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114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
1
Section
14.01: General Provisions
14.02: General Definitions
14.03: General Rate Provisions and Maximum Fees
14.04: Allowable Fees: Anesthesia Services (Hospital)
14.05: Allowable Fees: Non-Hospital Services
14.06: Allowable Fees: Hospital Services
14.07: 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
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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
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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
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(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 Description
I. Diagnostic
D0120 $20 $29 Periodic oral evaluation - established patient
D0140 $39 $49 Limited oral evaluation - problem focused
D0145 I.C. I.C.
Oral evaluation for a patient under three years
of age and counseling with primary caregiver
D0150 $37 $58 Comprehensive oral evaluation - new or
established patient
D0160 $60 $77 Detailed and extensive oral evaluation -
problem focused, by report
D0170 $36 $45 Re-evaluation - limited, problem focused
(established patient; not postoperative visit)
D0180 I.C. I.C.
Comprehensive periodontal evaluation - new
or established patient
D0210 $69 $88 Intraoral - complete series (including
bitewings)
D0220 $14 $20 Intraoral - periapical, first film
D0230 $12 $16 Intraoral - periapical, each additional film
D0240 $20 $26 Intraoral - occlusal film
D0250 $21 $28 Extraoral - first film
D0260 $21 $26 Extraoral - each additional film
D0270 $13 $17 Bitewing - single film
D0272 $22 $30 Bitewings - two films
D0273 I.C. I.C. Bitewings - three films
D0274 $33 $43 Bitewings - four films
D0277 $44 $55 Vertical bitewings - 7 to 8 films
D0290 $41 $53 Posterior-anterior or lateral skull and facial
bone survey film
D0310 $42 $48 Sialography
D0320 $214 $321 Temporomandibular joint arthrogram,
including injection
D0321 $89 $114 Other temporomandibular joint films, by report
D0322 I.C. I.C. Tomographic survey
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
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Code Allowed
Fee EPSDT
Rate Description
D0330 $62 $88 Panoramic film
D0340 $69 $85 Cephalometric film
D0350 $36 $47 Oral/facial photographic images
D0360 I.C. I.C. Cone beam CT - craniofacial data capture
D0362 I.C. I.C.
Cone beam - two-dimensional image
reconstruction using existing data, includes
multiple images
D0363 I.C. I.C.
Cone beam - three-dimensional image
reconstruction using existing data, includes
multiple images
D0415 I.C. I.C.
Collection of microorganisms for culture and
sensitivity
D0416 I.C. I.C. Viral culture
D0421 I.C. I.C. Genetic test for susceptibility to oral diseases
D0425 I.C. I.C. Caries susceptibility tests
D0431 I.C. I.C.
Adjunctive pre-diagnostic test that aids In
detection of mucosal abnormalities including
premalignant and malignant lesions, not to
include cytology or biopsy procedures
D0460 $29 $37 Pulp vitality tests
D0470 $58 $72 Diagnostic casts
D0472 $67 $87 Accession of tissue, gross examination,
preparation, and transmission of written report
D0473 I.C. I.C.
Accession of tissue, gross and microscopic
examination, preparation and transmission of
written report
D0474 I.C. I.C.
Accession of tissue, gross and microscopic
examination, including assessment of surgical
margins for presence of disease, preparation
and transmission of written report
D0475 I.C. I.C. Decalcification procedure
D0476 I.C. I.C. Special stains for microorganisms
D0477 I.C. I.C. Special stains, not for microorganisms
D0478 I.C. I.C. Immunohistochemical stains
D0479 I.C. I.C.
Tissue in-situ hybridization, including
interpretation
D0480 $50 $65
Accession of exfoliative cytologic smears,
microscopic examination, preparation and
transmission of written report
D0481 I.C. I.C. Electron microscopy - diagnostic
D0482 I.C. I.C. Direct immunofluorescence
D0483 I.C. I.C. Indirect immunofluorescence
D0484 I.C. I.C. Consultation on slides prepared elsewhere
D0485 I.C. I.C.
Consultation, including preparation of slides
from biopsy material supplied by referring
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
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Code Allowed
Fee EPSDT
Rate Description
source
D0486 I.C. I.C.
Accession of brush biopsy sample,
microscopic examination, preparation and
transmission of written report
D0502 I.C. I.C. Other oral pathology procedures, by report
D0999 I.C. I.C. Unspecified diagnostic procedure, by report
II. Preventative
D1110 $49 $70 Prophylaxis - adult
D1120 $36 $51 Prophylaxis - child
D1203 n/a $26 Topical application of fluoride (prophylaxis
not included) - child
D1204 $29 n/a Topical application of fluoride (prophylaxis
not included) - adult
D1206 $26 $26
Topical fluoride varnish; therapeutic
application for moderate to high caries risk
patients
D1310 I.C. I.C.
Nutritional counseling for the control of dental
disease
D1320 I.C. I.C.
Tobacco counseling for the control and
prevention of oral disease
D1330 $14 $21 Oral hygiene instruction
D1351 $28 $41 Sealant - per tooth
D1510 $178 $229 Space maintainer - fixed-unilateral
D1515 $285 $345 Space maintainer - fixed-bilateral
D1520 $214 $244 Space maintainer - removable-unilateral
D1525 $321 $368 Space maintainer - removable-bilateral
D1550 $33 $40 Recementation of space maintainer
D1555 I.C. I.C. Removal of fixed space maintainer
III. Restorative
D2140 $58 $77 Amalgam-one surface, primary or permanent
D2150 $72 $95 Amalgam-two surfaces, primary or permanent
D2160 $86 $110 Amalgam-three surfaces, primary or
permanent
D2161 $108 $137 Amalgam-four or more surfaces, primary or
permanent
D2330 $67 $91 Resin - one surface, anterior
D2331 $86 $110 Resin - two surfaces, anterior
D2332 $108 $137 Resin - three surfaces, anterior
D2335 $136 $175 Resin - four or more surfaces or involving
incisal angle (anterior)
D2390 $99 $124 Resin-based composite crown, anterior
D2391 $51 $92 Resin-based composite - one surface, posterior
D2392 $65 $115 Resin-based composite - two surfaces,
posterior
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
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Code Allowed
Fee EPSDT
Rate Description
D2393 $77 $124 Resin-based composite - three surfaces,
posterior
D2394 $106 $170 Resin-based composite - four or more surfaces,
posterior
D2410 I.C. I.C. Gold foil - one surface
D2420 I.C. I.C. Gold foil - two surfaces
D2430 I.C. I.C. Gold foil - three surfaces
D2510 I.C. I.C. Inlay - metallic - one surface
D2520 I.C. I.C. Inlay - metallic - two surfaces
D2530 $286 $367 Inlay - metallic - three or more surfaces
D2542 $465 $596 Onlay - metallic - two surfaces
D2543 $643 $788 Onlay - metallic - three surfaces
D2544 $666 $800 Onlay - metallic - four or more surfaces
D2610 I.C. I.C. Inlay - porcelain/ceramic - one surface
D2620 $393 $504 Inlay - porcelain/ceramic - two surfaces
D2630 $596 $744 Inlay - porcelain/ceramic - three or more
surfaces
D2642 $629 $722 Onlay - porcelain/ceramic - two surfaces
D2643 $607 $768 Onlay - porcelain/ceramic - three surfaces
D2644 $615 $788 Onlay - porcelain/ceramic - four or more
surfaces
D2650 I.C. I.C. Inlay - resin-based composite - one surface
D2651 I.C. I.C. Inlay - resin-based composite - two surfaces
D2652 I.C. I.C.
Inlay - resin-based composite - three or more
surfaces
D2662 $571 $656 Onlay - resin-based composite - two surfaces
D2663 $570 $727 Onlay - resin-based composite - three surfaces
D2664 $570 $731 Onlay - resin-based composite - four or more
surfaces
D2710 $214 $244 Crown - resin-based composite (indirect)
D2712 I.C. I.C. Crown - 3/4 resin-based composite (indirect)
D2720 $590 $757 Crown - resin with high noble metal
D2721 $429 $550 Crown - resin with predominantly base metal
D2722 $485 $558 Crown - resin with noble metal
D2740 $679 $853 Crown - porcelain/ceramic substrate
D2750 $639 $800 Crown - porcelain fused to high noble metal
D2751 $571 $727 Crown - porcelain fused to predominantly base
metal
D2752 $590 $735 Crown - porcelain fused to noble metal
D2780 $657 $841 Crown - 3/4 cast high noble metal
D2781 I.C. I.C. Crown - 3/4 cast predominately base metal
D2782 I.C. I.C. Crown - 3/4 cast noble metal
D2783 $635 $812 Crown - 3/4 porcelain/ceramic
D2790 $643 $808 Crown - full cast high noble metal
D2791 $501 $641 Crown - full cast predominantly base metal
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
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Code Allowed
Fee EPSDT
Rate Description
D2792 $607 $748 Crown - full cast noble metal
D2794 I.C. I.C. Crown - titanium
D2799 $178 $228 Provisional crown
D2910 $53 $69 Recement inlay, onlay or partial coverage
restoration
D2915 I.C. I.C. Recement cast or prefabricated post and core
D2920 $53 $68 Recement crown
D2930 $143 $205 Prefabricated stainless steel crown - primary
tooth
D2931 $159 $199 Prefabricated stainless steel crown - permanent
tooth
D2932 $197 $224 Prefabricated resin crown
D2933 $143 $184 Prefabricated stainless steel crown with resin
window
D2934 $143 $184 Prefabricated esthetic coated stainless steel
crown - primary tooth
D2940 $57 $72 Sedative filling
D2950 $153 $197 Core buildup, including any pins
D2951 $25 $31 Pin retention - per tooth, in addition to
restoration
D2952 $217 $276 Post and core in addition to crown, indirectly
fabricated
D2953 I.C. I.C.
Each additional indirectly fabricated post -
same tooth
D2954 $178 $229 Prefabricated post and core in addition to
crown
D2955 I.C. I.C.
Post removal (not in conjunction with
endodontic therapy)
D2957 I.C. I.C. Each additional prefabricated post - same tooth
D2960 $286 $420 Labial veneer (resin laminate) - chair side
D2961 $393 $504 Labial veneer (resin laminate) – laboratory
D2962 $535 $688 Labial veneer (porcelain laminate) – laboratory
D2970 I.C. I.C. Temporary crown (fractured tooth)
D2971 I.C. I.C.
Additional procedures to construct new crown
under existing partial denture framework
D2975 I.C. I.C. Coping
D2980 $107 $137 Crown repair, by report
D2999 I.C. I.C. Unspecified restorative procedure, by report
IV. Endodontics
D3110 $32 $40 Pulp cap - direct (excluding final restoration)
D3120 $32 $40 Pulp cap - indirect (excluding final restoration)
D3220 $82 $106
Therapeutic pulpotomy (excluding final
restoration) - removal of pulp coronal to the
dentinocemental junction and application of
medicament
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
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Code Allowed
Fee EPSDT
Rate Description
D3221 $107 $123 Pulpal debridement, primary and permanent
teeth
D3230 I.C. I.C.
Pulpal therapy (resorbable filling) - anterior,
primary tooth (excluding final restoration)
D3240 I.C. I.C.
Pulpal therapy (resorbable filling) - posterior,
primary tooth (excluding final restoration)
D3310 $375 $480 Anterior (excluding final restoration)
D3320 $440 $564 Bicuspid (excluding final restoration)
D3330 $569 $731 Molar (excluding final restoration)
D3331 I.C. I.C.
Treatment of root canal obstruction;
nonsurgical access
D3332 $178 $205 Incomplete endodontic therapy; inoperable,
unrestorable or fractured tooth
D3333 $214 $274 Internal root repair of perforation defects
D3346 $425 $545 Retreatment of previous root canal therapy –
anterior
D3347 $501 $641 Retreatment of previous root canal therapy –
bicuspid
D3348 $571 $789 Retreatment of previous root canal therapy –
molar
D3351 $114 $146
Apexification/recalcification - initial visit
(apical closure/calcific repair of perforations,
root resorption, etc.)
D3352 I.C. I.C.
Apexification/recalcification - interim
medication replacement (apical closure/calcific
repair of perforations, root resorption, etc.)
D3353 I.C. I.C.
Apexification/recalcification - final visit
(includes completed root canal therapy - apical
closure/calcific repair of perforations, root
resorption, etc.)
D3410 $379 $471 Apicoectomy/periradicular surgery - anterior
D3421 $429 $550 Apicoectomy/periradicular surgery - bicuspid
(first root)
D3425 $557 $639 Apicoectomy/periradicular surgery - molar
(first root)
D3426 $214 $264 Apicoectomy/periradicular surgery (each
additional root)
D3430 $72 $91 Retrograde filling - per root
D3450 $268 $343 Root amputation - per root
D3460 $430 $744 Endodontic endosseous implant
D3470 I.C. I.C.
Intentional replantation (including necessary
splinting)
D3910 I.C. I.C.
Surgical procedure for isolation of tooth with
rubber dam
D3920 $197 $243 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
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Code Allowed
Fee EPSDT
Rate Description
D3950 $64 $111 Canal preparation and fitting of preformed
dowel or post
D3999 I.C. I.C. Unspecified endodontic procedure, by report
V. Periodontics
D4210 $286 $343
Gingivectomy or gingivoplasty - Four or more
contiguous teeth or bounded teeth spaces per
quadrant
D4211 $103 $133
Gingivectomy or gingivoplasty - one to three
contiguous teeth or bounded teeth spaces per
quadrant
D4230 I.C. I.C.
Anatomical crown exposure - Four or more
contiguous teeth per quadrant
D4231 I.C. I.C.
Anatomical crown exposure - one to three
teeth per quadrant
D4240 $418 $606
Gingival flap procedure, including root
planning - four or more contiguous teeth or
bounded teeth spaces per quadrant
D4241 I.C. I.C.
Gingival flap procedure, including root
planning - one to three contiguous teeth or
bounded teeth spaces per quadrant
D4245 I.C. I.C. Apically positioned flap
D4249 $429 $550 Clinical crown lengthening - hard tissue
D4260 $741 $1,101
Osseous surgery (including flap entry and
closure) - four or more contiguous teeth or
bounded teeth spaces per quadrant
D4261 $660 $759
Osseous surgery (including flap entry and
closure) - one to three contiguous teeth or
bounded teeth spaces per quadrant
D4263 $236 $351 Bone replacement graft - first site in quadrant
D4264 $175 $202 Bone replacement graft - each additional site in
quadrant
D4265 I.C. I.C.
Biologic materials to aid in soft and osseous
tissue regeneration
D4266 $286 $359 Guided tissue regeneration - resorbable barrier,
per site
D4267 $286 $328 Guided tissue regeneration - nonresorbable
barrier, per site (includes membrane removal)
D4268 I.C. I.C. Surgical revision procedure, per tooth
D4270 $563 $800 Pedicle soft tissue graft procedure
D4271 $518 $704 Free soft tissue graft procedure (including
donor site surgery)
D4273 $607 $779 Subepithelial connective tissue graft
procedures, per tooth
D4274 $304 $384
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
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Code Allowed
Fee EPSDT
Rate Description
D4275 I.C. I.C. Soft tissue allograft
D4276 I.C. I.C.
Combined connective tissue and double
pedicle graft, per tooth
D4320 $124 $215 Provisional splinting – intracoronal
D4321 $106 $182 Provisional splinting - extracoronal
D4341 $125 $160 Periodontal scaling and root planning - four or
more teeth per quadrant
D4342 $84 $107 Periodontal scaling and root planning - one to
three teeth, per quadrant
D4355 $72 $93 Full mouth debridement to enable
comprehensive evaluation and diagnosis
D4381 $82 $121
Localized delivery of antimicrobial agents via
a controlled release vehicle into diseased
crevicular tissue, per tooth, by report
D4910 $75 $111 Periodontal maintenance
D4920 $62 $76 Unscheduled dressing change (by someone
other than treating dentist)
D4999 I.C. I.C. Unspecified periodontal procedure, by report
VI. Prosthodontics (Removable)
D5110 $680 $858 Complete denture – maxillary
D5120 $680 $852 Complete denture – mandibular
D5130 $715 $935 Immediate denture – maxillary
D5140 $714 $934 Immediate denture - mandibular
D5211 $518 $650
Maxillary partial denture - resin base
(including any conventional clasps, rests and
teeth)
D5212 $554 $691
Mandibular partial denture - resin base
(including any conventional clasps, rests and
teeth)
D5213 $1,022 $974
Maxillary partial denture - cast metal
framework with resin denture bases (including
any conventional clasps, rests and teeth)
D5214 $1,057 $986
Mandibular partial denture - cast metal
framework with resin denture bases (including
any conventional clasps, rests and teeth)
D5225 I.C. I.C.
Maxillary partial denture - flexible base
(including any clasps, rests and teeth)
D5226 I.C. I.C.
Mandibular partial denture - flexible base
(including any clasps, rests and teeth)
D5281 $393 $467 Removable unilateral partial denture - one
piece cast metal (including clasps and teeth)
D5410 $39 $49 Adjust complete denture - maxillary
D5411 $39 $49 Adjust complete denture - mandibular
D5421 $49 $56 Adjust partial denture - maxillary
D5422 $36 $45 Adjust partial denture - mandibular
D5510 $79 $109 Repair broken complete denture base
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
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Code Allowed
Fee EPSDT
Rate Description
D5520 $72 $89 Replace missing or broken teeth - complete
denture (each tooth)
D5610 $72 $93 Repair resin denture base
D5620 $97 $121 Repair cast framework
D5630 $92 $107 Repair or replace broken clasp
D5640 $72 $91 Replace broken teeth - per tooth
D5650 $86 $110 Add tooth to existing partial denture
D5660 $91 $125 Add clasp to existing partial denture
D5670 I.C. I.C.
Replace all teeth and acrylic on cast metal
framework (maxillary)
D5671 I.C. I.C.
Replace all teeth and acrylic on cast metal
framework (mandibular)
D5710 $236 $301 Rebase complete maxillary denture
D5711 $187 $257 Rebase complete mandibular denture
D5720 $214 $274 Rebase maxillary partial denture
D5721 $265 $323 Rebase mandibular partial denture
D5730 $147 $188 Reline complete maxillary denture (chair side)
D5731 $161 $184 Reline lower complete mandibular denture
(chair side)
D5740 $132 $169 Reline maxillary partial denture (chair side)
D5741 $125 $160 Reline mandibular partial denture (chair side)
D5750 $199 $255 Reline complete maxillary denture (laboratory)
D5751 $200 $256 Reline complete mandibular denture
(laboratory)
D5760 $197 $252 Reline maxillary partial denture (laboratory)
D5761 $197 $252 Reline mandibular partial denture (laboratory)
D5810 $135 $193 Interim complete denture (maxillary)
D5811 $135 $193 Interim complete denture (mandibular)
D5820 $250 $321 Interim partial denture (maxillary)
D5821 $275 $316 Interim partial denture (mandibular)
D5850 $67 $86 Tissue conditioning, maxillary
D5851 $61 $77 Tissue conditioning, mandibular
D5860 $765 $1,094 Overdenture - complete, by report
D5861 $825 $1,180 Overdenture - partial, by report
D5862 $214 $254 Precision attachment, by report
D5867 I.C. I.C.
Replacement of replaceable part of semi-
precision or precision attachment (male or
female component)
D5875 I.C. I.C.
Modification of removable prosthesis
following implant surgery
D5899 I.C. I.C.
Unspecified removable prosthodontic
procedure, by report
D5911 I.C. I.C. Facial moulage (sectional)
D5912 I.C. I.C. Facial moulage (complete)
D5913 I.C. I.C. Nasal prosthesis
D5914 I.C. I.C. Auricular prosthesis
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
13
Code Allowed
Fee EPSDT
Rate Description
D5915 I.C. I.C. Orbital prosthesis
D5916 I.C. I.C. Ocular prosthesis
D5919 I.C. I.C. Facial prosthesis
D5922 I.C. I.C. Nasal septal prosthesis
D5923 I.C. I.C. Ocular prosthesis, interim
D5924 I.C. I.C. Cranial prosthesis
D5925 I.C. I.C. Facial augmentation implant prosthesis
D5926 I.C. I.C. Nasal prosthesis, replacement
D5927 I.C. I.C. Auricular prosthesis, replacement
D5928 I.C. I.C. Orbital prosthesis, replacement
D5929 I.C. I.C. Facial prosthesis, replacement
D5931 I.C. I.C. Obturator prosthesis, surgical
D5932 I.C. I.C. Obturator prosthesis, definitive
D5933 I.C. I.C. Obturator prosthesis, modification
D5934 I.C. I.C.
Mandibular resection prosthesis with guide
flange
D5935 I.C. I.C.
Mandibular resection prosthesis without guide
flange
D5936 I.C. I.C. Obturator/prosthesis, interim
D5937 I.C. I.C. Trismus appliance (not for TM treatment)
D5951 I.C. I.C. Feeding aid
D5952 I.C. I.C. Speech aid prosthesis, pediatric
D5953 I.C. I.C. Speech aid prosthesis, adult
D5954 I.C. I.C. Palatal augmentation prosthesis
D5955 I.C. I.C. Palatal lift prosthesis, definitive
D5958 I.C. I.C. Palatal lift prosthesis, interim
D5959 I.C. I.C. Palatal lift prosthesis, modification
D5960 I.C. I.C. Speech aid prosthesis, modification
D5982 I.C. I.C. Surgical stent
D5983 I.C. I.C. Radiation carrier
D5984 I.C. I.C. Radiation shield
D5985 I.C. I.C. Radiation cone locator
D5986 I.C. I.C. Fluoride gel carrier
D5987 I.C. I.C. Commissure splint
D5988 I.C. I.C. Surgical splint
D5999 I.C. I.C. Unspecified maxillofacial prosthesis, by report
VII. Implant Services
D6010 $1,072 $1,374 Surgical placement of implant body: endosteal
implant
D6012 I.C. I.C.
Surgical placement of interim implant body for
transitional prosthesis: endosteal implant
D6040 $1,429 $1,632 Surgical placement: eposteal implant
D6050 $125 $162 Surgical placement: transosteal implant
D6053 I.C. I.C.
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
14
Code Allowed
Fee EPSDT
Rate Description
D6054 I.C I.C.
Implant/abutment supported removable
denture for partially edentulous arch
D6055 $214 $274 Dental implant supported connecting bar
D6056 $259 $331 Prefabricated abutment - includes placement
D6057 $375 $480 Custom abutment - includes placement
D6058 $857 $982 Abutment supported porcelain/ceramic crown
D6059 $704 $894 Abutment supported porcelain fused to metal
crown (high noble metal)
D6060 $679 $778 Abutment supported porcelain fused to metal
crown (predominantly base metal)
D6061 $706 $812 Abutment supported porcelain fused to metal
crown (noble metal)
D6062 $715 $894 Abutment supported cast metal crown (high
noble metal)
D6063 I.C I.C.
Abutment supported cast metal crown
(predominantly base metal)
D6064 $857 $1,091 Abutment supported cast metal crown (noble
metal)
D6065 $857 $1,015 Implant supported porcelain/ceramic crown
D6066 $818 $1,049
Implant supported porcelain fused to metal
crown (titanium, titanium alloy, high noble
metal)
D6067 $928 $1,067 Implant supported metal crown (titanium,
titanium alloy, high noble metal)
D6068 I.C I.C.
Abutment supported retainer for
porcelain/ceramic FPD
D6069 I.C I.C.
Abutment supported retainer for porcelain
fused to metal FPD (high noble metal)
D6070 I.C I.C.
Abutment supported retainer for porcelain
fused to metal FPD (predominantly base metal)
D6071 I.C I.C.
Abutment supported retainer for porcelain
fused to metal FPD (noble metal)
D6072 I.C I.C.
Abutment supported retainer for cast metal
FPD (high noble metal)
D6073 I.C I.C.
Abutment supported retainer for cast metal
FPD (predominantly base metal)
D6074 I.C. I.C.
Abutment supported retainer for cast metal
FPD (noble metal)
D6075 I.C. I.C. Implant supported retainer for ceramic FPD
D6076 I.C. I.C.
Implant supported retainer for porcelain fused
to metal FPD (titanium, titanium alloy, or high
noble metal)
D6077 I.C. I.C.
Implant supported retainer for cast metal FPD
(titanium, titanium alloy, or high noble metal)
D6078 I.C. I.C.
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
15
Code Allowed
Fee EPSDT
Rate Description
D6079 I.C. I.C.
Implant/abutment supported fixed denture for
partially edentulous arch
D6080 $89 $115
Implant maintenance procedures, including
removal of prosthesis, cleansing of prosthesis
and abutments, reinsertion of prosthesis
D6090 I.C. I.C. Repair implant supported prosthesis, by report
D6091 I.C. I.C.
Replacement of semi-precision or precision
attachment (male or female component) of
implant/abutment supported prosthesis, per
attachment
D6092 I.C. I.C. Recement implant/abutment supported crown
D6093 I.C. I.C.
Recement implant/abutment supported fixed
partial denture
D6094 I.C. I.C. Abutment supported crown - (titanium)
D6095 I.C. I.C. Repair implant abutment, by report
D6100 I.C. I.C. Implant removal, by report
D6190 I.C. I.C. Radiographic/surgical implant index, by report
D6194 I.C. I.C.
Abutment supported retainer crown for FPD -
(titanium)
D6199 I.C. I.C. Unspecified implant procedure, by report
D6205 I.C. I.C. Pontic - indirect resin based composite
D6210 $607 $748 Pontic - cast high noble metal
D6211 $544 $667 Pontic - cast predominantly base metal
D6212 $589 $676 Pontic - cast noble metal
D6214 I.C. I.C. Pontic – titanium
D6240 $625 $792 Pontic - porcelain fused to high noble metal
D6241 $565 $691 Pontic - porcelain fused to predominantly base
metal
D6242 $571 $731 Pontic - porcelain fused to noble metal
D6245 I.C. I.C. Pontic - porcelain/ceramic
D6250 $655 $807 Pontic - resin with high noble metal
D6251 $482 $575 Pontic - resin with predominantly base metal
D6252 $517 $691 Pontic - resin with noble metal
D6253 I.C. I.C. Provisional pontic
D6545 $250 $320 Retainer - cast metal for resin bonded fixed
prosthesis
D6548 I.C. I.C.
Retainer - porcelain/ceramic for resin bonded
fixed prosthesis
D6600 I.C. I.C. Inlay - porcelain/ceramic, two surfaces
D6601 I.C. I.C.
Inlay - porcelain/ceramic, three or more
surfaces
D6602 I.C. I.C. Inlay - cast high noble metal, two surfaces
D6603 I.C. I.C.
Inlay - cast high noble metal, three or more
surfaces
D6604 I.C. I.C.
Inlay - cast predominantly base metal, two
surfaces
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
16
Code Allowed
Fee EPSDT
Rate Description
D6605 I.C. I.C.
Inlay - cast predominantly base metal, three or
more surfaces
D6606 I.C. I.C. Inlay - cast noble metal, two surfaces
D6607 I.C. I.C. Inlay - cast noble metal, three or more surfaces
D6608 I.C. I.C. Onlay - porcelain/ceramic, two surfaces
D6609 I.C. I.C.
Onlay - porcelain/ceramic, three or more
surfaces
D6610 I.C. I.C. Onlay - cast high noble metal, two surfaces
D6611 I.C. I.C.
Onlay - cast high noble metal, three or more
surfaces
D6612 I.C. I.C.
Onlay - cast predominantly base metal, two
surfaces
D6613 I.C. I.C.
Onlay - cast predominantly base metal, three or
more surfaces
D6614 I.C. I.C. Onlay - cast noble metal, two surfaces
D6615 I.C. I.C.
Onlay - cast noble metal, three or more
surfaces
D6624 I.C. I.C. Inlay – titanium
D6634 I.C. I.C. Onlay – titanium
D6710 I.C I.C. Crown – indirect resin based composite
D6720 $491 $671 Crown - resin with high noble metal
D6721 $499 $610 Crown - resin with predominantly base metal
D6722 $193 $246 Crown - resin with noble metal
D6740 I.C I.C. Crown - porcelain/ceramic
D6750 $632 $779 Crown - porcelain fused to high noble metal
D6751 $568 $691 Crown - porcelain fused to predominantly base
metal
D6752 $571 $731 Crown - porcelain fused to noble metal
D6780 $482 $617 Crown - 3/4 cast high noble metal
D6781 I.C. I.C. Crown - 3/4 cast predominately base metal
D6782 I.C. I.C. Crown - 3/4 cast noble metal
D6783 I.C. I.C. Crown - 3/4 porcelain/ceramic
D6790 $655 $897 Crown - full cast high noble metal
D6791 $518 $661 Crown - full cast predominantly base metal
D6792 $549 $701 Crown - full cast noble metal
D6793 I.C. I.C. Provisional retainer crown
D6794 I.C. I.C. Crown – titanium
D6920 I.C. I.C. Connector bar
D6930 $67 $87 Recement bridge
D6940 $143 $204 Stress breaker
D6950 $155 $220 Precision attachment
D6970 $357 $408 Post and core in addition to fixed partial
denture retainer, indirectly fabricated
D6972 $143 $184 Prefabricated post and core in addition to
bridge retainer
D6973 $125 $160 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
17
Code Allowed
Fee EPSDT
Rate Description
D6975 I.C. I.C. Coping - metal
D6976 I.C. I.C.
Each additional indirectly fabricated post -
same tooth
D6977 I.C. I.C. Each additional prefabricated post - same tooth
D6980 $125 $155 Bridge repair, by report
D6985 I.C. I.C. Pediatric partial denture, fixed
D6999 I.C. I.C.
Unspecified fixed prosthodontic procedure, by
report
X. Exodontic
D7111 $70 $80 Extraction, coronal remnants - deciduous tooth
D7140 $70 $100 Extraction, erupted tooth or exposed root
(elevation and/or forceps removal)
D7210 $139 $179
Surgical removal of erupted tooth requiring
elevation of mucoperiosteal flap and removal
of bone and/or section of tooth
D7220 $178 $223 Removal of impacted tooth - soft tissue
D7230 $232 $286 Removal of impacted tooth - partially bony
D7240 $275 $378 Removal of impacted tooth - completely bony
D7241 $304 $427 Removal of impacted tooth - completely bony,
with unusual surgical complications
D7250 $134 $173 Surgical removal of residual tooth roots
(cutting procedure)
D7260 $316 $398 Oral antral fistula closure
D7261 I.C I.C. Primary closure of a sinus perforation
D7270 $99 $145 Tooth reimplantation and/or stabilization of
accidentally evulsed or displaced tooth
D7272 $150 $218
Tooth transplantation (includes reimplantation
from one site to another and splinting and/or
stabilization)
D7280 $354 $452 Surgical access of an unerupted tooth
D7282 I.C. I.C.
Mobilization of erupted or malpositioned tooth
to aid eruption
D7283 $68 $84 Placement of device to facilitate eruption of
impacted tooth
D7285 $114 $146 Biopsy of oral tissue - hard (bone, tooth)
D7286 $153 $197 Biopsy of oral tissue - soft
D7287 I.C. I.C. Exfoliative cytological sample collection
D7288 I.C. I.C.
Brush biopsy - transepithelial sample
collection
D7290 $74 $109 Surgical repositioning of teeth
D7291 $128 $165 Transseptal fiberotomy/supra crestal
fiberotomy, by report
D7292 I.C. I.C.
Surgical placement: temporary anchorage
device (screw retained plate) requiring surgical
flap
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
18
Code Allowed
Fee EPSDT
Rate Description
D7293 I.C. I.C.
Surgical placement: temporary anchorage
device requiring surgical flap
D7294 I.C. I.C.
Surgical placement: temporary anchorage
device without surgical flap
D7310 $132 $163
Alveoloplasty in conjunction with extractions-
four or more teeth or tooth spaces, per
quadrant
D7311 $119 $146 Alveoloplasty in conjunction with extractions -
one to three teeth or tooth spaces, per quadrant
D7320 $174 $202
Alveoloplasty not in conjunction with
extractions-four or more teeth or tooth spaces,
per quadrant
D7321 $139 $162
Alveoloplasty not in conjunction with
extractions - one to three teeth or tooth spaces,
per quadrant
D7340 $696 $796 Vestibuloplasty - ridge extension (second
epithelialization)
D7350 $879 $1,236
Vestibuloplasty - ridge extension (including
soft tissue grafts, muscle reattachments,
revision of soft tissue attachment and
management of hypertrophied and hyperplastic
tissue)
D7410 $107 $124 Excision of benign lesion up to 1.25 cm
D7411 $194 $254 Excision of benign lesion greater than 1.25 cm
D7412 I.C. I.C. Excision of benign lesion, complicated
D7413 I.C. I.C. Excision of malignant lesion up to 1.25 cm
D7414 I.C. I.C.
Excision of malignant lesion greater than 1.25
cm
D7415 I.C. I.C. Excision of malignant lesion, complicated
D7440 $175 $256 Excision of malignant tumor - lesion diameter
up to 1.25 cm
D7441 $232 $339 Excision of malignant tumor - lesion diameter
greater than 1.25 cm
D7450 $231 $252 Removal of benign odontogenic cyst or tumor
- lesion diameter up to 1.25 cm
D7451 $268 $343 Removal of benign odontogenic cyst or tumor
- lesion diameter greater than 1.25 cm
D7460 $113 $142 Removal of benign nonodontogenic cyst or
tumor - lesion diameter up to 1.25 cm
D7461 $133 $194 Removal of benign nonodontogenic cyst or
tumor - lesion diameter greater than 1.25 cm
D7465 $107 $122 Destruction of lesion(s) by physical or
chemical method, by report
D7471 $133 $194 Removal of lateral exostosis (maxilla or
mandible)
D7472 I.C. I.C. Removal of torus palatinus
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
19
Code Allowed
Fee EPSDT
Rate Description
D7473 I.C. I.C. Removal of torus mandibularis
D7485 I.C. I.C. Surgical reduction of osseous tuberosity
D7490 I.C. I.C. Radical resection of maxilla or mandible
D7510 $89 $115 Incision and drainage of abscess - intraoral soft
tissue
D7511 I.C. I.C.
Incision and drainage of abscess - intraoral soft
tissue - complicated (includes drainage of
multiple fascial spaces)
D7520 $75 $86 Incision and drainage of abscess - extraoral
soft tissue
D7521 I.C. I.C.
Incision and drainage of abscess - extraoral
soft tissue - complicated (includes drainage of
multiple fascial spaces)
D7530 $196 $224 Removal of foreign body from mucosa, skin,
or subcutaneous alveolar tissue
D7540 $432 $544 Removal of reaction-producing foreign bodies,
musculoskeletal system
D7550 I.C. I.C.
Partial ostectomy/sequestrectomy for removal
of nonvital bone
D7560 $249 $364 Maxillary sinusotomy for removal of tooth
fragment or foreign body
D7610 $1,165 $1,704 Maxilla - open reduction (teeth immobilized, if
present)
D7620 $390 $569 Maxilla - closed reduction (teeth immobilized,
if present)
D7630 $974 $1,425 Mandible - open reduction (teeth immobilized,
if present)
D7640 $581 $850 Mandible - closed reduction (teeth
immobilized, if present)
D7650 $776 $1,135 Malar and/or zygomatic arch - open reduction
D7660 $193 $282 Malar and/or zygomatic arch - closed reduction
D7670 $276 $387 Alveolus - closed reduction, may include
stabilization of teeth
D7671 I.C. I.C.
Alveolus - open reduction, may include
stabilization of teeth
D7680 I.C. I.C.
Facial bones - complicated reduction with
fixation and multiple surgical approaches
D7710 $1,165 $1,704 Maxilla – open reduction
D7720 I.C. I.C. Maxilla - closed reduction
D7730 $974 $1,425 Mandible - open reduction
D7740 $581 $846 Mandible - closed reduction
D7750 $776 $1,135 Malar and/or zygomatic arch - open reduction
D7760 $193 $282 Malar and/or zygomatic arch - closed reduction
D7770 $291 $380 Alveolus - open reduction stabilization of teeth
D7771 I.C. I.C.
Alveolus, closed reduction stabilization of
teeth
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
20
Code Allowed
Fee EPSDT
Rate Description
D7780 $107 $137 Facial bones - complicated reduction with
fixation and multiple surgical approaches
D7810 $485 $711 Open reduction of dislocation
D7820 $75 $109 Closed reduction of dislocation
D7830 I.C. I.C. Manipulation under anesthesia
D7840 $776 $1,135 Condylectomy
D7850 I.C. I.C. Surgical discectomy; with/without implant
D7852 I.C. I.C. Disc repair
D7854 I.C. I.C. Synovectomy
D7856 I.C. I.C. Myotomy
D7858 I.C. I.C. Joint reconstruction
D7860 I.C. I.C. Arthrotomy
D7865 I.C. I.C. Arthroplasty
D7870 $99 $145 Arthrocentesis
D7871 I.C. I.C. Nonarthroscopic lysis and lavage
D7872 I.C. I.C.
Arthroscopy - diagnosis, with or without
biopsy
D7873 I.C. I.C.
Arthroscopy - surgical: lavage and lysis of
adhesions
D7874 I.C. I.C.
Arthroscopy - surgical: disc repositioning and
stabilization
D7875 I.C. I.C. Arthroscopy - surgical: synovectomy
D7876 I.C. I.C. Arthroscopy - surgical: discectomy
D7877 I.C. I.C. Arthroscopy - surgical: debridement
D7880 $321 $367 Occlusal orthotic appliance
D7899 I.C. I.C. Unspecified TMD therapy, by report
D7910 $29 $42 Suture of recent small wounds up to 5 cm
D7911 $99 $129 Complicated suture - up to 5 cm
D7912 $99 $145 Complicated suture - greater than 5 cm
D7920 I.C. I.C.
Skin graft (identify defect covered, location
and type of graft)
D7940 I.C. I.C. Osteoplasty - for orthognathic deformities
D7941 I.C. I.C. Osteotomy - mandibular rami
D7943 $2,330 $3,409 Osteotomy - mandibular rami with bone graft;
includes obtaining the graft
D7944 $946 $1,384 Osteotomy-segmented or subapical
D7945 $1,942 $2,843 Osteotomy - body of mandible
D7946 I.C. I.C. LeFort I (maxilla - total)
D7947 I.C. I.C. LeFort I (maxilla - segmented)
D7948 I.C. I.C.
LeFort II or LeFort III (osteoplasty of facial
bones for midface hypoplasia or retrusion) -
without bone graft
D7949 I.C. I.C. LeFort II or LeFort III - with bone graft
D7950 $776 $1,135
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
21
Code Allowed
Fee EPSDT
Rate Description
D7951 I.C. I.C.
Sinus augmentation with bone or bone
substitutes
D7953 I.C. I.C.
Bone replacement graft for ridge preservation -
per site
D7955 I.C. I.C.
Repair of maxillofacial soft and/or hard tissue
defect
D7960 $100 $353 Frenulectomy (frenectomy or frenotomy) -
separate procedure
D7963 $388 $480 Frenuloplasty
D7970 $229 $334 Excision of hyperplastic tissue - per arch
D7971 $74 $109 Excision of pericoronal gingival
D7972 I.C. I.C. Surgical reduction of fibrous tuberosity
D7980 $99 $145 Sialolithotomy
D7981 $605 $850 Excision of salivary gland, by report
D7982 $263 $387 Sialodochoplasty
D7983 $482 $705 Closure of salivary fistula
D7990 I.C. I.C. Emergency tracheotomy
D7991 I.C. I.C. Coronoidectomy
D7995 I.C. I.C.
Synthetic graft - mandible or facial bones, by
report
D7996 I.C. I.C.
Implant - mandible for augmentation purposes
(excluding alveolar ridge), by report
D7997 I.C. I.C.
Appliance removal (not by dentist who placed
appliance), includes removal of archbar
D7998 I.C. I.C.
Intraoral placement of a fixation device not in
conjunction with a fracture
D7999 I.C. I.C. Unspecified oral surgery procedure, by report
XI. Orthodontic
D8010 I.C. I.C.
Limited orthodontic treatment of the primary
dentition
D8020 I.C. I.C.
Limited orthodontic treatment of the
transitional dentition
D8030 I.C. I.C.
Limited orthodontic treatment of the
adolescent dentition
D8040 I.C. I.C.
Limited orthodontic treatment of the adult
dentition
D8050 I.C. I.C.
Interceptive orthodontic treatment of the
primary dentition
D8060 I.C. I.C.
Interceptive orthodontic treatment of the
transitional dentition
D8070 I.C. I.C.
Comprehensive orthodontic treatment of the
transitional dentition
D8080 $1,143 $1,213 Comprehensive orthodontic treatment of the
adolescent dentition
D8090 I.C. I.C.
Comprehensive orthodontic treatment of the
adult dentition
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
22
Code Allowed
Fee EPSDT
Rate Description
D8210 $79 $95 Removable appliance therapy
D8220 I.C. I.C. Fixed appliance therapy
D8660 $22 $31 Preorthodontic treatment visit
D8670 $200 $268 Periodic orthodontic treatment visit (as part of
contract)
D8680 $79 $95 Orthodontic retention (removal of appliances,
construction and placement of retainer(s))
D8690 $114 $136 Orthodontic treatment (alternative billing to a
contract fee)
D8691 I.C. I.C. Repair of orthodontic appliance
D8692 $79 $95 Replacement of lost or broken retainer
D8693 I.C. I.C.
Rebonding or recementing; and/or repair, as
required, of fixed retainers
D8999 I.C. I.C. Unspecified orthodontic procedure, by report
XII. Adjunctive General Services
D9110 $33 $75 Palliative (emergency) treatment of dental pain
- minor procedure
D9120 I.C. I.C. Fixed partial denture sectioning
D9210 $10 $15 Local anesthesia not in conjunction with
operative or surgical procedures
D9211 I.C. I.C. Regional block anesthesia
D9212 I.C. I.C. Trigeminal division block anesthesia
D9215 I.C. I.C. Local anesthesia
D9220 $114 $208 Deep sedation/general anesthesia - first 30
minutes
D9221 $89 $114 Deep sedation/general anesthesia - each
additional 15 minutes
D9230 $14 $21 Analgesia, anxiolysis, inhalation of nitrous
oxide
D9241 $178 $221 Intravenous conscious sedation/analgesia - first
30 minutes
D9242 $73 $82 Intravenous conscious sedation/analgesia -
each additional 15 minutes
D9248 I.C. I.C. Nonintravenous conscious sedation
D9310 $50 $63
Consultation-diagnostic service provided by
dentist or physician other than requesting
dentist or physician
D9410 $36 $36 House/extended care facility call, once per
facility per day
D9420 $32 $48 Hospital call
D9430 $17 $26 Office visit for observation (during regularly
scheduled hours) - no other services performed
D9440 $21 $30 Office visit - after regularly scheduled hours
D9450 $19 $19 Case presentation, detailed and extensive
treatment planning
114.3 CMR DIVISION OF HEALTH CARE FINANCE AND POLICY
114.3 CMR 14.00: Dental Services
23
Code Allowed
Fee EPSDT
Rate Description
D9610 $27 $40 Therapeutic parenteral drug, single
administration
D9612 I.C. I.C.
Therapeutic parenteral drugs, two or more
administrations, different medications
D9630 $7 $10 Other drugs and/or medicaments, by report
D9910 $20 $22 Application of desensitizing medicament
D9911 I.C. I.C.
Application of desensitizing resin for cervical
and/or root surface, per tooth
D9920 $43 $43 Behavior management, by report
D9930 I.C. I.C.
Treatment of complications (postsurgical) -
unusual circumstances, by report
D9940 $239 $308 Occlusal guards, by report
D9941 $57 $85 Fabrication of athletic mouthguard
D9942 I.C. I.C. Repair and/or reline of occlusal guard
D9950 $30 $45 Occlusion analysis - mounted case
D9951 $30 $45 Occlusal adjustment - limited
D9952 $139 $179 Occlusal adjustment - complete
D9970 I.C. I.C. Enamel microabrasion
D9971 I.C. I.C.
Odontoplasty 1-2 teeth; includes removal of
enamel projections
D9972 I.C. I.C. External bleaching - per arch
D9973 I.C. I.C. External bleaching - per tooth
D9974 I.C. I.C. Internal bleaching - per tooth
D9999 I.C. I.C. 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
