10 Colo. Code Regs. § 2505-10-8.900, app 10 CCR 2505-10-8.960-A
Capitalized terms within this appendix shall have the meaning specified in the Definitions section.
Procedure Description | Alpha- numeric Code | Max Allowable Fee | Program Payment | Max Client Co-Pay | PROGRAM GUIDELINES |
Periodic oral evaluation - established client | D0120 | $46.00 | $46.00 | $0.00 | Evaluation performed on a client of record to determine any changes in the client's dental and medical health status since a previous comprehensive or periodic evaluation. This includes an oral cancer evaluation, periodontal screening where indicated, and may require interpretation of information acquired through additional diagnostic procedures. The findings are discussed with the client. Report additional diagnostic procedures separately. Frequency: One time per 6 month period per client. |
Limited oral evaluation - problem focused | D0140 | $63.14 | $53.14 | $10.00 | This code must be used in association with a specific oral health problem or complaint and is not to be used to address situations that arise during multi-visit treatments covered by a single fee, such as, endodontic or post-operative visits related to treatments including prosthesis. Specific problems may include dental emergencies, trauma, acute infections, etc. Cannot be used for adjustments made to prosthesis provided within previous 6 months. Cannot be used as an encounter fee. Frequency: Two of D0140 per year per grantee. Not reimbursable on the same date as D0120 or D0150. Dental hygienists may only provide for an established client of record. |
Comprehensive oral evaluation - new or established client | D0150 | $81.00 | $81.00 | $0.00 | Evaluation used by general dentist or a specialist when evaluating a client comprehensively. Applicable to new clients; established clients with significant health changes or other unusual circumstances; or established clients who have been absent from active treatment for three or more years. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues, and an evaluation and recording of the client's dental and medical history and general health assessment. A periodontal evaluation, oral cancer evaluation, diagnosis and treatment planning should be included. Frequency: 1 per 3 years per client. Cannot be charged on the same date as D0180. |
Comprehensive periodontal evaluation - new or established client | D0180 | $88.00 | $88.00 | $0.00 | Evaluation for clients presenting signs & symptoms of periodontal disease & clients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the client's dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships and oral cancer evaluation. Frequency: 1 per 3 years per client. Cannot be charged on the same date as D0150. |
Intraoral - comprehensive series of radiographic images | D0210 | $125.00 | $125.00 | $0.00 | Radiographic survey of whole mouth, intended to display the crowns & roots of all teeth, periapical areas, interproximal areas and alveolar bone including edentulous areas. Panoramic radiographic image & bitewing radiographic images taken on the same date of service shall not be billed as a D0210. Payment for additional periapical radiographs within 60 days of a full month series or a panoramic film is not covered unless there is evidence of trauma. Frequency: 1 per 5 years per client. Any combination of x-rays taken on the same date of service that equals or exceeds the max allowable fee for D0210 must be billed and reimbursed as D0210. Should not be charged in addition to panoramic film D0330. Either D0330 or D0210 per 5 year period. |
Intraoral - periapical first radiographic image | D0220 | $25.00 | $25.00 | $0.00 | Six of D0220 per 12 months per client. Report additional radiographs as D0230. Working and final endodontic treatment films are not covered. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. |
Intraoral - periapical each additional radiographic image | D0230 | $23.00 | $23.00 | $0.00 | D0230 must be utilized for additional films taken beyond D0220. Working and final endodontic treatment films are included in the endo codes. Not covered if billed with D3310, D3320, or D3330. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. |
Bitewing - single radiographic image | D0270 | $26.52 | $26.52 | $0.00 | Frequency: 1 in a 12 month period. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. |
Bitewings - two radiographic images | D0272 | $42.00 | $42.00 | $0.00 | Frequency: 1 time in a 12 month period. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. |
Bitewings - three radiographic images | D0273 | $52.00 | $52.00 | $0.00 | Frequency: 1 time in a 12 month period. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. |
Bitewings - four radiographic images | D0274 | $60.00 | $60.00 | $0.00 | Frequency: 1 time in a 12 month period. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. |
Vertical bitewings - seven to eight radiographic images | D0277 | $68.32 | $68.32 | $0.00 | Frequency: 1 time in a 12-month period. Counts as an intraoral complete series. Any combination of D0220 through D0277 taken on the same date of service that exceeds the max allowed fee for D0210 is reimbursed at the same fee as D0210. |
Panoramic radiographic image | D0330 | $63.00 | $63.00 | $0.00 | Frequency: 1 per 5 years per client. Cannot be charged in addition to full mouth series D0210. Either D0330 or D0210 per 5 years. |
Prophylaxis - adult | D1110 | $97.50 | $97.50 | $0.00 | Removal of plaque, calculus and stains from the tooth structures with intent to control local irritational factors. Frequency: * 1 time per 6 calendar months; 2 week window accepted. * May be billed for routine prophylaxis. * D1110 may be billed with D4341 and D4342 one time during initial periodontal therapy for prophylaxis of areas of the mouth not receiving nonsurgical periodontal therapy. When this option is used, individual should still be placed on D4910 for maintenance of periodontal disease. D1110 can only be charged once, not per quadrant, and represents areas of the mouth not included in the D4341 or D4342 being reimbursed. * May be alternated with D4910 for maintenance of periodontally-involved individuals. * D1110 cannot be billed on the same day as D4346 * Cannot be used as 1 month re-evaluation following nonsurgical periodontal therapy. |
Topical application of fluoride varnish | D1206 | $52.00 | $52.00 | $0.00 | Topical fluoride application is to be used in conjunction with prophylaxis or preventive appointment. Should be applied to whole mouth. Frequency: up to four (4) times per 12 calendar months. Cannot be used with D1208. |
Topical application of fluoride - excluding varnish | D1208 | $52.00 | $52.00 | $0.00 | Any fluoride application, including swishing, trays or paint on variety, to be used in conjunction with prophylaxis or preventive appointment. Frequency: one (1) time per 12 calendar months. Cannot be used with D1206. D1206 varnish should be utilized in lieu of D1208 whenever possible. |
Application of caries arresting medicament - per tooth | D1354 | $54.53 | $54.53 | $0.00 | Two of D1354 per 12 months per patient per tooth for primary and permanent teeth. Not to exceed 4 times per tooth in a lifetime. Cannot be billed on the same day as D1355 or any D2000 series code (D2140-D2954). Must Report tooth number. |
Caries preventive medicament application - per tooth | D1355 | $5.74 | $5.74 | $0.00 | For primary prevention or remineralization. Medicaments applied do not include topical fluorides. Medicaments that may be applied during the delivery of D1355 procedure include Silver Diamine Fluoride (SDF), Silver Nitrate (SN), thymol-CHX varnish, and topical povidone iodine (PVP-I). Cannot be billed on the same day as: D1206, D1208, D1354, D0140, D9110, or any restoration codes on the same day or within 12 months of D2140 thru D2954. Maximum of four D1355 per tooth per lifetime. Must report tooth number. |
Amalgam Restorations (including polishing): Tooth preparation, all adhesives (including amalgam bonding agents), liners and bases are included as part of the restoration. If pins are used, they should be reported separately (see D2951). | |||||
Amalgam - one surface, primary or permanent | D2140 | $120.02 | $110.02 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Amalgam - two surfaces, primary or permanent | D2150 | $150.59 | $140.59 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Amalgam - three surfaces, primary or permanent | D2160 | $182.40 | $172.40 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Amalgam - four or more surfaces, primary or permanent | D2161 | $218.93 | $208.93 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-Based Composite Restorations - Direct: Resin-based composite refers to a broad category of materials including but not limited to composites. May include bonded composite, light-cured composite, etc. Tooth preparation, acid etching, adhesives (including resin bonding agents), liners and bases, and curing are included as part of the restoration. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, they should be reported separately (see D2951). | |||||
Resin-based composite - one surface, anterior | D2330 | $116.82 | $106.82 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-based composite - two surfaces, anterior | D2331 | $146.00 | $136.00 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-based composite - three surfaces, anterior | D2332 | $179.00 | $169.00 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-based composite - four or more surfaces or involving incisal angle (anterior) | D2335 | $212.00 | $202.00 | $10.00 | Incisal angle to be defined as one of the angles formed by the junction of the incisal and the mesial or distal surface of an anterior tooth. Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-based composite - one surface, posterior | D2391 | $134.00 | $124.00 | $10.00 | Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive procedure. Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-based composite -two surfaces, posterior | D2392 | $176.00 | $166.00 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-based composite - three surfaces, posterior | D2393 | $218.00 | $208.00 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Resin-based composite - four or more surfaces, posterior | D2394 | $268.00 | $258.00 | $10.00 | Frequency: 36 months for the same restoration. See Explanation of Restorations. |
Crown - porcelain/ceramic | D2740 | $899.16 | $849.16 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - porcelain fused to high noble metal | D2750 | $891.06 | $841.06 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - porcelain fused to predominantly base metal | D2751 | $817.03 | $767.03 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - porcelain fused to noble metal | D2752 | $848.29 | $798.29 | $50.00 | Only one the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - 3/4 cast predominantly base metal | D2781 | $780.00 | $730.00 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - 3/4 cast noble metal | D2782 | $780.00 | $730.00 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - 3/4 porcelain/ceramic | D2783 | $780.00 | $730.00 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - full cast high noble metal | D2790 | $918.62 | $868.62 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - full cast predominantly base metal | D2791 | $780.00 | $730.00 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - full cast noble metal | D2792 | $780.00 | $730.00 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Crown - titanium | D2794 | $886.88 | $836.88 | $50.00 | Only one of the following will be reimbursed each 84 months per client per tooth: D2740, D2750, D2751, D2752, D2781, D2782, D2783, D2790, D2791, D2792, or D2794. Second molars are only covered if it is necessary to support a partial denture or to maintain eight posterior teeth in occlusion. |
Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration | D2910 | $87.00 | $77.00 | $10.00 | Not allowed within 6 months of placement. |
Re-cement or re-bond crown | D2920 | $89.00 | $79.00 | $10.00 | Not allowed within 6 months of placement. |
Core buildup, including any pins when required | D2950 | $225.00 | $200.00 | $25.00 | Only one of the following will be reimbursed per 84 months per client per tooth. D2950, D2952, or D2954. Refers to building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity in a preparation. Not payable on the same tooth and same day as D2951. |
Pin retention per tooth | D2951 | $50.00 | $40.00 | $10.00 | Pins placed to aid in retention of restoration. Can only be used in combination with a multi-surface amalgam. |
Cast post and core in addition to crown | D2952 | $332.00 | $307.00 | $25.00 | Only one of the following will be reimbursed per 84 months per client per tooth. D2950, D2952, or D2954. Refers to building up of anatomical crown when restorative crown will be placed. Not payable on the same tooth and same day as D2951. |
Prefabricated post and core in addition to crown | D2954 | $269.00 | $244.00 | $25.00 | Only one of the following will be reimbursed per 84 months per client per tooth. D2950, D2952, or D2954. Core is built around a prefabricated post. This procedure includes the core material and refers to building up of anatomical crown when restorative crown will be placed. Not payable on the same tooth and same day as D2951. |
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) Includes primary teeth without succedaneous teeth and permanent teeth. Complete root canal therapy; pulpectomy is part of root canal therapy. Includes all appointments necessary to complete treatment; also includes intra-operative radiographs. Does not include diagnostic evaluation and necessary radiographs/diagnostic images. | |||||
Endodontic therapy, anterior tooth (excluding final restoration) | D3310 | $849.76 | $799.76 | $50.00 | Frequency: One D3310 per lifetime per client per tooth. Teeth covered: 6-11 and 22-27. |
Endodontic therapy, premolar tooth (excluding final restoration) | D3320 | $967.71 | $917.71 | $50.00 | Frequency: One D3320 per lifetime per client per tooth. Teeth covered: 4, 5, 12, 13, 20, 21, 28, and 29. |
Endodontic therapy, molar tooth (excluding final restoration) | D3330 | $1,159.31 | $1,109.31 | $50.00 | Frequency: One D3330 per lifetime per client per tooth. Teeth covered: 2, 3, 14, 15, 18, 19, 30, and 31. |
Periodontal scaling & root planing - four or more teeth per quadrant | D4341 | $276.51 | $266.51 | $10.00 | Involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. For clients with periodontal disease and is therapeutic, not prophylactic. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in others. Frequency: * 1 time per quadrant per 36 month interval. * No more than 2 quadrants may be considered in a single visit in a non-hospital setting. * Cannot be charged on same date as D4346. * Any follow-up and re-evaluation are included in the initial reimbursement. |
Periodontal scaling & root planing - one to three teeth per quadrant | D4342 | $189.68 | $189.68 | $0.00 | Involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. For clients with periodontal disease and is therapeutic, not prophylactic. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in. Current periodontal charting must be present in client chart documenting active periodontal disease. Frequency: * 1 time per quadrant per 36 month interval. * No more than 2 quadrants may be considered in a single visit in a non-hospital setting.. Documentation of other treatment provided at same time will be requested. * Cannot be charged on same date as D4346. * Any follow-up and re-evaluation are included in the initial reimbursement. |
Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation | D4346 | $102.00 | $92.00 | $10.00 | The removal of plaque, calculus, and stains from supra- and sub-gingival tooth surfaces when there is generalized moderate or severe gingival inflammation in the absence of periodontitis. It is indicated for patients who have swollen, inflamed gingiva, generalized suprabony pockets, and moderate to severe bleeding on probing. Should not be reported in conjunction with prophylaxis, scaling and root planing, or debridement procedures. Frequency: once in a lifetime. * Any follow-up and re-evaluation are included in the initial reimbursement. * Cannot be charged on the same date as D1110, D4341, D4342, or D4910. |
Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit | D4355 | $100.04 | $90.04 | $10.00 | One of (D4335) per 3 year(s) per patient. Prophylaxis D1110 is not reimbursable when provided on the same day of service as D4355. D4355 is not reimbursable if patient record indicates D1110 or D4910 have been provided in the previous 12 month period. Other D4000 series codes are not reimbursable when provided on the same date of service as D4355. |
Periodontal maintenance procedures | D4910 | $149.01 | $149.01 | $0.00 | Procedure following periodontal therapy and continues at varying intervals, determined by the clinical evaluation of the dentist, for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated and polishing the teeth. Frequency: * Up to four times per fiscal year per client. * Cannot be charged on the same date as D4346. * Cannot be charged within the first three months following active periodontal treatment. |
Complete denture - maxillary | D5110 | $931.41 | $851.41 | $80.00 | Reimbursement made upon delivery of a complete maxillary denture to the client. D5110 or D5120 cannot be used to report an immediate denture, D5130 or D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A complete denture is made after teeth have been removed and the gum and bone tissues have healed - or to replace an existing denture. This can vary greatly depending upon client, oral health, overall health, and other confounding factors. Frequency: Program will only pay for one per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Complete denture - mandibular | D5120 | $932.94 | $852.94 | $80.00 | Reimbursement made upon delivery of a complete mandibular denture to the client. D5110 or D5120 cannot be used to report an immediate denture, D5130, D5140. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A complete denture is made after teeth have been removed and the gum and bone tissues have healed - or to replace an existing denture. This can vary greatly depending upon client, oral health, overall health, and other confounding factors. Frequency: Program will only pay for one per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Immediate denture - maxillary | D5130 | $931.41 | $851.41 | $80.00 | Reimbursement made upon delivery of an immediate maxillary denture to the client. Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement. An immediate denture is made prior to teeth being extracted and is inserted same day of extraction of remaining natural teeth. Frequency: D5130 can be reimbursed only once per lifetime per client. Complete denture, D5110, may be considered 5 years after immediate denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file. |
Immediate denture - mandibular | D5140 | $932.94 | $852.94 | $80.00 | Reimbursement made upon delivery of an immediate mandibular denture to the client. Routine follow-up adjustments/soft tissue condition relines within 6 months are to be anticipated and are included in the initial reimbursement. An immediate denture is made prior to teeth being extracted and is inserted same day of extraction of remaining natural teeth. Frequency: D5140 can be reimbursed only once per lifetime per client. Complete dentures, D5120, may be considered 5 years after immediate denture was reimbursed - documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file. |
Maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) | D5211 | $700.00 | $640.00 | $60.00 | Reimbursement made upon delivery of a complete partial maxillary denture to the client. D5211 and D5212 are considered definitive treatments. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial resin base denture can be made right after having teeth extracted (healing from only a few teeth is not as extensive as healing from multiple). A partial resin base denture can also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: Program will only pay for one resin maxillary per every 3 years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) | D5212 | $778.00 | $718.00 | $60.00 | Reimbursement made upon delivery of a complete partial mandibular denture to the client. D5211 and D5212 are considered definitive treatment. Routine follow-up adjustments/relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial resin base denture can be made right after having teeth extracted (healing from only a few teeth is not as extensive as healing from multiple). A partial resin base denture can also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: Program will only pay for one resin mandibular per every 3 years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | D5213 | $900.48 | $840.48 | $60.00 | Reimbursement made upon delivery of a complete partial maxillary denture to the client. D5213 and D5214 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial cast metal base can also be made right after having teeth extracted (healing from only a few teeth is not as extensive as healing from multiple). A partial cast metal base denture can be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: Program will only pay for one maxillary per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | D5214 | $900.48 | $840.48 | $60.00 | Reimbursement made upon delivery of a complete partial mandibular denture to the client. D5213 and D5214 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial cast metal base can be made right after having teeth extracted (healing from only a few teeth is not as extensive as healing from multiple). A partial cast metal base denture can also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: Program will only pay for one mandibular per every five years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Immediate maxillary partial denture - resin base (including any conventional clasps, rests and teeth) | D5221 | $646.83 | $586.83 | $60.00 | Reimbursement made upon delivery of an immediate partial maxillary denture to the client. D5221 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial reimbursement. An immediate partial resin base denture can be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: A maxillary partial denture may be considered 3 years after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file. |
Immediate mandibular partial denture - resin base (including any conventional clasps, rests and teeth) | D5222 | $646.83 | $586.83 | $60.00 | Reimbursement made upon delivery of an immediate partial mandibular denture to the client. D5222 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial reimbursement. An immediate partial resin base denture can be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: A mandibular partial denture may be considered 3 years after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file. |
Immediate maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | D5223 | $900.48 | $840.48 | $60.00 | Reimbursement made upon delivery of an immediate partial maxillary denture to the client. D5223 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months is to be anticipated and are included in the initial reimbursement. An immediate partial cast metal framework with resin base denture can be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: A maxillary partial denture may be considered 5 years after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file. |
Immediate mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | D5224 | $900.48 | $840.48 | $60.00 | Reimbursement made upon delivery of an immediate partial mandibular denture to the client. D5224 can be reimbursed only once per lifetime per client and must be on the same date of service as the extraction. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. An immediate partial cast metal framework with resin base denture can be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: A mandibular partial denture may be considered 5 years after immediate partial denture was reimbursed. Documentation that existing prosthesis cannot be made serviceable must be maintained. Immediate Denture Form must be on file. |
Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) | D5225 | $798.83 | $738.83 | $60.00 | Reimbursement made upon delivery of a partial maxillary denture to the client. D5225 and D5226 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial flexible base can be made right after having teeth extracted (healing from only a few teeth is not as extensive as healing from multiple). A partial flexible base denture can also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: Program will only pay for one maxillary per every three years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) | D5226 | $798.83 | $738.83 | $60.00 | Reimbursement made upon delivery of a partial mandibular denture to the client. D5225 and D5226 are considered definitive treatment. Routine follow-up adjustments or relines within 6 months are to be anticipated and are included in the initial reimbursement. A partial flexible base can be made right after having teeth extracted (healing from only a few teeth is not as extensive as healing from multiple). A partial flexible base denture can also be made before having teeth extracted if the teeth being removed are in the front or necessary healing will be minimal. Several impressions and "try-in" appointments may be necessary and are included in the cost. Frequency: Program will only pay for one mandibular per every three years - documentation that existing prosthesis cannot be made serviceable must be maintained. |
Repair broken complete denture base, mandibular | D5511 | $131.84 | $121.84 | $10.00 | Repair broken complete mandibular denture base. Frequency: two of D5511 per 12 months per client. |
Repair broken complete denture base, maxillary | D5512 | $131.84 | $121.84 | $10.00 | Repair broken complete maxillary denture base. Frequency: two of D5512 per 12 months per client. |
Replace missing or broken teeth - complete denture (each tooth) | D5520 | $98.85 | $88.85 | $10.00 | Replacement/repair of missing or broken teeth. Teeth 1 - 32 and must report tooth number. |
Repair resin partial denture base, mandibular | D5611 | $99.55 | $89.55 | $10.00 | Repair resin partial mandibular denture base. Frequency: two D5611 per 12 months per client. |
Repair resin partial denture base, maxillary | D5612 | $99.55 | $89.55 | $10.00 | Repair resin partial maxillary denture base. Frequency: two D5612 per 12 months per client. |
Repair cast partial framework, mandibular | D5621 | $129.27 | $119.27 | $10.00 | Repair cast partial mandibular framework. Frequency: two D5621 per 12 months per client. |
Repair cast partial framework, maxillary | D5622 | $129.27 | $119.27 | $10.00 | Repair cast partial maxillary framework. Frequency: Two D5622 per 12 months per client. |
Repair or replace broken retentive/clasping materials - per tooth | D5630 | $139.66 | $129.66 | $10.00 | Repair of broken clasp on partial denture base - per tooth. Teeth 1 - 32, report tooth number(s). |
Replace broken teeth-per tooth | D5640 | $100.04 | $90.04 | $10.00 | Repair/replacement of missing tooth. Teeth 1 - 32, report tooth number(s). |
Add tooth to existing partial denture | D5650 | $109.00 | $99.00 | $10.00 | Adding tooth to partial denture base. Documentation may be requested when charged on partial delivered in last 12 months. Teeth 1 - 32, report tooth number(s). |
Add clasp to existing partial denture | D5660 | $145.08 | $135.08 | $10.00 | Adding clasp to partial denture base - per tooth. Documentation may be requested when charged on partial delivered in last 12 months. Teeth 1 - 32, report tooth number(s). |
Rebase complete maxillary denture | D5710 | $322.00 | $297.00 | $25.00 | Frequency: one time per 12 months. Completed at laboratory. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period. |
Rebase complete mandibular denture | D5711 | $322.00 | $297.00 | $25.00 | Frequency: one time per 12 months. Completed at laboratory. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period. |
Rebase maxillary partial denture | D5720 | $304.00 | $279.00 | $25.00 | Frequency: one time per 12 months. Completed at laboratory. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period. |
Rebase mandibular partial denture | D5721 | $304.00 | $279.00 | $25.00 | Frequency: one time per 12 months. Completed at laboratory. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a reline in a 12 month period. |
Reline complete maxillary denture (chairside) | D5730 | $190.08 | $180.08 | $10.00 | Frequency: One time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Reline complete mandibular denture (chairside) | D5731 | $190.08 | $180.08 | $10.00 | Frequency: One time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Reline maxillary partial denture (chairside) | D5740 | $187.69 | $177.69 | $10.00 | Frequency: one time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Reline mandibular partial denture (chairside) | D5741 | $189.49 | $179.49 | $10.00 | Frequency: one time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Reline complete maxillary denture (laboratory) | D5750 | $253.13 | $228.13 | $25.00 | Frequency: one time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Reline complete mandibular denture (laboratory) | D5751 | $254.31 | $229.31 | $25.00 | Frequency: one time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Reline maxillary partial denture (laboratory) | D5760 | $251.33 | $226.33 | $25.00 | Frequency: one time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Reline mandibular partial denture (laboratory) | D5761 | $251.33 | $226.33 | $25.00 | Frequency: one time per 12 months. Cannot be charged on denture provided in the last 6 months. Cannot be charged in addition to a rebase in a 12 month period. |
Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | D7140 | $119.07 | $109.07 | $10.00 | Removal of tooth structure, minor smoothing of socket bone, and closure as necessary. Frequency: One D7140 per lifetime per client per tooth. Teeth 1 - 32. |
Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | D7210 | $184.54 | $174.54 | $10.00 | Includes related cutting of gingiva and bone, removal of tooth structure, minor smoothing of socket bone and closure. Frequency: One of D7210 per lifetime per client per tooth. Teeth 1 - 32 |
Removal of impacted tooth-soft tissue | D7220 | $220.66 | $200.66 | $20.00 | Occlusal surface of tooth covered by soft tissue; requires mucoperiosteal flap elevation. Teeth 1-32. Frequency: One of D7220 per 1 lifetime per client per tooth. |
Removal of impacted tooth-partially bony | D7230 | $272.40 | $252.40 | $20.00 | Part of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Teeth 1-32. Frequency: One of D7230 per 1 lifetime per patient per tooth |
Removal of impacted tooth-completely bony | D7240 | $316.18 | $296.18 | $20.00 | Most or all of crown covered by bone; requires mucoperiosteal flap elevation and bone removal. Teeth 1-32. Frequency: One of D7240 per 1 lifetime per patient per tooth. |
Removal of impacted tooth-completely boney, with unusual surgical complications | D7241 | $415.64 | $395.64 | $20.00 | Most or all of crown covered by bone; unusually difficult or complicated due to factors such as nerve dissection required, separate closure of maxillary sinus required or aberrant tooth position. Teeth 1-32. Frequency: One of D7241 per lifetime per patient per tooth. |
Removal of residual tooth roots (cutting procedure) | D7250 | $194.64 | $184.64 | $10.00 | Includes cutting of soft tissue and bone, removal of tooth structure, and closure. Cannot be charged for removal of broken off roots for recently extracted tooth. Teeth 1 - 32 Frequency: One D7250 per lifetime per patient per tooth. |
Primary closure of a sinus perforation | D7261 | $485.35 | $475.35 | $10.00 | Subsequent to surgical removal of tooth, exposure of sinus requiring repair, or immediate closure of oroantral or oralnasal communication in absence of fisulous tract. Narrative of medical necessity may be required and if the sinus perforation was caused by a current grantee or provider of the program. |
Incisional biopsy of oral tissue - hard (bone, tooth) | D7285 | $193.01 | $183.01 | $10.00 | For partial removal of specimen only. This procedure involves biopsy of osseous lesions and is not used for apicectomy/periradicular surgery. This procedure does not entail an excision. Only covered if there is a suspicious lesion. Must have a pathology report in file. |
Incisional biopsy of oral tissue-soft | D7286 | $391.00 | $381.00 | $10.00 | For partial removal of an architecturally intact specimen only. D7286 is not used at the same time as codes for apicoectomy/periradicular curettage and does not entail an excision. Treatment notes must include documentation and proof that biopsy was sent for evaluation. |
Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | D7310 | $150.00 | $140.00 | $10.00 | D7310 is distinct (separate procedure) from extractions. Usually in preparation for prosthesis or other treatments such as radiation therapy and transplant surgery. Frequency: One D7310 or D7311 per lifetime per patient per quadrant. Reported per quadrant. |
Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | D7311 | $148.69 | $138.69 | $10.00 | D7311 is distinct (separate procedure) from extractions. Usually in preparation for a prosthesis or other treatments such as radiation therapy and transplant surgery. Frequency: One D7311 or D7310 per lifetime per patient per quadrant. Reported per quadrant. |
Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant | D7320 | $214.11 | $204.11 | $10.00 | No extractions performed in an edentulous area. See D7310 if teeth are being extracted concurrently with the alveoloplasty. Usually in preparation for prosthesis or other treatments such as radiation therapy and transplant surgery. Frequency: One of D7320 or D7321 per lifetime per patient per quadrant. Reported per quadrant. |
Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant | D7321 | $214.11 | $204.11 | $10.00 | No extractions performed in an edentulous area. See D7311 if teeth are being extracted concurrently with the alveoloplasty. Usually in preparation for prosthesis or other treatments such as radiation therapy and transplant surgery. Frequency: One of D7320 or D7321 per lifetime per patient per quadrant. Reported per quadrant. |
Excision of benign Lesion up to 1.25 cm | D7410 | $197.16 | $187.16 | $10.00 | Must have a pathology report in file. |
Removal of benign nonodontogenic cyst or tumor-lesion diameter up to 1.25 cm | D7460 | $248.70 | $238.70 | $10.00 | Must have a pathology report in file. |
Removal of lateral exostosis (maxilla or mandible) | D7471 | $310.17 | $300.17 | $10.00 | Limited to the removal of exostosis, including the removal of tori, osseous tuberosities, and other osseous protuberances, when the mass prevents the seating of denture and does not allow denture seal. Reported per arch (LA or UA) |
Removal of torus palatinus | D7472 | $364.79 | $354.79 | $10.00 | Limited to the removal of exostosis, including the removal of tori, osseous tuberosities, and other osseous protuberances, when the mass prevents the seating of denture and does not allow denture seal. Must list quadrant. |
Removal of torus mandibularis | D7473 | $355.79 | $345.79 | $10.00 | Limited to the removal of exostosis, including the removal of tori, osseous tuberosities, and other osseous protuberances, when the mass prevents the seating of denture and does not allow denture seal. Must list quadrant. |
Incision & drainage of abscess - intraoral soft tissue | D7510 | $196.66 | $186.66 | $10.00 | Incision through mucosa, including periodontal origins. One of D7510 per lifetime per client per tooth. Report per tooth. |
Palliative treatment of dental pain - per visit | D9110 | $82.04 | $57.04 | $25.00 | Emergency treatment to alleviate pain/discomfort. This code cannot be used for filing claims or writing or calling in a prescription to the pharmacy or to address situations that arise during multi-visit treatments covered by a single fee such as surgical or endodontic treatment. Report per visit, no procedure. Frequency: Limit 1 time per year. Maintain documentation that specifies problem and treatment. |
Evaluation for moderate sedation, deep sedation or general anesthesia | D9219 | $43.83 | $43.83 | $0.00 | One of D9219 or D9310 per 12 month(s) per grantee |
Deep sedation/general anesthesia-each 15 minute increment | D9223 | $110.09 | $100.09 | $10.00 | Nine of D9223 per 1 day per patient. Not allowed with D9243 |
Intravenous moderate (conscious) sedation/analgesia-first 15 minutes | D9239 | $124.76 | $114.76 | $10.00 | One of D9239 per 1 day per patient. |
Intravenous moderate (conscious)sedation/analgesia-each 15 minute increment | D9243 | $110.09 | $100.09 | $10.00 | Thirteen of D9243 per 1 day per patient. Not allowed with D9223 |
EXPLANATION OF RESTORATIONS | ||
Location | Number of Surfaces | Characteristics |
Anterior - Mesial, Distal, Incisal, Lingual, or Facial (or Labial) | 1 | Placed on one of the five surface classifications.. |
2 | Placed, without interruption, on two of the surface classifications. | |
3 | Placed, without interruption, on three of the surface classifications. | |
4 or more | Placed, without interruption, on four or more of the surface classifications. | |
Posterior - Mesial, Distal, Occlusal, Lingual, or Buccal | 1 | Placed on one of the five surface classifications. |
2 | Placed, without interruption, on two of the surface classifications. | |
3 | Placed, without interruption, on three of the surface classifications. | |
4 or more | Placed, without interruption, on four or more of the surface classifications. | |
NOTE: Tooth surfaces are reported using the letters in the following table.
Surface | Code |
Buccal | B |
Distal | D |
Facial (or Labial) | F |
Incisal | I |
Lingual | L |
Mesial | M |
Occlusal | O |
10 CCR 2505-10-8.900, app 10 CCR 2505-10-8.960-A