New York Codes, Rules and Regulations › Title 18 - DEPARTMENT OF SOCIAL SERVICES › Chapter II - Regulations of the Department of Social Services › Subchapter E - Medical Care › Article 4 - Fees and Reimbursement › Part 535 - State Reimbursement For Payment To Dentists › Section 535.5 - Maximum reimbursable dental fee schedules

Current through Register Vol. 46, No. 28, July 10, 2024
[Additional statutory authority: Social Services Law,
			   § 363-a]
(a)
Maximum
			 reimbursable allowances for dental services except those dental services
			 provided in certain dental clinics as set forth in subdivision (b) of this
			 section and those provided in organized clinics in hosptials as set forth in
			 subdivision (c) of this section.
Fees for all services included in this subdivision shall
			   be effective for care and services provided on and after April 1, 1974.
DIAGNOSTIC
Fee
D011
Charting, history, oral examination and completion
					 of forms
$ 5.00
D012
Periodic recall examination (oral checking)
					 .......
5.00
Radiographic
D021
Complete intraoral series of 14 periapical films
					 and 2 bite-wing films .......
$ 15.00
D022
Intraoral periapical (first or single film)
					 .......
2.00
D023
Each additional single film (periapical or
					 bite-wing) .......
1.00
D024
Occlusal view x-ray .......
5.00
D025*
Lateral jaw x-ray, each .......
10.00
D027
Four bite-wing x-ray films .......
6.00
D028
First or single bite-wing film (use D023 for add.
					 films) .......
2.00
D029*
Antero-posterior x-ray of head and jaws .......
10.00
D030*
Cephalometric examination .......
10.00
D033
Panoramic (panography) .......
12.50
D034
Panoramic x-rays, supplemented by three (3) or
					 more additional intraoral films (periapical and/or bitewing) necessary to
					 establish an accurate diagnosis, maximum payment .......
$ 15.00
(for panography with fewer than (3) supplemental
					 films use Codes D023 and D033) .......
Supplementary Diagnostic Aids
D047*
Study models, where indicated .......
$ 10.00
PREVENTIVE
D111
Oral prophylaxis, child to age 12 .......
$ 6.90
D112
Over age 12 .......
8.80
Topical fluoride treatment following
					 prophylaxis
D121
4 treatments, sodium fluoride only .......
17.50
D122
1 treatment, other than sodium fluoride .......
6.00
PERIODONTICS
D212*
Subgingival curettage and root planning-per
					 quadrant (at least 5 teeth) .......
$ 10.00
D214
Incision and drainage of periodontal abscess
					 .......
8.00
D215**
Treatment for necrotizing ulcerative gingivitis
					 (Vincent's infection) (incl. debridement and medication) per visit .......
10.00
ORAL
					   SURGERY
D311
Extraction, uncomplicated, permanent tooth,
					 includes local anesthesia .......
$ 7.50
D312*
Extraction, uncomplicated, each additional
					 permanent tooth at same session, in same quadrant, includes local anesthesia
					 .......
6.90
D313
Extraction, uncomplicated, deciduous tooth,
					 includes local anesthesia .......
6.30
D314
Extraction, uncomplicated, each additional
					 deciduous tooth at same session, in same quadrant, includes local anesthesia
					 .......
5.00
D320
Extraction-surgical removal of erupted tooth,
					 includes local anesthesia .......
15.00
D321
Each additional adjacent tooth surgically removed
					 during the same session .......
7.50
D322*
Extraction-odontectomy, impacted tooth, soft
					 tissue, includes local anesthesia .......
15.00
D323
partially covered by bone-includes local
					 anesthesia .......
25.00
D324*
completely covered by bone-includes local
					 anesthesia .......
45.00
D325*
Extraction, removal of residual root covered by
					 bone, includes local anesthesia .......
15.00
D326*
Repair-surgical exposure of impacted tooth or
					 unerupted tooth-for orthodontic reasons including ligation, includes local
					 anesthesia .......
45.00
D331*
Repair-Alveolectomy per jaw-includes local
					 anesthesia .......
25.00
D360
Fracture, maxilla, simple or compound, no
					 reduction .......
By Report
D361
Fracture, maxilla, simple open reduction with
					 wiring of teeth and/or local fixation .......
FOLLOW- UP DAYS
200.00
Anesthesia .......
90
16+T
D362
Fracture, maxilla, simple closed reduction, with
					 wiring of teeth .......
120.00
Anesthesia .......
90
16+T
D363
Fracture, mandible, simple open reduction, with or
					 without wiring of teeth .......
200.00
Anesthesia .......
90
16+T
D364
Fracture, mandible, simple closed reduction and
					 wiring of teeth .......
120.00
Anesthesia .......
90
16+T
D365
Fracture, maxilla, complicated, open reduction,
					 fixation by headcap, multiple surgical approaches, internal fixation, wiring
					 teeth, etc. .......
By Report
Anesthesia .......
90
24+T
D369
Fracture, mandible, simple or compound, no
					 reduction .......
By Report
D373*
Repair-Osteoplasty (mandible, for prognathism or
					 mi-crognathism), one or two stages .......
400.00
Anesthesia .......
90
20+T
D374
Fracture, malar, simple or compound, no reduction
					 .......
By Report
D375
Closed reduction (incl. towel clip technique)
					 .......
20.00
Anesthesia .......
16+T
D376
Depressed, open reduction .......
120.00
Anesthesia .......
60
16+T
D377
Complicated, depressed, open reduction with
					 internal skeletal fixation and multiple surgical approaches .......
260.00
Anesthesia .......
90
20+T
D378
Fracture, mandible, skeletal pinning with external
					 fixation .......
160.00
Anesthesia .......
90
16+T
D384
Incision and drainage of abscess-Dento-alveolar
					 .......
10.00
D385
Infra-orbital, palatal, peri-coronal,
					 sub-maxillary, sublinqual, submental, masseteric, floor of mouth, others except
					 periodontal .......
$ 15.00
* Prior approval required except in emergency.
** Prior approval required in some cases (See regulations
			   or guidelines)
Fee
ENDODONTICS
(Including radiographs but
					   exclusive of restoration)
D420
Vital pulpotomy .......
$ 10.00
D431**
Single root canal filling .......
50.00
D432**
Double root canal filling .......
75.00
D439*
Anterior tooth: root canal filling with
					 apicoectomy and/or root-end amalgam .......
75.00
D440*
Apicoectomy (separate procedure) .......
35.00
OPERATIVE (RESTORATIVE)
					   SERVICES
(Filling includes bases as
					   necessary)
D511
Silver amalgam-1 surface .......
$ 6.30
D512
Silver amalgam-2 surface .......
11.30
D513
Silver amalgam-3 surface or more .......
17.50
D514
Silver amalgam-reinforcement pins-1st pin (to be
					 added to restoration cost) .......
5.00
D515
-each additional pin .......
3.00
D520
Silicate cement filling-maximum payment two
					 fillings per tooth .......
7.00
D531
Plastic Class III-maximum payment two fillings per
					 tooth .......
9.00
D532
Plastic Class IV-maximum payment two fillings per
					 tooth .......
12.00
D551*
Cast gold-1 surface .......
35.00
D552*
Cast gold-2 surfaces .......
45.00
D553*
Cast gold-3 surfaces .......
60.00
CROWN AND
					   BRIDGE
D610*
Acrylic jacket (quick cure) .......
$ 30.00
D611*
Acrylic or vinyl jacket crown .......
70.00
D614*
Porcelain jacket crown .......
80.00
D617*
Acrylic veneer jacket crown .......
75.00
D618*
Porcelain veneer jacket crown .......
100.00
D619*
Cast gold full crown .......
70.00
D620*
Gold band crown with cast occlusal .......
60.00
D622*
3/4 cast gold crown .......
60.00
D624
Crowns: stainless steel-primary or permanent tooth
					 .......
20.00
D625*
Pontics: Cast gold (sanitary) .......
40.00
D626*
Steele's facing .......
50.00
D627*
Tru-pontic type .......
50.00
D628*
Plastic processed to gold .......
50.00
D629*
Gold dowel and core for porcelain or acrylic
					 jacket crown .......
35.00
D642
Recementing crown .......
10.00
D643
Recementing fixed bridge .......
20.00
D651
Replacing facing (slot and tube) .......
15.00
PROSTHETICS
D711*
Full upper acrylic denture including necessary
					 adjustments .......
$150.00
D712*
Full lower acrylic denture including necessary
					 adjustments .......
150.00
D713*
Immediate denture including chairside
					 relines-including necessary adjustments .......
165.00
D722*
Partial acrylic denture, upper or lower, including
					 teeth and two clasps with rests .......
110.00
D727*
Cast chrome partial-two clasps, acrylic saddle
					 .......
170.00
D728*
Wrought lingual bar-2 wrought clasps, acrylic
					 saddle .......
120.00
D731*
Each additional clasp with rest .......
22.00
D732*
Each additional wrought clasp, with rest .......
20.00
D743
Denture repair-no teeth .......
12.50
D744
Repair of denture base plus replacing one tooth
					 .......
16.30
D745
Replacing each additional tooth .......
6.30
D746
Replacing broken tooth-no other repair .......
10.00
D747
Add tooth to partial, replace extracted tooth in
					 acrylic .......
16.30
D748
Add tooth to partial, replacing extracted tooth
					 with welded loop .......
25.00
D749*
Partial acrylic denture, upper or lower, replacing
					 one or two anterior teeth, no clasps. (Flipper or Stayplate)-Use D745 for each
					 additional tooth .......
75.00
D750
Replacing one arm of a clasp .......
17.50
D751
Replacing undamaged clasp on partial .......
18.00
D752
Replacing broken clasp with new clasp .......
30.00
D753*
Rebasing upper or lower, full denture .......
43.80
D754*
Rebasing upper or lower partial .......
43.80
D757*
Duplicating denture, full or partial .......
75.00
ORTHODONTICS
Active treatment in private office:
D853*
1st year including appliances 1/ .......
$500.00
D854*
2nd year .......
375.00
D855*
3rd year .......
125.00
(Maximum cost for active treatment $1,000.00)
D856*
Retention not to exceed 12 visits per year at
					 $6.25 per visit, annual maximum payment .......
75.00
D857*
Observation not to exceed 6 visits per year at
					 $6.25 per visit, annual maximum payment .......
37.50
1/ Billing for first year of care should be from
					 date appliances are inserted. This is based on a fee of $187.50 for preparation
					 and construction of appliance and $26.04 per month for 12 months of active
					 treatment after the appliances are inserted, making a total tee of $500.00 for
					 first year of care.
MISCELLANEOUS
					   SERVICES
D910
Palliative treatment of dental pain (in office,
					 during office hours) .......
$ 5.00
D911
Home visits 2/, by dentist per visit, regardless
					 of number of patients seen (to be added to fee services) .......
5.00
D913
Hospital Visit 3/, by dentist per visit,
					 regardless of number of patients seen (to be added to fee for service) .......
5.00
D923
Anesthesia-general in office, by qualified person
					 other than operating dentist, 1st hour .......
10.00
each additional 30 minutes .......
5.00
D925
General Anesthesia for multiple extractions in
					 hospital (basic fee) .......
15.00
basic fee plus each 15 minutes of anesthesia time
					 .......
5.00
D940
Consultation by qualified specialist .......
20.00
2/ The fee for a home visit represents the total
					 extra charge permitted, and is not applicable to each patient seen at such
					 visit. Payments at home call rates apply to services provided to persons in
					 boarding homes, nursing homes, convalescent homes, proprietary homes for
					 adults, private homes for the aged, institutions for the blind, and places of
					 residence used as an individual's home.
3/ The fee for a hospital visit is not applicable
					 when covered by a specified number of follow-up days.
NONSPECIALISTS
Clinic
					   Session
D950
Three-hour session .......
$ 35.00
D951
Each additional hour (per hour) .......
7.00
Shorter Clinic
					   Session
(Less than 3 hours)
D953
One-hour session .......
15.00
D954
Two-hour session .......
25.00
SPECIALISTS
Clinic
					   Session
D960
Three-hour session .......
50.00
D961
Each additional hour (per hour) .......
10.00
Shorter Clinic
					   Session
(Less than 3 hours)
D963
One-hour session .......
20.00
D964
Two-hour session .......
35.00
(b)
Maximum reimbursable
					 allowances dental services rendered in dental clinics affiliated with State
					 University New York at Buffalo School of Dentistry, Columbia University School
					 of Dental and Oral Surgery, and New York University College of
					 Dentistry.
Code
Procedure
Fee
DIAGNOSTIC
DC011
Charting, history, oral examination and completion
					 of forms
$ 3.00
DC012
Periodic recall examination (oral checking)
					 .......
3.00
RADIOGRAPHIC
DC021
Complete intraoral series of 14 periapical films
					 and 2 bite-wing films .......
7.50
DC022
First intraoral periapical (single film) .......
.50
DC023
Each additional single film .......
.50
DC024
Occlusal view x-ray .......
1.00
DC025
Lateral jaw x-ray each .......
2.00
DC027
Four bite-wing x-ray films .......
2.00
DC028
Single bite-wing film .......
.50
DC029
Antero-posterior x-ray of head and jaws .......
5.00
DC030
Cephalometric examination .......
5.00
DC033
Fanoramic (panography) .......
10.00
SUPPLEMENTARY DIAGNOSTIC AIDS
DC047
Study models, where indicated .......
5.00
PREVENTIVE
DC111
Oral prophylaxis, child to age 12 .......
2.00
DC112
Over age 12 .......
3.00
DC120
Topical fluoride treatment following prophylaxis
					 .......
DC121
4 treatments .......
10.00
DC122
1 treatment .......
3.00
PERIODONTICS
DC212
Subgingival scaling and planning-per quadrant (at
					 least 5 teeth) .......
5.00
DC214
Incision and drainage of periodontal abscess
					 .......
5.00
DC215
Treatment for rectitizing ulcerative gingivitis
					 (Vincent's infection)(incl. debridement and medication) per visit .......
5.00
DC216
Night guard or day guard (bite guard) .......
15.00
DC217
Temporary splinting (wire ligation or stainless
					 steel bands) .......
10.00
DC218
Splint resin .......
15.00
DC219
Gingivectomy and/or gingivoplasty (per quadrant)
					 .......
20.00
DC220
Periodontal surgical flap (per quadrant) .......
20.00
DC221
Periodontal surgical bone implant .......
20.00
ORAL SURGERY
DC311
Extraction, removal of tooth, uncomplicated
					 includes local anesthesia .......
2.00
DC312
Extraction-multiple removal of teeth, per tooth,
					 includes local anesthesia .......
2.00
DC321
Extraction-surgical removal of erupted tooth,
					 includes local anesthesia .......
3.00
DC322
Extraction-odontectomy, impacted tooth, soft
					 tissue, includes local anesthesia .......
10.00
DC323
partially covered by bone-includes local
					 anesthesia .......
15.00
DC324
completely covered by bone-includes local
					 anesthesia .......
25.00
DC325
Extraction-removal of residual root covered by
					 bone, includes local anesthesia .......
10.00
DC326
Repair-surgical exposure of impacted tooth or
					 unerupted tooth-for orthodontic reasons including ligation, includes local
					 anesthesia .......
10.00
DC331
Repair-alveolectomy per jaw-includes local
					 anesthesia .......
10.00
DC360
Fracture, maxilla, simple or compound no reduction
					 .......
by report
DC361
Fracture, maxilla, simple open reduction, with
					 wiring of teeth and/or local fixation .......
100.00
DC362
Fracture, maxilla, simple closed reduction, with
					 wiring of teeth .......
75.00
DC363
Fracture, mandible, simple open reduction, with or
					 without wiring of teeth .......
100.00
DC364
Fracture, mandible, simple closed reduction and
					 wiring of teeth .......
75.00
DC365
Fracture, maxilla, complicated, open reduction,
					 fixation by head cap, multiple surgical approaches, internal fixation wiring
					 teeth, etc .......
by report
DC369
Fracture, mandible, simple or compound, no
					 reduction .......
by report
DC373
Repair-osteoplasty (mandible, for prognathism or
					 micrognathism), one or two stages .......
200.00
DC374
Fracture, malar, simple or compound no reduction
					 .......
by report
DC375
Closed reduction (incl. towel clip technique)
					 .......
10.00
DC376
Depressed, open reduction .......
75.00
DC377
Complicated, depressed, open reduction with
					 internal skeletal fixation and multiple surgical approaches .......
130.00
DC378
Fracture, mandible, skeletal pinning with external
					 fixation .......
75.00
DC384
Incision and drainage of abscess-dento-alveolar
					 .......
7.00
DC385
Infra-orbital, palatal peri-coronal, submaxillary,
					 sublingual, submental. masseteric. floor of mouth, others except periodontal
					 .......
10.00
DC386
Biopsy .......
10.00
DC387
Tumor excision .......
25.00
DC388
Redundant tissue removal .......
25.00
DC389
Frenectomy .......
15.00
DC390
Cysts-soft tissue .......
10.00
DC391
Cysts-bone .......
25.00
DC392
Tuberosity reduction .......
10.00
DC393
Torus mandibularis removal .......
20.00
DC394
Torus palatinus removed .......
30.00
ENDODONTICS (Including radiographs but
					 exclusive of restoration)
DC410
Pulp capping .......
3.00
DC420
Vital pulpotomy .......
5.00
DC431
Single root canal filling .......
30.00
DC432
Double root canal filling .......
40.00
DC439
Anterior tooth; root canal filling with
					 apicoectomy and/or root-end amalgam .......
40.00
DC440
Apicoestomy (separate procedure) .......
10.00
DC441
Molar (3 or more canals) .......
50.00
OPERATIVE (RESTORATIVE) SERVICES
(Fees for fillings include excavations and
					 bases as necessary)
DC511
Silver amalgam-1 surface .......
3.00
DC512
Silver amalgam-2 surface .......
5.00
DC513
Silver amalgam-3 surface or more .......
5.00
DC514
Silver amalgam reinforcement pins-1st pin (to be
					 added to restoration cost) .......
3.00
DC515
-each additional pin .......
2.00
DC520
Silicate cement filling .......
3.00
DC531
Plastic Class III .......
3.00
DC532
Plastic Class IV .......
3.00
DC551
Cast gold-1 surface .......
6.00
DC552
Cast gold-2 surface .......
10.00
DC553
Cast gold-3 surface .......
12.00
DC554
Gold foil .......
7.00
DC555
Inlays, porcelain .......
10.00
CROWN AND BRIDGE
DC610
Acrylic jacket (quick cure) .......
10.00
DC611
Acrylic or vinyl jacket crown .......
25.00
DC614
Porcelain jacket crown .......
25.00
DC617
Acrylic veneer jacket crown .......
35.00
DC618
Porcelain veneer jacket crown .......
60.00
DC619
Cast gold full crown .......
35.00
DC620
Gold band crown with cast occlusal .......
30.00
DC622
3/4 cast gold crown .......
30.00
DC624
Crowns, stainless steel-primary or permanent tooth
					 .......
10.00
DC625
Pontics: Cast gold (sanitary) .......
25.00
DC626
Steele's facing .......
30.00
DC627
Tru-pontic type .......
30.00
DC628
Plastic processed to gold .......
30.00
DC629
Gold dowel and core for porcelain or acrylic
					 jacket crown .......
10.00
DC642
Recementing crown .......
5.00
DC643
Recementing fixed bridge .......
10.00
DC651
Replacing facing (slot or tube) .......
10.00
DC658
Space maintainer .......
20.00
PROSTHETICS
DC711
Full upper acrylic denture including necessary
					 adjustments .......
75.00
DC712
Full lower acrylic denture including necessary
					 adjustments .......
75.00
DC713
Immediate denture including chairside
					 relines-including necessary adjustments .......
80.00
DC722
Partial acrylic denture, upper or lower, including
					 teeth and 2 clasps with rests .......
50.00
DC727
Cast chrome partial-two clasps, acrylic saddle
					 (acrylic base) .......
115.00
DC728
Wrought lingual bar-2 wrought clasps acrylic
					 saddle .......
75.00
DC731
Each additional clasp with rest .......
10.00
DC732
Each additional wrought clasp .......
10.00
DC743
Denture repair-no teeth .......
7.00
DC744
Denture repair replacing one tooth .......
9.00
DC745
Replacing each additional tooth .......
3.00
DC746
Replacing broken tooth-no other repair .......
5.00
DC748
Add tooth to partial replacing extracted tooth
					 .......
15.00
DC751
Replacing undamaged clasp on partial .......
10.00
DC752
Replacing broken clasp with new clasp .......
25.00
DC753
Rebasing upper lower, full denture .......
25.00
DC754
Rebasing upper or lower, partial .......
25.00
DC757
Duplicating denture, full or partial .......
40.00
MISCELLANEOUS SERVICES
DC910
Palliative treatment of dental pain (in clinic
					 during clinic hours) .......
3.00
DC923
Anesthesia-general in clinic, by qualified person
					 other than operating dentist, 1st hour .......
5.00
DC924
each additional 30 minutes .......
5.00
DC926
Temporomandibular joint-history and and clinical
					 exam .......
5.00
(All injectables are to be reimbursed at
					 cost.)
(c)
Maximum reimbursable fees payable
			 to qualified dentists for dental services provided on a per session basis in
			 organized clinics of hospitals possessing valid operating certificates issued
			 by the New York State Department of Health.
Practitioners who receive compensation from the facility
			   for providing health services shall be ineligible for additional payment. The
			   fees listed below shall be prorated in accordance with the ratio of medical
			   assistance recipients to the total number of patients seen during a clinic
			   session. The fees listed below shall not apply to services provided in dental
			   school clinics nor to care provided in independent, out-of-hospital facilities.
			   The fees listed in this subdivision shall apply to services rendered on and
			   after August 1, 1969.
Nonspecialists
Clinic
					   session
D950
Three-hour session
$28.00
D951
Each additional hour, per hour
5.60
Shorter clinic
					   session
(less than three hours)
D953
One-hour session
12.00
D954
Two-hour session
20.00
Specialists
Clinic
					   session
D960
Three-hour session
40.00
D961
Each additional hour, per hour
8.00
Shorter clinic
					   session
(less than three hours)
D963
One-hour session
16.00
D964
Two-hour session
28.00
Footnotes
* Prior approval required except in emergency.
** Prior approval required in some cases (See regulations
			   or guidelines)