Download NC Medicaid Dental Reimbursement Rates

NC Medicaid Dental Reimbursement Rates
General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist
Effective Date: January 1, 2014
The inclusion of a rate on this table does not guarantee that a service is covered.
Please refer to the Medicaid Billing Guide and the Medicaid and Health Choice Clinical Coverage Policies on the DMA website.
CDT 2014 (including procedure codes, descriptions, and other data) is copyrighted by the American Dental
Association. © 2014 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.
CDT 2014
Code
Description
Periodic oral evaluation
D0120
Limited oral evaluation - problem focused
D0140
Oral evaluation for a patient under three years of age and counseling with primary caregiver
D0145
Comprehensive oral evaluation - new or established patient
D0150
Detailed and extensive oral evaluation - problem focused, by report
D0160
Re-evaluation - limited, problem focused (established patient; not post-operative visit)
D0170
Intraoral - complete series of radiographic image
D0210
Intraoral - periapical first radiographic image
D0220
Intraoral - periapical each additional radiographic image
D0230
Intraoral - occlusal radiographic image
D0240
Extraoral - first radiographic image
D0250
Extraoral - each additional radiographic image
D0260
Bitewing - single radiographicimage
D0270
Bitewings - two radiographic images
D0272
Bitewings - three radiographic images
D0273
Bitewings - four radiographicimages
D0274
Posterior-anterior or lateral skull and facial bone survey radiographic image
D0290
Sialography
D0310
Temporomandibular joint arthrogram, including injection
D0320
Panoramic radiographic image
D0330
Cephalometric radiographic image
D0340
Diagnostic casts
D0470
Accession of tissue, gross and microscopic examination
D0473
Prophylaxis - adult
D1110
Prophylaxis - child
D1120
Topical application of fluoride varnish
D1206
Topical application of fluoride
D1208
Sealant - per tooth
D1351
Space maintainer - fixed - unilateral
D1510
Space maintainer - fixed - bilateral
D1515
Amalgam - one surface, primary or permanent
D2140
Amalgam - two surfaces, primary or permanent
D2150
Amalgam - three surfaces, primary or permanent
D2160
Amalgam - four or more surfaces, primary or permanent
D2161
Resin-based composite - one surface, anterior
D2330
Resin-based composite - two surfaces, anterior
D2331
Resin-based composite - three surfaces, anterior
D2332
Resin-based composite - four or more surfaces or involving incisal angle (anterior)
D2335
Resin-based composite crown, anterior
D2390
Resin-based composite - one surface, posterior
D2391
Resin-based composite - two surfaces, posterior
D2392
Resin-based composite - three surfaces, posterior
D2393
Medicaid
Rate
24.51
34.94
34.55
42.41
64.89
27.32
68.25
14.18
11.44
15.19
20.46
16.90
10.79
17.59
24.02
30.50
42.70
91.62
186.79
56.32
49.81
40.66
46.25
36.21
25.87
15.25
15.25
27.17
181.53
254.14
68.89
87.29
101.06
111.25
62.64
77.39
91.49
115.89
164.74
73.72
97.81
118.96
D2394
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2970
D3220
D3222
D3230
D3240
D3310
D3320
D3330
D3351
D3352
D3353
D3410
D4210
D4211
D4240
D4241
D4341
D4342
D4355
D4910
D5110
D5120
D5130
D5140
D5211
D5212
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5730
D5731
D5740
D5741
D5750
D5751
Resin-based composite - four or more surfaces, posterior
Prefabricated stainless steel crown - primary tooth
Prefabricated stainless steel crown - permanent tooth
Prefabricated resin crown
Prefabricated stainless steel crown with resin window
Prefabricated esthetic coated stainless steel crown - primary tooth
Protective restoration
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Temporary crown (fractured tooth)
Therapeutic pulpotomy (excluding final restoration)
Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development
Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
Endodontic therapy, anterior tooth (excluding final restoration)
Endodontic therapy, bicuspid tooth (excluding final restoration)
Endodontic therapy, molar (excluding final restoration)
Apexification/recalcification/pulpal regeneration - initial visit
Apexification/recalcification/pulpal regeneration - interim medication replacement
Apexification/recalcification - final visit
Apicoectomy/periradicular surgery - anterior
Gingivectomy or gingivoplasty - four or more contiguous teeth per quadrant
Gingivectomy or gingivoplasty - one to three contiguous teeth per quadrant
Gingival flap procedure, including root planing - four or more contiguous teeth per quadrant
Gingival flap procedure, including root planing - one to three contiguous teeth per quadrant
Periodontal scaling and root planing - four or more contiguous teeth per quadrant
Periodontal scaling and root planing - one to three teeth per quadrant
Full mouth debridement to enable comprehensive evaluation and diagnosis
Periodontal maintenance
Complete denture - maxillary
Complete denture - mandibular
Immediate denture - maxillary
Immediate denture - mandibular
Maxillary partial denture - resin base
Mandibular partial denture - resin base
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
Repair broken complete denture base
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
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
Reline complete maxillary denture (laboratory)
Reline complete mandibular denture (laboratory)
144.14
137.15
147.49
161.15
179.71
179.71
37.80
93.39
22.68
132.82
77.09
77.09
136.15
181.53
269.56
318.58
389.65
131.36
95.57
191.15
247.02
236.24
87.74
278.39
235.25
95.57
55.59
64.04
47.14
555.93
555.93
603.07
603.07
412.27
412.27
30.24
30.24
30.24
30.24
73.33
61.82
73.33
99.62
140.68
62.26
75.60
113.45
128.97
128.97
126.75
126.75
164.10
164.10
D5760
D5761
D6985
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7260
D7270
D7280
D7283
D7285
D7286
D7288
D7310
D7311
D7320
D7321
D7340
D7350
D7410
D7411
D7412
D7413
D7414
D7415
D7440
D7441
D7450
D7451
D7460
D7461
D7465
D7471
D7472
D7473
D7485
D7490
D7510
D7520
D7530
D7540
D7550
D7560
D7610
D7620
D7630
D7640
Reline maxillary partial denture (laboratory)
Reline mandibular partial denture (laboratory)
Pediatric partial denture, fixed
Extraction, coronal remnants - deciduous tooth
Extraction, erupted tooth or exposed root
Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including
elevation of mucoperiosteal flap if indicated
Removal of impacted tooth - soft tissue
Removal of impacted tooth - partially bony
Removal of impacted tooth - completely bony
Removal of impacted tooth - completely bony, with unusual surgical complications
Surgical removal of residual tooth roots (cutting procedure)
Oroantral fistula closure
Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth
Surgical access of an unerupted tooth
Placement of device to facilitate eruption of impacted tooth
Biopsy of oral tissue - hard (bone, tooth)
Biopsy of oral tissue - soft (all others)
Brush biopsy - transepithelial sample collection
Alveoloplasty in conjunction with extractions - four or more tooth spaces, per quadrant
Alveoloplasty in conjunction with extractions - one to three tooth spaces, per quadrant
Alveoloplasty not in conjunction with extractions - four or more tooth spaces, per quadrant
Alveoloplasty not in conjunction with extractions - one to three tooth spaces, per quadrant
Vestibuloplasty - ridge extension (secondary epithelialization)
Vestibuloplasty - ridge extension (including soft tissue grafts)
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
Excision of malignant tumor - lesion diameter greater than 1.25 cm
Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm
Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm
Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm
Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm
Destruction of lesion(s) by physical or chemical method, by report
Removal of lateral exostosis (maxilla or mandible)
Removal of torus palatinus
Removal of torus mandibularis
Surgical reduction of osseous tuberosity
Radical resection of mandible with bone graft
Incision and drainage of abscess - intraoral soft tissue
Incision and drainage of abscess - extraoral soft tissue
Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue
Removal of reaction producing foreign bodies, musculoskeletal system
Partial ostectomy/sequestrectomy for removal of non-vital bone
Maxillary sinusotomy for removal of tooth fragment or foreign body
Maxilla - open reduction (teeth immobilized, if present)
Maxilla - closed reduction (teeth immobilized, if present)
Mandible - open reduction (teeth immobilized, if present)
Mandible - closed reduction (teeth immobilized, if present)
160.11
160.11
326.00
49.01
60.40
103.83
118.12
157.79
183.80
220.56
113.22
362.02
200.95
180.86
203.40
129.86
102.84
102.84
97.84
91.49
142.76
128.09
497.92
922.44
153.49
201.02
265.06
220.59
322.88
386.92
177.90
317.68
169.00
216.59
224.64
336.38
132.98
214.53
249.06
247.72
223.26
2,821.88
105.52
226.91
120.08
222.37
289.54
363.80
1,456.53
1,144.32
1,435.17
1,127.41
D7650
D7660
D7670
D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770
D7780
D7810
D7820
D7830
D7840
D7850
D7858
D7860
D7865
D7870
D7872
D7873
D7910
D7911
D7912
D7920
D7940
D7941
D7943
D7944
D7945
D7946
D7947
D7948
D7949
D7950
D7955
D7960
D7963
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991
D8080
D8670
D9110
D9220
Malar and/or zygomatic arch - open reduction
Malar and/or zygomatic arch - closed reduction
Alveolus - closed reduction, may include stabilization of teeth
Facial bones - complicated reduction with fixation and multiple surgical approaches
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
Facial bones - complicated reduction with fixation and multiple surgical approaches
Open reduction of dislocation
Closed reduction of dislocation
Manipulation under anesthesia
Condylectomy
Surgical discectomy, with/without implant
Joint reconstruction
Arthrotomy
Arthroplasty
Arthrocentesis
Arthroscopy - diagnosis, with or without biopsy
Arthroscopy - surgical: lavage and lysis of adhesions
Suture of recent small wounds up to 5 cm
Complicated suture - up to 5 cm
Complicated suture - greater than 5 cm
Skin graft
Osteoplasty - for orthognathic deformities
Osteotomy - mandibular rami
Osteotomy - mandibular rami with bone graft; includes obtaining the graft
Osteotomy - segmented or subapical
Osteotomy - body of mandible
LeFort I (maxilla - total)
LeFort I (maxilla - segmented)
LeFort II or LeFort III - without bone graft
LeFort II or LeFort III - with bone graft
Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla
Repair of maxillofacial soft and hard tissue defect
Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another
procedure
Frenuloplasty
Excision of pericoronal gingiva
Surgical reduction of fibrous tuberosity
Sialolithotomy
Excision of salivary gland, by report
Sialodochoplasty
Closure of salivary fistula
Emergency tracheotomy
Coronoidectomy
Comprehensive orthodontic treatment of the adolescent dentition
Periodic orthodontic treatment visit (as part of contract)
Palliative (emergency) treatment of dental pain - minor procedure
Deep sedation/general anesthesia - first 30 minutes
1,302.20
1,106.52
452.75
2,185.90
1,534.36
1,117.19
1,556.59
1,205.24
1,372.47
1,519.23
889.48
2,617.74
1,420.94
173.45
227.71
1,838.11
1,852.79
1,271.73
566.96
958.14
117.86
440.96
524.85
158.78
246.69
306.17
812.54
1,321.86
3,454.87
3,181.87
2,642.74
2,744.68
3,219.12
3,253.91
3,725.91
4,279.25
913.94
1,166.56
168.11
256.02
145.22
244.60
289.69
511.92
554.59
364.69
411.38
1,307.54
778.27
91.49
40.47
141.65
D9221
D9230
D9241
D9242
D9410
D9420
D9440
D9610
D9612
D9630
Deep sedation/general anesthesia - each additional 15 minutes
Inhalation of nitrous oxide/anziolysis, analgesia
Intravenous conscious sedation/analgesia - first 30 minutes
Intravenous conscious sedation/analgesia - each additional 15 minutes
House/extended care facility call
Hospital or ambulatory surgical center call
Office visit - after regularly scheduled hours
Therapeutic parenteral drug, single administration
Therapeutic parenteral drugs, two or more administrations, different medications
Other drugs and/or medicaments, by report
60.29
40.85
147.03
56.37
71.16
112.50
55.59
33.36
55.14
14.45
Providers should always bill their usual and customary charges. Please use the monthly NC Medicaid Bulletins for additions,
changes, and deletion to this schedule.