ARM 24.29.1551. DENTAL SPECIALTY AREA FEES

(1) Fees for dental medical specialty area services are payable only for the procedure codes listed in subsection (4), below, according to the unit values listed. None of the procedure codes, descriptions, or unit values in Relative Values for Physicians apply to dental services. (2) Nothing in this rule is to be construed so as to broaden the scope of a provider's practice. Each provider is to limit their services to those which can be performed within the limits and restrictions of the provider's professional licensure. Providers may only charge for services performed that are consistent with the scope of their practice and licensure. (3) The conversion factor used depends on the date the service was rendered: (a) Effective April 1, 1993, the conversion factor for dental specialty area services, procedure codes D0110 through D9960 is $7.27. (b) Effective January 1, 1994, and each year annually thereafter, the conversion factor will increase in the manner specified by ARM 24.29.1536 . (4) Effective April 1, 1993, the following schedule of procedure codes, with the associated description and unit values, are recognized for the dental service areas: (a) Procedure Code Description Unit Value D0110 Initial oral examination 1.8 D0120 Periodic oral examination 2.0 D0130 Emergency oral examination 2.1 (b) D0210 Intraoral--complete series 5.2 D0220 Intraoral--periapical, first film 0.9 D0230 Intraoral--periapical, each additional film 0.7 D0272 Bitewings--two films 1.6 D0274 Bitewings--four films 2.1 (c) D0321 Other temporomandibular joint films BR D0330 Panoramic film 4.7 D0340 Cephalometric film 5.2 (d) D0460 Pulp vitality tests 1.4 D0470 Diagnostic casts 4.1 D0471 Diagnostic photographs 2.4 (e) D1110 Prophylaxis--adult 4.1 (f) D2140 Amalgam--one surface, permanent 4.4 D2150 Amalgam--two surfaces, permanent 4.5 D2160 Amalgam--three surf., permanent 9.4 D2161 Amalgam--four or more surf., perm. 8.2 (g) D2330 Resin--one surface 4.5 D2331 Resin--two surfaces 7.1 D2332 Resin--three surfaces 8.1 D2335 Resin--four or more surfaces or involving incisal angle 10.6 (h) D2740 Crown--porcelain/ceramic substrate 45.8 D2750 Crown--single restoration only--porcelain fused to high noble metal 42.3 D2751 Crown--single restoration only--porcelain fused to predominantly base metal 44.1 D2752 Crown--single restoration only--porcelain fused to noble metal 45.7 D2790 Crown--full cast high noble metal 41.4 (i) D2810 Crown--3/4 cast metallic 41.1 (j) D2950 Crown build-up, including any pins 6.3 D2951 Pin retention--per tooth, in addition to restoration 0.9 D2952 Cast post and core in addition to crown 14.8 D2954 Prefabricated post and core in addition to crown 8.7 D2970 Temporary (fractured tooth) 5.0 (k) D3220 Therapeutic pulpotomy (excluding final restoration) 6.7 (l) D3310 Endodontic treatment--one canal (excluding final restoration) 20.0 D3320 Endodontic treatment--two canals (excluding final restoration) 26.7 D3330 Endodontic treatment--three canals (excluding final restoration) 27.6 (m) D3410 Apicoectomy (per tooth)-- first root 17.8 (n) D5110 Complete upper dentures 52.9 D5120 Complete lower dentures 67.5 (o) D5211 Upper partial--acrylic base (including any conventional clasps and rests) 22.0 D5213 Upper partial--predominantly base cast base with acrylic saddles (including any conventional clasps and rests) 55.8 (p) D5640 Replace broken teeth--per tooth 4.7 (q) D5820 Temporary partial--stayplate denture (upper) 20.6 (r) D6210 Pontic--cast high noble metal 52.1 D6240 Pontic--porcelain fused to high noble metal 38.9 D6241 Pontic--porcelain fused to predominately base metal 37.0 D6242 Pontic--porcelain fused to noble metal 41.1 D6251 Pontic--resin with predominantly base metal 48.4 (s) D6750 Bridge retainers--crown--porcelain fused to high noble metal 38.9 D6751 Bridge retainers--crown--porcelain fused to predominantly base metal 37.0 D6752 Bridge retainers--crown--porcelain fused to noble metal 41.1 (t) D7110 Single tooth extraction 4.7 D7120 Each additional tooth extraction 4.1 (u) D7210 Surgical removal of erupted tooth requiring elevation of muco-periosteal flap and removal of bone and/or section of tooth 9.0 D7250 Surgical removal of residual tooth roots (cutting procedure) 7.8 (v) D7880 Occlusal orthotic appliance 33.5 (w) D8999 Unspecified orthodontic procedure BR (x) D9110 Palliative (emergency) treatment of dental pain--minor procedures 2.4 (y) D9220 General anesthesia 14.5 (z) D9951 Occlusal adjustment--limited 3.8 D9952 Occlusal adjustment--complete 5.9 D9961 Special reports such as insurance forms, or the review of dental data to clarify a patient's status--more than information conveyed in the usual reports. BR