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. 13, March 29, 2023

[Additional statutory authority: Social Services Law, §363-a ]

DIAGNOSTIC

Fee D011 Charting, history, oral examination and $ 5.00 completion of forms D012 Periodic recall examination (oral 5.00 checking)............ Radiographic D021 Complete intraoral series of 14 periapical films $ 15.00 and 2 bite-wing films............ D022 Intraoral periapical (first or single 2.00 film)............ D023 Each additional single film (periapical or 1.00 bite-wing)............ D024 Occlusal view x-ray............ 5.00 D025 Lateral jaw x-ray, each............ 10.00 [FN*] D027 Four bite-wing x-ray films............ 6.00 D028 First or single bite-wing film (use D023 for 2.00 add. films)............ D029* Antero-posterior x-ray of head and 10.00 jaws............ D030* Cephalometric examination............ 10.00 D033 Panoramic (panography)............ 12.50 D034 Panoramic x-rays, supplemented by three (3) or $ 15.00 more additional intraoral films (periapical and/or bitewing) necessary to establish an accurate diagnosis, maximum payment............ (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 6.00 fluoride............ PERIODONTICS D212* Subgingival curettage and root planning--per $ 10.00 quadrant (at least 5 teeth)............ D214 Incision and drainage of periodontal 8.00 abscess............ D215 Treatment for necrotizing ulcerative gingivitis 10.00 [FN**] (Vincent's infection) (incl. debridement and medication) per visit............ ORAL SURGERY D311 Extraction, uncomplicated, permanent tooth, $ 7.50 includes local anesthesia............ D312* Extraction, uncomplicated, each additional 6.90 permanent tooth at same session, in same quadrant, includes local anesthesia............ D313 Extraction, uncomplicated, deciduous tooth, 6.30 includes local anesthesia............ D314 Extraction, uncomplicated, each additional 5.00 deciduous tooth at same session, in same quadrant, includes local anesthesia............ D320 Extraction-surgical removal of erupted tooth, 15.00 includes local anesthesia............ D321 Each additional adjacent tooth surgically 7.50 removed during the same session............ D322* Extraction-odontectomy, impacted tooth, soft 15.00 tissue, includes local anesthesia............ D323 partially covered by bone--includes local 25.00 anesthesia............ D324* completely covered by bone--includes local 45.00 anesthesia............ D325* Extraction, removal of residual root covered by 15.00 bone, includes local anesthesia............ D326* Repair--surgical exposure of impacted tooth or 45.00 unerupted tooth--for orthodontic reasons including ligation, includes local anesthesia............ D331* Repair--Alveolectomy per jaw--includes local 25.00 anesthesia............ D360 Fracture, maxilla, simple or compound, no By reduction............ Report D361 Fracture, maxilla, simple open reduction with FOLLOW- 200.00 wiring of teeth and/or local UP DAYS fixation............ Anesthesia............ 90 16+T D362 Fracture, maxilla, simple closed reduction, with 120.00 wiring of teeth............ Anesthesia............ 90 16+T D363 Fracture, mandible, simple open reduction, with 200.00 or without wiring of teeth............ Anesthesia............ 90 16+T D364 Fracture, mandible, simple closed reduction and 120.00 wiring of teeth............ Anesthesia............ 90 16+T D365 Fracture, maxilla, complicated, open reduction, By fixation by headcap, multiple surgical Report approaches, internal fixation, wiring teeth, etc............. Anesthesia............ 90 24+T D369 Fracture, mandible, simple or compound, no By reduction............ Report D373* Repair--Osteoplasty (mandible, for prognathism 400.00 or mi-crognathism), one or two stages............ Anesthesia............ 90 20+T D374 Fracture, malar, simple or compound, no By reduction............ Report D375 Closed reduction (incl. towel clip 20.00 technique)............ Anesthesia............ 16+T D376 Depressed, open reduction............ 120.00 Anesthesia............ 60 16+T D377 Complicated, depressed, open reduction with 260.00 internal skeletal fixation and multiple surgical approaches............ Anesthesia............ 90 20+T D378 Fracture, mandible, skeletal pinning with 160.00 external fixation ............ Anesthesia............ 90 16+T D384 Incision and drainage of 10.00 abscess-Dento-alveolar............ D385 Infra-orbital, palatal, peri-coronal, $ 15.00 sub-maxillary, sublinqual, submental, masseteric, floor of mouth, others except periodontal ............

FN* Prior approval required except in emergency.

FN** 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 75.00 root-end amalgam............ 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 5.00 restoration cost)............ D515 --each additional pin............ 3.00 D520 Silicate cement filling--maximum payment two fillings per 7.00 tooth............ 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 20.00 tooth............ 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 165.00 necessary adjustments............ D722* Partial acrylic denture, upper or lower, including teeth and 110.00 two clasps with rests............ 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 16.30 acrylic............ D748 Add tooth to partial, replacing extracted tooth with welded 25.00 loop ............ D749* Partial acrylic denture, upper or lower, replacing one or two 75.00 anterior teeth, no clasps. (Flipper or Stayplate)--Use D745 for each additional tooth............ 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, 75.00 annual maximum payment............ D857* Observation not to exceed 6 visits per year at $6.25 per 37.50 visit, annual maximum payment............ 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 $ 5.00 hours)............ D911 Home visits 2/, by dentist per visit, regardless of number of 5.00 patients seen (to be added to fee services)............ D913 Hospital Visit 3/, by dentist per visit, regardless of number 5.00 of patients seen (to be added to fee for service)............ D923 Anesthesia--general in office, by qualified person other than 10.00 operating dentist, 1st hour............ each additional 30 minutes............ 5.00 D925 General Anesthesia for multiple extractions in hospital (basic 15.00 fee)............ 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 7.50 bite-wing films............ 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 5.00 teeth)............ DC214 Incision and drainage of periodontal abscess............ 5.00 DC215 Treatment for rectitizing ulcerative gingivitis (Vincent's 5.00 infection)(incl. debridement and medication) per visit............ 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 2.00 anesthesia............ DC312 Extraction-multiple removal of teeth, per tooth, includes 2.00 local anesthesia............ DC321 Extraction--surgical removal of erupted tooth, includes local 3.00 anesthesia............ DC322 Extraction--odontectomy, impacted tooth, soft tissue, includes 10.00 local anesthesia............ DC323 partially covered by bone--includes local 15.00 anesthesia............ DC324 completely covered by bone--includes local 25.00 anesthesia............ DC325 Extraction--removal of residual root covered by bone, includes 10.00 local anesthesia............ DC326 Repair--surgical exposure of impacted tooth or unerupted 10.00 tooth--for orthodontic reasons including ligation, includes local anesthesia............ DC331 Repair-alveolectomy per jaw-includes local 10.00 anesthesia............ DC360 Fracture, maxilla, simple or compound no reduction............ by report DC361 Fracture, maxilla, simple open reduction, with wiring of teeth 100.00 and/or local fixation............ DC362 Fracture, maxilla, simple closed reduction, with wiring of 75.00 teeth ............ DC363 Fracture, mandible, simple open reduction, with or without 100.00 wiring of teeth............ DC364 Fracture, mandible, simple closed reduction and wiring of 75.00 teeth ............ DC365 Fracture, maxilla, complicated, open reduction, fixation by by head cap, multiple surgical approaches, internal fixation report wiring teeth, etc............ DC369 Fracture, mandible, simple or compound, no by reduction............ report DC373 Repair-osteoplasty (mandible, for prognathism or 200.00 micrognathism), one or two stages............ 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 130.00 fixation and multiple surgical approaches............ 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, 10.00 submental. masseteric. floor of mouth, others except periodontal ............ 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 40.00 root-end amalgam............ 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 3.00 restoration cost)............ 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 10.00 tooth............ 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 80.00 necessary adjustments............ DC722 Partial acrylic denture, upper or lower, including teeth and 2 50.00 clasps with rests............ DC727 Cast chrome partial--two clasps, acrylic saddle (acrylic 115.00 base)............ 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 3.00 hours)............ DC923 Anesthesia--general in clinic, by qualified person other than 5.00 operating dentist, 1st hour............ 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.)