Total CO Medicaid FFS Base CDT Allowable Value Conversion ...
21
Medicaid Dental FFS Fee Schedule Effective 10/01/2021 New Rates in Bold CDT Procedure Code Procedure Code Description FFS Base Value Effective 10/01/2021 Conversion Factor Total CO Medicaid Allowable (Base Value x Conversion Factor) Min Age Max Age D0120 Periodic oral evaluation $22.42 1.00 $22.42 000 999 D0140 Limited Oral Evaluation Problem Focused $33.63 1.00 $33.63 000 999 D0145 Oral evaluation, pt < 3yrs $31.95 1.00 $31.95 000 2 D0150 Comprehensive Oral Evaluation $38.66 1.00 $38.66 000 999 D0160 Detail & Ext Oral Eval, Prob Focus $70.02 1.00 $70.02 000 999 D0170 Re-Eval Limit/Prob Focus, Est Patient $30.81 1.00 $30.81 000 999 D0180 Comprehensive Periodontal Evaluation $42.03 1.00 $42.03 000 999 D0190 Screening of a patient $16.69 1.00 $16.69 003 20 D0210 Intraor complete film series $82.41 1.00 $82.41 000 999 D0220 Intraoral periapical first $12.32 1.00 $12.32 000 999 D0230 Intraoral periapical ea add $12.32 1.00 $12.32 000 999 D0240 Intraoral occlusal film $19.60 1.00 $19.60 000 20 D0250 Extraoral first film $28.00 1.00 $28.00 000 20 D0251 Extraoral posterior dental radiographic image $28.00 1.00 $28.00 000 20 D0270 Dental bitewing single image $12.87 1.00 $12.87 000 999 D0272 Dental bitewings two images $20.72 1.00 $20.72 000 999 D0273 Bitewings - three images $24.42 1.00 $24.42 000 999 D0274 Bitewings four images $29.12 1.00 $29.12 000 999 D0277 Vert bitewings 7 to 8 images $43.16 1.00 $43.16 000 999 D0310 Sialography $139.49 1.00 $139.49 000 20 D0320 TMJ Arthrogram, Including Injection $269.18 1.00 $269.18 000 20 D0321 Other TMJ images by report $96.91 1.00 $96.91 000 20 D0322 Tomographic Survey $221.29 1.00 $221.29 000 20 D0330 Panoramic image $51.52 1.00 $51.52 006 999 D0340 Cephalometric image $58.26 1.00 $58.26 000 20 D0350 2d oral/facial photographic image obtained intra-orally or extra- orally $31.37 1.00 $31.37 000 20 D0351 3d photographic image $31.37 1.00 $31.37 000 20 D0365 Cone beam ct interprete man $173.14 1.00 $173.14 000 20 D0366 Cone beam ct interprete max $173.14 1.00 $173.14 000 20 D0367 Cone beam ct interp both jaw $173.14 1.00 $173.14 000 20 Changes in bold. v1.0 10/01/2021
Transcript of Total CO Medicaid FFS Base CDT Allowable Value Conversion ...
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
CDT
Procedure
Code
Procedure Code Description
FFS Base
Value
Effective
10/01/2021
Conversion
Factor
Total CO
Medicaid
Allowable
(Base Value
x
Conversion
Factor)
Min
Age
Max
Age
D0120 Periodic oral evaluation $22.42 1.00 $22.42 000 999
D0140Limited Oral Evaluation Problem
Focused$33.63 1.00 $33.63 000 999
D0145 Oral evaluation, pt < 3yrs $31.95 1.00 $31.95 000 2
D0150 Comprehensive Oral Evaluation $38.66 1.00 $38.66 000 999
D0160Detail & Ext Oral Eval, Prob
Focus$70.02 1.00 $70.02 000 999
D0170Re-Eval Limit/Prob Focus, Est
Patient$30.81 1.00 $30.81 000 999
D0180Comprehensive Periodontal
Evaluation$42.03 1.00 $42.03 000 999
D0190 Screening of a patient $16.69 1.00 $16.69 003 20
D0210 Intraor complete film series $82.41 1.00 $82.41 000 999
D0220 Intraoral periapical first $12.32 1.00 $12.32 000 999
D0230 Intraoral periapical ea add $12.32 1.00 $12.32 000 999
D0240 Intraoral occlusal film $19.60 1.00 $19.60 000 20
D0250 Extraoral first film $28.00 1.00 $28.00 000 20
D0251Extraoral posterior dental
radiographic image$28.00 1.00 $28.00 000 20
D0270 Dental bitewing single image $12.87 1.00 $12.87 000 999
D0272 Dental bitewings two images $20.72 1.00 $20.72 000 999
D0273 Bitewings - three images $24.42 1.00 $24.42 000 999
D0274 Bitewings four images $29.12 1.00 $29.12 000 999
D0277 Vert bitewings 7 to 8 images $43.16 1.00 $43.16 000 999
D0310 Sialography $139.49 1.00 $139.49 000 20
D0320TMJ Arthrogram, Including
Injection$269.18 1.00 $269.18 000 20
D0321 Other TMJ images by report $96.91 1.00 $96.91 000 20
D0322 Tomographic Survey $221.29 1.00 $221.29 000 20
D0330 Panoramic image $51.52 1.00 $51.52 006 999
D0340 Cephalometric image $58.26 1.00 $58.26 000 20
D0350
2d oral/facial photographic image
obtained intra-orally or extra-
orally
$31.37 1.00 $31.37 000 20
D0351 3d photographic image $31.37 1.00 $31.37 000 20
D0365 Cone beam ct interprete man $173.14 1.00 $173.14 000 20
D0366 Cone beam ct interprete max $173.14 1.00 $173.14 000 20
D0367 Cone beam ct interp both jaw $173.14 1.00 $173.14 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D0381 Cone beam ct capt mandible $137.60 1.00 $137.60 000 20
D0382 Cone beam ct capt maxilla $137.60 1.00 $137.60 000 20
D0391Interpretation of Diagnostic
Image, by report$82.54 1.00 $82.54 000 999
D0411HBA1C In-Office Point of Service
Testing$43.10 1.00 $43.10 000 999
D0412 Blood Glucose Level Test $18.40 1.00 $18.40 000 999
D0414 Lab Process Microbial Spec $50.37 1.00 $50.37 020 999
D0425 Caries Susceptibility Test $42.03 1.00 $42.03 000 20
D0460 Pulp Vitality Tests $26.31 1.00 $26.31 000 999
D0470 Diagnostic Casts $47.62 1.00 $47.62 000 20
D0999Unspecified Diagnostic
Procedure, By Report
Code is
Manually
Priced
1.00
Code is
Manually
Priced000 999
D1110 Prophylaxis Adult $41.15 1.00 $41.15 012 999
D1120 Prophylaxis Child $30.81 1.00 $30.81 000 20
D1206 Topical fluoride varnish $16.79 1.00 $16.79 000 999
D1208Topical application of fluoride -
excluding varnish$11.43 1.00 $11.43 000 999
D1351 Sealant Per Tooth $34.53 1.00 $34.53 000 20
D1352 Prev resin rest, perm tooth $34.53 1.00 $34.53 000 20
D1353 Sealant repair - per tooth $34.53 1.00 $34.53 000 20
D1354
Interim Caries Arresting
Medicament Application, Per
Tooth
$5.60 1.00 $5.60 000 20
D1510 Space Maintainer Fixed Unilateral $145.09 1.00 $145.09 000 20
D1516Space Maintainer Fixed Bilateral
Maxillary $222.92 1.00 $222.92 000 14
D1517Space Maintainer Fixed Bilateral
Mandibular$222.92 1.00 $222.92 000 14
D1520Space Maintainer Removable
Unilateral$179.84 1.00 $179.84 000 20
D1526Space Maintainer Removable
Bilateral Maxillary$144.73 1.00 $144.73 000 14
D1527
Space Maintainer Removable
Bilateral Mandibular
(Replaces D1525)
$144.73 1.00 $144.73 000 14
D1551
Re-cement or Re-bond Bilateral
Space Maintainer- Maxillary
(Replacing D1550)
$36.42 1.00 $36.42 000 14
D1552
Re-cement or Re-bond Bilateral
Space Maintainer- Mandibular
(Replacing D1550)
$36.42 1.00 $36.42 000 14
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D1553
Re-cement or Re-bond Unilateral
Space Maintainer- Per Quadrant
(Replacing D1550)
$36.42 1.00 $36.42 000 14
D1556
Removal of Fixed Unilateral
Space Maintainer- Per Quadrant
(Replacing D1555)
$36.42 1.00 $36.42 000 20
D1557
Removal of Fixed Bilateral Space
Maintainer- Maxillary
(Replacing D1555)
$36.42 1.00 $36.42 000 20
D1558
Removal of Fixed Bilateral Space
Maintainer- Mandibular
(Replacing D1555)
$36.42 1.00 $36.42 000 20
D1575Distal Shoe Space Maintainer-
Fixed, Unilateral$152.42 1.00 $152.42 000 14
D1701
Pfizer-BioNTech Covid-19
vaccine administration - first
dose
SARSCOV2 COVID-19 VAC
mRNA 30mcg/0.3mL IM DOSE 1
$41.18 1.00 $41.18 000 999
D1702
Pfizer-BioNTech Covid-19
vaccine administration -
second dose
SARSCOV2 COVID-19 VAC
mRNA 30mcg/0.3mL IM DOSE 2
$41.18 1.00 $41.18 000 999
D1703
Moderna Covid-19 vaccine
administration - first dose
SARSCOV2 COVID-19 VAC
mRNA 100mcg/0.5mL IM DOSE
1
$41.18 1.00 $41.18 000 999
D1704
Moderna Covid-19 vaccine
administration - second dose
SARSCOV2 COVID-19 VAC
mRNA 100mcg/0.5mL IM DOSE
2
$41.18 1.00 $41.18 000 999
D1707
Janssen Covid-19 vaccine
administration
SARSCOV2 COVID-19 VAC
Ad26 5x1010 VP/.5mL IM
SINGLE DOSE
$41.18 1.00 $41.18 000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D1999Unspecified Preventative
Procedure, By Report
Code is
Manually
Priced
1.00
Code is
Manually
Priced000 999
D2140Amalgam One Surface
Permanent$102.67 1.00 $102.67 000 999
D2150Amalgam Two Surfaces
Permanent$131.20 1.00 $131.20 000 999
D2160Amalgam Three Surfaces
Permanent$160.88 1.00 $160.88 000 999
D2161Amalgam 4 or > Surfaces
Permanent$194.96 1.00 $194.96 000 999
D2330 Resin One Surface Anterior $99.69 1.00 $99.69 000 999
D2331 Resin Two Surfaces Anterior $123.35 1.00 $123.35 000 999
D2332 Resin Three Surfaces Anterior $151.25 1.00 $151.25 000 999
D2335Resin Four or > Surface/Incis
Anterior$182.49 1.00 $182.49 000 999
D2390Resin Based Composite Crown
Anterior$239.74 1.00 $239.74 000 999
D2391Resin Based Comp One Surface
Posterior$102.67 1.00 $102.67 000 999
D2392Resin Based Comp Two Surfaces
Posterior$131.20 1.00 $131.20 000 999
D2393Resin Base Comp Three Surface
Posterior$160.88 1.00 $160.88 000 999
D2394Resin Base Comp 4 or > Surface
Posterior$194.96 1.00 $194.96 000 999
D2710Crown, Resin-based composite
(indirect)$240.44 1.00 $240.44 000 999
D2712Crown Resin Base Comp
(Indirect)$240.44 1.00 $240.44 000 999
D2721Crown, Resin w predom. base
metal$240.44 1.00 $240.44 000 999
D2722 Crown Resin Noble Metal $240.44 1.00 $240.44 000 999
D2740Crown, Porcelain/Ceramic
substrate$459.37 1.00 $459.37 000 999
D2750Crown Porcelain High Noble
Metal$459.37 1.00 $459.37 000 999
D2751 Crown Porcelain Base Metal $459.37 1.00 $459.37 000 999
D2752 Crown Porcelain Noble Metal $459.37 1.00 $459.37 000 999
D2753Crown Porcelain Fused to
Titanium and Titanium Alloys$459.37 1.00 $459.37 000 999
D2781 Crown 3/4 Base Metal $459.37 1.00 $459.37 000 999
D2782 Crown 3/4 Cast Noble Metal $459.37 1.00 $459.37 000 999
D2783 Crown 3/4 Porcelain/Ceramic $459.37 1.00 $459.37 000 999
D2790 Crown Full Cast High Noble Metal $459.37 1.00 $459.37 000 999
D2791 Crown Full Cast Base Metal $459.37 1.00 $459.37 000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D2792 Crown Full Cast Noble Metal $459.37 1.00 $459.37 000 999
D2794 Crown Titanium $459.37 1.00 $459.37 000 999
D2799 Provisional crown $120.21 1.00 $120.21 000 999
D2910
Re-cement or re-bond inlay,
onlay, veneer or partial coverage
restoration
$48.73 1.00 $48.73 000 999
D2920 Re-cement or re-bond crown $49.86 1.00 $49.86 000 999
D2928 Prefabricated porcelain/ceramic
crown – permanent tooth$145.09 1.00 $145.09 000 999
D2929Prefabricated Porcelain/Ceramic
Crown- Primary Tooth$125.47 1.00 $125.47 000 20
D2930Prefab Stainless Steel Crown
Primary$125.47 1.00 $125.47 000 20
D2931Prefab Stainless Steel Crown
Permanent$145.09 1.00 $145.09 000 999
D2932 Prefabricated Resin Crown $156.87 1.00 $156.87 000 20
D2933Prefab Stainless Steel Crown with
Resin$161.89 1.00 $161.89 000 999
D2934Prefab Stainless Steel Crown
Primary$171.97 1.00 $171.97 000 20
D2940 Protective Restoration $51.52 1.00 $51.52 000 999
D2941 Interim Therapeutic Restoration $51.52 1.00 $51.52 000 20
D2950 Core Buildup Including Pins $126.05 1.00 $126.05 000 999
D2951 Pin Retention Per Tooth $30.81 1.00 $30.81 000 20
D2952 Post and core cast + crown $193.28 1.00 $193.28 000 999
D2953 Each addtnl cast post $132.20 1.00 $132.20 000 20
D2954 Prefab Post and Core + Crown $153.50 1.00 $153.50 000 999
D2955 Post removal $132.20 1.00 $132.20 000 20
D2957 Each Additional Prefab Post $74.50 1.00 $74.50 000 20
D2980 Crown repair $127.19 1.00 $127.19 000 20
D2999Unspecified Restorative
Procedure
Code is
manually
priced
1.00
Code is
manually
priced
000 999
D3110 Pulp Cap Direct $36.98 1.00 $36.98 000 20
D3120 Pulp Cap Indirect $36.98 1.00 $36.98 000 20
D3220 Therapeutic Pulpotomy $86.84 1.00 $86.84 000 20
D3221 Pulpal Debridement $105.67 1.00 $105.67 000 20
D3222 Part pulp for apexogenesis $86.84 1.00 $86.84 000 20
D3230 Pulpal Therapy Anterior Primary $120.44 1.00 $120.44 000 20
D3240 Pulpal Therapy Posterior Primary $139.49 1.00 $139.49 000 20
D3310 End thxpy, anterior tooth $324.93 1.00 $324.93 000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D3320 End thxpy, bicuspid tooth $384.86 1.00 $384.86 000 999
D3330 End thxpy, molar $463.31 1.00 $463.31 000 999
D3331Root Canal Obstruction Non
Surgical
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D3332 Incomplete Endodontic Therapy $185.99 1.00 $185.99 000 20
D3333 Internal Root Repair $128.85 1.00 $128.85 000 20
D3346 Retreatment Root Canal Anterior $373.66 1.00 $373.66 000 999
D3347 Retreatment Root Canal Bicuspid $431.37 1.00 $431.37 000 999
D3348 Retreatment Root Canal Molar $510.36 1.00 $510.36 000 999
D3351
Apexification/recalcification -
initial visit (apical closure/calcific
repair of perforations, root
resorption, etc.)
$185.75 1.00 $185.75 000 20
D3352 Apexification/recalc interim $114.28 1.00 $114.28 000 20
D3353 Apexification/Recalcification Final $232.49 1.00 $232.49 000 20
D3355Pupal regeneration Initial visit
(replaces D3354)$185.75 1.00 $185.75 000 20
D3356
Pupal regeneration interim
medication replacement (replaces
D3354)
$114.28 1.00 $114.28 000 20
D3357Pupal regeneration completion of
treatment (replaces D3354)$232.49 1.00 $232.49 000 20
D3410Apicoectomy/Periradicular
Surgery Anter$298.59 1.00 $298.59 000 20
D3421Apicoectomy/Periradicular
Surgery Bicus$336.68 1.00 $336.68 000 20
D3425Apicoectomy/Periradicular
Surgery Molar$392.14 1.00 $392.14 000 20
D3426Apicoectomy/Periradicular
Surgery Ea Add$161.33 1.00 $161.33 000 20
D3430 Retrograde Filling Per Root $123.22 1.00 $123.22 000 20
D3450 Root Amputation Per Root $244.71 1.00 $244.71 000 20
D3460 Endodontic Endosseous Implant $607.84 1.00 $607.84 000 20
D3470 Intentional Reimplantation $364.13 1.00 $364.13 000 20
D3910Surgical Isolation Tooth with
Rubber Dam$72.07 1.00 $72.07 000 20
D3920Hemisection Incl Rt Remov Excl
Rt Canal$207.84 1.00 $207.84 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D3950Canal Prep and Fitting of
Dowel/Post$113.16 1.00 $113.16 000 20
D3999Unspecified Endodontic
Procedure
Code is
manually
priced
1.00
Code is
manually
priced
000 999
D4210 Gingivectomy/plasty 4 or mor $280.11 1.00 $280.11 000 999
D4211 Gingivectomy/plasty 1 to 3 $121.90 1.00 $121.90 000 999
D4212 Gingivectomy/plasty rest $72.07 1.00 $72.07 000 999
D4240 Gingival Flap Proc w Planin $331.64 1.00 $331.64 000 20
D4245 Apically Positioned Flap $387.11 1.00 $387.11 000 20
D4249 Crown Lengthening Hard Tissue $338.38 1.00 $338.38 000 20
D4260
Osseous surgery (including
elevation of a full thickness flap
entry and closure) - four or more
contiguous teeth or tooth
bounded spaces per quadrant
$476.19 1.00 $476.19 000 20
D4261
Osseous surgery (including
elevation of a full thickness flap
entry and closure) - one to three
contiguous teeth or tooth
bounded spaces per quadrant
$392.14 1.00 $392.14 000 20
D4263Bone Replacement Graft First
Site$295.80 1.00 $295.80 000 20
D4264Bone Replacement Graft Each
Additional
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D4266 Guided Tissue Regen Resorbable $391.03 1.00 $391.03 000 999
D4267Guided Tissue Regen
Nonresorbable$457.15 1.00 $457.15 000 20
D4268Surgical revision procedure, per
tooth$373.10 1.00 $373.10 000 20
D4270Pedicle soft tissue graft
procedure$374.22 1.00 $374.22 000 20
D4273Subepithelial Connective Tissue
Graft$476.19 1.00 $476.19 000 20
D4274 Distal/Proximal Wedge $310.92 1.00 $310.92 000 20
D4277 Soft tissue graft firsttooth $583.15 1.00 $583.15 000 20
D4278 Soft tissue graft addl tooth $228.87 1.00 $228.87 000 20
D4283
Autogenous connective tissue
graft procedure (including donor
and recipient surgical sites) –
each additional contiguous tooth,
implant or edentulous tooth
position in same graft site
$476.19 1.00 $476.19 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D4285
Non-autogenous connective
tissue graft procedure (including
recipient surgical site and donor
material) – each additional
contiguous tooth, implant or
edentulous tooth position in same
graft site
$476.19 1.00 $476.19 000 20
D4320 Provisional Splinting Intracoronal $228.57 1.00 $228.57 000 20
D4321 Provisional Splinting Extracoronal $207.27 1.00 $207.27 000 20
D4341Periodontal Scaling & Root
Planing$113.73 1.00 $113.73 000 999
D4342 Periodontal Scaling 1 to 3 Teeth $91.50 1.00 $91.50 000 999
D4346
Scaling in the Presence of
Generalized Moderate or Severe
Gingival Inflammation- Full
Mouth, After Oral Evaluation
$44.69 1.00 $44.69 000 999
D4355 Full Mouth Debridement $84.02 1.00 $84.02 013 999
D4381 Localized delivery antimicro $78.97 1.00 $78.97 000 20
D4910 Periodontal Maintenance $64.04 1.00 $64.04 000 999
D4999Unspecified Periodontal
Procedure
Code is
manually
priced
1.00
Code is
manually
priced
000 999
D5110 Complete Denture Maxillary $794.52 1.00 $794.52 000 999
D5120 Complete Denture Mandibular $795.94 1.00 $795.94 000 999
D5130 Immediate Denture Maxillary $794.52 1.00 $794.52 000 20
D5140 Immediate Denture Mandibular $795.94 1.00 $795.94 000 20
D5211 Maxillary Partial Denture Resin $547.61 1.00 $547.61 000 999
D5212 Mandibular Partial Denture Resin $547.61 1.00 $547.61 000 999
D5213Maxillary Partial Denture Cast
Metal$784.31 1.00 $784.31 000 999
D5214Mandibular Partial Denture Cast
Metal$784.31 1.00 $784.31 000 999
D5221
Immediate Maxillary partial
denture- resin base (including any
conventional clasps, rests and
teeth)
$547.61 1.00 $547.61 000 20
D5222
Immediate mandibular partial
denture – resin base (including
any conventional clasps, rests
and teeth)
$547.61 1.00 $547.61 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D5223
Immediate maxillary partial
denture – cast metal framework
with resin denture bases
(including any conventional
clasps, rests and teeth)
$784.31 1.00 $784.31 000 20
D5224
Immediate mandibular partial
denture – cast metal framework
with resin denture bases
(including any conventional
clasps, rests and teeth)
$784.31 1.00 $784.31 000 20
D5225Maxillary Partial Denture Flexible
Base$689.45 1.00 $689.45 000 999
D5226Mandibular Part Denture Flexible
Base$689.45 1.00 $689.45 000 999
D5282
Removable Unilateral Partial
Denture- One Piece Cast Metal
Including Clasps and Teeth,
Maxillary
$459.31 1.00 $459.31 000 20
D5283
Removable Unilateral Partial
Denture- One Piece Cast Metal
Including Clasps and Teeth,
Mandibular
$459.31 1.00 $459.31 000 20
D5284
Removable Unilateral Partial
Denture- One Piece Flexible Base
(Including Clasps and Teeth)- Per
Quadrant
$459.31 1.00 $459.31 000 20
D5286
Removable Unilateral Partial
Denture- One Piece Resin
(Including Clasps and Teeth)- Per
Quadrant
$459.31 1.00 $459.31 000 20
D5410Adjust Complete Denture
Maxillary$41.44 1.00 $41.44 000 999
D5411Adjust Complete Denture
Mandibular$41.44 1.00 $41.44 000 999
D5421 Adjust Partial Denture Maxillary $41.44 1.00 $41.44 000 999
D5422 Adjust Partial Denture Mandibular $41.44 1.00 $41.44 000 999
D5511Repair Broken Complete Denture
Base- Mandibular$113.70 1.00 $113.70 000 999
D5512Repair Broken Complete Denture
Base- Maxillary$113.70 1.00 $113.70 000 999
D5520Replace Complete Denture, Each
Tooth$82.91 1.00 $82.91 000 999
D5611Repair Resin Partial Denture
Base- Mandibular$83.56 1.00 $83.56 000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D5612Repair Resin Partial Denture
Base- Maxillary$83.56 1.00 $83.56 000 999
D5621Repair Cast Partial Framework-
Mandibular$111.29 1.00 $111.29 000 999
D5622Repair Cast Partial Frameowork-
Maxillary$111.29 1.00 $111.29 000 999
D5630 Repair/Replace Broken Clasp $121.00 1.00 $121.00 000 999
D5640 Replace Broken Teeth, Per Tooth $84.02 1.00 $84.02 000 999
D5650Add Tooth to Existing Partial
Denture$74.52 1.00 $74.52 000 999
D5660Add Clasp to Existing Partial
Denture$126.05 1.00 $126.05 000 999
D5670Replace Teeth & Acrylic Cast
Metal Max$311.25 1.00 $311.25 000 999
D5671Replace Teeth & Acrylic Cast
Metal Mandi$311.25 1.00 $311.25 000 999
D5710Rebase Complete Maxillary
Denture$263.29 1.00 $263.29 000 999
D5711Rebase Complete Mandibular
Denture$264.41 1.00 $264.41 000 999
D5720 Rebase Maxillary Partial Denture $252.65 1.00 $252.65 000 999
D5721Rebase Mandibular Partial
Denture$252.65 1.00 $252.65 000 999
D5730Reline Complete Maxillary
Denture Chair$168.05 1.00 $168.05 000 999
D5731Reline Comp Mandibular Denture
Chair$168.05 1.00 $168.05 000 999
D5740Reline Maxillary Partial Denture
Chair$165.82 1.00 $165.82 000 999
D5741Reline Mandibular Partial Denture
Chair$167.49 1.00 $167.49 000 999
D5750Reline Complete Maxillary
Denture Lab$212.89 1.00 $212.89 000 999
D5751Reline Complete Mandibular
Denture Lab$213.98 1.00 $213.98 000 999
D5760Reline Maxillary Partial Denture
Lab$211.21 1.00 $211.21 000 999
D5761Reline Mandibular Partial Denture
Lab$211.21 1.00 $211.21 000 999
D5810Interim Complete Denture
Maxillary$371.98 1.00 $371.98 000 20
D5811Interim Complete Denture
Mandibular$372.54 1.00 $372.54 000 20
D5820 Interim Partial Denture Maxillary $308.12 1.00 $308.12 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D5821Interim Partial Denture
Mandibular$308.12 1.00 $308.12 000 20
D5850 Tissue Conditioning Maxillary $91.88 1.00 $91.88 000 999
D5851 Tissue Conditioning Mandibular $91.88 1.00 $91.88 000 999
D5862 Precision attachment, by report $308.12 1.00 $308.12 000 999
D5863 Overdenture-complete maxillary $449.58 1.00 $449.58 000 20
D5864 Overdenture-partial maxillary $448.17 1.00 $448.17 000 20
D5865Overdenture-complete
mandibular$449.58 1.00 $449.58 000 20
D5866 Overdenture-partial mandibular $448.17 1.00 $448.17 000 20
D5867Replacement of Precision
Attachment$148.45 1.00 $148.45 000 999
D5875Modification of Removable
Prosthesis$165.82 1.00 $165.82 000 20
D5899Unspecified Removable
Prosthodontic
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5911 Facial moulage (sectional)
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5912 Facial moulage (complete)
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5913 Nasal Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5914 Auricular Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5915 Orbital Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5916 Ocular Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5919 Facial Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5922 Nasal Septal Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5923 Ocular Prosthesis Interim
Code is
manually
priced
1.00
Code is
manually
priced
000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D5924 Cranial Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5925Facial Augmentation Implant
Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5926 Nasal Prosthesis Replacement
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5927 Auricular Prosthesis Replacement
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5928 Orbital Prosthesis Replacement
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5929 Facial Prosthesis Replacement
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5931 Obturator Prosthesis Surgical
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5932 Obturator Prosthesis Definitive $1,194.97 1.00 $1,194.97 000 20
D5933 Obturator Prosthesis Modification
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5934Mandibular Resection Prosthesis
Flange
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5935Mandibular Resect Prosthesis w/o
Flange
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5936 Obturator/prosthesis, interim
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5937 Trimus Appliance not for TMD $289.08 1.00 $289.08 000 20
D5951 Feeding Aid $374.91 1.00 $374.91 000 20
D5952 Speech Aid Prosthesis Pediatric $407.70 1.00 $407.70 000 20
D5954 Palatal Augmentation Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5955 Palatal Life Prosthesis Definitive
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5958 Palatal Lift Prosthesis Interim
Code is
manually
priced
1.00
Code is
manually
priced
000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D5959Palatal Lift Prosthesis
Modification
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5960Speech Aid Prosthesis
Modification
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5982 Surgical Stent $190.47 1.00 $190.47 000 20
D5983 Radiation Carrier
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5984 Radiation Shield
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5985 Radiation Cone Locator
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5986 Fluoride Gel Carrier $89.07 1.00 $89.07 000 20
D5987 Commissure Splint
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5988 Surgical Splint $626.20 1.00 $626.20 000 20
D5991 Topical medicament carrier $89.07 1.00 $89.07 000 20
D5992 Adjust max prost appliance
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5993 Main/clean max prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 20
D5999Unspecified Maxillofacial
Prosthesis
Code is
manually
priced
1.00
Code is
manually
priced
000 999
D6055 Implant connecting bar $1,258.83 1.00 $1,258.83 000 20
D6056 Prefabricated abutment $336.13 1.00 $336.13 000 20
D6057 Custom abutment $432.50 1.00 $432.50 000 20
D6060Abutment Support Porc to Base
Metal$573.66 1.00 $573.66 000 20
D6063 Abutment Support Base Metal $560.22 1.00 $560.22 000 20
D6070 Abut Supp Retain Por-Base Metal $560.22 1.00 $560.22 000 20
D6073 Abut Supp Retain Base Metal $560.22 1.00 $560.22 000 20
D6080 Implant Maintenance $126.05 1.00 $126.05 000 20
D6081
Scaling and Debridement in the
Presence of Inflammation or
Mucositis of a Single Implant,
Including Cleaning of the Implant
Surfaces, Without Flap Entry and
Closure
$85.05 1.00 $85.05 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D6082
Implant Supported Crown-
Porcelain Fused to Predominantly
Base Alloy
$573.67 1.00 $573.67 000 20
D6086Implant Supported Crown-
Predominantly Base Alloys$560.22 1.00 $560.22 000 20
D6090Repair Implant Supported
Prosthesis$336.13 1.00 $336.13 000 20
D6092
Re-cement or re-bond
implant/abutment supported
crown
$72.81 1.00 $72.81 012 20
D6093
Re-cement or re-bond
implant/abutment supported fixed
partial denture
$79.55 1.00 $79.55 012 20
D6095Repair implant abutment, by
report$334.43 1.00 $334.43 000 20
D6098
Implant Supported Retainer-
Porcelain Fused to Predominantly
Base Alloys
$560.22 1.00 $560.22 000 20
D6100 Implant removal, by report $352.95 1.00 $352.95 000 20
D6118
Implant/Abutment Supported
Interim Fixed Denture for
Edentulous Arch- Mandibular
$1,510.79 1.00 $1,510.79 000 20
D6119
Implant/Abutment Supported
Interim Fixed Denture for
Edentulous Arch-Maxillary
$1,510.79 1.00 $1,510.79 000 20
D6121
Implant Supported Retainer for
Metal FPD- Predominantly Base
Alloys
$560.22 1.00 $560.22 000 20
D6199Unspecified implant procedure, by
report
Code is
manually
priced
1.00
Code is
manually
priced
000 999
D6211Pontic Cast Predominantly Base
Metal$449.28 1.00 $449.28 000 20
D6241 Pontic Porcelain-Base Metal $462.17 1.00 $462.17 000 20
D6545 Retainer Cast Metal $347.34 1.00 $347.34 000 20
D6751Crown Porcelain Fused Base
Metal$459.38 1.00 $459.38 000 20
D6791Crown Full Cast Predominantly
Base Metal$451.00 1.00 $451.00 000 20
D6920 Connector Bar $449.28 1.00 $449.28 000 20
D6930Re-cement or re-bond fixed
partial denture$75.06 1.00 $75.06 000 20
D6940 Stress Breaker $190.47 1.00 $190.47 000 20
D6950 Precision Attachment $293.57 1.00 $293.57 000 20
D6980 Fixed partial repair $173.66 1.00 $173.66 000 20
D6999 Unspecified Fixed Prosthodontic
Code is
manually
priced
1.00
Code is
manually
priced
000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D7111 Extraction, coronal remnants $46.34 1.00 $46.34 000 20
D7140Extraction Erupted
Tooth/Exposed Root$101.78 1.00 $101.78 000 999
D7210 Rem imp tooth w mucoper flp $162.88 1.00 $162.88 000 999
D7220Removal Impacted Tooth Soft
Tissue$187.25 1.00 $187.25 000 999
D7230Removal Impacted Tooth Partially
Bony$235.53 1.00 $235.53 000 999
D7240Removal Impacted Tooth
Complete Bony$276.38 1.00 $276.38 000 999
D7241Remov Impact Tooth Comp Bony
Surg Comp$369.20 1.00 $369.20 000 999
D7250Surg Remov Residual Tooth
Roots$172.30 1.00 $172.30 000 999
D7251 Coronectomy $354.44 1.00 $354.44 000 999
D7260 Oral Antral Fistula Closure $353.52 1.00 $353.52 000 999
D7261 Primary Closure Sinus Perforation $443.59 1.00 $443.59 000 999
D7270 Tooth Reimplantation $245.37 1.00 $245.37 000 20
D7272 Tooth Transplantation $400.04 1.00 $400.04 000 20
D7280Surgical Access an Unerupted
Tooth$215.11 1.00 $215.11 000 999
D7282 Mobilize Erupt/Malpo Tooth $250.48 1.00 $250.48 000 20
D7283 Place device impacted tooth $241.44 1.00 $241.44 000 20
D7285Incisional biopsy of oral tissue -
hard (bone, tooth)$174.20 1.00 $174.20 000 999
D7286Incisional biopsy of oral tissue -
soft$138.93 1.00 $138.93 000 999
D7287 Cytology Sample Collection
Code is
manually
priced
1.00
Code is
manually
priced
000 999
D7290 Surgical repositioning of teeth $215.69 1.00 $215.69 000 20
D7291 Transseptal Fiberotomy $136.69 1.00 $136.69 000 20
D7296Corticotomy- One to Three Teeth
or Tooth Spaces, Per Quadrant$228.07 1.00 $228.07 000 20
D7297Corticotomy- Four or More Teeth
or Tooth Spaces, Per Quadrant$236.12 1.00 $236.12 000 20
D7310 Alveoplasty w/ extraction $129.42 1.00 $129.42 000 999
D7311 Alveoloplasty with Extractions 1-3 $129.42 1.00 $129.42 000 999
D7320 Alveoplasty w/o extraction $190.47 1.00 $190.47 000 999
D7321 Alveoloplasty not w/extracts $190.47 1.00 $190.47 000 999
D7340 Vestibuloplasty Ridge Extension $444.81 1.00 $444.81 000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D7350Vestibuloplasty Ridge Extension
Grafts$902.51 1.00 $902.51 000 20
D7410Excision of Benign Lesion up to
1.25 cm$178.15 1.00 $178.15 000 999
D7411 Excision Benign Lesion > 1.25 cm $263.87 1.00 $263.87 000 999
D7412Excision Benign Lesion
Complicated$661.22 1.00 $661.22 000 999
D7413Excision Malignant Lesion up to
1.25 cm$296.92 1.00 $296.92 000 999
D7414Excision Malignant Lesion > 1.25
cm$445.38 1.00 $445.38 000 999
D7415Excision Malignant Lesion
Complicated$546.24 1.00 $546.24 000 999
D7440Excision Malignant Tumor Lesion
1.25 cm$246.51 1.00 $246.51 000 999
D7441Excision Malignant Tumor Lesion
> 1.25 c$476.01 1.00 $476.01 000 999
D7450Remov Ben Odontogenic Cyst to
1.25 cm$217.94 1.00 $217.94 000 999
D7451Remov Ben Odontogenic Cyst >
1.25 cm$285.69 1.00 $285.69 000 999
D7460Remov Ben Nonodontogenic Cyst
to 1.25 cm$227.21 1.00 $227.21 000 999
D7461Remov Ben Nonodontogenic Cyst
> 1.25 cm$321.57 1.00 $321.57 000 999
D7465Destruction Lesion
Physical/Chemical$172.55 1.00 $172.55 000 20
D7471 Removal Lateral Exostosis $280.11 1.00 $280.11 000 999
D7472 Removal of Torus Palatinus $331.08 1.00 $331.08 000 999
D7473 Removal of Torus Mandibularis $322.69 1.00 $322.69 000 999
D7485Surgical Reduction of Osseous
Tuberosity$298.04 1.00 $298.04 000 999
D7490 Radical Resection of Mandible $3,753.49 1.00 $3,753.49 000 999
D7510Incision & Drainage Abscess
Intraoral$101.96 1.00 $101.96 000 999
D7511 Incision/drain abscess intra $295.20 1.00 $295.20 000 999
D7520Incis & Drain Abscess Extraoral
Soft$174.20 1.00 $174.20 000 999
D7521 Incision/drain abscess extra $247.08 1.00 $247.08 000 999
D7530Removal Foreign
Body/Skin/Tissue$157.41 1.00 $157.41 000 999
D7540Removal Reaction Producing
Foreign Body$324.90 1.00 $324.90 000 999
D7550 Part Ostectomy/Sequestrectomy $231.39 1.00 $231.39 000 999
D7560 Maxillary Sinusotomy $507.55 1.00 $507.55 000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D7610Maxilla Open Reduction Teeth
Immobilize$1,908.11 1.00 $1,908.11 000 999
D7620Maxilla Close Reduction Teeth
Immobilize$1,510.36 1.00 $1,510.36 000 999
D7630Mandible Open Reduction Teeth
Immobilize$1,909.79 1.00 $1,909.79 000 999
D7640Mandible Close Reduct Teeth
Immobilize$1,474.51 1.00 $1,474.51 000 999
D7650Malar/Zygomatic Arch Open
Reduction$1,717.09 1.00 $1,717.09 000 999
D7660Malar/Zygomatic Arch Closed
Reduction$1,412.88 1.00 $1,412.88 000 999
D7670 Alveolus Closed Reduction $604.47 1.00 $604.47 000 999
D7671 Alveolus Open Reduction $801.53 1.00 $801.53 000 999
D7680Facial Bones Complicated
Reduction$2,861.63 1.00 $2,861.63 000 999
D7710 Maxilla Open Reduction $1,989.36 1.00 $1,989.36 000 999
D7720 Maxilla Closed Reduction $1,486.84 1.00 $1,486.84 000 999
D7730 Mandible Open Reduction $2,107.56 1.00 $2,107.56 000 999
D7740 Mandible Closed Reduction $1,587.67 1.00 $1,587.67 000 999
D7750Malar/Zygomatic Arch Open
Reduction$1,814.01 1.00 $1,814.01 000 999
D7760Malar/Zygomatic Arch Close
Reduction$2,102.54 1.00 $2,102.54 000 999
D7770Alveolus Open Reduction
Stabilization$1,185.42 1.00 $1,185.42 000 999
D7771Alveolus Closed Reduction
Stabilization$1,135.54 1.00 $1,135.54 000 999
D7780Facial Bones Complicated
Reduction$3,544.55 1.00 $3,544.55 000 999
D7910Suture Recent Small Wounds up
to 5 cm$132.20 1.00 $132.20 000 999
D7911 Complicated Suture up to 5 cm $248.15 1.00 $248.15 000 999
D7912 Complicated Suture > 5 cm $397.89 1.00 $397.89 000 999
D7920Skin Graft Identify Defect
Covered$1,067.79 1.00 $1,067.79 000 999
D7940Osteplasty Orthognathic
Deformities$1,617.36 1.00 $1,617.36 000 20
D7941 Osteotomy Mandibular Rami $4,158.54 1.00 $4,158.54 000 20
D7943Osteotomy Mandibular Rami w/
Bone Graft$3,827.48 1.00 $3,827.48 000 20
D7944 Bone cutting segmented
Code is
manually
priced
1.00
Code is
manually
priced000 20
D7945 Osteotomy Body Mandible $4,848.11 1.00 $4,848.11 000 20
D7946 LeFort I Maxilla Total $3,702.53 1.00 $3,702.53 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D7947 LeFort I Maxilla Segmented $3,853.22 1.00 $3,853.22 000 999
D7948 LeFort II/LeFortIII w/o Bone Graft $4,391.62 1.00 $4,391.62 000 20
D7949 LeFort II/LeFortIII w/ Bone Graft $4,944.55 1.00 $4,944.55 000 20
D7950 Mandible graft $1,408.59 1.00 $1,408.59 000 999
D7951 Sinus aug w bone or bone sub $1,242.58 1.00 $1,242.58 012 20
D7955Repair Maxillofacial Soft & Hard
Tissue$2,384.66 1.00 $2,384.66 000 999
D7961
Buccal/labial frenectomy
(frenulectomy)- Separate
procedure not incidental to
another procedure
(Replacing D7960)
$198.87 1.00 $198.87 000 20
D7962
Lingual frenectomy
(frenulectomy)-Separate
procedure not incidental to
another procedure
(Replacing D7960)
$198.87 1.00 $198.87 000 20
D7963 Frenuloplasty $224.08 1.00 $224.08 000 20
D7970Excision Hyperplastic Tissue per
Arch$224.08 1.00 $224.08 000 999
D7971 Excision Pericoronal Gingiva $104.75 1.00 $104.75 000 999
D7972Surgical Reduction Fibrous
Tuberosity$326.06 1.00 $326.06 000 999
D7979 Non-Surgical Sialithotomy $196.06 1.00 $196.06 000 999
D7980 Sialolithotomy $366.85 1.00 $366.85 000 999
D7981Excision of salivary gland, by
report
Code is
manually
priced
1.00
Code is
manually
priced000 999
D7982 Sialodochoplasty $752.94 1.00 $752.94 000 999
D7983 Closure Salivary Fistula $547.36 1.00 $547.36 000 999
D7990 Emergency Tracheotomy $566.95 1.00 $566.95 000 999
D7991 Coronoidectomy
Code is
manually
priced
1.00
Code is
manually
priced000 999
D7995Synthetic Graft Mandible/Facial
Bones
Code is
manually
priced
1.00
Code is
manually
priced000 20
D7996Implant Mandible Augmentation
Purposes
Code is
manually
priced
1.00
Code is
manually
priced000 20
D7997 Appliance Removal $127.19 1.00 $127.19 000 999
D7999 Unspecified Oral Surgery
Code is
manually
priced
Code is
manually
priced000 999
D8050Interceptive Ortho Primary
Dentition$1,022.19 1.00 $1,022.19 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D8060Interceptive Ortho Transition
Dentition$1,201.66 1.00 $1,201.66 000 20
D8070Comprehen Ortho Transition
Dentition$2,056.34 1.00 $2,056.34 000 20
D8080Comprehen Ortho Adolescent
Dentition$2,390.06 1.00 $2,390.06 000 20
D8090 Comprehen Ortho Adult Dentition $2,723.76 1.00 $2,723.76 000 20
D8210 Removable Appliance Therapy $392.14 1.00 $392.14 000 20
D8220 Fixed Appliance Therapy $448.18 1.00 $448.18 000 20
D8660
Pre-orthodontic treatment
examination to monitor growth
and development
$140.06 1.00 $140.06 000 20
D8670Periodic Orthodontic Treatment
Visit$126.87 1.00 $126.87 000 20
D8680 Orthodontic Retention $232.73 1.00 $232.73 000 20
D8695
Removal of Fixed Orthodontic
Appliances for Reasons Oher
Than Completion of Treatment
$75.92 1.00 $75.92 000 20
D8696
Repair of Orthodonitic Appliance-
Maxillary
(Replacing D8691)
$172.36 1.00 $172.36 000 20
D8697
Repair of Orthodontic Appliance-
Mandibular
(Replacing D8691)
$172.36 1.00 $172.36 000 20
D8698
Re-cement or Re-bond Fixed
Retainer- Maxillary
(Replacing D8693)
$106.99 1.00 $106.99 000 20
D8699
Re-cement or Rebond Fixed
Retainer- Mandibular
(Replacing D8693)
$106.99 1.00 $106.99 000 20
D8701
Repair of Fixed Retainer, Includes
Reattachment- Maxillary
(Replacing D8694)
$73.95 1.00 $73.95 000 20
D8702
Repair of Fixed Retainer, Includes
Reattachment- Mandibular
(Replacing D8694)
$73.95 1.00 $73.95 000 20
D8703
Replacement of Lost or Broken
Retainer- Maxillary
(Replacing D8692)
$147.89 1.00 $147.89 000 20
D8704
Replacement of Lost or Broken
Retainer- Mandibular
(Replacing D8692)
$147.89 1.00 $147.89 000 20
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D8999Unspec orthodontic procedure by
report
Code is
manually
priced
1.00
Code is
manually
priced000 20
D9110 Palliative Emergency Minor $53.23 1.00 $53.23 000 999
D9219Evaluation for deep sedation or
general anesthesia$40.90 1.00 $40.90 000 999
D9222Deep Sedation/General
Anesthesia- First 15 Minutes$107.09 1.00 $107.09 000 999
D9223
Deep sedation/general
anesthesia – each 15 minute
increment
$93.40 1.00 $93.40 000 999
D9230 Analgesia $31.37 1.00 $31.37 000 20
D9239
Intravenous Moderate
(Conscious) Sedation/Analgesia-
First 15 Minutes
$107.09 1.00 $107.09 000 999
D9243
Intravenous moderate (conscious)
sedation/analgesia – each 15
minute increment
$93.40 1.00 $93.40 000 999
D9248Non-intravenous moderate
(conscious) sedation$140.06 1.00 $140.06 000 20
D9310 Dental consultation $40.89 1.00 $40.89 000 999
D9311Consultation with Medical Health
Care Professional$42.33 1.00 $42.33 000 999
D9410House/Extended Care Facility
Call$98.03 1.00 $98.03 000 999
D9420 Hospital/ASC call $112.05 1.00 $112.05 000 999
D9613
Infiltration of Sustained Release
Therapeutic Drug- Single or
Multiple Sites
$31.51 1.00 $31.51 000 999
D9911 Application Desensitizing Resin $34.74 1.00 $34.74 000 20
D9943 Occlusal guard adjustment $41.45 1.00 $41.45 000 20
D9944Occlusal Guard- Hard Appliance,
Full Arch$263.76 1.00 $263.76 000 20
D9945Occlusal Guard- Soft Appliance,
Full Arch$263.74 1.00 $263.74 000 20
D9946Occlusal Guard- Hard Appliance,
Partial Arch$184.80 1.00 $184.80 000 20
D9951 Occlusal Adjustment Limited $77.88 1.00 $77.88 000 20
D9952 Occlusal Adjustment Complete $221.36 1.00 $221.36 000 20
D9971 Odontoplasty 1-2 Teeth $12.32 1.00 $12.32 000 20
D9995Teledentistry- Synchronous; real-
time encounter$16.86 1.00 $16.86 000 999
D9996 Tele-Dentistry- Asynchronous $0.00 1.00 $0.00 000 999
Changes in bold.
v1.0 10/01/2021
Medicaid Dental FFS Fee Schedule
Effective 10/01/2021
New Rates in Bold
D9999Unspec adjunctive procedure, by
report
Code is
manually
priced
1.00
Code is
manually
priced000 999
Changes in bold.
v1.0 10/01/2021
