18 CRR-NY 535.5NY-CRR
18 CRR-NY 535.5
18 CRR-NY 535.5
535.5 Maximum reimbursable dental fee schedules.
[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 | ¾ 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)
18 CRR-NY 535.5
Current through July 31, 2021
| End of Document |
IMPORTANT NOTE REGARDING CONTENT CURRENCY: JULY 31, 2023, is the date of the most recently produced official NYCRR supplement covering this rule section. For later updates to this section, if any, please: consult editions of the NYS Register published after this date; or contact the NYS Department of State Division of Admisnistrative Rules at [email protected]. See Help for additional information on the currency of this unofficial version of the NYS Rules.