Return to MDA News

Proc Cd Procedure Description Effective Date Fee Schedule PA Min Age Max Age 08 Fee
  DIAGNOSTICS            
D0120 PERIODIC ORAL EVALUATION, Adults allowed every 6 months. 10/01/2007 FEE SCHED N 0 999 21.60
D0140 LIMIT ORAL EVAL PROBLM FOCUS 10/01/2007 FEE SCHED N 0 999 30.85
D0150 COMPREHENSVE ORAL EVALUATION, Initial visit for new clients of record.  Adults allowed every 3 yrs. 10/01/2007 FEE SCHED N 0 999 30.85
  RADIOGRAPHS            
D0210 INTRAOR COMPLETE FILM SERIES, min of 14 films, 1 film=1 unit of service, adults every 3 yrs. 10/01/2007 FEE SCHED N 0 999 61.70
D0220 INTRAORAL PERIAPICAL FIRST F 10/01/2007 FEE SCHED N 0 999 15.43
D0230 INTRAORAL PERIAPICAL EA ADD 10/01/2007 FEE SCHED N 0 999 7.71
D0240 INTRAORAL OCCLUSAL FILM 10/01/2007 FEE SCHED N 0 999 18.51
D0250 EXTRAORAL FIRST FILM 10/01/2007 FEE SCHED N 0 999 30.85
D0260 EXTRAORAL EA ADDITIONAL FILM 10/01/2007 FEE SCHED N 0 999 21.60
D0270 DENTAL BITEWING SINGLE FILM, adults limitred to 4 films per year. 10/01/2007 FEE SCHED N 0 999 15.43
D0272 DENTAL BITEWINGS TWO FILMS, adults limited to 4 films per year. 10/01/2007 FEE SCHED N 0 999 18.51
D0273 BITEWINGS - THREE FILMS 10/01/2007 FEE SCHED N 0 999 24.68
D0274 DENTAL BITEWINGS FOUR FILMS, adults limited to 4 films per year. 10/01/2007 FEE SCHED N 0 999 30.85
D0275 BITEWINGS-EACH ADDITIONAL FILM 10/01/2007 FEE SCHED N 0 999 7.71
D0277 VERTICAL BITEWINGS-SEVEN TO EIGHT FILMS. 10/01/2007 FEE SCHED N 0 999 37.02
D0330 DENTAL PANORAMIC FILM, afults limited to 1 film every 3 years. 10/01/2007 FEE SCHED N 0 999 49.36
D0340 DENTAL CEPHALOMETRIC FILM, adults alloweed 1 full mouth every 3 yrs. 10/01/2007 FEE SCHED N 0 999 61.70
D0350 ORAL/FACIAL PHOTO IMAGES 10/01/2007 FEE SCHED N 0 999 30.85
D0360 CONE BEAM CT 10/01/2007 BY REPORT N 0 999 85%
D0362 CONE BEAM, TWO DIMENSIONAL 10/01/2007 BY REPORT N 0 999 85%
D0363 CONE BEAM, THREE DIMENSIONAL 10/01/2007 BY REPORT N 0 999 85%
D0460 PULP VITALITY TEST 10/01/2007 FEE SCHED N 0 20 24.68
D0470 DIAGNOSTIC CASTS 10/01/2007 FEE SCHED N 18 20 38.56
D0486 ACCESSION OF BRUSH BIOPSY 10/01/2007 BY REPORT N 0 999 85%
  PREVENTIVE:  Prophylaxis            
D1110 DENTAL PROPHYLAXIS ADULT, every 6 months 10/01/2007 FEE SCHED N 0 999 46.28
D1120 DENTAL PROPHYLAXIS CHILD 10/01/2007 FEE SCHED N 0 999 30.85
  PREVENTIVE:  Fluoride            
D1203 TOPICAL FLUOR W/O PROPHY CHI 10/01/2007 FEE SCHED N 0 17 15.43
D1204 TOPICAL FLUOR W/O PROPHY ADULT, every 6 months 10/01/2007 FEE SCHED N 18 999 15.43
D1206 TOPICAL FLUORIDE VARNISH mod-high risk 10/01/2007 FEE SCHED N 0 20 80.21
  PREVENTIVE:  Sealant            
D1351 DENTAL SEALANT PER TOOTH 10/01/2007 FEE SCHED N 0 20 24.68
               
  PREVENTIVE:  Space Maintenance            
D1510 SPACE MAINTAINER FXD UNILAT 10/01/2007 FEE SCHED N 0 20 123.40
D1515 FIXED BILAT SPACE MAINTAINER 10/01/2007 FEE SCHED N 0 20 185.10
D1550 RECEMENT SPACE MAINTAINER 10/01/2007 FEE SCHED N 0 20 37.02
D1555 REMOVE FIX SPACE MAINTAINER 10/01/2007 BY REPORT N 0 20 85%
  RESTORATION:  Amalgam Fillings            
D2140 AMALGAM ONE SURFACE PERMANEN 10/01/2007 FEE SCHED N 0 999 61.70
D2150 AMALGAM TWO SURFACES PERMANE 10/01/2007 FEE SCHED N 0 999 67.87
D2160 AMALGAM THREE SURFACES PERMA 10/01/2007 FEE SCHED N 0 999 83.30
D2161 AMALGAM 4 OR > SURFACES PERM 10/01/2007 FEE SCHED N 0 999 101.81
  RESTORATION:  Resin-Based Compostie            
D2330 RESIN ONE SURFACE-ANTERIOR 10/01/2007 FEE SCHED N 0 999 61.70
D2331 RESIN TWO SURFACES-ANTERIOR 10/01/2007 FEE SCHED N 0 999 92.55
D2332 RESIN THREE SURFACES-ANTERIO 10/01/2007 FEE SCHED N 0 999 107.98
D2335 RESIN 4/> SURF OR W INCIS ANTERIOR 10/01/2007 FEE SCHED N 0 999 123.40
D2390 ANT RESIN-BASED CMPST CROWN 10/01/2007 FEE SCHED N 0 999 209.78
D2391 POST 1 SRFC RESINBASED CMPST 10/01/2007 FEE SCHED N 0 999 61.70
D2392 POST 2 SRFC RESINBASED CMPST 10/01/2007 FEE SCHED N 0 999 123.40
D2393 POST 3 SRFC RESINBASED CMPST 10/01/2007 FEE SCHED N 0 999 166.59
D2394 POST >=4SRFC RESINBASE CMPST 10/01/2007 FEE SCHED N 0 999 175.85
  CROWNS:  Non-Pre-Fab Crowns            
  ANTERIOR (6-11 AND 22-27) ONLY, unless needed for abutments. 1 per 5YRS, ages 0-20.            
D2710 CROWN RESIN-BASED INDIRECT 10/01/2007 FEE SCHED N 0 20 308.50
D2712 CROWN 3/4 RESIN-BASED COMPOS 10/01/2007 FEE SCHED N 0 20 456.58
D2720 CROWN RESIN W/ HIGH NOBLE ME 10/01/2007 FEE SCHED N 0 20 617.00
D2721 CROWN RESIN W/ BASE METAL 10/01/2007 FEE SCHED N 0 20 462.75
D2722 CROWN RESIN W/ NOBLE METAL 10/01/2007 FEE SCHED N 0 20 524.45
D2740 CROWN PORCELAIN/CERAMIC SUBS 10/01/2007 FEE SCHED N 0 20 617.00
D2750 CROWN PORCELAIN W/ H NOBLE M 10/01/2007 FEE SCHED N 0 20 678.70
D2751 CROWN PORCELAIN FUSED BASE M 10/01/2007 FEE SCHED N 0 20 493.60
D2752 CROWN PORCELAIN W/ NOBLE MET 10/01/2007 FEE SCHED N 0 20 555.30
D2780 CROWN 3/4 CAST HI NOBLE MET 10/01/2007 FEE SCHED N 0 20 555.30
D2781 CROWN 3/4 CAST BASE METAL 10/01/2007 FEE SCHED N 0 20 401.05
D2782 CROWN 3/4 CAST NOBLE METAL 10/01/2007 FEE SCHED N 0 20 462.75
D2783 CROWN 3/4 PORCELAIN/CERAMIC 10/01/2007 FEE SCHED N 0 20 586.15
D2790 CROWN FULL CAST HIGH NOBLE M 10/01/2007 FEE SCHED N 0 20 586.15
D2791 CROWN FULL CAST BASE METAL 10/01/2007 FEE SCHED N 0 20 431.90
D2792 CROWN FULL CAST NOBLE METAL 10/01/2007 FEE SCHED N 0 20 493.60
D2794 CROWN-TITANIUM 10/01/2007 FEE SCHED N 0 20 492.98
D2799 PROVISIONAL CROWN 10/01/2007 FEE SCHED N 0 20 308.50
  CROWNS:  Pre-Fab and Other (Clients w/Full Medicaid, 1 per 5yrs)            
D2910 RECEMENT INLAY ONLAY OR PART 10/01/2007 FEE SCHED N 0 999 46.28
D2920 DENTAL RECEMENT CROWN 10/01/2007 FEE SCHED N 0 999 46.28
D2930 PREFAB STNLSS STEEL CRWN PRIMARY TOOTH 10/01/2007 FEE SCHED N 0 999 123.40
D2931 PREFAB STNLSS STEEL CROWN PERMANENT 10/01/2007 FEE SCHED N 0 999 185.10
D2932 PREFABRICATED RESIN CROWN 10/01/2007 FEE SCHED N 0 999 148.08
D2933 PREFAB STAINLESS STEEL CROWN 10/01/2007 FEE SCHED N 0 999 138.83
D2940 DENTAL SEDATIVE FILLING 10/01/2007 FEE SCHED N 0 999 46.28
D2950 CORE BUILD-UP INCLUDNG ANY PINS 10/01/2007 FEE SCHED N 0 999 123.40
D2951 TOOTH PIN RETENTION 10/01/2007 FEE SCHED N 0 20 30.85
D2952 POST AND CORE CAST + CROWN 10/01/2007 FEE SCHED N 0 999 246.80
D2953 EACH ADDTNL CAST POST 10/01/2007 FEE SCHED N 0 999 200.53
D2954 PREFAB POST/CORE + CROWN 10/01/2007 FEE SCHED N 0 999 154.25
D2957 EACH ADDTNL PREFAB POST 10/01/2007 FEE SCHED N 0 999 107.98
D2960 LAMINATE LABIAL VENEER 10/01/2007 FEE SCHED N 0 999 185.10
D2961 LAB LABIAL VENEER RESIN 10/01/2007 FEE SCHED N 0 999 308.50
D2962 LAB LABIAL VENEER PORCELAIN 10/01/2007 FEE SCHED N 0 999 444.24
D2980 CROWN REPAIR 10/01/2007 FEE SCHED N 0 999 126.49
D2999 DENTAL UNSPEC RESTORATIVE PR 10/01/2007 BY REPORT N 0 999 85%
  ENDODONTICS            
D3110 PULP CAP DIRECT 10/01/2007 FEE SCHED N 0 999 38.56
D3120 PULP CAP INDIRECT 10/01/2007 FEE SCHED N 0 999 30.85
D3220 THERAPEUTIC PULPOTOMY 10/01/2007 FEE SCHED N 0 20 92.55
D3221 GROSS PULPAL DEBRIDEMENT 10/01/2007 FEE SCHED N 0 999 123.40
D3230 PULPAL THERAPY ANTERIOR PRIMARY 10/01/2007 FEE SCHED N 0 20 101.81
D3240 PULPAL THERAPY POSTERIOR PRIMARY 10/01/2007 FEE SCHED N 0 20 114.15
D3310 ANTERIOR 10/01/2007 FEE SCHED N 0 999 314.67
D3320 ROOT CANAL THERAPY 2 CANALS 10/01/2007 FEE SCHED N 0 999 354.78
D3330 ROOT CANAL THERAPY 3 CANALS 10/01/2007 FEE SCHED N 0 999 431.90
D3331 NON-SURG TX ROOT CANAL OBS 10/01/2007 FEE SCHED N 0 999 311.59
D3346 RETREAT ROOT CANAL ANTERIOR 10/01/2007 FEE SCHED N 0 999 339.35
D3347 RETREAT ROOT CANAL BICUSPID 10/01/2007 FEE SCHED N 0 999 413.39
D3348 RETREAT ROOT CANAL MOLAR 10/01/2007 FEE SCHED N 0 999 509.03
D3410 APICOECT/PERIRAD SURG ANTER 10/01/2007 FEE SCHED N 0 20 280.74
D3421 ROOT SURGERY BICUSPID 10/01/2007 FEE SCHED N 0 20 323.93
D3425 ROOT SURGERY MOLAR 10/01/2007 FEE SCHED N 0 20 360.95
D3426 ROOT SURGERY EA ADD ROOT 10/01/2007 FEE SCHED N 0 20 299.25
D3430 RETROGRADE FILLING 10/01/2007 FEE SCHED N 0 999 92.55
  PERIODONTICS            
  1quaddrant=1 unit of service.  LL-Lower Left, UL- Upper Left, LR- Lower Right, UP- Upper Right            
D4210 GINGIVECTOMY/PLASTY PER QUAD 10/01/2007 FEE SCHED N 0 20 293.08
D4211 GINGIVECTOMY/PLASTY PER TOOT 10/01/2007 FEE SCHED N 0 20 252.97
D4230 ANA CROWN EXP 4 OR> PER QUAD 10/01/2007 BY REPORT N 0 20 85%
D4231 ANA CROWN EXP 1-3 PER QUAD 10/01/2007 BY REPORT N 0 20 85%
D4240 GINGIVAL FLAP PROC W/ PLANIN 10/01/2007 FEE SCHED N 0 20 336.27
D4241 GNGVL FLAP W ROOTPLAN 1-3 TH 10/01/2007 FEE SCHED N 0 20 95.64
D4260 OSSEOUS SURGERY PER QUADRANT 10/01/2007 FEE SCHED N 0 999 493.60
D4261 OSSEOUS SURGL-3TEETHPERQUAD 10/01/2007 FEE SCHED N 0 999 246.80
D4270 PEDICLE SOFT TISSUE GRAFT PR 10/01/2007 FEE SCHED N 0 999 376.37
D4271 FREE SOFT TISSUE GRAFT PROC 10/01/2007 FEE SCHED N 0 999 388.71
D4320 PROVISION SPLNT INTRACORONAL 10/01/2007 FEE SCHED N 0 999 209.78
D4321 PROVISIONAL SPLINT EXTRACORO 10/01/2007 FEE SCHED N 0 999 185.10
D4341 PERIODONTAL SCALING & ROOT 10/01/2007 FEE SCHED N 0 999 154.25
D4342 PERIODONTAL SCALING 1-3TEETH 10/01/2007 FEE SCHED N 0 999 83.30
D4355 FULL MOUTH DEBRIDEMENT 10/01/2007 FEE SCHED N 0 999 77.13
D4910 PERIODONTAL MAINT PROCEDURES 10/01/2007 FEE SCHED N 0 999 61.70
D4920 UNSCHEDULED DRESSING CHANGE 10/01/2007 FEE SCHED N 0 999 40.11
D4999 UNSPECIFIED PERIODONTAL PROC 10/01/2007 BY REPORT N 0 999 85%
  PROSTHODONTICS:  Removable            
  Partials, 1 per 5 yrs if lost, Full, 1 per 10 yrs if lost.  Call to verify.            
D5110 DENTURES COMPLETE MAXILLARY 10/01/2007 FEE SCHED N 0 999 771.25
D5120 DENTURES COMPLETE MANDIBLE 10/01/2007 FEE SCHED N 0 999 771.25
D5130 DENTURES IMMEDIAT MAXILLARY 10/01/2007 FEE SCHED N 0 999 848.38
D5140 DENTURES IMMEDIAT MANDIBLE 10/01/2007 FEE SCHED N 0 999 848.38
D5211 DENTURES MAXILL PART RESIN 10/01/2007 FEE SCHED N 0 999 524.45
D5212 DENTURES MAND PART RESIN 10/01/2007 FEE SCHED N 0 999 546.05
D5213 DENTURES MAXILL PART METAL 10/01/2007 FEE SCHED N 0 999 925.50
D5214 DENTURES MANDIBL PART METAL 10/01/2007 FEE SCHED N 0 999 925.50
D5225 MAXILLARY PART DENTURE FLEX 10/01/2007 FEE SCHED N 0 999 677.47
D5226 MANDIBULAR PART DENTURE FLEX 10/01/2007 FEE SCHED N 0 999 678.70
D5410 DENTURES ADJUST CMPLT MAXIL 10/01/2007 FEE SCHED N 0 999 37.02
D5411 DENTURES ADJUST CMPLT MAND 10/01/2007 FEE SCHED N 0 999 37.02
D5421 DENTURES ADJUST PART MAXILL 10/01/2007 FEE SCHED N 0 999 37.02
D5422 DENTURES ADJUST PART MANDBL 10/01/2007 FEE SCHED N 0 999 37.02
D5510 DENTUR REPR BROKEN COMPL BAS 10/01/2007 FEE SCHED N 0 999 92.55
D5520 REPLACE DENTURE TEETH COMPLT 10/01/2007 FEE SCHED N 0 999 61.70
D5610 DENTURES REPAIR RESIN BASE 10/01/2007 FEE SCHED N 0 999 92.55
D5620 REP PART DENTURE CAST FRAME 10/01/2007 FEE SCHED N 0 999 126.49
D5630 REP PARTIAL DENTURE CLASP 10/01/2007 FEE SCHED N 0 999 114.15
D5640 REPLACE PART DENTURE TEETH 10/01/2007 FEE SCHED N 0 999 92.55
D5650 ADD TOOTH TO PARTIAL DENTURE 10/01/2007 FEE SCHED N 0 999 92.55
D5660 ADD CLASP TO PARTIAL DENTURE 10/01/2007 FEE SCHED N 0 999 154.25
D5710 DENTURES REBASE CMPLT MAXIL 10/01/2007 FEE SCHED N 0 999 308.50
D5711 DENTURES REBASE CMPLT MAND 10/01/2007 FEE SCHED N 0 999 308.50
D5720 DENTURES REBASE PART MAXILL 10/01/2007 FEE SCHED N 0 999 246.80
D5721 DENTURES REBASE PART MANDBL 10/01/2007 FEE SCHED N 0 999 246.80
D5730 DENTURE RELN CMPLT MAXIL CH 10/01/2007 FEE SCHED N 0 999 185.10
D5731 DENTURE RELN CMPLT MAND CHR 10/01/2007 FEE SCHED N 0 999 185.10
D5740