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. 45, No. 52, December 27, 2023

[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)

Disclaimer: These regulations may not be the most recent version. New York may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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