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114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Section
14.01:
14.02:
14.03:
14.04:
14.05:
14.06:
14.07:

General Provisions
General Definitions
General Rate Provisions and Maximum Fees
Allowable Fees: Anesthesia Services (Hospital)
Allowable Fees: Non-Hospital Services
Allowable Fees: Hospital Services
Severability

14.01: General Provisions
(1) Scope, Purpose and Effective Date. 114.3 CMR 14.00 governs the rates of payments to be
used by all governmental units in making payments to eligible dental providers for dental services
rendered to publicly-aided individuals on or after January 22, 2011. The rates set forth in
114.3 CMR 14.00 do not apply to individuals covered by M.G.L. c. 152 (the Workers'
Compensation Act), as most recently amended by St. 1991, c. 398. Rates for service rendered to
such individuals are set forth at 114.3 CMR 40.00. The codes used in 114.3 CMR 14.00 are the
Health Care Financing Administration’s Common Procedure Coding System (HCPCS).
(2) Coverage. The rates of payment contained herein, or rates of payment determined in
accordance with the provisions of 114.3 CMR 14.00, are full compensation for dental services
rendered to publicly-aided individuals as well as for any related administrative or supervisory
duties in connection with the provision of services, without regard to where these services are
rendered.
(3) Authority. 114.3 CMR 14.00 is adopted pursuant to M.G.L. c. 118G.
(4) Disclaimer of Authorization of Services. 114.3 CMR 14.00 is neither authorization for nor
approval of the substantive services for which rates are determined pursuant to 114.3 CMR 14.00.
Governmental units that purchase services from eligible providers are responsible for the
definition, authorization, and approval of services extended to publicly-aided patients.
(5) Coding Updates and Corrections. The Division may publish procedure code updates and
corrections in the form of an Informational Bulletin. Updates may reference coding systems
including but not limited to the American Medical Association’s Current Procedural Terminology
(CPT). The publication of such updates and corrections will list:
(a) codes for which only the code numbers change, with the corresponding cross references
between existing and new codes;
(b) deleted codes for which there are no corresponding new codes; and
(c) codes for entirely new services that require pricing. The Division will list these codes
and apply individual consideration (I.C.) reimbursement for these codes until
appropriate rates can be developed.
14.02: General Definitions
Confirmatory (Additional Opinion) Consultation. When the consulting physician or dentist is
aware of the confirmatory nature of the opinion that is sought (e.g., when a patient requests a

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
second/third opinion on the necessity or appropriateness of a recommended medical treatment or
surgical procedure).
Consultation. A type of service provided by a physician or dentist whose opinion or advice
regarding evaluation and/or management of a specific problem is requested by another physician
or dentist or other appropriate source. A physician consultant may initiate diagnostic and/or
therapeutic services.
The request for a consultation from the attending physician or dentist or other appropriate source
and the need for consultation must be documented in the patient's medical record. The
consultant's opinion and any services that were ordered or performed must also be documented in
the patient's medical record and communicated to the requesting physician or other appropriate
source.
Any specifically identifiable procedure (i.e., identified with a specific HCPCS code) performed
on or subsequent to the date of the initial consultation should be reported separately.
If a consultant subsequently assumes responsibility for management of a portion or all of the
patient's condition(s), the consultation codes should not be used.
Dental Enhancement Fee. D9450 or case presentation; detailed and extensive treatment planning
is a dental enhancement fee for Community Health Centers and Hospital Licensed Health Centers
who have signed an agreement with MassHealth. This code is used as a Dental Enhancement Fee
per Dental User. This code may be billed when other dental procedures are performed on the
same day and can only be billed once per dental user per day.
Division: The Division of Health Care Finance and Policy, established under M.G.L. c. 118G.
Eligible Provider. A provider of dental services who meets such conditions of participation as
have been or may be adopted from time to time by a governmental unit purchasing such services
and:
(a) Dentists registered by the Massachusetts Board of Registration in Dentistry in
accordance with the provisions of M.G.L. c. 112; or
(b) Authorized governmental, nonprofit or charitably incorporated dental clinics not
involved with teaching dental students; or
(c) Authorized dental clinics that wholly or partially derive support from Title V funds
under the Social Security Act; or
(d) Teaching dental clinics operated by dental education institutions; or
(e) Qualified physicians, physician assistants, nurse practitioners, registered nurses, and
licensed practical nurses who provide D1206 therapeutic application Fluoride Varnish for
moderate to high caries risk patients in accordance with the applicable MassHealth
program regulations; or
(f) Public health dental hygienists who are certified by the Massachusetts Board of
Registration in Dentistry and provide services in public health settings that include
schools, long-term nursing facilities, medical facilities and shelters.

Established Patient. A patient who has received professional services from the physician or
dentist within the past three years.
Evaluation and Management (E/M) Services. . The E/M section is divided into broad categories
such as office visits, hospital visits and consultations. Most of the categories are further divided

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
into two or more subcategories of E/M services. For a full discussion of these services, refer to
the most current Physician’s Current Procedural Terminology (CPT) Handbook.
Governmental Unit. The Commonwealth, any department, division, agency board, or
commission of the Commonwealth, and any political subdivision of the Commonwealth.
Levels of E/M Services. Within each category or subcategory of E/M service, there are three to
five levels of E/M services available for reporting purposes. Levels of E/M services are not
interchangeable among the different categories or subcategories of service.
The levels of E/M services include examinations, evaluations, treatments, conferences with or
concerning patients, preventive pediatric and adult health supervision and similar medical
services. The levels of E/M services encompass the wide variations in skill, effort, time,
responsibility and medical knowledge required for the prevention or diagnosis and treatment of
illness or injury and the promotion of optimal health. Each level of E/M services may be used by
all physicians or dentists. Coordination of care with other providers or agencies without a patient
encounter on that day is reported using the case management codes. For a full discussion of the
levels of E/M services, please refer to the most current CPT handbook.
New Patient. A patient who has not received any professional services from the physician or
dentist within the past three years.
Publicly Aided Individual. A person who receives medical or dental care and services for which
a governmental unit is liable, in whole or in part, under a statutory program of public assistance.
14.03: General Rate Provisions and Maximum Fees
(1) Rate Determination. Rates of payment for authorized dental services to which 114.3 CMR
14.00 applies will be the lower of:
(a) The eligible dentist provider's usual fee to patients other than publicly-aided
individuals or industrial accident patients; or
(b) The fees listed in 114.3 CMR 14.04, 14.05, 14.06.
(2) Early Periodic Screening, Diagnosis and Treatment (EPSDT). Division of Medical
Assistance regulation 130 CMR 420.421 states that dental services provided to members under
age 21 must comply with all applicable requirements for Early and Periodic Screening, Diagnosis
and Treatment (EPSDT) Services set forth in Division of Medical Assistance regulation 130
CMR 450. 140-149.
(3) Individual Consideration (I.C.). Non-listed procedures and dental procedures designated
I.C. are individually considered items. Determination of appropriate payment for procedures
designated I.C. will be in accordance with the following standards and criteria:
(a) Time required to perform the procedure;
(b) Degree of skill required in the procedure performed;
(c) Severity and/or complexity of the patient's dental disease or condition;
(d) Policies, procedures and practices of other third-party purchasers of dental services,
both governmental and private;
(e) Should an eligible provider believe that any such procedure merits a higher fee than
recommended, the provider may submit the prescribed claim form with supporting
documentation. Such claims will be individually processed.

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
(4) Prior Approval. A number of procedures require authorization of the appropriate purchasing
agency prior to the rendering of service and before payment will be made. Providers should
refer to the appropriate purchasing agency manual before providing services.
14.04: Allowable Fees: Anesthesia Services (Hospital)
Reimbursement of anesthesia services is set forth in 114.3 CMR 16.00: Surgery and Related
Anesthesia Services.

14.05: Allowable Fees: Non-Hospital Services

Code

Allowed
Fee

EPSDT
Rate

D0120
D0140

$20
$39

$29
$49

D0145

I.C.

D0150

$37

$58

D0160

$60

$77

D0170

$36

$45

D0180

I.C.

D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277

$69
$14
$12
$20
$21
$21
$13
$22
I.C.
$33
$44

$88
$20
$16
$26
$28
$26
$17
$30
I.C.
$43
$55

D0290
D0310

$41
$42

$53
$48

D0320
D0321
D0322

$214
$89
I.C.

$321
$114
I.C.

Description
I. Diagnostic
Periodic oral evaluation - established patient
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 postoperative visit)
Comprehensive periodontal evaluation - new
or established patient
Intraoral - complete series (including
bitewings)
Intraoral - periapical, first film
Intraoral - periapical, each additional film
Intraoral - occlusal 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
Posterior-anterior or lateral skull and facial
bone survey film
Sialography
Temporomandibular joint arthrogram,
including injection
Other temporomandibular joint films, by report
Tomographic survey

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code
D0330
D0340
D0350
D0360

Allowed
Fee
$62
$69
$36
I.C.

EPSDT
Rate
$88
$85
$47
I.C.

D0362

I.C.

D0363

I.C.

D0415
D0416
D0421
D0425

I.C.
I.C.
I.C.
I.C.

D0431
D0460
D0470

I.C.
$29
$58

I.C.
$37
$72

D0472

$67

D0473

I.C.

D0474
D0475
D0476
D0477
D0478

I.C.
I.C.
I.C.
I.C.
I.C.

D0479

I.C.

D0480
D0481
D0482
D0483
D0484

$50
I.C.
I.C.
I.C.
I.C.

D0485

I.C.

Description
Panoramic film
Cephalometric film
Oral/facial photographic images
Cone beam CT - craniofacial data capture
Cone beam - two-dimensional image
reconstruction using existing data, includes
multiple images
Cone beam - three-dimensional image
reconstruction using existing data, includes
multiple images
Collection of microorganisms for culture and
sensitivity
Viral culture
Genetic test for susceptibility to oral diseases
Caries susceptibility tests
Adjunctive pre-diagnostic test that aids In
detection of mucosal abnormalities including
premalignant and malignant lesions, not to
include cytology or biopsy procedures
Pulp vitality tests
Diagnostic casts

Accession of tissue, gross examination,
$87 preparation, and transmission of written report
Accession of tissue, gross and microscopic
examination, preparation and transmission of
I.C. written report
Accession of tissue, gross and microscopic
examination, including assessment of surgical
margins for presence of disease, preparation
I.C. and transmission of written report
I.C. Decalcification procedure
I.C. Special stains for microorganisms
I.C. Special stains, not for microorganisms
I.C. Immunohistochemical stains
Tissue in-situ hybridization, including
I.C. interpretation
Accession of exfoliative cytologic smears,
microscopic examination, preparation and
$65 transmission of written report
I.C. Electron microscopy - diagnostic
I.C. Direct immunofluorescence
I.C. Indirect immunofluorescence
I.C. Consultation on slides prepared elsewhere
Consultation, including preparation of slides
I.C. from biopsy material supplied by referring

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

Description
source

D0486
D0502
D0999

I.C.
I.C.
I.C.

D1110
D1120

$49
$36

$70
$51

D1203

n/a

$26

D1204

$29

n/a

D1206

$26

D1310

I.C.

D1320
D1330
D1351
D1510
D1515
D1520
D1525
D1550
D1555

I.C.
$14
$28
$178
$285
$214
$321
$33
I.C.

I.C.
$21
$41
$229
$345
$244
$368
$40
I.C.

D2140
D2150

$58
$72

$77
$95

D2160

$86

$110

D2161
D2330
D2331
D2332

$108
$67
$86
$108

$137
$91
$110
$137

D2335
D2390
D2391

$136
$99
$51

$175
$124
$92

D2392

$65

$115

Accession of brush biopsy sample,
microscopic examination, preparation and
transmission of written report
Other oral pathology procedures, by report
Unspecified diagnostic procedure, by report
II. Preventative
Prophylaxis - adult
Prophylaxis - child
Topical application of fluoride (prophylaxis
not included) - child
Topical application of fluoride (prophylaxis
not included) - adult
Topical fluoride varnish; therapeutic
application for moderate to high caries risk
patients
Nutritional counseling for the control of dental
disease
Tobacco counseling for the control and
prevention of oral disease
Oral hygiene instruction
Sealant - per tooth
Space maintainer - fixed-unilateral
Space maintainer - fixed-bilateral
Space maintainer - removable-unilateral
Space maintainer - removable-bilateral
Recementation of space maintainer
Removal of fixed space maintainer
III. Restorative
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 - one surface, anterior
Resin - two surfaces, anterior
Resin - three surfaces, anterior
Resin - 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

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D2393

$77

$124

D2394
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620

$106
I.C.
I.C.
I.C.
I.C.
I.C.
$286
$465
$643
$666
I.C.
$393

$170
I.C.
I.C.
I.C.
I.C.
I.C.
$367
$596
$788
$800
I.C.
$504

D2630
D2642
D2643

$596
$629
$607

$744
$722
$768

D2644
D2650
D2651

$615
I.C.
I.C.

$788
I.C.
I.C.

D2652
D2662
D2663

I.C.
$571
$570

I.C.
$656
$727

D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750

$570
$214
I.C.
$590
$429
$485
$679
$639

$731
$244
I.C.
$757
$550
$558
$853
$800

D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791

$571
$590
$657
I.C.
I.C.
$635
$643
$501

$727
$735
$841
I.C.
I.C.
$812
$808
$641

Description
Resin-based composite - three surfaces,
posterior
Resin-based composite - four or more surfaces,
posterior
Gold foil - one surface
Gold foil - two surfaces
Gold foil - three surfaces
Inlay - metallic - one surface
Inlay - metallic - two surfaces
Inlay - metallic - three or more surfaces
Onlay - metallic - two surfaces
Onlay - metallic - three surfaces
Onlay - metallic - four or more surfaces
Inlay - porcelain/ceramic - one surface
Inlay - porcelain/ceramic - two surfaces
Inlay - porcelain/ceramic - three or more
surfaces
Onlay - porcelain/ceramic - two surfaces
Onlay - porcelain/ceramic - three surfaces
Onlay - porcelain/ceramic - four or more
surfaces
Inlay - resin-based composite - one surface
Inlay - resin-based composite - two surfaces
Inlay - resin-based composite - three or more
surfaces
Onlay - resin-based composite - two surfaces
Onlay - resin-based composite - three surfaces
Onlay - resin-based composite - four or more
surfaces
Crown - resin-based composite (indirect)
Crown - 3/4 resin-based composite (indirect)
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown - porcelain/ceramic substrate
Crown - porcelain fused to high noble metal
Crown - porcelain fused to predominantly base
metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominately base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly base metal

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code
D2792
D2794
D2799

Allowed
Fee
$607
I.C.
$178

D2910
D2915
D2920

$53
I.C.
$53

D2930

$143

D2931
D2932

$159
$197

D2933

$143

D2934
D2940
D2950

$143
$57
$153

D2951

$25

D2952

$217

D2953

I.C.

D2954

$178

D2955
D2957
D2960
D2961
D2962
D2970

I.C.
I.C.
$286
$393
$535
I.C.

D2971
D2975
D2980
D2999

I.C.
I.C.
$107
I.C.

D3110
D3120

$32
$32

D3220

$82

EPSDT
Rate
Description
$748 Crown - full cast noble metal
I.C. Crown - titanium
$228 Provisional crown
Recement inlay, onlay or partial coverage
$69 restoration
I.C. Recement cast or prefabricated post and core
$68 Recement crown
Prefabricated stainless steel crown - primary
$205 tooth
Prefabricated stainless steel crown - permanent
$199 tooth
$224 Prefabricated resin crown
Prefabricated stainless steel crown with resin
$184 window
Prefabricated esthetic coated stainless steel
$184 crown - primary tooth
$72 Sedative filling
$197 Core buildup, including any pins
Pin retention - per tooth, in addition to
$31 restoration
Post and core in addition to crown, indirectly
$276 fabricated
Each additional indirectly fabricated post I.C. same tooth
Prefabricated post and core in addition to
$229 crown
Post removal (not in conjunction with
I.C. endodontic therapy)
I.C. Each additional prefabricated post - same tooth
$420 Labial veneer (resin laminate) - chair side
$504 Labial veneer (resin laminate) – laboratory
$688 Labial veneer (porcelain laminate) – laboratory
I.C. Temporary crown (fractured tooth)
Additional procedures to construct new crown
I.C. under existing partial denture framework
I.C. Coping
$137 Crown repair, by report
I.C. Unspecified restorative procedure, by report
IV. Endodontics
$40 Pulp cap - direct (excluding final restoration)
$40 Pulp cap - indirect (excluding final restoration)
Therapeutic pulpotomy (excluding final
restoration) - removal of pulp coronal to the
dentinocemental junction and application of
$106 medicament

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D3221

$107

$123

D3230

I.C.

D3240
D3310
D3320
D3330

I.C.
$375
$440
$569

I.C.
$480
$564
$731

D3331

I.C.

D3332
D3333

$178
$214

$205
$274

D3346

$425

$545

D3347

$501

$641

D3348

$571

$789

D3351

$114

$146

D3352

I.C.

D3353
D3410

I.C.
$379

I.C.
$471

D3421

$429

$550

D3425

$557

$639

D3426
D3430
D3450
D3460

$214
$72
$268
$430

$264
$91
$343
$744

D3470

I.C.

D3910

I.C.

D3920

$197

$243

Description
Pulpal debridement, primary and permanent
teeth
Pulpal therapy (resorbable filling) - anterior,
primary tooth (excluding final restoration)
Pulpal therapy (resorbable filling) - posterior,
primary tooth (excluding final restoration)
Anterior (excluding final restoration)
Bicuspid (excluding final restoration)
Molar (excluding final restoration)
Treatment of root canal obstruction;
nonsurgical access
Incomplete endodontic therapy; inoperable,
unrestorable 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 repair of perforations,
root resorption, etc.)
Apexification/recalcification - interim
medication replacement (apical closure/calcific
repair of perforations, root resorption, etc.)
Apexification/recalcification - final visit
(includes completed root canal therapy - apical
closure/calcific repair of perforations, root
resorption, etc.)
Apicoectomy/periradicular surgery - anterior
Apicoectomy/periradicular surgery - bicuspid
(first root)
Apicoectomy/periradicular surgery - molar
(first root)
Apicoectomy/periradicular surgery (each
additional root)
Retrograde filling - per root
Root amputation - per root
Endodontic endosseous implant
Intentional replantation (including necessary
splinting)
Surgical procedure for isolation of tooth with
rubber dam
Hemisection (including any root removal), not
including root canal therapy

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D3950
D3999

$64
I.C.

$111
I.C.

D4210

$286

$343

D4211

$103

$133

D4230

I.C.

D4231

I.C.

D4240

$418

$606

D4241
D4245
D4249

I.C.
I.C.
$429

I.C.
I.C.
$550

D4260

$741

$1,101

D4261
D4263

$660
$236

$759
$351

D4264

$175

$202

D4265

I.C.

D4266

$286

$359

D4267
D4268
D4270

$286
I.C.
$563

$328
I.C.
$800

D4271

$518

$704

D4273

$607

$779

D4274

$304

$384

Description
Canal preparation and fitting of preformed
dowel or post
Unspecified endodontic procedure, by report
V. Periodontics
Gingivectomy or gingivoplasty - Four or more
contiguous teeth or bounded teeth spaces per
quadrant
Gingivectomy or gingivoplasty - one to three
contiguous teeth or bounded teeth spaces per
quadrant
Anatomical crown exposure - Four or more
contiguous teeth per quadrant
Anatomical crown exposure - one to three
teeth per quadrant
Gingival flap procedure, including root
planning - four or more contiguous teeth or
bounded teeth spaces per quadrant
Gingival flap procedure, including root
planning - one to three contiguous teeth or
bounded teeth spaces per quadrant
Apically positioned flap
Clinical crown lengthening - hard tissue
Osseous surgery (including flap entry and
closure) - four or more contiguous teeth or
bounded teeth spaces per quadrant
Osseous surgery (including flap entry and
closure) - one to three contiguous teeth or
bounded teeth spaces per quadrant
Bone replacement graft - first site in quadrant
Bone replacement graft - each additional site in
quadrant
Biologic materials to aid in soft and osseous
tissue regeneration
Guided tissue regeneration - resorbable barrier,
per site
Guided tissue regeneration - nonresorbable
barrier, per site (includes membrane removal)
Surgical revision procedure, per tooth
Pedicle soft tissue graft procedure
Free soft tissue graft procedure (including
donor site surgery)
Subepithelial connective tissue graft
procedures, per tooth
Distal or proximal wedge procedure (when not
performed in conjunction with surgical
procedures in the same anatomical area)

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code
D4275

Allowed
Fee
I.C.

D4276
D4320
D4321

I.C.
$124
$106

D4341

$125

D4342

$84

D4355

$72

D4381
D4910

$82
$75

D4920
D4999

$62
I.C.

D5110
D5120
D5130
D5140

$680
$680
$715
$714

D5211

$518

D5212

$554

D5213

$1,022

D5214

$1,057

D5225

I.C.

D5226

I.C.

D5281
D5410
D5411
D5421
D5422
D5510

$393
$39
$39
$49
$36
$79

EPSDT
Rate
Description
I.C. Soft tissue allograft
Combined connective tissue and double
I.C. pedicle graft, per tooth
$215 Provisional splinting – intracoronal
$182 Provisional splinting - extracoronal
Periodontal scaling and root planning - four or
$160 more teeth per quadrant
Periodontal scaling and root planning - one to
$107 three teeth, per quadrant
Full mouth debridement to enable
$93 comprehensive evaluation and diagnosis
Localized delivery of antimicrobial agents via
a controlled release vehicle into diseased
$121 crevicular tissue, per tooth, by report
$111 Periodontal maintenance
Unscheduled dressing change (by someone
$76 other than treating dentist)
I.C. Unspecified periodontal procedure, by report
VI. Prosthodontics (Removable)
$858 Complete denture – maxillary
$852 Complete denture – mandibular
$935 Immediate denture – maxillary
$934 Immediate denture - mandibular
Maxillary partial denture - resin base
(including any conventional clasps, rests and
$650 teeth)
Mandibular partial denture - resin base
(including any conventional clasps, rests and
$691 teeth)
Maxillary partial denture - cast metal
framework with resin denture bases (including
$974 any conventional clasps, rests and teeth)
Mandibular partial denture - cast metal
framework with resin denture bases (including
$986 any conventional clasps, rests and teeth)
Maxillary partial denture - flexible base
I.C. (including any clasps, rests and teeth)
Mandibular partial denture - flexible base
I.C. (including any clasps, rests and teeth)
Removable unilateral partial denture - one
$467 piece cast metal (including clasps and teeth)
$49 Adjust complete denture - maxillary
$49 Adjust complete denture - mandibular
$56 Adjust partial denture - maxillary
$45 Adjust partial denture - mandibular
$109 Repair broken complete denture base

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D5520
D5610
D5620
D5630
D5640
D5650
D5660

$72
$72
$97
$92
$72
$86
$91

$89
$93
$121
$107
$91
$110
$125

D5670

I.C.

D5671
D5710
D5711
D5720
D5721
D5730

I.C.
$236
$187
$214
$265
$147

I.C.
$301
$257
$274
$323
$188

D5731
D5740
D5741
D5750

$161
$132
$125
$199

$184
$169
$160
$255

D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
D5860
D5861
D5862

$200
$197
$197
$135
$135
$250
$275
$67
$61
$765
$825
$214

$256
$252
$252
$193
$193
$321
$316
$86
$77
$1,094
$1,180
$254

D5867

I.C.

D5875

I.C.

D5899
D5911
D5912
D5913
D5914

I.C.
I.C.
I.C.
I.C.
I.C.

Description
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
Replace all teeth and acrylic on cast metal
framework (maxillary)
Replace all teeth and acrylic on cast metal
framework (mandibular)
Rebase complete maxillary denture
Rebase complete mandibular denture
Rebase maxillary partial denture
Rebase mandibular partial denture
Reline complete maxillary denture (chair side)
Reline lower complete mandibular denture
(chair side)
Reline maxillary partial denture (chair side)
Reline mandibular partial denture (chair side)
Reline complete maxillary denture (laboratory)
Reline complete mandibular denture
(laboratory)
Reline maxillary partial denture (laboratory)
Reline mandibular partial denture (laboratory)
Interim complete denture (maxillary)
Interim complete denture (mandibular)
Interim partial denture (maxillary)
Interim partial denture (mandibular)
Tissue conditioning, maxillary
Tissue conditioning, mandibular
Overdenture - complete, by report
Overdenture - partial, by report
Precision attachment, by report
Replacement of replaceable part of semiprecision or precision attachment (male or
female component)
Modification of removable prosthesis
following implant surgery
Unspecified removable prosthodontic
procedure, by report
Facial moulage (sectional)
Facial moulage (complete)
Nasal prosthesis
Auricular prosthesis

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code
D5915
D5916
D5919
D5922
D5923
D5924
D5925
D5926
D5927
D5928
D5929
D5931
D5932
D5933

Allowed
Fee
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.

EPSDT
Rate
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.

D5934

I.C.

D5935
D5936
D5937
D5951
D5952
D5953
D5954
D5955
D5958
D5959
D5960
D5982
D5983
D5984
D5985
D5986
D5987
D5988
D5999

I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.

D6010

$1,072

$1,374

D6012
D6040
D6050

I.C.
$1,429
$125

I.C.
$1,632
$162

D6053

I.C.

Description
Orbital prosthesis
Ocular prosthesis
Facial prosthesis
Nasal septal prosthesis
Ocular prosthesis, interim
Cranial prosthesis
Facial augmentation implant prosthesis
Nasal prosthesis, replacement
Auricular prosthesis, replacement
Orbital prosthesis, replacement
Facial prosthesis, replacement
Obturator prosthesis, surgical
Obturator prosthesis, definitive
Obturator prosthesis, modification
Mandibular resection prosthesis with guide
flange
Mandibular resection prosthesis without guide
flange
Obturator/prosthesis, interim
Trismus appliance (not for TM treatment)
Feeding aid
Speech aid prosthesis, pediatric
Speech aid prosthesis, adult
Palatal augmentation prosthesis
Palatal lift prosthesis, definitive
Palatal lift prosthesis, interim
Palatal lift prosthesis, modification
Speech aid prosthesis, modification
Surgical stent
Radiation carrier
Radiation shield
Radiation cone locator
Fluoride gel carrier
Commissure splint
Surgical splint
Unspecified maxillofacial prosthesis, by report
VII. Implant Services
Surgical placement of implant body: endosteal
implant
Surgical placement of interim implant body for
transitional prosthesis: endosteal implant
Surgical placement: eposteal implant
Surgical placement: transosteal implant
Implant/abutment supported removable
denture for completely edentulous arch

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D6054
D6055
D6056
D6057
D6058

I.C
$214
$259
$375
$857

I.C.
$274
$331
$480
$982

D6059

$704

$894

D6060

$679

$778

D6061

$706

$812

D6062

$715

$894

D6063

I.C

I.C.

D6064
D6065

$857
$857

$1,091
$1,015

D6066

$818

$1,049

D6067

$928

$1,067

D6068

I.C

I.C.

D6069

I.C

I.C.

D6070

I.C

I.C.

D6071

I.C

I.C.

D6072

I.C

I.C.

D6073

I.C

I.C.

D6074
D6075

I.C.
I.C.

D6076

I.C.

D6077

I.C.

D6078

I.C.

Description
Implant/abutment supported removable
denture for partially edentulous arch
Dental implant supported connecting bar
Prefabricated abutment - includes placement
Custom abutment - includes placement
Abutment supported porcelain/ceramic crown
Abutment supported porcelain fused to metal
crown (high noble metal)
Abutment supported porcelain fused to metal
crown (predominantly base metal)
Abutment supported porcelain fused to metal
crown (noble metal)
Abutment supported cast metal crown (high
noble metal)
Abutment supported cast metal crown
(predominantly base metal)
Abutment supported cast metal crown (noble
metal)
Implant supported porcelain/ceramic crown
Implant supported porcelain fused to metal
crown (titanium, titanium alloy, high noble
metal)
Implant supported metal crown (titanium,
titanium alloy, high noble metal)
Abutment supported retainer for
porcelain/ceramic FPD
Abutment supported retainer for porcelain
fused to metal FPD (high noble metal)
Abutment supported retainer for porcelain
fused to metal FPD (predominantly base metal)
Abutment supported retainer for porcelain
fused to metal FPD (noble metal)
Abutment supported retainer for cast metal
FPD (high noble metal)
Abutment supported retainer for cast metal
FPD (predominantly base metal)
Abutment supported retainer for cast metal
FPD (noble metal)
Implant supported retainer for ceramic FPD
Implant supported retainer for porcelain fused
to metal FPD (titanium, titanium alloy, or high
noble metal)
Implant supported retainer for cast metal FPD
(titanium, titanium alloy, or high noble metal)
Implant/abutment supported fixed denture for
completely edentulous arch

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D6079

I.C.

D6080
D6090

$89
I.C.

$115
I.C.

D6091
D6092

I.C.
I.C.

D6093
D6094
D6095
D6100
D6190

I.C.
I.C.
I.C.
I.C.
I.C.

D6194
D6199
D6205
D6210
D6211
D6212
D6214
D6240

I.C.
I.C.
I.C.
$607
$544
$589
I.C.
$625

I.C.
I.C.
I.C.
$748
$667
$676
I.C.
$792

D6241
D6242
D6245
D6250
D6251
D6252
D6253

$565
$571
I.C.
$655
$482
$517
I.C.

$691
$731
I.C.
$807
$575
$691
I.C.

D6545

$250

$320

D6548
D6600

I.C.
I.C.

D6601
D6602

I.C.
I.C.

D6603

I.C.

D6604

I.C.

Description
Implant/abutment supported fixed denture for
partially edentulous arch
Implant maintenance procedures, including
removal of prosthesis, cleansing of prosthesis
and abutments, reinsertion of prosthesis
Repair implant supported prosthesis, by report
Replacement of semi-precision or precision
attachment (male or female component) of
implant/abutment supported prosthesis, per
attachment
Recement implant/abutment supported crown
Recement implant/abutment supported fixed
partial denture
Abutment supported crown - (titanium)
Repair implant abutment, by report
Implant removal, by report
Radiographic/surgical implant index, by report
Abutment supported retainer crown for FPD (titanium)
Unspecified implant procedure, by report
Pontic - indirect resin based composite
Pontic - cast high noble metal
Pontic - cast predominantly base metal
Pontic - cast noble metal
Pontic – titanium
Pontic - porcelain fused to high noble metal
Pontic - porcelain fused to predominantly base
metal
Pontic - porcelain fused to noble metal
Pontic - porcelain/ceramic
Pontic - resin with high noble metal
Pontic - resin with predominantly base metal
Pontic - resin with noble metal
Provisional pontic
Retainer - cast metal for resin bonded fixed
prosthesis
Retainer - porcelain/ceramic for resin bonded
fixed prosthesis
Inlay - porcelain/ceramic, two surfaces
Inlay - porcelain/ceramic, three or more
surfaces
Inlay - cast high noble metal, two surfaces
Inlay - cast high noble metal, three or more
surfaces
Inlay - cast predominantly base metal, two
surfaces

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D6605
D6606
D6607
D6608

I.C.
I.C.
I.C.
I.C.

D6609
D6610

I.C.
I.C.

D6611

I.C.

D6612

I.C.

D6613
D6614

I.C.
I.C.

D6615
D6624
D6634
D6710
D6720
D6721
D6722
D6740
D6750

I.C.
I.C.
I.C.
I.C
$491
$499
$193
I.C
$632

I.C.
I.C.
I.C.
I.C.
$671
$610
$246
I.C.
$779

D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6793
D6794
D6920
D6930
D6940
D6950

$568
$571
$482
I.C.
I.C.
I.C.
$655
$518
$549
I.C.
I.C.
I.C.
$67
$143
$155

$691
$731
$617
I.C.
I.C.
I.C.
$897
$661
$701
I.C.
I.C.
I.C.
$87
$204
$220

D6970

$357

$408

D6972
D6973

$143
$125

$184
$160

Description
Inlay - cast predominantly base metal, three or
more surfaces
Inlay - cast noble metal, two surfaces
Inlay - cast noble metal, three or more surfaces
Onlay - porcelain/ceramic, two surfaces
Onlay - porcelain/ceramic, three or more
surfaces
Onlay - cast high noble metal, two surfaces
Onlay - cast high noble metal, three or more
surfaces
Onlay - cast predominantly base metal, two
surfaces
Onlay - cast predominantly base metal, three or
more surfaces
Onlay - cast noble metal, two surfaces
Onlay - cast noble metal, three or more
surfaces
Inlay – titanium
Onlay – titanium
Crown – indirect resin based composite
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown - porcelain/ceramic
Crown - porcelain fused to high noble metal
Crown - porcelain fused to predominantly base
metal
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - 3/4 cast predominately base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain/ceramic
Crown - full cast high noble metal
Crown - full cast predominantly base metal
Crown - full cast noble metal
Provisional retainer crown
Crown – titanium
Connector bar
Recement bridge
Stress breaker
Precision attachment
Post and core in addition to fixed partial
denture retainer, indirectly fabricated
Prefabricated post and core in addition to
bridge retainer
Core build up for retainer, including any pins

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code
D6975

Allowed
Fee
I.C.

D6976
D6977
D6980
D6985

I.C.
I.C.
$125
I.C.

D6999

I.C.

D7111

$70

D7140

$70

D7210
D7220
D7230
D7240

$139
$178
$232
$275

D7241

$304

D7250
D7260
D7261

$134
$316
I.C

D7270

$99

D7272
D7280

$150
$354

D7282

I.C.

D7283
D7285
D7286
D7287

$68
$114
$153
I.C.

D7288
D7290

I.C.
$74

D7291

$128

D7292

I.C.

EPSDT
Rate
Description
I.C. Coping - metal
Each additional indirectly fabricated post I.C. same tooth
I.C. Each additional prefabricated post - same tooth
$155 Bridge repair, by report
I.C. Pediatric partial denture, fixed
Unspecified fixed prosthodontic procedure, by
I.C. report
X. Exodontic
$80 Extraction, coronal remnants - deciduous tooth
Extraction, erupted tooth or exposed root
$100 (elevation and/or forceps removal)
Surgical removal of erupted tooth requiring
elevation of mucoperiosteal flap and removal
$179 of bone and/or section of tooth
$223 Removal of impacted tooth - soft tissue
$286 Removal of impacted tooth - partially bony
$378 Removal of impacted tooth - completely bony
Removal of impacted tooth - completely bony,
$427 with unusual surgical complications
Surgical removal of residual tooth roots
$173 (cutting procedure)
$398 Oral antral fistula closure
I.C. Primary closure of a sinus perforation
Tooth reimplantation and/or stabilization of
$145 accidentally evulsed or displaced tooth
Tooth transplantation (includes reimplantation
from one site to another and splinting and/or
$218 stabilization)
$452 Surgical access of an unerupted tooth
Mobilization of erupted or malpositioned tooth
I.C. to aid eruption
Placement of device to facilitate eruption of
$84 impacted tooth
$146 Biopsy of oral tissue - hard (bone, tooth)
$197 Biopsy of oral tissue - soft
I.C. Exfoliative cytological sample collection
Brush biopsy - transepithelial sample
I.C. collection
$109 Surgical repositioning of teeth
Transseptal fiberotomy/supra crestal
$165 fiberotomy, by report
Surgical placement: temporary anchorage
device (screw retained plate) requiring surgical
I.C. flap

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D7293

I.C.

D7294

I.C.

D7310

$132

$163

D7311

$119

$146

D7320

$174

$202

D7321

$139

$162

D7340

$696

$796

D7350
D7410
D7411
D7412
D7413

$879
$107
$194
I.C.
I.C.

$1,236
$124
$254
I.C.
I.C.

D7414
D7415

I.C.
I.C.

D7440

$175

$256

D7441

$232

$339

D7450

$231

$252

D7451

$268

$343

D7460

$113

$142

D7461

$133

$194

D7465

$107

$122

D7471
D7472

$133
I.C.

$194
I.C.

Description
Surgical placement: temporary anchorage
device requiring surgical flap
Surgical placement: temporary anchorage
device without surgical flap
Alveoloplasty in conjunction with extractionsfour or more teeth or tooth spaces, per
quadrant
Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant
Alveoloplasty not in conjunction with
extractions-four or more teeth or tooth spaces,
per quadrant
Alveoloplasty not in conjunction with
extractions - one to three teeth or tooth spaces,
per quadrant
Vestibuloplasty - ridge extension (second
epithelialization)
Vestibuloplasty - ridge extension (including
soft tissue grafts, muscle reattachments,
revision of soft tissue attachment and
management of hypertrophied and hyperplastic
tissue)
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

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code
D7473
D7485
D7490

Allowed
Fee
I.C.
I.C.
I.C.

D7510

$89

D7511

I.C.

D7520

$75

D7521

I.C.

D7530

$196

D7540

$432

D7550

I.C.

D7560

$249

D7610

$1,165

D7620

$390

D7630

$974

D7640
D7650
D7660

$581
$776
$193

D7670

$276

D7671

I.C.

D7680
D7710
D7720
D7730
D7740
D7750
D7760
D7770

I.C.
$1,165
I.C.
$974
$581
$776
$193
$291

D7771

I.C.

EPSDT
Rate
Description
I.C. Removal of torus mandibularis
I.C. Surgical reduction of osseous tuberosity
I.C. Radical resection of maxilla or mandible
Incision and drainage of abscess - intraoral soft
$115 tissue
Incision and drainage of abscess - intraoral soft
tissue - complicated (includes drainage of
I.C. multiple fascial spaces)
Incision and drainage of abscess - extraoral
$86 soft tissue
Incision and drainage of abscess - extraoral
soft tissue - complicated (includes drainage of
I.C. multiple fascial spaces)
Removal of foreign body from mucosa, skin,
$224 or subcutaneous alveolar tissue
Removal of reaction-producing foreign bodies,
$544 musculoskeletal system
Partial ostectomy/sequestrectomy for removal
I.C. of nonvital bone
Maxillary sinusotomy for removal of tooth
$364 fragment or foreign body
Maxilla - open reduction (teeth immobilized, if
$1,704 present)
Maxilla - closed reduction (teeth immobilized,
$569 if present)
Mandible - open reduction (teeth immobilized,
$1,425 if present)
Mandible - closed reduction (teeth
$850 immobilized, if present)
$1,135 Malar and/or zygomatic arch - open reduction
$282 Malar and/or zygomatic arch - closed reduction
Alveolus - closed reduction, may include
$387 stabilization of teeth
Alveolus - open reduction, may include
I.C. stabilization of teeth
Facial bones - complicated reduction with
I.C. fixation and multiple surgical approaches
$1,704 Maxilla – open reduction
I.C. Maxilla - closed reduction
$1,425 Mandible - open reduction
$846 Mandible - closed reduction
$1,135 Malar and/or zygomatic arch - open reduction
$282 Malar and/or zygomatic arch - closed reduction
$380 Alveolus - open reduction stabilization of teeth
Alveolus, closed reduction stabilization of
I.C. teeth

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D7780
D7810
D7820
D7830
D7840
D7850
D7852
D7854
D7856
D7858
D7860
D7865
D7870
D7871

$107
$485
$75
I.C.
$776
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
$99
I.C.

$137
$711
$109
I.C.
$1,135
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
I.C.
$145
I.C.

D7872

I.C.

D7873

I.C.

D7874
D7875
D7876
D7877
D7880
D7899
D7910
D7911
D7912

I.C.
I.C.
I.C.
I.C.
$321
I.C.
$29
$99
$99

I.C.
I.C.
I.C.
I.C.
$367
I.C.
$42
$129
$145

D7920
D7940
D7941

I.C.
I.C.
I.C.

D7943
D7944
D7945
D7946
D7947

$2,330
$946
$1,942
I.C.
I.C.

$3,409
$1,384
$2,843
I.C.
I.C.

D7948
D7949

I.C.
I.C.

D7950

$776

$1,135

Description
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
Disc repair
Synovectomy
Myotomy
Joint reconstruction
Arthrotomy
Arthroplasty
Arthrocentesis
Nonarthroscopic lysis and lavage
Arthroscopy - diagnosis, with or without
biopsy
Arthroscopy - surgical: lavage and lysis of
adhesions
Arthroscopy - surgical: disc repositioning and
stabilization
Arthroscopy - surgical: synovectomy
Arthroscopy - surgical: discectomy
Arthroscopy - surgical: debridement
Occlusal orthotic appliance
Unspecified TMD therapy, by report
Suture of recent small wounds up to 5 cm
Complicated suture - up to 5 cm
Complicated suture - greater than 5 cm
Skin graft (identify defect covered, location
and type of 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 (osteoplasty of facial
bones for midface hypoplasia or retrusion) without bone graft
LeFort II or LeFort III - with bone graft
Osseous, osteoperiosteal, or cartilage graft of
the mandible or maxilla-autogenous or
nonautogenous, by report

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D7951

I.C.

D7953

I.C.

D7955

I.C.

D7960
D7963
D7970
D7971
D7972
D7980
D7981
D7982
D7983
D7990
D7991

$100
$388
$229
$74
I.C.
$99
$605
$263
$482
I.C.
I.C.

$353
$480
$334
$109
I.C.
$145
$850
$387
$705
I.C.
I.C.

D7995

I.C.

D7996

I.C.

D7997

I.C.

D7998
D7999

I.C.
I.C.

D8010

I.C.

D8020

I.C.

D8030

I.C.

D8040

I.C.

D8050

I.C.

D8060

I.C.

D8070

I.C.

D8080

$1,143

$1,213

D8090

I.C.

Description
Sinus augmentation with bone or bone
substitutes
Bone replacement graft for ridge preservation per site
Repair of maxillofacial soft and/or hard tissue
defect
Frenulectomy (frenectomy or frenotomy) separate procedure
Frenuloplasty
Excision of hyperplastic tissue - per arch
Excision of pericoronal gingival
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 archbar
Intraoral placement of a fixation device not in
conjunction with a fracture
Unspecified oral surgery procedure, by report
XI. Orthodontic
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
Interceptive orthodontic treatment of the
primary dentition
Interceptive orthodontic treatment of the
transitional dentition
Comprehensive orthodontic treatment of the
transitional dentition
Comprehensive orthodontic treatment of the
adolescent dentition
Comprehensive orthodontic treatment of the
adult dentition

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code
D8210
D8220
D8660

Allowed
Fee
$79
I.C.
$22

D8670

$200

D8680

$79

D8690
D8691
D8692

$114
I.C.
$79

D8693
D8999

I.C.
I.C.

D9110
D9120

$33
I.C.

D9210
D9211
D9212
D9215

$10
I.C.
I.C.
I.C.

D9220

$114

D9221

$89

D9230

$14

D9241

$178

D9242
D9248

$73
I.C.

D9310

$50

D9410
D9420

$36
$32

D9430
D9440

$17
$21

D9450

$19

EPSDT
Rate
Description
$95 Removable appliance therapy
I.C. Fixed appliance therapy
$31 Preorthodontic treatment visit
Periodic orthodontic treatment visit (as part of
$268 contract)
Orthodontic retention (removal of appliances,
$95 construction and placement of retainer(s))
Orthodontic treatment (alternative billing to a
$136 contract fee)
I.C. Repair of orthodontic appliance
$95 Replacement of lost or broken retainer
Rebonding or recementing; and/or repair, as
I.C. required, of fixed retainers
I.C. Unspecified orthodontic procedure, by report
XII. Adjunctive General Services
Palliative (emergency) treatment of dental pain
$75 - minor procedure
I.C. Fixed partial denture sectioning
Local anesthesia not in conjunction with
$15 operative or surgical procedures
I.C. Regional block anesthesia
I.C. Trigeminal division block anesthesia
I.C. Local anesthesia
Deep sedation/general anesthesia - first 30
$208 minutes
Deep sedation/general anesthesia - each
$114 additional 15 minutes
Analgesia, anxiolysis, inhalation of nitrous
$21 oxide
Intravenous conscious sedation/analgesia - first
$221 30 minutes
Intravenous conscious sedation/analgesia $82 each additional 15 minutes
I.C. Nonintravenous conscious sedation
Consultation-diagnostic service provided by
dentist or physician other than requesting
$63 dentist or physician
House/extended care facility call, once per
$36 facility per day
$48 Hospital call
Office visit for observation (during regularly
$26 scheduled hours) - no other services performed
$30 Office visit - after regularly scheduled hours
Case presentation, detailed and extensive
$19 treatment planning

114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY

114.3 CMR 14.00: Dental Services
Code

Allowed
Fee

EPSDT
Rate

D9610

$27

$40

D9612
D9630
D9910

I.C.
$7
$20

I.C.
$10
$22

D9911
D9920

I.C.
$43

D9930
D9940
D9941
D9942
D9950
D9951
D9952
D9970

I.C.
$239
$57
I.C.
$30
$30
$139
I.C.

I.C.
$308
$85
I.C.
$45
$45
$179
I.C.

D9971
D9972
D9973
D9974
D9999

I.C.
I.C.
I.C.
I.C.
I.C.

Description
Therapeutic parenteral drug, single
administration
Therapeutic parenteral drugs, two or more
administrations, different medications
Other drugs and/or medicaments, by report
Application of desensitizing medicament
Application of desensitizing resin for cervical
and/or root surface, per tooth
Behavior management, by report
Treatment of complications (postsurgical) unusual circumstances, by report
Occlusal guards, by report
Fabrication of athletic mouthguard
Repair and/or reline of occlusal guard
Occlusion analysis - mounted case
Occlusal adjustment - limited
Occlusal adjustment - complete
Enamel microabrasion
Odontoplasty 1-2 teeth; includes removal of
enamel projections
External bleaching - per arch
External bleaching - per tooth
Internal bleaching - per tooth
Unspecified adjunctive procedure, by report

14.06: Allowable Fees: Hospital Services
Maximum allowable fees for professional services rendered in a hospital setting are governed
under 114.3 CMR 16.00: Surgery and Related Anesthesia Care, 114.3 CMR 18.00: Radiology,
and 114.3 CMR 17.00: Medical and Related Anesthesia Care.

14.07: Severability of the Provisions of 114.3 CMR 14.00
The provisions of 114.3 CMR 14.00 are severable and if any provisions of 114.3 CMR 14.00 or
application of such provision to any eligible dental service provider or any such circumstances are
held to be invalid or unconstitutional, such invalidity will not be construed to affect the validity or
constitutionality of any remaining provisions to any eligible dental service providers or
circumstances other than those held invalid.

REGULATORY AUTHORITY
114.3 CMR 14.00: M.G.L. c. 118G

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