Download Dental Matrix - Care1st DDD 0108

Care1st DDD Dental Matrix
CARE1ST DDD
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
DESCRIPTION
PERIODIC ORAL EVALUATION
LIMITED ORAL EVALUATION - PROBLEM FOCUSED
ORAL EVALUATION (Patient under 3 years of Age)
COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT
DETAILED AND EXTENSIVE ORAL EVALUATION - PROBLEM FOCUSED, BY
REPORT
COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR ESTABLISHED
PATIENT
INTRAORAL - COMPLETE SERIES (INCLUDING BITEWINGS)
INTRAORAL - PERIAPICAL - FIRST FILM
INTRAORAL - PERIAPICAL - EACH ADDITIONAL FILM
INTRAORAL - 0CCLUSAL FILM
EXTRAORAL - FIRST FILM
EXTRAORAL - EACH ADDITIONAL FILM
BITEWING - SINGLE FILM
BITEWINGS - TWO FILMS
BITEWINGS - THREE FILMS
BITEWINGS - FOUR FILMS
VERTICAL BITEWINGS - 7 TO 8 FILMS
D0290
D0310
D0320
D0321
D0330
D0340
D0350
D0470
D0502
D0999
D1110
D1120
POSTERIOR- ANTERIOR OR LATERAL SKULL AND FACIAL BONE SURVEY FILM
SIALOGRAPHY
TEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING INJECTION
OTHER TEMPOROMANDIBULAR JOINT FILMS, BY REPORT
PANORAMIC FILM
CEPHALOMETRIC FILM (LIMITED TO ORAL SURGEONS)
ORAL/FACIAL IMAGES (INCLUDES INTRA AND EXTRAORAL IMAGES)
DIAGNOSTIC CASTS
OTHER ORAL PATHOLOGY PROCEDURES, BY REPORT
UNSPECIFIED DIAGNOSTIC PROCEDURE, BY REPORT
PROPHYLAXIS - ADULT
PROPHYLAXIS - CHILD
PROC
D0120
D0140
D0145
D0150
D0160
D1203 TOPICAL APPLICATION OF FLUORIDE (PROPHYLAXIS NOT INCLUDED) - CHILD
D1204 TOPICAL APPLICATION OF FLOURIDE (AGES 14-20 ONLY)
TOPICAL FLOURIDE VARNISH, THERAPEUTIC APPL (AGE LIMITED TO AGE 6 AND
D1206 ANTERIOR TEETH ONLY)
SEALANT - PER TOOTH (LIMITED TO 1ST & 2ND PRIMARY PERMANENT MOLARS
D1351 ONLY)
D1510 SPACE MAINTAINER - FIXED UNILATERAL
D1515 SPACE MAINTAINER - FIXED BILATERAL
D1520 SPACE MAINTAINER - REMOVABLE UNILATERAL
D1525 SPACE MAINTAINER - REMOVABLE BILATERAL
D1550 RECEMENTATION OF SPACE MAINTAINER
REMOVAL OF FIXED SPACE MAINTAINER (DOES NOT APPLY IF THE SAME
D1555 PROVIDER INSERTED THE APPLIANCE)
D2140 AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT
D2150 AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT
D2160 AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT
D2161 AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENT
D2330 RESIN - ONE SURFACE, ANTERIOR
D2331 RESIN - TWO SURFACES, ANTERIOR
D2332 RESIN - THREE SURFACES, ANTERIOR
01.01.08
Page 1 of 9
Age
Frequency
Limits
0 - 99
0 - 99
0 - 99
0 - 99
1
1Y
1
1Y
PA
Required
Y/N
N
N
N
N
0 - 99
1
2Y
Y
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
1
1
2Y
3Y
4
2
1Y
1Y
1
1
1Y
1Y
Y
N
N
N
N
N
N
N
N
N
N
N
0 - 99
0 - 99
0 - 99
0 -99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 -99
14 - 99
1
2Y
1
6 month
1
6 month
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
N
N
N
N
0-6
Y
0
0
0
0
0
0
N
Y
Y
Y
Y
Y
- 99
- 99
- 99
- 99
- 99
- 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
1
2Y
N
N
N
N
N
N
N
N
Care1st DDD Dental Matrix
Age
PROC DESCRIPTION
D2335 RESIN - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) 0 - 99
D2390 RESIN - BASED COMPOSITE CROWN
NC
RESIN - BASED COMPOSITE - ONE SURFACE, POSTERIOR A,B,I,L,S,T, AND 1 to
D2391 15, 12 to 21, 28 to 32
0 - 99
RESIN - BASED COMPOSITE - TWO SURFACES, POSTERIOR A,B,I,L,S,T, AND 1
D2392 to 15, 12 to 21, 28 to 32
0 - 99
RESIN - BASED COMPOSITE - THREE SURFACES, POSTERIOR A,B,I,L,S,T, AND 1
D2393 to 15, 12 to 21, 28 to 32
0 - 99
D2394 RESIN - BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR
0 - 99
D2750 CROWN - PORCELIN FUSED TO HIGH NOBLE
18 - 99
D2751 CROWN - PROCELAIN FUSED TO PREDOMINANTLY BASE METAL
18 - 99
D2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL
18 - 99
D2792 CROWN - FULL CAST NOBLE METAL (WITH ROOT CANAL THERAPY)
18 - 99
D2794 CROWN - TITANIUM
18 - 99
D2910 RECEMENT INLAY
18 +
D2915 RECEMENT CAST OR PREFABRICATED POST AND CORE
Frequency
Limits
PA
Required
Y/N
N
N
N
N
N
Y
Y
Y
Y
Y
N
18 +
Y
0 - 99
0 - 12
6+
6+
N
Y
Y
Y
0 - 99
Y
0 - 99
0 - 99
0 - 99
0 - 99
Y
N
N
Y
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
Y
Y
Y
Y
N
N
0 - 99
0 - 99
Y
Y
0 - 99
Y
0
0
0
0
- 99
- 99
- 99
- 99
Y
Y
Y
Y
D3331 TREATMENT OF ROOT CANAL OBSTRUCTION; NON - SURGICAL ACCESS
0 - 99
Y
INCOMPLETE ENDODONTIC THERAPY; INOPERABLE OR FRACTURED TOOTH
INTERNAL ROOT REPAIR OF PERFORATION DEFECTS
RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - ANTERIOR
RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - BICUSPID
RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - MOLAR
APEXIFICATION/RECALCIFICATION - INITIAL VISIT (APICAL CLOSURE/CALCIFIC
D3351 REPAIR OF P
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
0 - 99
Y
RECEMENT CROWN
PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH
PREFABRICATED STAINLESS STEEL CROWN - PERMANENT TOOTH
PREFABRICATED RESIN CROWN (LIMITED TO ANTERIOR TEETH ONLY)
PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW (LIMITED TO
D2933 ANTERIOR TEETH ONLY)
D2920
D2930
D2931
D2932
D2934
D2940
D2950
D2951
D2952
D2954
D2970
D2999
D3110
D3120
D3220
D3221
D3230
D3240
D3310
D3320
D3330
PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN - PRIMARY
SEDATIVE FILLING
CORE BUILD - UP, INCLUDING ANY PINS (LIMITATIONS)
PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION
CAST POST AND CORE IN ADDITION TO CROWN (LIMITED TO ANTERIOR TEETH
ONLY)
PREFABRICATED POST AND CORE IN ADDITION TO CROWN
TEMPORARY CROWN (FRACTURED TOOTH) ANTERIOR TEETH ONLY
UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT
PULP CAP - DIRECT (EXCLUDING FINAL RESTORATION)
PULP CAP - INDIRECT (EXCLUDING FINAL RESTORATION LIMIITATIONS)
THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) REMOVAL OF
PULP CORONAL TO
PULPAL DEBRIDEMENT, PRIMARY AND PERMANENT TEETH
PULPAL THERAPY (RESORBABLE FILLING) - ANTERIOR, PRIMARY TOOTH
(EXCLUDING FINAL RESTORATION REMOVAL OF PULP CORONAL)
PULPAL THERAPY (RESORBABLE FILLING) - POSTERIOR, PRIMARY TOOTH
(EXCLUDING FINAL RESTORATION LIMITATIONS)
ANTERIOR (EXCLUDING FINAL RESTORATION)
BICUSPID (EXCLUDING FINAL RESTORATION)
MOLAR (EXCLUDING FINAL RESTORATION)
D3331-D3430 (LIMITED TO ENDODONTIST)
D3332
D3333
D3346
D3347
D3348
01.01.08
Page 2 of 9
Care1st DDD Dental Matrix
Age
Frequency
Limits
PROC DESCRIPTION
APEXIFICATION/RECALCIFICATION - INTERIM MEDICATION REPLACEM ENT
D3352 (APICAL CLOSURE/C
APEXIFICATION/RECALCIFICATION - FINAL VISIT (INCLUDES COMPLETED ROOT
D3353 CANAL THERAPY
D3410 APICOECTOMY/PERIRADICULAR SURGERY - ANTERIOR
D3421 APICOECTOMY/PERIRADICULAR SURGERY - BICUSPID (FIRST ROOT)
D3425 APICOECTOMY/PERIRADICULAR SURGERY - MOLAR (FIRST ROOT).
D3426 APICOECTOMY/PERIRADICULAR SURGERY (EACH ADDITIONAL ROOT)
D3430 RETROGRADE FILLING - PER ROOT
D3450 ROOT AMPUTATION - PER ROOT
HEMISECTION (INCLUDING ANY ROOT REMOVAL), NOT INCLUDING ROOT CANAL
D3920 THERAPY
D3999 UNSPECIFIED ENDODONTIC PROCEDURE, BY REPORT
D4210 - D4276 (LIMITED TO PERIODONTIST)
GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH
D4210 OR BOUNDED TEETH S
PA
Required
Y/N
0 - 99
Y
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
Y
Y
0 - 99
0 - 99
Y
Y
0 - 99
0 - 99
Y
D4211 GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE TEETH, PER QUADRANT
GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE
D4240 CONTIGUOUS TEETH
GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - ONE TO THREE
D4241 TEETH, PER QUADRA
D4249 CLINICAL CROWN LENGTHENING - HARD TISSUE
OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - FOUR OR
D4260 MORE CONTIGUOUS TEE
OSSEOUS SURGERY (INCLUDING FLAP ENTRY/CLOSURE) ONE TO THREE
D4261 TEETH PER QUADRANT
D4263 BONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANT
D4264 BONE REPLACEMENT GRAFT - EACH ADDITIONAL SITE IN QUADRANT
0 - 99
Y
0 - 99
Y
0 - 99
0 - 99
Y
Y
0 - 99
Y
0 - 99
0 - 99
0 - 99
Y
Y
Y
D4265 BIOLOGIC MATERIAL TO AID IN SOFT AND OSSEOUS TISSUE REGENERATION
D4266 GUIDED TISSUE REGENERATION - RESORBABLE BARRIER, PER SITE
GUIDED TISSUE REGENERATION - NONRESORBABLE BARRIER, PER SITE,
D4267 (INCLUDES MEMBRANE
D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE
0 - 99
0 - 99
Y
Y
0 - 99
0 - 99
Y
Y
D4271 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE SURGERY)
D4273 SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES
DISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN NOT PERFORMED IN
D4274 CONJUCTION WITH SURGIC
D4275 SOFT TISSUE ALLOGRAFT
D4276 COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT
D4320 PROVISIONAL SPLINTING - INTRACORONAL
D4321 PROVISIONAL SPLINTING - EXTRACORONAL
PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE CONTIGUOUS
D4341 TEETH OR BOUNDED
PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, PER
D4342 QUADRANT
FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND
D4355 DIAGNOSIS (NOT TO BE USED AS PART OF A CLEANING)
D4910 PERIODONTAL MAINTENANCE
UNSCHEDULED DRESSING CHANGE (BY SOMEONE OTHER THAN TREATING
D4920 DENTIST)
D4999 UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORT
0 - 99
0 - 99
Y
Y
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
0 - 99
Y
0 - 99
Y
01.01.08
Page 3 of 9
0 - 99
0 - 99
0 - 99
0 - 99
1
1
Y
Y
N
Y
Care1st DDD Dental Matrix
Age
PROC DESCRIPTION
COMPLETE DENTURE - MAXILLARY (OVER 20 MUST BE MEDICALLY
D5110 NECESSARY)
COMPLETE DENTURE - MANDIBULAR (OVER 20 MUST BE MEDICALLY
D5120 NECESSARY)
IMMEDIATE DENTURE - MAXILLARY (OVER 20 MUST BE MEDICALLY
D5130 NECESSARY)
IMMEDIATE DENTURE - MANDIBULAR (OVER 20 MUST BE MEDICALLY
D5140 NECESSARY)
UPPER PARTIAL - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS,
D5211 RESTS AND TEETH) (OVER 20 MUST BE MEDICALLY NECESSARY)
LOWER PARTIAL - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS,
D5212 RESTS AND TEETH) (OVER 20 MUST BE MEDICALLY NECESSARY)
MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN
D5213 DENTURE BASES (OVER 20 MUST BE MEDICALLY NECESSARY)
MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN
D5214 DENTURE BASES (OVER 20 MUST BE MEDICALLY NECESSARY)
D5281
REMOVAL UNILATERAL PARTIAL DENTURE - ONE CAST METAL (INCLUDING CLASPS AND
TEETH)
Frequency
Limits
PA
Required
Y/N
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 -20
Y
D5410
D5411
D5421
D5422
D5510
ADJUST COMPLETE DENTURE - MAXILLARY
ADJUST COMPLETE DENTURE - MANDIBULAR
ADJUST PARTIAL DENTURE - MAXILLARY
ADJUST PARTIAL DENTURE - MANDIBULAR
REPAIR BROKEN COMPLETE DENTURE BASE
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5820
D5821
D5850
D5851
D5899
REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE (EACH TOOTH)
REPAIR RESIN DENTURE BASE
REPAIR CAST FRAMEWORK
REPAIR OR REPLACE BROKEN CLASP
REPLACE BROKEN TEETH - PER TOOTH
ADD TOOTH TO EXISTING PARTIAL DENTURE
ADD CLASP TO EXISTING PARTIAL DENTURE
REBASE COMPLETE MAXILLARY DENTURE
REBASE COMPLETE MANDIBULAR DENTURE
REBASE MAXILLARY PARTIAL DENTURE
REBASE MANDIBULAR PARTIAL DENTURE
RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE)
RELINE LOWER COMPLETE MANDIBULAR DENTURE (CHAIRSIDE)
RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE)
RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE)
RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)
RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY)
RELINE MAXILLARY PARTIAL DENTURE (LABORATORY)
RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY)
INTERIM PARTIAL DENTURE (MAXILLARY)
INTERIM PARTIAL DENTURE (MANDIBULAR)
TISSUE CONDITIONING, MAXILLARY
TISSUE CONDITIONING, MANDIBULAR
UNSPECIFIED REMOVABLE PROSTHODONTIC PROCEDURE, BY REPORT
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0 - 99
0 - 99
0 - 99
Y
Y
Y
D5911 - D5999 (LIMITED TO ORAL SURGEONS
ONLY)
D5911 FACIAL MOULAGE (SECTIONAL)
D5912 FACIAL MOULAGE (COMPLETE)
D5913 NASAL PROSTHESIS
01.01.08
Page 4 of 9
Care1st DDD Dental Matrix
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 2
0 - 16
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
0 - 99
18 - 99
PA
Required
Y/N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0 - 99
N
0 - 99
N
0
0
0
0
- 99
- 99
- 99
- 99
N
N
Y
Y
0 - 99
Y
0 - 99
N
0 - 99
0 - 99
N
N
Age
PROC DESCRIPTION
D5914 AURICULAR PROSTHESIS
D5915 ORBITAL PROSTHESIS
D5916 OCULAR PROSTHESIS
D5919 FACIAL PROSTHESIS
D5922 NASAL SEPTAL PROSTHESIS
D5923 OCULAR PROSTHESIS, INTERIM
D5924 CRANIAL PROSTHESIS
D5925 FACIAL AUGMENTATION IMPLANT PROSTHESIS
D5926 NASAL PROSTHESIS, REPLACEMENT
D5927 AURICULAR PROSTHESIS, REPLACEMENT
D5928 ORBITAL PROSTHESIS, REPLACEMENT
D5929 FACIAL PROSTHESIS, REPLACEMENT
D5931 OBTURATOR PROSTHESIS, SURGICAL
D5932 OBTURATOR PROSTHESIS, DEFINITIVE
D5933 OBTURATOR PROSTHESIS, MODIFICATION
D5934 MANDIBULAR RESECTION PROSTHESIS WITH GUIDE FLANGE
D5935 MANDIBULAR RESECTION PROSTHESIS WITHOUT GUIDE FLANGE
D5936 OBTURATOR/PROSTHESIS, INTERIM
D5937 TRISMUS APPLIANCE (NOT FOR TM TREATMENT)
D5951 FEEDING AID
D5952 SPEECH AID PROSTHESIS, PEDIATRIC
D5953 SPEECH AID PROSTHESIS, ADULT
D5954 PALATAL AUGMENTATION PROSTHESIS
D5955 PALATAL LIFT PROSTHESIS, DEFINITIVE
D5958 PALATAL LIFT PROSTHESIS, INTERIM
D5959 PALATAL LIFT PROSTHESIS, MODIFICATION
D5960 SPEECH AID PROSTHESIS, MODIFICATION
D5982 SURGICAL STENT
D5983 RADIATION CARRIER
D5984 RADIATION SHIELD
D5985 RADIATION CONE LOCATOR
D5986 FLUORIDE GEL CARRIER
D5987 COMMISSURE SPLINT
D5988 SURGICAL SPLINT
D5999 UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT
D6999 UNSPECIFIED FIXED PROSTHODONTIC PROCEDURE, BY REPORT
CORONAL REMNANTS - DECIDUOUS TOOTH - includes soft tissue - retained
D7111 remnants
EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR
D7140 FORCEPS REMOVAL)
SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING ELEVATION OF
D7210 MUCOPERIOSTEAL FLAP
D7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE
D7230 REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY
D7240 REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY
REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY, WITH UNUSUAL
D7241 SURGICAL COMPLICATIONS
D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)
Frequency
Limits
D7260 - D7290 (LIMITED TO ORAL SURGEONS
ONLY)
D7260 ORAL ANTRAL FISTULA CLOSURE
D7261 PRIMARY CLOSURE OF A SINUS PERFORATION
01.01.08
Page 5 of 9
Care1st DDD Dental Matrix
Age
PROC DESCRIPTION
Frequency
Limits
PA
Required
Y/N
TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY EVULSED
D7270 OR DISPLACED T
D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH
0 - 99
0 - 99
N
Y
D7281 SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH TO AID ERUPTION
0 - 99
Y
D7282 MOBILIZATION OF UN ERUPTED OR MALPOSITIONED TOOTH TO AID ERUPTION
0 - 99
Y
D7283 Placement of device to facilitate eruption of impacted tooth
Y
0 - 99
0 - 99
0 - 99
D7285 BIOPSY OF ORAL TISSUE - HARD (BONE, TOOTH)
D7286 BIOPSY OF ORAL TISSUE - SOFT (ALL OTHERS)
D7288 BRUSH BIOPSY - TRANSEPITHELIAL SAMPLE COLLECTION
Y
Y
Y
0 - 99
D7292
SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE (screw retained plate)
REQUIRING SURGICAL FLAP
Y
0 - 99
Y
D7293 SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE REQUIRING SURGICAL FLAP
0 - 99
Y
D7294 SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE WITHOUT SURGICAL FLAP
0 - 99
D7310 - D7670 (LIMITED TO ORAL SURGEONS
ONLY)
D7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - PER QUADRANT
D7311
ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH OR
TOOTH SPACES, PER QUADRANT (ONLY WITH AN APPROVED DENTURE)
ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - PER
D7320 QUADRANT
D7321
D7410
D7411
D7412
D7413
D7414
D7415
D7440
ALVEOLOPLASTRY NOT IN CONJUNCTION WITH EXTRACTIONS - ONE TO THREE TEETH
OR TOOTH SPACES, PER QUADRANT (Only with an approved denture)
EXCISION OF BENIGN LESION UP TO 1.25 CM
EXCISION OF BENIGN LESION GREATER THAN 1.25 CM
EXCISION OF BENIGN LESION, COMPLICATED
EXCISION OF MALIGNANT LESION UP TO 1.25 CM
EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM
EXCISION OF MALIGNANT LESION, COMPLICATED
EXCISION OF MALIGNANT TUMOR - LESION DIAMETER UP TO 1.25 CM
D7441 EXCISION OF MALIGNANT TUMOR - LESION DIAMETER GREATER THAN 1.25 CM
REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP
D7450 T0 1.25 CM
REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER
D7451 GREATER THAN 1.25 CM
REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION
D7460 DIAMETER UP TO 1.25 CM
REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION
D7461 DIAMETER GREATER THAN 1.25
DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHODS, BY
D7465 REPORT
01.01.08
Page 6 of 9
0 - 99
Y
y
0 - 99
0 - 99
Y
Y
0
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
Y
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
0 - 99
Y
Care1st DDD Dental Matrix
Age
PROC DESCRIPTION
D7471 REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE)
D7472 REMOVAL OF TORUS PALATINUS
D7473 REMOVAL OF TORUS MANDIBULARIS
D7485 SURGICAL REDUCTION OF OSSEOUS TUBEROSITY
D7490 RADICAL RESECTION OF MANDIBLE WITH BONE GRAFT
D7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE
D7520 INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE
REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS
D7530 ALVEOLAR TISSUE
REMOVAL OF REACTION - PRODUCING FOREIGN BODIES - MUSCULOSKELETAL
D7540 SYSTEM
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Frequency
Limits
PA
Required
Y/N
Y
Y
Y
Y
Y
Y
Y
0 - 99
Y
0 - 99
Y
D7550 PARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NON - VITAL BONE
MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN
D7560 BODY
D7610 MAXILLA - OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)
D7620 MAXILLA - CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)
D7630 MANDIBLE - OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)
D7640 MANDIBLE - CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)
D7650 MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION
D7660 MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION
0 - 99
Y
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
Y
Y
D7670 ALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETH
D7671 ALVEOLUS - OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETH
0 - 99
0 - 99
Y
Y
0
0
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
Y
Y
Y
Y
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
D7680 - D7999 (LIMITED TO ORAL SURGEONS
ONLY)
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7771
D7780
D7810
D7820
D7830
D7840
D7850
D7852
D7854
D7856
D7858
D7860
D7865
D7870
D7871
D7872
D7873
D7874
FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MUL - TIPLE
SURGICAL APPROAC
MAXILLA - OPEN REDUCTION
MAXILLA - CLOSED REDUCTION
MANDIBLE - OPEN REDUCTION
MANDIBLE - CLOSED REDUCTION
MALAR AND/OR ZYGOMATIC ARCH - OPEN REDUCTION
MALAR AND/OR ZYGOMATIC ARCH - CLOSED REDUCTION
ALVEOLUS - OPEN REDUCTION STABILIZATION OF TEETH
ALVEOLUS, CLOSED REDUCTION STABILIZATION OF TEETH
FACIAL BONES - COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE
SURGICAL APPROACHE
OPEN REDUCTION OF DISLOCATION
CLOSED REDUCTION OF DISLOCATION
MANIPULATION UNDER ANESTHESIA
CONDYLECTOMY
SURGICAL DISCECTOMY; WITH/WITHOUT IMPLANT
DISC REPAIR
SYNOVECTOMY
MYOTOMY
JOINT RECONSTRUCTION
ARTHROTOMY
ARTHROPLASTY
ARTHROCENTESIS
NON - ARTHROSCOPIC LYSIS AND LAVAGE
ARTHROSCOPY - DIAGNOSIS, WITH OR WITHOUT BIOPSY
ARTHROSCOPY - SURGICAL: LAVAGE AND LYSIS OF ADHESIONS
ARTHROSCOPY - SURGICAL: DISC REPOSITIONING AND STABILIZATION
01.01.08
Page 7 of 9
Care1st DDD Dental Matrix
Age
PROC DESCRIPTION
D7875 ARTHROSCOPY - SURGICAL: SYNOVECTOMY
D7876 ARTHROSCOPY - SURGICAL: DISCECTOMY
D7877 ARTHROSCOPY - SURGICAL: DEBRIDEMENT
D7880 OCCLUSAL ORTHOTIC APPLIANCE
D7899 UNSPECIFIED TMD THERAPY, BY REPORT
D7910 SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM
D7911 COMPLICATED SUTURE - UP TO 5 CM
D7912 COMPLICATED SUTURE - GREATER THAN 5 CM
0
0
0
0
0
0
0
0
D7920 SKIN GRAFT (IDENTIFY DEFECT COVERED, LOCATION, AND TYPE OF GRAFT)
D7940 OSTEOPLASTY - FOR ORTHOGNATHIC DEFORMITIES
D7941 OSTEOTOMY - MANDIBULAR RAMI
OSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING
D7943 THE GRAFT
D7944 OSTEOTOMY - SEGMENTED OR SUBAPICAL - PER SEXTANT OR QUADRANT
D7945 OSTEOTOMY - BODY OF MANDIBLE
D7946 LEFORT I (MAXILLA - TOTAL)
D7947 LEFORT I (MAXILLA - SEGMENTED)
LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE
D7948 HYPOPLASIA OR R
D7949 LEFORT II OR LEFORT III - WITH BONE GRAFT
OSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR
D7950 FACIAL BONES - AUT
D7955 REPAIR OF MAXILLOFACIAL SOFT AND HARD TISSUE DEFECT
D7960
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D7995
D7996
D7997
D7999
D8010
D8020
D8030
D8040
FRENULECTOMY (FRENECTOMY OR FRENOTOMY) - SEPARATE PROCEDURE
EXCISION OF HYPERPLASTIC TISSUE - PER ARCH
EXCISION OF PERICORONAL GINGIVA
SURGICAL REDUCTION OF FIBROUS TUBEROSITY
SIALOLITHOTOMY
EXCISION OF SALIVARY GLAND, BY REPORT
SIALODOCHOPLASTY
CLOSURE OF SALIVARY FISTULA
EMERGENCY TRACHEOTOMY
CORONOIDECTOMY
SYNTHETIC GRAFT - MANDIBLE OR FACIAL BONES, BY REPORT
IMPLANT - MANDIBLE FOR AUGMENTATION PURPOSES (EXCLUDING ALVEOLAR
RIDGE), BY REPORT
APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED APPLIANCE), INCLUDES
REMOVAL OF ARC
UNSPECIFIED ORAL SURGERY PROCEDURE, BY REPORT
LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION
LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION
LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION
LIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITION
D8060 INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL
D8070 DENTITION
COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT
D8080 DENTITION
D8090 COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITION
D8210 REMOVABLE APPLIANCE THERAPY
D8220 FIXED APPLIANCE THERAPY
D8660 PRE - ORTHODONTIC VISIT
01.01.08
Page 8 of 9
Frequency
Limits
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
PA
Required
Y/N
Y
Y
Y
Y
Y
Y
Y
Y
0 - 99
0 - 99
0 - 99
Y
Y
Y
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
0 - 99
0 - 99
Y
Y
0 - 99
0 - 99
Y
Y
0
0
0
0
0
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
- 99
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
0 - 99
Y
0
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
- 99
1
1
1
1
3Y
3Y
3Y
3Y
Y
Y
Y
Y
Y
Y
0 - 99
1
3Y
Y
0 - 99
1
3Y
Y
0
0
0
0
0
1
1
3Y
3Y
1
1Y
Y
Y
Y
Y
Y
- 99
- 99
- 99
- 99
- 99
Care1st DDD Dental Matrix
PROC DESCRIPTION
D8670 PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT)
ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND
D8680 PLACEMENT OF RETA
D8690 ORTHODONTIC TREATMENT (ALTERNATIVE BILLING TO A CONTRACT FEE)
D8691 REPAIR OF ORTHODONTIC APPLIANCE
D8692 REPLACEMENT OF LOST OR BROKEN RETAINER
PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN - MINOR
D9110 PROCEDURES
LOCAL ANESTHESIA N0T IN CONJUNCTION WITH OPERATIVE OR SURGICAL
D9210 PROCEDURES
D9220 DEEP SEDATION/GENERAL ANESTHESIA - FIRST 30 MINUTES
D9221 DEEP SEDATION/GENERAL ANESTHESIA - EACH ADDITIONAL 15 MINUTES
D9230 ANALGESIA, ANXIOLYSIS, INHALATION OF NITROUS OXIDE
D9241 INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - FIRST 30 MINUTES
INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - EACH ADDITIONAL 15
D9242 MINUTES
D9248 NON - INTRAVENOUS CONSCIOUS SEDATION
CONSULTATION (DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN
D9310 OTHER THAN PRA
D9410 HOUSE/EXTENDED CARE FACILITY CALL
D9420 HOSPITAL CALL
OFFICE VISIT FOR OBSERVATION (DURING REGULARLY SCHEDULED HOURS)
D9430 NO OTHER SERVICE
D9440 OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS
D9610 THERAPEUTIC DRUG INJECTION, BY REPORT
D9920 BEHAVIOR MANAGEMENT, BY REPORT
TREATMENT OF COMPLICATIONS (POSTSURGICAL) - UNUSUAL
D9930 CIRCUMSTANCES, BY REPORT
D9940 OCCLUSAL GUARDS, BY REPORT
D9951 OCCLUSAL ADJUSTMENT - LIMITED
D9999 UNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORT
01.01.08
Page 9 of 9
Age
Frequency
Limits
0 - 99
1
1Y
PA
Required
Y/N
Y
0
0
0
0
1
1
1
1
1Y
3Y
4Y
1Y
Y
Y
Y
Y
- 99
- 99
- 99
- 99
0 - 99
N
0
0
0
0
0
- 99
- 99
- 99
- 99
- 99
N
Y
Y
N
Y
0 - 99
0 - 99
Y
Y
0 - 99
0 - 99
0 - 99
Y
N
N
0
0
0
0
- 99
- 99
- 99
- 99
Y
N
Y
N
0 - 99
0 - 99
0 - 99
0 - 99
N
Y
N
N