13 Dental Fee Schedule

The Industrial Commission has a special bill form for use by dentists. All dentists rendering treatment to Workers’ Compensation claimants must prepare a full itemized statement of services rendered on I.C. Form No.25D, sign the form at the place indicated, and forward two copies to the employer or insurance carrier. The dentist should charge for each service rendered the charge he customarily makes for the same service to the public generally, but not to exceed those set forth below. Procedures not listed below are by report.

Whenever a dentist’s fees exceed those listed herein, complete written additional information must be furnished in order to justify any additional approval.

 

00100-00999 I. Diagnostic

CLINICAL ORAL EXAMINATIONS

ADA Code Description Allowance
00110 Initial oral examination $48.00
00120 Periodic oral examination $48.00
00130 Emergency oral examination $90.50
00140 Limited oral examination $32.00
00150 Comprehensive Oral Evaluation $48.00
00160 Detailed oral examination $90.00

 

RADIOGRAPHS

ADA Code Description Allowance
00210 Intraoral—complete series agents (including bitewings), by report $85.00
00220 Intraoral—periapical—first film $15.00
00230 Intraoral—periapical each additional film $12.00
00240 Intraoral—occlusal film $16.00
00250 Extraoral—first film $66.00
00260 Extraoral—each additional film $66.00
00270 Bitewings—single film $15.00
00272 Bitewings—two films $27.00
00274 Bitewings—four films $35.00
00290 Posterior—anterior or lateral skull and facial bone survey film $66.00
00310 Sialography $184.00
00320 Temporomandibular joint arthrogram, including injection $25.00
00321 Other temporomandibular joint films $82.00
00322 Tomographic survey BR
00330 Panoramic film $66.00
00340 Cephalometric film $66.00

 

TESTS AND LABORATORY EXAMINATIONS

ADA Code Description Allowance
00415 Bacteriologic studies for determination of pathologic agents $26.00
00425 Caries susceptibility tests $30.00
00460 Pulp vitality tests $35.00
00470 Diagnostic casts $52.00
00471 Diagnostic photographs $41.00
00501 Histopathologic examinations $80.00
00502 Other oral pathology procedures, by report $35.00
00999 Unspecified diagnostic procedure, by report BR

 

01000-01999 II. PREVENTATIVE

DENTAL PROPHYLAXIS

ADA Code Description Allowance
01110 Prophylaxis—adult $48.00
01120 Prophylaxis—child $34.00

 

TOPICAL FLUORIDE TREATMENT (OFFICE PROCEDURE)

ADA Code Description Allowance
01201 Topical application of fluoride (including prophylaxis)—child $50.00
01203 Topical application of fluoride (excluding prophylaxis)—child $16.00
01204 Topical application of fluoride (excluding prophylaxis)—adult $18.00
01205 Topical application of fluoride (including prophylaxis)—adult $64.00

 

OTHER PREVENTATIVE SERVICES

ADA Code Description Allowance
01310 Nutritional counseling for the control of dental disease $30.00
01330 Oral hygiene instruction $30.00
01351 Sealant—per tooth $32.00

 

SPACE MAINTENANCE (PASSIVE APPLIANCES)

ADA Code Description Allowance
01510 Space maintainer—fixed unilateral $237.00
01515 Space maintainer—fixed bilateral $380.00
01520 Space maintainer—removable unilateral $279.00
01525 Space maintainer—removable bilateral $197.00
01550 Recommendation. of space maintainer $33.00

 

02000-02999 III. RESTORATIVE

AMALGAM RESTORATIONS (INCLUDING POLISHING)

ADA Code Description Allowance
02110 Amalgam—one surface, primary $62.00
02120 Amalgam—two surfaces, primary $82.00
02130 Amalgam—three surfaces, primary $97.00
02131 Amalgam—four or more surfaces, primary $121.00
02140 Amalgam—one surface, permanent $73.00
02150 Amalgam—two surfaces, permanent $88.00
02160 Amalgam—three surfaces, permanent $102.00
02161 Amalgam—four or more surfaces, permanent $132.00

 

SILICATE RESTORATIONS

ADA Code Description Allowance
02210 Silicate cement—per restoration $46.00

 

RESIN RESTORATIONS

ADA Code Description Allowance
02330 Resin—one surface, anterior $75.00
02331 Resin—two surfaces, anterior $92.00
02332 Resin—three surfaces, anterior $109.00
02335 Resin—four or more surfaces or involving incisal angle, anterior $132.00
02336 Composite resin crown anterior—primary $125.00
02380 Resin—one surface, posterior—primary $78.00
02381 Resin—two surfaces, posterior—primary $113.00
02382 Resin—three or more surfaces, posterior—primary $151.00
02385 Resin—one surface, posterior—permanent $93.00
02386 Resin—two surfaces, posterior—permanent $124.00
02387 Resin—three or more surfaces, posterior—permanent $172.00

 

GOLD FOIL RESTORATIONS

ADA Code Description Allowance
02410 Gold foil—one surface BR
02420 Gold foil—two surfaces BR
02430 Gold foil—three surfaces BR

 

INLAY RESTORATIONS

ADA Code Description Allowance
02510 Inlay—metallic—one surface $382.00
02520 Inlay—metallic—two surfaces $442.00
02530 Inlay—metallic—three surfaces $492.00
02540 Onlay—metallic—per tooth (in addition to inlay) $592.00
02543 Onlay—metallic—three surface $594.00
02544 Onlay—metallic—four surface $612.00
02610 Inlay—porcelain/ceramic—one surface $357.00
02620 Inlay—porcelain/ceramic—two surfaces $412.00
02630 Inlay—porcelain/ceramic—three surfaces $495.00
02640 Onlay—porcelain/ceramic—per tooth ( in addition to inlay) BR
02650 Inlay—composite/resin—one surface (laboratory processed) BR
02651 Inlay—composite/resin—two surfaces (laboratory processed) BR
02652 Inlay—composite/resin—three surfaces (laboratory processed) BR
02660 Onlay—composite/resin—per tooth ( in addition to inlay laboratory processed) BR

 

CROWNS—SINGLE RESTORATION ONLY

ADA Code Description Allowance
02710 Crown—resin (laboratory) $145.00
02720 Crown—resin with high noble metal $504.00
02721 Crown—resin with predominantly base metal $504.00
02722 Crown—resin with noble metal $504.00
02740 Crown—porcelain/ceramic substrate $742.00
02750 Crown—porcelain fused to high noble metal $708.00
02751 Crown—porcelain fused to predominantly base metal $504.00
02752 Crown—porcelain fused to noble metal $504.00
02790 Crown—full cast high noble metal $654.00
02791 Crown—full cast predominantly base metal $504.00
02810 Crown—3/4 cast metallic $654.00

 

OTHER RESTORATIVE SERVICES

ADA Code Description Allowance
02910 Recement inlay $76.00
02920 Recement crown $76.00
02930 Prefabricated stainless steel crown—primary tooth $135.00
02931 Prefabricated stainless steel crown—permanent tooth $172.00
02932 Prefabricated resin crown $172.00
02933 Prefabricated stainless steel crown with resin window $189.00
02940 Sedative filling $76.00
02950 Core buildup, including any pins $142.00
02951 Pin retention—per tooth, in addition to restoration $41.00
02952 Cast post and core in addition to crown $247.00
02954 Prefabricated post and core in addition to crown $154.00
02960 Labial veneer (laminate) chairside $150.00
02961 Labial veneer (laminate) laboratory BR
02962 Labial veneer (resin laminate) laboratory $542.00
02970 Temporary crown (fractured tooth) $137.00
02980 Crown repair, by report BR
02999 Unspecified restorative procedure, by report BR

 

03000-03999 IV. ENDODONTICS

PULP CAPPING

ADA Code Description Allowance
03110 Pulp cap—direct (excluding final restoration) $36.00
03120 Pulp cap—indirect (excluding final restoration) $42.00

 

PULPOTOMY

ADA Code Description Allowance
03220 Therapeutic pulpotomy (excluding final restoration) Root canal therapy (including treatment plan, clinical procedures, and follow-up care) $121.00
03310 Anterior (excluding final restoration) $322.00
03320 Bicuspid (excluding final restoration) $424.00
03330 Molar (excluding final restoration) $572.00
03346 Retreatment—anterior $432.00
03347 Retreatment—bicusbid $562.00
03348 Retreatment—molar $642.00
03351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $162.00
03352 Apexification/recalcification interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) $110.00
03353 Apexification/recalcification final visit (includes completed root canal therapy—apical closure/calcific repair of perforations, root resorption, etc.) $432.00

 

PERIAPICAL SERVICES

ADA Code Description Allowance
03410 Apicoectomy/Periradicular surgery—anterior $632.00
03421 Apicoectomy/Periradicular surgery—bicuspid (first root) $660.00
03425 Apicoectomy/Periradicular surgery—molar (first root) $740.00
03426 Apicoectomy/Periradicular surgery (each additional root) BR
03430 Retrograde filling—per root $82.00
03450 Root amputation—per root $210.00
03460 Endodontic endosseous implant BR
03470 Intentional replantation (including necessary splinting) BR

 

OTHER ENDODONTIC PROCEDURES

ADA Code Description Allowance
03910 Surgical procedure for isolation of tooth with rubber dam $126.00
03920 Hemisection (including any root removal), not including root canal therapy $210.00
03950 Canal preparation and fitting of preformed dowel or post BR
03960 Bleaching of discolored tooth $210.00
03999 Unspecified endodontic procedure BR

 

04000-04999 V. PERIODONTICS

SURGICAL SERVICES (INCLUDING USUAL POSTOPERATIVE SERVICES)

ADA Code Description Allowance
04210 Gingivectomy or gingivoplasty—per quadrant $372.00
04211 Gingivectomy or gingivoplasty—per tooth $61.00
04220 Gingival cuterrage, surgical, per quadrant, by report $210.00
04240 Gingival flap procedure, including root planing—per quadrant $372.00
04249 Crown lengthening—hard and soft tissue, by report $272.00
04250 Mucogingival surgery—per quadrant BR
04260 Osseous surgery (including flap entry and closure)—per quadrant $472.00
04261 Bone replacement graft—single site (including flap entry and closure) $272.00
04262 Bone replacement graft multiple sites (including flap entry and closure) BR
04268 Guided tissue regeneration (includes the surgery and reentry) BR
04270 Pedicle soft tissue graft procedure BR
04271 Free soft tissue graft procedure (including donor site) BR

 

ADJUNCTIVE PERIODONTAL SERVICES

ADA Code Description Allowance
04320 Provisional splinting—intracoronal BR
04321 Provisional splinting—extracoronal $124.00
04341 Periodontal scaling and root planing—per quadrant $135.00
04345 Periodontal scaling performed in the presence of gingival inflammation BR
04381 Periodontal scaling per tooth $48.00

 

OTHER PERIODONTAL SERVICES

ADA Code Description Allowance
04910 Periodontal maintenance procedures (following active therapy) $72.00
04920 Unscheduled dressing change (by someone other than treating dentist) BR
04999 Unspecified periodontal procedure, by report BR

 

05000-05899 VI. PROSTHODONTICS (REMOVABLE)

COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE)

ADA Code Description Allowance
05110 Complete upper $810.00
05120 Complete lower $810.00
05130 Immediate upper $810.00
05140 Immediate lower $810.00

 

PARTIAL DENTURES (INCLUDING ROUTINE POSTDELIVERY CARE)

ADA Code Description Allowance
05211 Upper partial—resin base (including any conventional clasps, rests and teeth) $424.00
05212 Lower partial—resin base (including any conventional clasps, rests and teeth) $424.00
05213 Upper partial—cast metal base with resin saddles (including any conventional clasps, rests and teeth) $950.00
05214 Lower partial—cast metal base with resin saddles (including any conventional clasps, rests and teeth $950.00
05281 Removable unilateral partial denture—one piece cast metal, (including clasps and pontics) $950.00
No code Upper precision—partial, fitted to crowns $1275.00
No code Lower precision—partial, fitted to crowns $1275.00

 

ADJUSTMENTS TO REMOVABLE PROSTHESES

ADA Code Description Allowance
05410 Adjust complete denture—upper $39.00
05411 Adjust complete denture—lower $39.00
05421 Adjust partial denture—upper $39.00
05422 Adjust partial denture—lower $39.00

 

REPAIRS TO COMPLETE DENTURES

ADA Code Description Allowance
05510 Repair broken complete denture base $132.00
05520 Replace missing or broken teeth—complete denture (each tooth) $124.00

 

REPAIRS TO PARTIAL DENTURES

ADA Code Description Allowance
05610 Repair resin saddle or base $124.00
05620 Repair cast framework $212.00
05630 Repair or replace broken clasp $210.00
05640 Replace broken teeth—per tooth $104.00
05650 Add tooth to existing partial denture $132.00
05660 Add clasp to existing partial denture $232.00

 

DENTURE REBASE PROCEDURES

ADA Code Description Allowance
05710 Rebase complete upper denture $272.00
05711 Rebase complete lower denture $272.00
05720 Rebase upper partial denture $242.00
05721 Rebase lower partial denture $242.00

 

DENTURE RELINE PROCEDURES

ADA Code Description Allowance
05730 Reline complete upper denture (chairside) $139.00
05731 $Reline complete lower denture (chairside) $139.00
05740 Reline upper partial denture (chairside) $139.00
05741 Reline lower partial denture (chairside) $139.00
05750 Reline complete upper denture (laboratory) $236.00
05751 Reline complete lower denture (laboratory) $236.00
05760 Reline upper partial denture (laboratory) $236.00
05761 Reline lower partial denture (laboratory) $236.00

 

OTHER REMOVABLE PROSTHETIC SERVICES

ADA Code Description Allowance
05810 Interim complete denture (upper) $450.00
05811 Interim complete denture (lower) $450.00
05820 Interim partial denture (upper) $450.00
05821 Interim partial denture (lower) $450.00
05850 Tissue conditioning, upper—per denture unit $72.00
05851 Tissue conditioning, lower—per denture unit $72.00
05860 Overdenture—complete $1050.00
05861 Overdenture—partial BR
05862 Precision attachment $286.00
05899 Unspecified removable prosthodontic procedure BR

 

05900-05999 VII. MAXILLOFACIAL PROSTHETICS

MAXILLOFACIAL PROSTHETICS

ADA Code Description Allowance
05911 Facial moulage (sectional) BR
05912 Facial moulage (complete) BR
05913 Nasal prosthesis $1455.00
05914 Auricular prosthesis $1698.00
05915 Orbital prosthesis $2183.00
05916 Ocular prosthesis $1455.00
05919 Facial prosthesis $728.00
05922 Nasal septal prosthesis BR
05923 Ocular prosthesis, interim BR
05924 Cranial prosthesis BR
05925 Facial augmentation implant prosthesis BR
05926 Nasal prosthesis, replacement BR
05927 Auricular prosthesis, replacement BR
05928 Orbital prosthesis, replacement BR
05929 Facial prosthesis, replacement BR
05931 Obturator prosthesis, surgical $728.00
05932 Obturator prosthesis, definitive $2183.00
05933 Obturator prosthesis, modification $509.00
05934 Mandibular resection prosthesis with guide flange $1698.00
05935 Mandibular resection prosthesis with guide flange $1698.00
05936 Obturator prosthesis, interim BR
05937 Trismus appliance (not for TMD treatment) BR
05951 Feeding Aid $728.00
05952 Speech aid prosthesis, pediatric $1698.00
05953 Speech aid prosthesis, adult $2183.00
05954 Palatal augmentation prosthesis $2183.00
05955 Palatal lift prosthesis, modification $2183.00
05958 Palatal lift prosthesis, interim BR
05959 Palatal lift prosthesis, modification BR
05960 Speech aid prosthesis, modification BR
05982 Surgical stent $1091.00
05983 Radiation carrier $1698.00
05984 Radiation shield $1091.00
05985 Radiation cone locator $1091.00
05986 Fluoride gel carrier $72.00
05987 Commissure splint BR
05988 Surgical splint BR
05999 Unspecified maxillofacial prosthesis BR

 

06000-061999 VIII. IMPLANT SERVICES

ADA Code Description Allowance
06030 Endosseous implant (in the bone) BR
06040 Subperiosteal implant BR
06050 Transosseous implant BR
06055 Implant connecting bar BR
06080 Implant maintenance procedures, including; removal of prosthesis, cleansing of prosthesis and abutments, reinsertion of prosthesis BR
06090 Repair implant BR
06100 Impant removal BR
06199 Unspecified implant procedure, by report BR

 

06200-06999 IX. PROSTHODONTICS, FIXED (EACH ABUTMENT AND EACH PONTIC CONSTITUTE A UNIT IN A BRIDGE)

BRIDGE PONTICS

ADA Code Description Allowance
06210 Pontic—cast high noble metal $672.00
06211 Pontic—cast predominantly base metal $642.00
06212 Pontic—cast noble metal $672.00
06240 Pontic—porcelain fused to high noble metal $672.00
06241 Pontic—porcelain fused to predominantly base metal $642.00
06242 Pontic—porcelain fused to noble metal $672.00
06250 Pontic—resin with high noble metal $504.00
06251 Pontic—resin with predominantly base metal $504.00
06252 Pontic—resin with noble metal $504.00

 

RETAINERS

ADA Code Description Allowance
06520 Inlay—metallic—two surfaces $504.00
06530 Inlay—metallic—three or more surfaces $572.00
06540 Onlay—metallic—per tooth (in addition to inlay) BR
06545 Retainer—cast metal for acid etched fixed prosthesis $324.00

 

BRIDGE RETAINERS—CROWNS

ADA Code Description Allowance
06720 Crown—resin with high noble metal $504.00
06721 Crown—resin with predominantly base metal $504.00
06722 Crown—resin with noble metal $504.00
06750 Crown—porcelain fused to high noble metal $672.00
06751 Crown—porcelain fused to predominantly base metal $672.00
06752 Crown—porcelain fused to noble metal $672.00
06780 Crown—3/4 cast noble metal $672.00
06790 Crown—full cast high noble metal $672.00
06791 Crown—full cast predominantly base metal $642.00
06792 Crown—full cast noble metal $672.00

 

OTHER FIXED PROSTHETIC SERVICES

ADA Code Description Allowance
06930 Recement bridge $105.00
06940 Stress breaker $145.00
06950 Precision attachment $286.00
06970 Cast post and core in addition to bridge retainer $247.00
06971 Cast post as part of bridge retainer $82.50
06972 Prefabricated post and core in addition to bridge retainer $154.00
06973 Core build up for retainer, including any pins $142.00
06975 Coping—metal BR
06980 Bridge repair, by report BR
06999 Unspecified fixed prosthetic procedure, by report BR

 

07000-07999 X. ORAL SURGERY

EXTRACTIONS—INCLUDES LOCAL ANESTHESIA AND ROUTINE POSTOPERATIVE CARE

ADA Code Description Allowance
07110 Single tooth $110.00
07120 Each additional tooth $110.00
07130 Root removal—exposed roots $72.00

 

SURGICAL EXTRACTIONS—INCLUDES LOCAL ANETHESIA AND ROUTINE POSTOPERATIVE CARE

ADA Code Description Allowance
07210 Surgical removal of erupted tooth requiring elevation of mucoperisteal flap and removal of bone and/or section of tooth $132.00
07220 Removal of impacted tooth soft tissue $142.00
07230 Removal of impacted tooth partially bony $210.00
07240 Removal of impacted tooth completely bony $242.00
07241 Removal of impacted tooth completely bony, with unusual surgical complications $128.50
07250 Surgical removal of residual tooth roots (cutting procedure) $61.50

 

OTHER SURGICAL PROCEDURES

ADA Code Description Allowance
07260 Oral antral fistula closure 128.50
07270 Tooth reimplantation and/or stabilization of accidental evulsed or displaced tooth and/or alveolus $382.00
07271 Tooth implantation BR
07272 Tooth Transplantation BR
07280 Surgical exposure of impacted tooth or unerupted tooth for othodontic reasons (including orthodontic attachments) $310.00
07281 Surgical exposure of impacted or unerupted tooth to aid eruption $210.00
07285 Biopsy of oral tissue—hard $101.50
07286 Biopsy of oral tissue—soft $101.50
07290 Surgical repositioning of teeth BR
07291 Transseptal fiberotomy $110.00

 

ALVEOPLASTY—SURGICAL PREPARATION OF RIDGE FOR DENTURES

ADA Code Description Allowance
07310 Alveoplasty in conjuction with extractions—per quadrant $82.00
07320 Alveoplasty not in conjunction with extractions—per quadrant $210.00

 

VESTIBULOPLASTY

ADA Code Description Allowance
07340 Vestibuloplasty—ridge extention (secondary epithelialization) BR
07350 Vestibuloplasty—ridge extention (including soft tissue grafts, muscle reattachments, revision of soft tissue attachments, and management of hypertrophied and hyperplastic tissue) BR

 

SURGICAL EXCISION OF REACTIVE INFLAMMITORY LESIONS (SCAR TISSUE OR LOCALIZED CONGENITAL LESIONS)

ADA Code Description Allowance
07410 Radical excision—lesion diameter up to 1.25 cm $82.50
07420 Radical excision—lesion diameter greater than 1.25 cm $154.00

 

REMOVAL OF TUMORS, CYSTS AND NEOPLASMS

ADA Code Description Allowance
07430 Excision of benign tumor—lesion diameter up to 1.25 cm BR
07431 Excision of benign tumor—lesion diameter greater than 1.25 cm BR
07440 Excision of malignant tumor—lesion diameter up to 1.25 cm BR
07441 Excision of malignant tumor—lesion greater than 1.25 cm BR
07450 Removal of odontogenic cyst or tumor—lesion diameter up to 1.25 cm BR
07451 Removal of odontogenic cyst or tumor—lesion greater than 1.25 cm $159.50
07460 Removal of nonodontogenic cyst or tumor—lesion up to 1.25 cm $148.50
07461 Removal of nonodontagenic cyst or tumor—lesion greater than 1.25 cm $148.50
07465 Destruction of lesion(s) by physical or chemical method BR

 

EXCISION OF BONE TISSUE

ADA Code Description Allowance
07470 Removal of exostosis—maxilla or mandible $310.00
07480 Partial ostectomy (guttering or saucerization) $168.50
07490 Radical resection of mandible with bone graft BR

 

SURGICAL INCISION

ADA Code Description Allowance
07510 Incision and drainage of abscess—intraoral soft tissue $101.50
07520 Incision and drainage of abscess—extraoral soft tissue $101.50
07530 Removal of foreign body, skin, reduction with fixation and or subcutaneous areolar tissue $101.50
07540 Removal of reaction—producing foreign bodies—muscuoskeletal system BR
07550 Sequestrectomy for osteomyelitis BR
07560 Maxillary sinusotomy for removal of tooth fragment or foreign body BR

 

TREATMENT OF FRACTURES—SIMPLE

ADA Code Description Allowance
07610 Maxilla—open reduction (teeth immobilized if present BR
07620 Maxilla—closed reduction BR
07630 Mandible—open reduction BR
07640 Mandible—closed reduction BR
07650 Malar and/or zygomatic arch—open reduction BR
07660 Malar and/or zygomatic arch—closed reduction BR
07670 Alveolus—stabilization of teeth, open reduction BR
07680 Facial bones—complicated reduction with fixation and multiple surgical approaches BR

 

TREATMENT OF FRACTURES—COMPOUND

ADA Code Description Allowance
07710 Maxilla—open reduction BR
07720 Maxilla—closed reduction BR
07730 Mandible—open reduction BR
07740 Mandible—closed reduction BR
07750 Malar and/or zygomatic arch—open reduction BR
07760 Malar and/or zygomatic arch—closed reduction BR
07770 Alveolus—stabilization of teeth, open reduction splinting BR
07780 Facial bones—complicated reduction with fixation and multiple surgical approaches BR

 

TREATMENT OF FRACTURES—COMPOUND

ADA Code Description Allowance
07810 Open reduction of dislocation BR
07820 Closed reduction of dislocation BR
07830 Manipulation under anesthesia BR
07840 Condylectomy BR
07850 Surgical discectomy; with/without implant BR
07852 Disc repair BR
07854 Synovectomy BR
07856 Myotomy BR
07858 Joint reconstruction BR
07860 Arthrotomy BR
07865 Arthroplasty BR
07870 Arthrocentesis BR
07872 Arthroscopy—diagnosis, with or without biopsy BR
07873 Arthroscopy—surgical; lavage and lysis of adhesions BR
07874 Arthroscopy—surgical; disc repositioning and stabilization BR
07875 Arthroscopy—surgical, synovectomy BR
07876 Arthroscopy—surgical, discectomy BR
07877 Arthroscopy—surgical, debridement BR
07880 Occlusal orthotic device BR
07899 Unspecified TMD therapy BR

 

REPAIR OF TRAUMATIC WOUNDS

ADA Code Description Allowance
07910 Suture of recent small wounds up to 5 cm $325.00

 

COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE)

ADA Code Description Allowance
07911 Complicated suture—up to 5 cm $524.00
07912 Complicated suture—greater than 5 cm BR

 

OTHER REPAIR PROCEDURES

ADA Code Description Allowance
07920 Skin grafts (identify defect covered, location, and type of graft) BR
07940 Osteoplasty—for orthognathic deformities BR
07941 Osteotomy—ramus, closed BR
07942 Osteotomy—ramus, open BR
07943 Osteotomy—ramus, open with bone graft BR
07944 Osteotomy—segmented or subapical—per sextant or quadrant BR
07945 Osteotomy—body of mandible BR
07946 LeFort I (maxilla—total) BR
07947 LeFort I (maxilla—segmented) BR
07948 LeFort II of LeFort III (osteoplasty of facial bone for midface hyoplasia or retrusion)—without bone graft BR
07949 LeFort II or LeFort III—with bone graft BR
07950 Osseous, osteoperiosteal, periosteal, or cartilage graft of the mandible—autogenous or nonautogenous BR
07955 Repair of maxillofacial soft and hard tissue defects BR
07960 Frenulectomy (frenectomy or frenotomy) separate procedure BR
07970 Excision of hyperplastic tissue—per arch BR
07971 Excision of pericoronal gingiva BR
07980 Sialolithotomy $165.00
07981 Excision of salivary fistula BR
07982 Sialodochoplasty BR
07983 Closure of salivary fistula BR
07990 Emergency tracheotomy BR
07991 Coronoidectomy BR
07993 Impact—facial bones (homologous, heterologous, or alloplastic BR
07994 Impact—other than facial bones BR
07999 Unspecified oral surgery procedure BR

 

08000-08999 XI. 0RTHODONTICS

MINOR TREATMENT FOR TOOTH GUIDANCE

ADA Code Description Allowance
08110 Removable appliance therapy BR
08120 Fixed appliance therapy BR

 

MINOR TREATMENT TO CONTROL HARMFUL HABITS

ADA Code Description Allowance
08210 Removable appliance therapy $472.00
08220 Fixed appliance therapy $472.00

 

INTERCEPTIVE ORTHODONTIC TREATMENT

ADA Code Description Allowance
08360 Removable appliance therapy BR
08370 Fixed appliance therapy BR

 

COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION

ADA Code Description Allowance
08460 Class I malocclusion BR
08470 Class II malocclusion BR
08480 Class III malocclussion BR

 

COMPREHENSIVE ORTHODONTIC TREATMENT—PERMANENT DENTITION

ADA Code Description Allowance
08560 Class I malocclusion BR
08570 Class II malocclusion BR
08580 Class III malocclussion BR

 

OTHER ORTHODONTIC DEVICES

ADA Code Description Allowance
08650 Treatment for the atypical or extended skeletal case $450.00
08750 Posttreatment stabilization BR
08999 Unspecified orthodontic procedure BR

 

09000-09999 XII. ADJUNCTIVE GENERAL SERVICES

UNCLASSIFIED TREATMENT

ADA Code Description Allowance
09110 Palliative (emergency) treatmentof dental pain—minor procedures $46.00

 

ANESTHESIA

ADA Code Description Allowance
09210 Local anesthesia not in conjunction with operative or surgical procedures $42.00
09211 Regional block anesthesia BR
09212 Trigeminal division block anesthesia BR
09215 Local anesthesia $42.00
09220 General anesthesia—first 30 minutes BR
09221 General anesthesia—additional 15 minutes BR
09230 Analgesia BR
09240 Intravenous sedation BR

 

PROFESSIONAL CONSULTATION

ADA Code Description Former Allowance Allowance
09310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) $27.50 $42.00

 

PROFESSIONAL VISITS

ADA Code Description Former Allowance Allowance
09410 House call BR BR
09420 Hospital call $58.00 $58.00
09430 Office visit for observation (during regularly scheduled hours)—no other services performed $24.50 $24.50
09440 Office visit—after regularly schedule hours $48.50 $48.50

 

DRUGS

ADA Code Description Former Allowance Allowance
09610 Therapeutic drug injection BR BR
09630 Other drugs and/or medicaments BR BR

 

MISCELLANEOUS SERVICES

ADA Code Description Former Allowance Allowance
09910 Application of desensitizing medicaments $27.50 $35.00
09920 Behavior management BR BR
09930 Treatment of complication (post-surgical) unusual circumstances BR BR
09940 Occlusal guards $247.50 $310.00
09941 Fabrication of athletic mouthguards BR $110.00
09950 Occlusion analysis—mounted case BR $110.00
09951 Occlusion adjustment—limited $82.50 $82.50
09952 Occlusal adjustment—complete $220.00 $272.00
09999 Unspecified adjustive procedure BR BR

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N.C. Industrial Commission 4319 Mail Service Center Raleigh, NC 27699-4319
Main:  (919) 733-4820    Fax:  (919) 715-0282    BBS:  (919) 715-5920
Internet Address:  http://www.comp.state.nc.us/