Maximum Fee | ||||||
HCPCS | Allowance | |||||
IND | Code | Mod | Procedure Description | S | $ | NS |
D7110 | Single Tooth | 32.00 | 30.00 | |||
D7120 | Extraction--each additional tooth | 32.00 | 30.00 | |||
D7130 | Root Removal--Exposed Roots | 19.50 | 18.00 |
NOTE 1: Per tooth.
# | D7210 | Surgical Removal of Erupted Tooth | 33.00 | 31.00 |
Requiring Elevation of | ||||
Mucoperiosteal Flap and Removal of | ||||
Bone and/or Section of Tooth | ||||
# | D7220 | Removal of Impacted Tooth--Soft | 43.00 | 40.00 |
Tissue | ||||
# | D7230 | Removal of Impacted | 114.00 | 106.00 |
Tooth--Partially Bony | ||||
# | D7240 | Removal of Impacted | 114.00 | 106.00 |
Tooth--Completely Bony | ||||
# | D7250 | Surgical Removal of Residual Tooth | 43.00 | 39.00 |
Roots (Cutting Procedure) |
NOTE: Includes cutting of soft tissue and bone, removal of tooth structure and closure.
D7260 | Oroantral Fistula Closure | 108.00 | 99.00 |
NOTE 1: Code may also be used for antral root recovery.
NOTE 2: Excision of fistulous tract between maxillary sinus and oral cavity and closure by advancement flap.
D7270 | Tooth Re-implantation and/or | 93.00 | 85.00 | |
Stabilization of Accidentally | ||||
Avulsed or Displaced Tooth and/or | ||||
Alveolus | ||||
D7280 | Surgical Exposure of Impacted or | 101.00 | 94.00 | |
Unerupted Tooth for Orthodontic | ||||
Reason (Including Orthodontic | ||||
Attachments) | ||||
D7281 | Surgical Exposure of Impacted or | 45.00 | 41.00 | |
Unerupted Tooth to Aid Eruption | ||||
d | D7285 | Biopsy of Oral Tissue--Hard | 30.00 | 26.00 |
NOTE: Independent procedure (laboratory must bill separately).
d | D7286 | Biopsy of Oral Tissue-Soft | 18.00 | 16.00 |
NOTE: Independent procedure (laboratory must bill separately).
D7310 | Alveoloplasty in Conjunction with | 62.50 | 56.50 |
Extractions--Per Quadrant |
NOTE 1: In conjunction with extractions of at least three teeth or the roots of at least three teeth in the same quadrant.
NOTE 2: Specify quadrant.
D7320 | Alveoloplasty Not In Conjunction | 62.50 | 56.50 |
with extraction--Per Quadrant |
D7340 | Vestibuloplasty--Ridge Extension | 65.00 | 59.00 |
(Secondary Epithelialization) |
NOTE: Including management of hypertrophied and hyperplastic tissue, per quadrant.
D7350 | Vestibuloplasty--Ridge Extension | 169.00 | 153.00 |
(Including Soft Tissue Grafts, | |||
Muscle Re-attachments, Revision of | |||
Soft Tissue Attachment, and | |||
Management of Hypertrophied and | |||
Hyperplastic Tissue) |
NOTE: Per Quadrant.
NOTE: Biopsy report must be available upon request for review by the Division's dental consultants.
D7410 | Radical Excision--Lesion Diameter | 30.00 | 26.00 |
Up to 1.25 cm. | |||
D7420 | Radical Excision--Lesion Diameter | 42.00 | 37.00 |
Over 1.25 cm. |
NOTE: Up to and including three cm.
D7420 | 22 | Radical Excision--Lesion Diameter | 100.00 | 86.00 |
Over 3 cm. |
D7430 | Excision of Benign Tumor--Lesion | 30.00 | 26.00 |
Diameter Up to 1.25 cm. | |||
D7431 | Excision of Benign Tumor--Lesion | 42.00 | 37.00 |
Diameter Over 1.25 cm. |
D7431 | 22 | Excision of Benign Tumor--Lesion | 100.00 | 86.00 |
Diameter Over 3 cm. | ||||
D7440 | Excision of Malignant | 100.00 | 86.00 | |
Tumor--Lesion Diameter Up to 1.25 | ||||
cm. | ||||
D7441 | Excision of Malignant | 274.00 | 256.00 | |
Tumor--Lesion Diameter Over 1.25 | ||||
cm. |
NOTE: Up to and including three cm.
D7441 | 22 | Excision of Malignant | 473.00 | 413.00 |
Tumor--Lesion Diameter Over 3 cm. | ||||
D7450 | Removal of Odontogenic Cyst or | 50.00 | 43.00 | |
Tumor--Lesion Diameter Up to 1.25 | ||||
cm. | ||||
D7451 | Removal of Odontogenic Cyst or | 100.00 | 87.00 | |
Tumor--Lesion Diameter Over 1.25 | ||||
cm. |
NOTE: Up to and including three cm.
D7451 | 22 | Removal of Odontogenic Cyst or | 150.00 | 130.00 |
Tumor--Lesion Diameter Over 3 cm. | ||||
D7460 | Removal of Non Odontogenic Cyst or | 50.00 | 43.00 | |
Tumor--Lesion Diameter Up to 1.25 | ||||
cm. | ||||
D7461 | Removal of Non Odontogenic Cyst or | 100.00 | 87.00 | |
Tumor--Lesion Diameter Over 1.25 | ||||
cm. |
NOTE: Up to and including three cm.
D7461 | 22 | Removal of Non Odontogenic Cyst or | 150.00 | 130.00 |
Tumor--Lesion Diameter Over 3 cm. | ||||
D7465 | Destruction of Lesion(s) by | 18.00 | 15.00 | |
Physical Methods: Electrosurgery, | ||||
Chemotherapy, Cryotherapy or Laser |
D7471 | Removal of Exostosis--per site | 62.50 | 56.50 |
NOTE: Per quadrant.
D7471 | 22 | Removal of Exostosis | 109.00 | 98.00 |
NOTE: Torus palatinus.
D7480 | Partial Ostectomy (Guttering or | 211.00 | 184.00 |
Saucerization) | |||
D7490 | Radical Resection of Mandible with | 807.00 | 807.00 |
Bone Graft |
D7510 | Incision and Drainage of | 28.00 | 26.00 |
Abscess--Intraoral Soft Tissue | |||
D7520 | Incision and Drainage of | 42.00 | 37.00 |
Abscess--Extraoral Soft Tissue | |||
D7530 | Removal of Foreign Body, Skin, or | 18.00 | 16.00 |
Subcutaneous Areolar Tissue | |||
D7540 | Removal of Reaction Producing | 51.00 | 45.00 |
Foreign Bodies, Musculoskeletal | |||
System | |||
D7550 | Sequestrectomy for Osteomyelitis | 48.00 | 42.00 |
NOTE: Intraoral.
D7550 | 22 | Sequestrectomy for Osteomyelitis | 90.00 | 75.00 |
NOTE: Extraoral.
D7560 | Maxillary Sinusotomy for Removal | 242.00 | 210.00 |
of Tooth Fragment or Foreign Body |
NOTE: Sinusotomy, maxillary (antrotomy, Caldwell Luc, unilateral).
D7610 | Maxilla--Open Reduction (Teeth | 273.00 | 249.00 | |
Immobilized if Present) | ||||
D7620 | Maxilla--Closed Reduction (Teeth | 182.00 | 166.00 | |
Immobilized if Present) | ||||
D7620 | 52 | Maxilla--Closed Reduction | 80.00 | 76.00 |
NOTE: No manipulation or fixation.
D7630 | Mandible--Open Reduction (Teeth | 363.00 | 331.00 | |
Immobilized if Present) | ||||
D7630 | 22 | Mandible--Open Reduction (Teeth | 454.00 | 414.00 |
Immobilized if Present) |
NOTE: Complicated--multiple surgical approaches (three or more) including internal fixation, interdental fixation, skeletal pinning with extraoral fixation.
D7640 | Mandible--Closed Reduction (Teeth | 182.00 | 166.00 | |
Immobilized if Present) | ||||
D7640 | 52 | Mandible--Closed Reduction | 80.00 | 76.00 |
NOTE: No manipulation or fixation.
D7650 | Malar and/or Zygomatic Arch--Open | 182.00 | 166.00 |
Reduction | |||
D7660 | Malar and/or Zygomatic | 63.00 | 58.00 |
Arch--Closed Reduction |
NOTE: Including towel clip technique.
D7660 | 52 | Malar and/or Zygomatic | 56.00 | 52.00 |
Arch--Closed Reduction |
NOTE: No manipulation or fixation.
D7670 | Alveolus--Stabilization of Teeth, | 138.00 | 126.00 |
Open Reduction Splinting |
NOTE 1: Alveolar fracture.
NOTE 2: Reduction with wiring, application of arch bar or splint.
D7680 | Facial Bones--Complicated | 363.00 | 331.00 |
Reduction with Fixation and | |||
Multiple Surgical Approaches |
NOTE 1: Maxilla, malar and/or zygomatic arch.
NOTE 2: Multiple surgical approaches (three or more), fixation, traction, head frame, multiple internal and/or external fixation, and head cap.
D7710 | Maxilla--Open Reduction | 273.00 | 249.00 |
NOTE: Teeth immobilized if present.
D7720 | Maxilla--Closed Reduction | 182.00 | 166.00 |
NOTE: Teeth immobilized if present.
D7720 | 52 | Maxilla--Closed Reduction | 80.00 | 76.00 |
NOTE: No manipulation or fixation.
D7730 | Mandible--Open Reduction | 363.00 | 331.00 |
NOTE: Teeth immobilized if present.
D7730 | 22 | Mandible--Open Reduction | 454.00 | 414.00 |
NOTE: Complicated--multiple surgical approaches (three or more) including internal fixation, interdental fixation, and skeletal pinning with extraoral fixation.
D7740 | Mandible--Closed Reduction | 182.00 | 166.00 |
NOTE: Teeth immobilized if present.
D7740 | 52 | Mandible--Closed Reduction | 80.00 | 76.00 |
NOTE: No manipulation or fixation.
D7750 | Malar and/or Zygomatic Arch--Open | 182.00 | 166.00 |
Reduction | |||
D7760 | Malar and/or Zygomatic | 63.00 | 58.00 |
Arch--Closed Reduction |
NOTE: Including towel clip technique.
D7760 | 52 | Malar and/or Zygomatic | 56.00 | 52.00 |
Arch--Closed Reduction |
NOTE: No manipulation or fixation.
D7770 | Alveolus--Stabilization of Teeth, | 138.00 | 126.00 |
Open Reduction Splinting |
NOTE 1: Alveolar fracture.
NOTE 2: Reduction with wiring, application of arch bar or splint.
D7780 | Facial Bones--Complicated | 363.00 | 331.00 |
Reduction with Fixation and | |||
Multiple Surgical Approaches |
NOTE 1: Maxilla, malar and/or zygomatic arch.
NOTE 2: Multiple surgical approaches (three or more), fixation, traction, head frame, multiple internal and/or external fixation, and head cap.
D7810 | Open Reduction of Dislocation | 273.00 | 249.00 | |
D7820 | Closed Reduction of Dislocation | 27.00 | 25.00 | |
d | D7830 | Manipulation under Anesthesia | 27.00 | 25.00 |
NOTE: Anesthesia additional.
D7840 | Condylectomy | 362.00 | 315.00 |
D7850 | Meniscectomy | 362.00 | 315.00 |
D7852 | Disc repair | 362.00 | 308.00 |
NOTE: Unilateral.
D7854 | Synovectomy | 200.00 | 173.00 |
D7858 | Joint reconstruction | 623.00 | 623.00 |
D7860 | Arthrotomy | 182.00 | 155.00 |
D7865 | Arthroplasty | 362.00 | 308.00 |
NOTE: Unilateral.
d | D7870 | Arthrocentesis | 18.00 | 16.00 |
NOTE: Injection or aspiration (give complete details).
D7871 | Non-arthroscopic lysis and lavage | 190.00 | 190.00 | |
D7872 | Arthroscopy--diagnosis, with or | 75.00 | 65.00 | |
without biopsy | ||||
D7873 | Arthroscopy--surgical: lavage and | 200.00 | 200.00 | |
lysis of adhesions | ||||
D7874 | Arthroscopy--surgical: disc | 500.00 | 425.00 | |
repositioning and stabilization | ||||
D7875 | Arthroscopy--surgical: synovectomy | 264.00 | 224.00 | |
D7877 | Arthroscopy--surgical: debridement | 160.00 | 136.00 | |
* | D7880 | Occlusal orthotic device, by report | BR | BR |
D7899 | Unspecified TMD therapy, by report | BR | BR |
D7910 | Suture of Recent Small Wounds up | 35.00 | 32.00 |
to 5 cm. |
NOTE: 2.5 cm. up to five cm.
D7911 | Complicated suture--Up to 5 cm. | 138.00 | 138.00 |
D7912 | Complicated suture--greater than 5 | 242.00 | 242.00 |
cm. | |||
D7920 | Skin graft (identify defect | 70.50 | 70.50 |
covered, location and type of | |||
graft) |
D7940 | Osteoplasty--For Orthognathic | 225.00 | 191.00 |
Deformities | |||
D7941 | Osteotomy--Mandibular rami | 726.00 | 726.00 |
NOTE: Unilateral.
D7943 | Osteotomy--Mandibular rami with | 1,058 | 1,058 |
bone graft; includes obtaining the | |||
graft |
NOTE: Unilateral.
D7944 | Osteotomy--Segmented or | 332.00 | 289.00 | |
subapical--per sextant or quadrant | ||||
D7945 | Osteotomy--body of mandible | 332.00 | 289.00 | |
D7946 | LeFort I (maxilla--total) | 546.00 | 546.00 | |
* | D7947 | LeFort I (maxilla--segmented) | 365.00 | 365.00 |
D7948 | LeFort II or LeFort III | 1,095 | 1,095 | |
(Osteoplasty of facial bones for | ||||
midface Hypoplasia or | ||||
retrusion)--without bone graft | ||||
D7949 | LeFort II or LeFort III--with bone | 1,427 | 1,427 | |
graft | ||||
D7950 | Osseous, osteoperiosteal, or | 575.00 | 489.00 | |
cartilage graft of the mandible or | ||||
facial bones--autogenous or | ||||
nonautogenous, by report | ||||
D7955 | Repair of Maxillofacial Soft and | 203.00 | 176.00 | |
Hard Tissue Defects | ||||
D7960 | Frenulectomy (Frenectomy or | 60.00 | 56.00 | |
Frenotomy)--Separate Procedure | ||||
D7970 | Excision of hyperplastic | 45.00 | 39.00 | |
tissue--per arch | ||||
D7971 | Excision of pericoronal gingiva | 42.00 | 37.00 | |
D7980 | Sialolithotomy | 48.00 | 42.00 | |
D7981 | Excision of Salivary Gland, by | 182.00 | 158.00 | |
report | ||||
D7982 | Sialodochoplasty | 151.00 | 131.00 | |
D7983 | Closure of Salivary Fistula | 151.00 | 131.00 | |
D7990 | Emergency Tracheotomy | 121.00 | 105.00 | |
D7991 | Coronoidectomy | 362.00 | 308.00 | |
* | D7995 | Synthetic graft--mandible or | BR | BR |
facial bones, by report | ||||
D7996 | Implant--mandible for augmentation | BR | BR | |
purposes (excluding alveolar | ||||
ridge), by report | ||||
D7997 | Appliance removal (not by dentist | 151.00 | 151.00 | |
who placed appliance), includes | ||||
removal of archbar | ||||
** | D7999 | Unspecified Oral Surgery | BR | BR |
Procedure, By Report |
NOTE: Complete description of procedure and the reason the procedure was performed.
N.J. Admin. Code § 10:56-3.10
See: 20 N.J.R. 2101(a).
Amended by R.1989 d.135, effective 3/20/1989.
See: 20 N.J.R. 2558(a), 21 N.J.R. 760(a).
Qualifier added to 07130, in (c); prior authorization requirement removed from 07210, in (d).
Administrative Corrections to (c), ( l)1 and (q).
See: 22 N.J.R. 1375(a).
Amended by R.1990 d.456, effective 9/4/1990.
See: 22 N.J.R. 1660(b), 22 N.J.R. 2713(a).
In (d): revised (d)1 to specify conditions for extraction, by incorporating text from old (d)2. Recodified (d)3 as (d)2 and added new (d)3. Deleted asterisks in List. In (f)1: added new "07310".
Amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
Changed Maximum Fee Allowances throughout.
Amended by R.2001 d.268, effective 8/6/2001.
See: 33 N.J.R. 1554(a), 33 N.J.R. 2666(b).
In (g)1, inserted a reference to NJ FamilyCare.
Amended by R.2003 d.16, effective 1/6/2002.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
In (g)1, inserted reference to NJ FamilyCare.