New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 56 - MANUAL FOR DENTAL SERVICES
Subchapter 3 - HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
Section 10:56-3.6 - D4000 D4999 PERIODONTICS
Current through Register Vol. 56, No. 18, September 16, 2024
(a) Surgical services (including usual post-operative services):
| Maximum Fee | ||||||
| HCPCS | Allowance | |||||
| IND | Code | Mod | Procedure Description | S | $ | NS |
| # | D4210 | Gingivectomy or Gingivoplasty--Per | 43.60 | 37.50 | ||
| Quadrant | ||||||
| * | D4211 | Gingivectomy or Gingivoplasty--Per | 6.00 | 5.50 | ||
| Tooth | ||||||
NOTE 1: Maximum number of teeth reimbursable--Three.
NOTE 2: D4210 PA required only when exceeding four quadrants, twice annually.
| # | D4220 | Gingival Curettage, Surgical--Per | 22.50 | 19.50 |
| Quadrant | ||||
| # | D4260 | Osseous Surgery (including Flap | 75.00 | 64.50 |
| Entry and Closure)--Per Quadrant | ||||
| * | D4261 | Osseous, Single Site | 56.25 | 48.40 |
| * | D4263 | Bone Replacement Graft First Site | 261.00 | 261.00 |
| in Quadrant | ||||
| * | D4264 | Bone Replacement Graft--Each | 130.50 | 130.50 |
| Additional Site in Quadrant (Use | ||||
| if Performed on Same Date of | ||||
| Service) | ||||
| # | D4270 | Pedicle Soft Tissue Graft Procedure | 32.00 | 28.00 |
NOTE 1: Per site.
NOTE 2: D4220, D4260, D4261, D4270 PA required only for services exceeding four quadrants, twice annually.
| # | D4271 | Free Soft Tissue Graft Procedure | 49.00 | 42.00 |
| (Including Donor Site) |
NOTE: Per site.
| * | D4245 | Apically Positioned Flap | 36.00 | 31.50 |
NOTE: Per quadrant.
| * | D4249 | Clinical Crown Lengthening--Hard | 75.00 | 64.50 |
| Tissue |
NOTE: Per quadrant.
| * | D4274 | Distal or Proximal Wedge Procedure | 169.00 | 153.00 |
| (When Not Performed in Conjunction | ||||
| with Surgical Procedures in the | ||||
| same Anatomical Area) |
(b) Adjunctive periodontal services:
| D4320 | Provisional Splinting--Intracoronal | 18.00 | 16.00 |
NOTE: Per tooth.
| D4321 | Provisional Splinting--Extracoronal | 11.00 | 10.00 |
NOTE 1: Per tooth.
NOTE 2: This code may also be used for stabilization of traumatized teeth.
| # | D4341 | Periodontal Scaling and Root | 37.50 | 34.50 |
| Planing--Per Quadrant | ||||
| D4355 | Full Mouth Debridement to Enable | 11.00 | 10.00 | |
| Comprehensive Periodontal | ||||
| Evaluation and Diagnosis | ||||
| D4355 | 76 | Full Mouth Debridement to Enable | 11.00 | 10.00 |
| Comprehensive Periodontal | ||||
| Evaluation and Diagnosis |
NOTE 1: Code to replace Y2105-76--additional scaling.
NOTE 2: Code to be used when the beneficiary is developmentally disabled * [on]* *or* neurologically impaired (see 10:56-2.9(a)1 ii).
NOTE 3: D4341 PA required for services exceeding four quadrants, twice annually.
| d* | D4999 | Unspecified Periodontal Procedure, | BR | BR |
| By Report |
