measurement

*1 time per year and accompanied by ADA or comparable documentation

$5.65

D0425 Caries susceptibility test

*1 time per year and accompanied by ADA or comparable documentation

$50.25

D0460 Pulp Vitality Test $38.65

D0470 Diagnostic casts $67.80

D0601-0603 Caries Risk Assessment low to high risk

*1 time per year and accompanied by ADA or comparable documentation

$10.40

D0604 Antigen test public health related

*must have results

$26.00

D0605 Antibody test for public health related incl. coronavirus *must have results $26.00

D1110 Prophylaxis - adult

*2 times per year or as per patient treatment plan with documentation and prior approval

$63.19

D1206 Topical application of fluoride varnish $27.84

D1208 Topical application of fluoride $27.84

D1310 Nutritional counseling control of dental disease

*1 time per year and accompanied by ADA or comparable documentation

$26.00

D1320 Tobacco counseling control and prevention

*1 time per year and accompanied by ADA or comparable documentation

$26.00

D1321 Counseling for control and prevention of oral disease

*As needed and accompanied by ADA or comparable documentation

$26.00

D1330 Oral Hygiene Instruction $26.00

D1351 Sealant-per tooth $43.22

D1354 Interim caries arresting medicament application(SDF) per tooth $16.07

Fillings will not be covered for the same tooth number and surface unless documentation, oral photographs or xrays are provided to show rate of re-current decay or broken teeth.

D2140 Amalgam - one surface $79.51

D2150 Amalgam - two surfaces $101.14

D2160 Amalgam - three surfaces $119.41

D2161 Amalgam - four or more surfaces $134.38

D2330 Resin-based composite - one surface, anterior $99.46

D2331 Resin-based composite - two surfaces, anterior $119.41

D2332 Resin-based composite - three surfaces, anterior $154.35

D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior)

$177.63

D2390 Resin-based composite crown anterior $212.07

D2391 Resin-based composite - one surface, posterior $99.46

D2392 Resin-based composite - two surfaces, posterior $119.41

D2393 Resin-based composite - three surfaces, posterior $154.35

D2394 Resin-based composite - four or more surfaces, posterior $170.99

D2740 through D2794

Crowns by pre-authorization on teeth that have been root canal treated. $699.50

D2920 Re-cement or re-bond crown $58.20

D2928 Pre-fabrication porcelain/ceramic crown perm tooth $240.86

D2929 Pre-fab porcelain/ceramic crown primary tooth $240.86

D2930 Pre-fab stainless steel crown primary tooth $183.35

D2931 Prefabricated stainless-steel crown permanent tooth $183.35

D2932 Prefabricated resin crown $171.69

D2940 Sedative filling $54.87

D2950 Core buildup, including any pins when required $147.65

D2951 Pin retention - per tooth, in addition to restoration $26.60

D2952 Cast post and core in addition to crown $164.78

D2954 Prefabricated post and core in addition to crown $147.65

D3110 Pulp cap $24.65

D3120 Pulp cap indirect $24.65

D3221 Gross pulpal debridement $90.37

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $502.13

D3320 Endodontic therapy, premolar tooth (excluding final restoration) $575.77

D3330 Endodontic therapy, molar tooth (excluding final restoration) $909.18

D3346 Retreatment previous rc therapy-anterior $577.45

D3347 Re-treatment previous rc therapy pre-molar $662.14

D3348 Re-treatment previous rc therapy molar $1045.56

D4210 Gingivectomy or gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant

$455.61

D4211 Gingivectomy or gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant

$267.80

Periodontal therapies will be covered 1 time. Repeat procedures will need to be pre-approved with x-rays or oral photographs and periodontal measurements.

D4341 Periodontal scaling and root planing - four or more teeth per quadrant $124.71

D4342 Periodontal scaling and root planing - one to three teeth per quadrant $65.71

D4346 Scaling in presence of generalized moderate or severe gingival inflammation– full mouth, after oral evaluation

$63.19

D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit

$104.81

D4381 Loc delivery anti-microbial agent crevicular tissue- per quadrant $96.35

D4910 Periodontal maintenance procedures $83.14

D5110 Complete denture - maxillary $903.63

D5120 Complete denture - mandibular $903.63

D5211 Maxillary partial denture-resin base $884.62

D5212 Mandibular partial denture-resin base $884.62

D5213 Maxillary partial denture - cast metal framework $993.99

D5214 Mandibular partial denture - cast metal framework $993.99

D5410 Adjust complete denture-maxillary $43.22

D5421 Adjust partial denture- maxillary $26.60

D5422 Adjust partial denture- mandibular $26.60

D5511 Repair broken complete denture base mandibular $111.39

D5512 Repair broken complete denture base maxillary $111.39

D5520 Replace tooth complete denture $91.44

D5640 Replace tooth partial denture $146.31

D5650 Add tooth to partial denture $128.05

D5730 Reline complete maxillary denture (chair) $271.00

D5731 Reline complete mandibular denture (chair) $271.00

D5750 Reline complete maxillary denture (laboratory) $317.53

D5751 Reline complete mandibular denture (laboratory) $317.53

D6010 Surg placement implant body $1121.60

D6011 Second Stage implant surgery $346.40

D6013 Surgical placement of mini implant $1121.60

D6051 Interim abutment $404.80

D6057 Custom fabricated abutment – includes placement $521.60

D6058 Abutment supported porcelain/ceramic crown $776.80

D6065 Implant supported porcelain/ceramic crown $776.80

D6082 Implant suppt crown, porc fused to prefom base $744.00

D6092 Recement implant/abutment supported crown $86.40

D6242 Pontic- porc fused to noble metal $669.50

D6245 Pontic- porcelain ceramic $669.50

D6740 Retainer crown porcelain/ceramic $669.50

D6752 Retainer Crown- Porcelain fused to noble metal $669.50

D6930 Re-cement or re-bond bridge $63.33

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

$92.39

D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

$171.39

D7220 Removal of impacted tooth-soft tissue $206.21

D7230 Removal of impacted tooth-partially bony $285.21

D7240 Removal of impacted tooth-completely bony $330.73

D7241 Removal of impacted tooth-completely bony, with unusual surgical complications

$356.17

D7250 Surgical removal of residual tooth roots (cutting procedure) $171.39

D7260 Oroantral fistula closure $512.00

D7261 Primary closure of a sinus perforation $246.41

D7285 Incisional biopsy of oral tissue-hard (bone, tooth) $109.74

D7286 Incisional biopsy of oral tissue-soft $109.74

D7288 Brush biopsy - transepithelial sample collection $82.15

D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

$136.36

D7311 Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

$65.71

D7320 Alveoloplasty - not with extractions per quadrant $229.47

D7321 Alveoloplasty not with extractions 1 to 3 teeth $114.99

D7450 Removal of odontogenic cyst or tumor - lesion diameter up to 1.25cm $190.32

D7451 Removal of odontogenic cyst or tumor - lesion greater than 1.25cm $215.59

D7471 Removal of exostosis - per site $229.47

D7472 Removal of torus palate $328.59

D7473 Removal of torus mandible $229.47

D7510 Incision and drainage of abscess intraoral soft tissue $44.56

D7511 Incision and drainage of abscess intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

$91.05

D7880 Occlusal orthotic device $524.09

D9110 Palliative (emergency) treatment of dental pain - minor procedure $64.85

General anesthesia will be considered with documentation as to why another sedation method is not appropriate for the individual. It will otherwise be paid at the conscious moderate sedation rate.

D9222 deep sedation/general anesthesia first 15 minutes

*See D9999

$85.70

D9223 deep sedation/general anesthesia - each subsequent 15-minute increment

*See D9999

$85.70

Sedation will be covered for approved individuals up to 2 times per year.

Additional sedation visits must be submitted as a special treatment plan and is subject to approval and availability of funds

D9230 Analgesia nitrous $45.18

D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes

*See D9999

$70.30

D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15minute increment

*See D9999

$70.30

D9248 Non-intravenous moderate (conscious) sedation/ per appointment $147.29

D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician

$111.39

D9410 House/extended care facility $105.32

D9420 Hospital call $86.45

D9610 Therapeutic drug injection $26.60

D9630 Other drugs and/or medicaments $26.60

D9930 Treatment of complications (post- surgical) $44.89

D9986 Missed Appointment

*For individuals who have not provided the 24 hours’ notice. After the second missed appointment individuals will need to reapply to the program.

$50.00

D9986.01 Missed Sedation appointment

*For individuals who have not provided the 24 hours’ notice. After the second missed appointment individuals will need to reapply to the program.

$250.00

D9990 Translation language services $16.74

D9992 Dental case management-care coordination $11.08

D9994 Dental case management-patient education $11.08

D9995 Teledentistry – synchronous; real-time encounter $46.87

D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

$20.09

D9997 Dental Case Mgmt-sp healthcare concerns

*1 time per year

$37.00

D9999 Unspecified adjunctive procedure, by report

**Code to be used as an adjunctive procedure during IV conscious moderate sedation or approved general anesthesia. Code is 1 time per 60 minutes. Subject to review of sedation record at the time of billing.

**Code can be used as a one-time add on for non-IV cons moderate sedation..

$193.80