Title: Section 535.5 - Maximum reimbursable dental fee schedules.
535.5 Maximum reimbursable dental fee schedules. (Additional statutory authority: Social Services Law, Section 363-a)
(a) Maximum reimbursable allowances for dental services except those dental services provided in certain dental clinics as set forth in subdivision (b) of this section and those provided in organized clinics in hospitals as set forth in sub-division (c) of this section. Fees for all services included in this subdivision shall be effective for care and services provided on and after April 1, 1974.
DIAGNOSTIC
Fee D011 Charting, history, oral examination
and completion of forms................... $5.00 D012 Periodic recall examination (oral checking) 5.00
Radiographic D021 Complete intraoral series of 14 periapical
films and 2 bite-wing films............... $15.00 D022 Intraoral periapical (first or single film) 2.00 D023 Each additional single film
(periapical or bite-wing)................. 1.00 D024 Occlusal view x-ray....................... 5.00 D025* Lateral jaw x-ray, each................... 10.00 D027 Four bite-wing x-ray films................ 6.00 D028 First or single bite-wing film
(use D023 for add. films)................. 2.00 D029* Antero-posterior x-ray of head and jaws... 10.00 D030* Cephalometric examination................. 10.00 D033 Panoramic (panography).................... 12.50 D034 Panoramic x-rays, supplemented by three (3)
or more additional intra-oral films
(periapical and/or bitewing) necessary to establish an accurate diagnosis, maximum payment........................... $15.00
(for panography with fewer than (3) supplemental films use Codes D023 and D033)
Supplementary Diagnostic Aids D047* Study models, where indicated............. $10.00
PREVENTIVE D111 Oral prophylaxis, child to age 12......... $6.90 D112 Over age 12............................ 8.80
Topical fluoride treatment following prophylaxis D121 4 treatments, sodium fluoride
only...................................... 17.50 D122 1 treatment, other than
sodium fluoride........................... 6.00
PERIODONTICS D212* Subgingival curettage and root planning--per
quadrant (at least 5 teeth)............... $10.00 D214 Incision and drainage of periodontal abscess 8.00 D215** Treatment for necrotizing ulcerative
gingivitis (Vincent's infection)
(incl. debridement and medication) per visit 10.00
ORAL SURGERY D311 Extraction, uncomplicated, permanent
tooth, includes local anesthesia.......... $7.50 D312** Extraction, uncomplicated, each
additional permanent tooth at same session, in same quadrant, includes local anesthesia.......................... 6.90 D313 Extraction, uncomplicated,
deciduous tooth, includes local anesthesia................................ 6.30 D314 Extraction, uncomplicated, each
additional deciduous tooth at same session, in same quadrant, includes local anesthesia.......................... 5.00 D320 Extraction--surgical removal of
erupted tooth, includes local anesthesia . 15.00 D321 Each additional adjacent tooth
surgically removed during the same session................................... 7.50 D322* Extraction--odontectomy, impacted
tooth, soft tissue, includes local anesthesia................................ 15.00 D323 partially covered by bone -
includes local anesthesia................. 25.00 D324* completely covered by bone -
includes local anesthesia................. 45.00 D325* Extraction, removal of residual
root covered by bone, includes local anesthesia................................ 15.00 D326* Repair--surgical exposure of
impacted tooth or unerupted tooth-for orthodontic reasons including ligation, includes local anesthesia....... 45.00 D331* Repair-Alveolectomy per jaw -
includes local anesthesia................. 25.00 D360 Fracture, maxilla, simple or
compound, no reduction.................... By Report D361 Fracture, maxilla, simple open reduction,
with wiring of teeth and/or local FOLLOW fixation UP DAYS 200.00 Anesthesia 90 16+T D362 Fracture, maxilla, simple closed
reduction, with wiring of teeth 120.00 Anesthesia 90 16+T D363 Fracture, mandible, simple open
reduction. with or without wiring of teeth 200.00 Anesthesia 90 16+T D364 Fracture, mandible, simple closed
reduction and wiring of teeth 120.00 Anesthesia 90 16+T D365 Fracture, maxilla, complicated,
open reduction, fixation by headcap, multiple surgical approaches, internal fixation, wiring teeth, etc By Report D369 Fracture, mandible, simple
or compound, no reduction By Report D373* Repair--Osteoplasty (mandible,
for prognathism or micrognathism), one or two stages 400.00 Anesthesia 90 20+T D374 Fracture, malar, simple or
compound, no reduction By Report D375 Closed reduction (incl.
towel clip technique) 20.00 Anesthesia 16+T D376 Depressed, open reduction 120.00
Anesthesia 60 16+T D377 Complicated, depressed, open
reduction with internal skeletal fixation and multiple surgical approaches 260.00 Anesthesia 90 20+T D378 Fracture, mandible, skeletal
pinning with external fixation 160.00 Anesthesia 90 16+T D384 Incision and drainage of abscess-Dento-alveolar 10.00 D385 Infra-orbital, palatal, peri-coronol,
sub-maxillary, sublinqual, submental, masseteric, floor of mouth, others except periodontal $15.00 ________________________________________________________________________
* Prior approval required except in emergency. ** Prior approval required in some cases (See regulations or guidelines)
Fee
ENDODONTICS
(Including radiographs but exclusive of restoration) D420 Vital pulpotomy $ 10.00 D431** Single root canal filling 50.00 D432** Double root canal filling 75.00 D439* Anterior tooth: root canal filling
with apicoectomy and/or root-end amalgam 75.00 D440* Apicoectomy (separate procedure) 35.00
OPERATIVE (RESTORATIVE) SERVICES
(Filling includes bases as necessary) D511 Silver amalgam--1 surface $6.30 D512 Silver amalgam--2 surface 11.30 D513 Silver amalgam--3 surface or more $17.50 D514 Silver amalgam--reinforcement pins--1st pin
(to be added to restoration cost) $5.00 D515 --each additional pin 3.00 D520 Silicate cement filling--maximum payment
two fillings per tooth 7.00 D531 Plastic Class III--maximum payment two
fillings per tooth 9.00 D532 Plastic Class IV--maximum payment two
fillings per tooth 12.00 D551* Cast gold--1 surface 35.00 D552* Cast gold--2 surfaces 45.00 D553* Cast gold--3 surfaces or more 60.00
CROWN AND BRIDGE D610* Acrylic jacket (quick cure) $30.00 D611* Acrylic or vinyl jacket crown 70.00 D614* Porcelain jacket crown 80.00 D617* Acrylic veneer jacket crown 75.00 D618* Porcelain veneer jacket crown 100.00 D619* Cast gold full crown 70.00 D620* Gold band crown with cast occlusal 60.00 D622* 3/4 cast gold crown 60.00 D624 Crowns, stainless steel--primary
or permanent tooth 20.00 D625* Pontics: Cast gold (sanitary) 40.00 D626* Steele's facing 50.00 D627* Tru-pontic type 50.00 D628* Plastic processed to gold 50.00 D629* Gold dowel and core for porcelain
or acrylic jacket crown 35.00 D642 Recementing crown 10.00 D643 Recementing fixed bridge 20.00 D651 Replacing facing (slot and tube) 15.00
PROSTHETICS D711* Full upper acrylic denture including
necessary adjustments $150.00 D712* Full lower acrylic denture including
necessary adjustments 150.00 D713* Immediate denture including chairside
relines--including necessary adjustments 165.00 D722* Partial acrylic denture, upper or
lower, including teeth and two clasps with rests 110.00 D727* Cast chrome partial--two clasps,
acrylic saddle 170.00 D728* Wrought lingual bar-2 wrought
clasps, acrylic saddle 120.00 D731* Each additional clasp with rest 22.00 D732* Each additional wrought clasp,
with rest 20.00 D743 Denture repair--no teeth 12.50 D744 Repair of denture base plus
replacing one tooth 16.30 D745 Replacing each additional tooth 6.30 D746 Replacing broken tooth -- no other
repair 10.00 D747 Add tooth to partial, replace
extracted tooth in acrylic 16.30 D748 Add tooth to partial, replacing
extracted tooth with welded loop 25.00 D749* Partial acrylic denture, upper
or lower, replacing one or two anterior teeth, no clasps
(Flipper or Stayplate)--Use 10745 for each additional tooth 75.00 D750 Replacing one arm of a clasp 17.50 D751 Replacing undamaged clasp
on partial 18.00 D752 Replacing broken clasp with
new clasp 30.00 D753* Rebasing upper or lower,
full denture 43.80 D754* Rebasing upper or lower partial 43.80 D757* Duplicating denture, full
or partial 75.00
ORTHODONTICS
Active treatment in private office: D853* 1st year including appliances 1/ $500.00 D854* 2nd year 375.00 D855* 3rd year $125.00
(Maximum cost for active treatment $1,000.00) D856* Retention not to exceed 12 visits
per year at $6.25 per visit, annual maximum payment 75.00 D857* Observation not to exceed 6 visits
per year at $6.25 per visit, annual maximum payment 37.50 1/ Billing for first year of care should be from date appliances are inserted. This is based on a fee of $187.50 for preparation and construction of appliance and $26.04 per month for 12 months of active treatment after the appliances are inserted, making a total fee of $500.00 for first year of care.
(See regulations or guidelines)
MISCELLANEOUS SERVICES D910 Palliative treatment of dental pain
(in office, during office hours) $5.00 D911 Home visits 2/, by dentist per
visit, regardless of number of patients seen (to be added to fee for service) 5.00 D913 Hospital Visit 3/, by dentist per,
visit, regardless of number of patients seen (to be added to fee for service) 5.00 D923 Anesthesia--general in office,
by qualified person other than operating dentist, 1st hour 10.00 each additional 30 minutes 5.00 D925 General Anesthesia for multiple
extractions in hospital
(basic fee) 15.00 basic fee plus each 15 minutes of anesthesia time 5.00 D940 Consultation by qualified
specialist 20.00 2/ The fee for a home visit represents the total extra charge permitted, and is not applicable to each patient seen at such visit. Payments at home call rates apply to services provided to persons in boarding homes nursing homes, convalescent homes, proprietary homes for adults, private homes for the aged, institutions for the blind, and places of residence used as an individual's home. 3/ The fee for a hospital visit is not applicable when covered by a specified number of follow-up days.
NON-SPECIALISTS Clinic Session D950 Three-hour session $35.00 D951 Each additional hour (per hour) 7.00
Shorter Clinic Session
(Less than 3 hours) D953 One-hour session 15.00 D954 Two-hour session 25.00
SPECIALISTS
Clinic Session D960 Three-hour session 50.00 D961 Each additional hour (per hour). 10.00
Shorter Clinic Session
(Less than 3 hours) D963 One-hour session 20.00 D964 Two-hour session 35.00
(b) Maximum reimbursable allowances for dental services rendered in dental clinics affiliated with State University of New York at Buffalo School of Dentistry,Columbia University School of Dental and Oral Surgery, and New York University College of Dentistry. Code Procedure Fee
DIAGNOSTIC DC011 Charting, history, oral
examination and completion of forms $3.00 DC012 Periodic recall examination
(oral checking) 3.00 RADIOGRAPHIC DC021 Complete intraoral series of 14
periapical films and 2 bite-wing films 7.50 DC022 First intraoral periapical
(single film) .50 DC023 Each additional single film .50 DC024 Occlusal view x-ray. 1.00 DC025 Lateral jaw x-ray each 2.00 DC027 Four bite-wing x-ray films 2.00 DC028 Single bite-wing film .50 DC029 Antero-posterior x-ray of
head and jaws 5.00 DC030 Cephalometric examination 5.00 DC033 Panoramic (panography) 10.00
SUPPLEMENTARY DIAGNOSTIC AIDS DC047 Study models, where indicated 5.00
PREVENTIVE DC111 Oral prophylaxis, child to age 12 2.00 DC112 Over age 12 3.00 DC120 Topical fluoride treatment following
prophylaxis DC121 4 treatments 10.00 DC122 1 treatment 3.00
PERIODONTICS DC212 Subgingival scaling and planning
per quadrant (at least 5 teeth) 5.00 DC214 Incision and drainage of
periodontal abscess 5.00 DC215 Treatment for rectitizing
ulcerative gingivitis (Vincent's infection) (incl. debridement and medication) per visit 5.00 DC216 Night guard or day guard
(bite guard) 15.00 DC217 Temporary splinting (wire ligation
or stainless steel bands) 10.00 DC218 Splint resin 15.00 DC219 Gingivectomy and/or gingivoplasty
(per quadrant) 20.00 DC220 Periodontal surgical flap
(per quadrant) 20.00 DC221 Periodontal surgical bone implant 20.00 ORAL SURGERY DC311 Extraction, removal of tooth,
uncomplicated, includes local anesthesia 2.00 DC312 Extraction--multiple removal of
teeth, per tooth, includes local anesthesia 2.00 DC321 Extraction--surgical removal of
erupted tooth, includes local anesthesia 3.00 DC322 Extraction--odontectomy, impacted
tooth, soft tissue, includes local anesthesia 10.00 DC323 partially covered by bone--includes
local anesthesia 15.00 DC324 completely covered by bone--includes
local anesthesia 25.00 DC325 Extraction--removal of residual root
covered by bone, includes local anesthesia 10.00 DC326 Repair--surgical exposure of
impacted tooth or unerupted tooth--for orthodontic reasons including ligation, includes local anesthesia 10.00 DC331 Repair--alveolectomy per jaw-
includes local anesthesia 10.00 DC360 Fracture, maxilla, simple or
compound, no reduction By report DC361 Fracture, maxilla, simple open
reduction, with wiring of teeth and/or local fixation 100.00 DC362 Fracture, maxilla, simple closed
reduction, with wiring of teeth 75.00 DC363 Fracture, mandible, simple open
reduction, with or without wiring o.100.00 DC364 Fracture, mandible, simple closed
reduction and wiring of teeth 75.00 DC365 Fracture, maxilla, complicated,
open reduction, fixation by head cap, multiple surgical approaches, internal fixation, wiring teeth, etc by report DC369 Fracture, mandible, simple or
compound, no reduction by report DC373 Repair--osteoplasty (mandible,
for prognathism or micrognathism), one or two stages $200.00 DC374 Fracture, malar, simple or compound,
no reduction by report DC375 Closed reduction (incl. towel
clip technique) 10.00 DC376 Depressed, open reduction 75.00 DC377 Complicated, depressed, open
reduction with internal skeletal fixation and multiple surgical approaches 130.00 DC378 Fracture, mandible, skeletal
pinning with external fixation 75.00 DC384 Incision and drainage of
abscess- dento-alveolar 7.00 DC385 Infra-orbital, palatal, peri-coronal,
submaxillary, sublingual, submental, masseteric, floor of mouth, others except periodontal 10.00 DC386 Biopsy 10.00 DC387 Tumor excision 25.00 DC388 Redundant tissue removal 25.00 DC389 Frenectomy 15.00 DC390 Cysts--soft tissue 10.00 DC391 Cysts--bone 25.00 DC392 Tuberosity reduction 10.00 DC393 Torus mandibularis removal 20.00 DC394 Torus palatinus removal 30.00
ENDODONTICS (including radiographs but exclusive of restoration) DC410 Pulp capping 3.00 DC420 Vital pulpotomy 5.00 DC431 Single root canal filling 30.00 DC432 Double root canal filling 40.00 DC439 Anterior tooth: root canal filling
with apicoectomy and/or root-end amalgam 40.00 DC440 Apicoectomy (separate procedure) 10.00 DC441 Molar (3 or more canals) 50.00
OPERATIVE (RESTORATIVE) SERVICES
(Fees for fillings include excavation and bases as necessary) DC511 Silver amalgam--1 surface 3.00 DC512 Silver amalgam--2 surface 5.00 DC513 Silver amalgam--3 surface or more 5.00 DC514 Silver amalgam reinforcement pins
-1st pin (to be added to restoration cost) 3.00 DC515 --each addition pin 2.00 DC520 Silicate cement filling 3.00 DC531 Plastic class III 3.00 DC532 Plastic class IV 3.00 DC551 Cast gold--1 surface 6.00 DC552 Cast gold--2 surface 10.00 DC553 Cast gold--3 surface 12.00 DC554 Gold foil 7.00 DC555 Inlays, porcelain 10.00
CROWN AND BRIDGE DC610 Acrylic jacket (quick cure) 10.00 DC611 Acrylic or vinyl jacket crown 25.00 DC614 Porcelain jacket crown 25.00 DC617 Acrylic veneer jacket crown 35.00 DC618 Porcelain veneer jacket crown 60.00 DC619 Cast gold full crown 35.00 DC620 Gold band crown with cast occlusal 30.00 DC622 3/4 Cast gold crown 30.00 DC624 Crowns, stainless steel--primary
or permanent tooth 10.00 DC625 Pontic: Cast gold (sanitary) 25.00 DC626 Steele's facing 30.00 DC627 Tru-pontic type 30.00 DC628 Plastic processed to gold 30.00 DC629 Gold dowel and core for porcelain
or acrylic jacket crown 10.00 DC642 Recementing crown 5.00 DC643 Recementing fixed bridge 10.00 DC651 Replacing facing (slot or tube) 10.00 DC658 Space maintainer 20.00
PROSTHETICS DC711 Full upper acrylic denture including
necessary adjustments 75.00 DC712 Full lower acrylic denture including
necessary adjustments 75.00 DC713 Immediate denture including
chairside relines--including necessary adjustments 80.00 DC722 Partial acrylic denture, upper
or lower, including teeth and 2 clasps with rests 50.00 DC727 Cast chrome partial--two clasps,
acrylic saddle (acrylic base) 115.00 DC728 Wrought lingual bar--2 wrought
clasps acrylic saddle 75.00 DC731 Each additional clasp with rest 10.00 DC732 Each additional wrought clasp 10.00 DC743 Denture repair--no teeth 7.00 DC744 Denture repair replacing
one tooth 9.00 DC745 Replacing each additional tooth 3.00 DC746 Replacing broken tooth--no other
repair 5.00 DC748 Add tooth to partial replacing
extracted tooth 15.00 DC751 Replacing undamaged clasp on
partial 10.00 DC752 Replacing broken clasp with
new clasp 25.00 DC753 Rebasing upper or lower, full
denture 25.00 DC754 Rebasing upper or lower, partial 25.00 DC757 Duplicating denture, full
or partial 40.00 MISCELLANEOUS SERVICES DC910 Palliative treatment of dental
pain (in clinic, during clinic hours) 3.00 DC923 Anesthesia--general in clinic,
by qualified person other than operating dentist, 1st hour 5.00 DC924 each additional 30 minutes 5.00 DC926 Temporomandibular joint--history
and clinical exam 5.00
(All injectables are to be reimbursed at cost.)
(c) Maximum reimbursable fees payable to qualified dentists for dental services provided on a per session basis in organized clinics of hospitals possessing valid operating certificates issued by the New York State Department of Health. Practitioners who receive compensation from the facility for providing health services shall be ineligible for additional payment. The fees listed below shall be prorated in accordance with the ratio of medical assistance recipients to the total number of patients seen during a clinic session. The fees listed below shall not apply to services provided in dental school clinics nor to care provided in independent, out-of-hospital facilities. The fees listed in this subdivision shall apply to services rendered on and after August 1, 1969.
Non-specialists Clinic session D950 Three-hour session $28.00 D951 Each additional hour, per hour 5.60
Shorter clinic session
(less than three hours) D953 One-hour session 12.00 D954 Two-hour session 20.00
Specialists
Clinic session D960 Three-hour session 40.00 D961 Each additional hour, per hour 8.00
Shorter clinic session
(less than three hours) D963 One-hour session 16.00 D964 Two-hour session 28.00
Volume
VOLUME C (Title 18)