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NC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2016 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 2016 (including procedure codes, descriptions, and other data) is copyrighted by the American Dental Association. © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CDT 2016 Code D0120 D0140 D0145 D0150 D0160 D0170 D0210 D0220 D0230 D0240 Description Periodic oral evaluation Limited oral evaluation - problem focused Oral evaluation for a patient under three years of age and counseling with primary caregiver Comprehensive oral evaluation - new or established patient Detailed and extensive oral evaluation - problem focused, by report Re-evaluation - limited, problem focused (established patient; not post-operative visit) Intraoral - complete series of radiographic image Intraoral - periapical first radiographic image Intraoral - periapical each additional radiographic image Intraoral - occlusal radiographic image D0250 D0270 D0272 D0273 D0274 D0290 D0310 D0320 D0330 D0340 D0470 D0473 D1110 D1120 D1206 D1208 D1351 D1510 D1515 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 Extra-oral - 2D projection radiographic image created using a stationary radiation source, and detector Bitewing - single radiographicimage Bitewings - two radiographic images Bitewings - three radiographic images Bitewings - four radiographicimages Posterior-anterior or lateral skull and facial bone survey radiographic image Sialography Temporomandibular joint arthrogram, including injection Panoramic radiographic image 2D Cephalometric radiographic image - acquistion, measurement and analysis Diagnostic casts Accession of tissue, gross and microscopic examination Prophylaxis - adult Prophylaxis - child Topical application of fluoride varnish Topical application of fluoride Sealant - per tooth Space maintainer - fixed - unilateral Space maintainer - fixed - bilateral Amalgam - one surface, primary or permanent Amalgam - two surfaces, primary or permanent Amalgam - three surfaces, primary or permanent Amalgam - four or more surfaces, primary or permanent Resin-based composite - one surface, anterior Resin-based composite - two surfaces, anterior Resin-based composite - three surfaces, anterior Resin-based composite - four or more surfaces or involving incisal angle (anterior) Resin-based composite crown, anterior Resin-based composite - one surface, posterior Resin-based composite - two surfaces, posterior Resin-based composite - three surfaces, posterior Resin-based composite - four or more surfaces, posterior Medicaid Rate 24.51 34.94 34.55 42.41 64.89 27.32 68.25 14.18 11.44 15.19 20.46 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 15.72 27.17 181.53 254.14 71.02 89.99 104.19 114.69 62.64 77.39 91.49 115.89 164.74 76.00 100.84 122.64 148.60 NC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2016 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 2016 (including procedure codes, descriptions, and other data) is copyrighted by the American Dental Association. © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CDT 2016 Code D2930 D2931 D2932 D2933 D2934 D2940 D2950 D2951 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 Description 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 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 Medicaid Rate 137.15 147.49 161.15 179.71 179.71 37.80 93.39 22.68 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 NC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2016 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 2016 (including procedure codes, descriptions, and other data) is copyrighted by the American Dental Association. © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CDT 2016 Code D5640 D5650 D5660 D5730 D5731 D5740 D5741 D5750 D5751 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 Description 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) 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 Medicaid Rate 62.26 75.60 113.45 128.97 128.97 126.75 126.75 164.10 164.10 160.11 160.11 326.00 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 NC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2016 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 2016 (including procedure codes, descriptions, and other data) is copyrighted by the American Dental Association. © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CDT 2016 Code D7451 D7460 D7461 D7465 D7471 D7472 D7473 D7485 D7490 D7510 D7520 D7530 D7540 D7550 D7560 D7610 D7620 D7630 D7640 D7650 D7660 D7670 D7680 D7710 D7720 D7730 D7740 D7750 D7760 D7770 D7780 D7810 D7820 D7830 D7840 D7850 D7858 D7860 D7865 D7870 D7872 D7873 Description 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) 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 Medicaid Rate 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 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 NC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2016 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 2016 (including procedure codes, descriptions, and other data) is copyrighted by the American Dental Association. © 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. CDT 2016 Code 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 D9223 D9230 D9243 D9410 D9420 D9440 D9610 D9612 D9630 Description 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 - each 15 minute increment Inhalation of nitrous oxide/anziolysis, analgesia Intravenous moderate (conscious) sedation/analgesia - each 15 minute increment 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 Medicaid Rate 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 67.36 40.85 68.51 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.