maryland medicaid dental fee schedule and procedure codes cdt 2011

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Code Description of CDT code FeeD2954 Prefab post and core in addition to crown 70D2955 Post removal, not in conjunction with endo therapy 25 PAD2960 Labial veneer (laminate) bonding 81D2961 Labial veneer (resin laminate) lab 81D2962 Labial veneer (porcelain laminate) lab 108D2970 Temporary crown 75D2980 Crown repair 93 BRD3000-D3999 EndodonticsPulp cappingD3110 Pulp cap direct (excluding final restoration) 15D3120 Pulp cap indirect (excluding final restoration) 15PulpotomyD3220 Therapeutic pulpotomy (excluding final restoration) 60D3221 Pupal debridement, primary and permanent teeth (not to be 70used by provider completing endodontic treatment)Endodontic Therapy on Primary TeethD3230 Pulpal therapy anterior primary tooth 96D3240 Pulpal therapy posterior primary tooth 115Endodontic Therapy (includes treatment plan, procedure and follow-up)D3310 endodontic therapy, anterior tooth (excluding final restoration) 230D3320 endodontic therapy, bicuspid (excluding final restoration) 280D3330 endodontic therapy, molar (excluding final restoration) 325Endodontic RetreatmentD3346* Retreatment of prior root canal, anterior 230 PAD3347* Retreatment of prior root canal, bicuspid 280 PAD3348* Retreatment of prior root canal, molar 325 PA* Not covered when service is provided by the same provider or an associate within two years of original service.Apexification/Recalcification ProceduresD3351 Apexification /recalcification initial visit 108D3352 Apexification /recalcification interim visit 67D3353 Apexification /recalcification final visit 67Apicometomy/Periradicular ServicesD3410 Surgery, anterior 108 PAD3421 Surgery, bicuspid 118 PAD3425 Surgery, molar 128 PAD3426 Surgery, each additional root 81 PAD3430 Retrograde filling per root 24 PAD3450 Root amputation per root 81D3470 Intentional reimplantation (includes splinting) 275
Code Description of CDT code FeeOther Endodontic ProceduresD3920 Hemisection (includes root removal) 27D4210-D4999 PeriodonticsSurgical Services, includes usual postoperative careD4210 Gingivectomy or gingivoplasty, four or more contiguous teeth 108 PAor tooth bounded spaces per quadrantD4211 Gingivectomy or gingivoplasty, one to three contiguous teeth 25 PAor tooth bounded spaces per quadrantD4230 Anatomical crown exposure, four or more contiguous 108 PAteeth per quadrantD4231 Anatomical crown exposure, one to three teeth 25 PAper quadrantD4240 Gingival flap procedure, includes root planning four or more 63 PAcontiguous teeth or tooth bounded spaces per quadrantD4241 Gingival flap procedure, includes root planning one to three 75 PAcontiguous teeth or tooth bounded spaces per quadrantD4249 Clinical crown lengthening, hard tissue 150 PAD4260 Osseous surgery, includes flap entry and closure, four or 108 PAmore contiguous teeth or tooth bounded spaces per quadrantD4261 Osseous surgery, includes flap entry and closure, one to 150 PAthree contiguous teeth or tooth bounded spaces per quadrantNon-Surgical Periodontal ServiceD4320 Provisional splint, intracoronal 90 PAD4321 Provisional splint, extracoronal 100 PAD4341 Peridontal scaling and root planing, four or more teeth, 75 PAper quadrantD4342 Peridontal scaling and root planing, one to three teeth, 54 PAper quadrantD4355 Full mouth debridement to enable comprhensive evaluation 100and diagnosisOther Periodontal ServicesD4910 Periodontal maintenance 54D4920 Unscheduled dressing change by another dentist 24 PAD5000-D5999 Prosthodontics (removable)Complete dentures (includes routine post delivery care)D5110 Complete maxillary 375 PAD5120 Complete mandibular 375 PA
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maryland medicaid dental fee schedule and procedure codes cdt 2011

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