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§ 10:56-3.3. D1000-D1999 PREVENTIVE

(a) Dental prophylaxis:



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NOTE: Patients 16 years of age or older, maxillary and mandibular arches; includes additional scaling.



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NOTE 1: Patients 16 years of age or older, maxillary or mandibular arch, includes additional scaling.

NOTE 2: Code to be used if patient is edentulous in one arch.

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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches; includes additional scaling, includes additional scaling.

1. The following codes should be used when a beneficiary is developmentally disabled or neurologically impaired. (See N.J.A.C. 10:56-2.9(a)1ii.)

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NOTE: Patients 16 years of age or older, maxillary and mandibular arches.



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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.

(b) Topical fluoride treatment (office procedure):

1. Topical application of stannous fluoride or acid fluoride phosphate-one treatment following a complete prophylaxis (fee includes both services).



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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.



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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.



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NOTE: Patients age 16 up to and including 20 years of age, maxillary and mandibular arches.



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NOTE: Patients age 16 up to and including 20 years of age, maxillary and mandibular arches.



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NOTE: Patients age 16 up to and including 20 years of age, maxillary or mandibular arch. Code to be used if patient is edentulous in one arch.

2. The following codes should be used when a beneficiary is developmentally disabled or neurologically impaired (see N.J.A.C. 10:56-2.9(a)1ii) when the topical application of fluoride in conjunction with a complete prophylaxis (code includes both services) is necessary.

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NOTE: Patients up to and including 15 years of age, maxillary and mandibular arches.



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NOTE: Patients age 16 up to and including 20 years of age, maxillary and mandibular arches.

(c) Other Preventive Services

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NOTE 1: Unfilled premolars and permanent molars.

NOTE 2: Beneficiaries up to and including 16 years of age.

(d) Space Maintenance (passive appliances)



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NOTE: Utilizing band(s) or stainless steel crowning.



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NOTE: Lingual or palatal arch utilizing bands or stainless steel crowning.



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NOTE: The complete description of procedure(s) and the reason(s) the procedure was performed must be included in the report.



37 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES



SUBCHAPTER 3. HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
N.J.A.C. 10:56-3.4 (2014)
§ 10:56-3.4 D2000-D2999 RESTORATIVE
(a) Amalgam restorations (including polishing):




Maximum Fee




HCPCS







Allowance

IND

Code

Mod

Procedure Description

S

$

NS




D2110




Amalgam--One Surface, Primary

32.00




30.00




D2120




Amalgam--Two Surfaces, Primary

38.00




35.50




D2130




Amalgam--Three Surfaces, Primary

44.00




41.00




D2131




Amalgam--Four or More Surfaces,

51.00




46.50










Primary













D2140




Amalgam--One Surface, Permanent

32.00




30.00




D2150




Amalgam--Two Surfaces, Permanent

38.00




35.50




D2160




Amalgam--Three Surfaces, Permanent

44.00




41.00




D2161




Amalgam--Four or More Surfaces,

51.00




46.50










Permanent










(b) Filled or Unfilled Resin Restorations:

1. Proximal restorations in anterior teeth are normally considered to be single surface restorations. When access to a proximal cavity is gained by involvement of a second surface, reimbursement will be permitted for only one surface. A two or three surface proximal restoration will be reimbursed only when the facial and/or lingual margin(s) of the restoration extends beyond the proximal one-third of the facial and/or lingual surface(s).



2. Reimbursement will include acid etch where appropriate.




D2330




Resin-based composite--One

35.50




33.00










Surface, anterior













D2331




Resin-based composite--Two

42.50




39.00










Surfaces, anterior













D2332




Resin-based composite--Three

49.50




45.00










Surfaces, anterior













D2335




Resin-based composite--Four or

59.50




54.00










more Surfaces or involving incisal



















angle (anterior)













D2336




Resin-based composite crown,

40.00




35.00










anterior--primary













D2337




Resin-based composite crown,

40.00




35.00










anterior--permanent













D2380




Resin-based composite--One

32.00




30.00










surface, posterior--primary













D2381




Resin-based--Two surfaces,

38.00




35.00










posterior--primary













D2382




Resin-based composite--three or

44.00




41.00










more surfaces, posterior--primary










For permanent teeth only:




D2385




Resin-based composite--One

32.00




30.00










surface, posterior--permanent













D2386




Resin-based composite--two

38.00




35.50










surfaces, posterior--permanent













D2387




Resin-based composite--three

44.00




41.00










surfaces, posterior--permanent













D2388




Resin-based composite--four or

44.00




41.00










more surfaces, posterior--permanent










NOTE: Code to be used for three or more surfaces.

(c) Gold Foil Restorations:

1. Primarily for use in Dental Colleges.




D2410




Gold Foil--One Surface

9.00




8.00




D2420




Gold Foil--Two Surfaces

18.00




16.00




D2430




Gold Foil--Three Surfaces

27.00




24.00

NOTE: Code to be used for three or more surfaces.

(d) Inlay Restorations:

1. Primarily for use in dental colleges.




D2510




Inlay--Metallic--One Surface

31.00




27.00




D2520




Inlay--Metallic--Two Surfaces

56.00




49.00




D2530




Inlay--Metallic--Three or more

75.00




65.00










Surfaces










NOTE: Code to be used for three or more surfaces.




D2542




Onlay--Metallic--Two Surfaces

79.00




69.00




D2543




Onlay--Metallic--Three Surfaces

98.00




85.00

(e) Crowns--single restoration only:

1. There is only one fee for each type of crown Use the type of alloy most appropriate for the patient's needs.



2. The Noble Metal Classification System has been adopted as a more precise method of reporting various alloys used in dentistry. The alloys are defined on the basis of the percentage of noble metal content.






High




Predominantly




Noble

Noble

Base

Classification

Alloy

Alloy

Alloy

Weight %

Au., Pd. and/or

Au., Pd. and/or

Au., Pd. and/or




Pt. >60% (with

Pt. >25%

Pt.




at least 40% Au)





3. Codes to be used for crowns, single restoration only:




D2710




Crown Resin (Laboratory)

98.00




85.00

NOTE: Laboratory processed.




D2720




Crown--Resin with High Noble Metal

161.00




140.00

NOTE: Acrylic veneer.




D2721




Crown--Resin with Predominantly

161.00




140.00










Base Metal










NOTE: Acrylic veneer.




D2722




Crown--Resin with Noble Metal

161.00




140.00

NOTE: Acrylic veneer.




D2750




Crown--Porcelain Fused to High

279.00




253.00










Noble Metal













D2751




Crown--Porcelain Fused to

279.00




253.00










Predominantly Base Metal













D2752




Crown--Porcelain Fused to Noble

279.00




253.00










Metal













D2790




Crown--Full Cast High Noble Metal

161.00




140.00




D2791




Crown--Full Cast Predominantly

161.00




140.00










Base Metal













D2792




Crown--Full Cast Noble Metal

161.00




140.00

(f) Other restorative services:




D2910




Recement Inlay

7.00




6.00




D2920




Recement Crown

7.00




6.00




D2930




Prefabricated Stainless Steel

76.00




70.00










Crown--Primary Tooth










NOTE: Reimbursable only for deciduous teeth.




D2931




Prefabricated Stainless Steel

76.00




70.00










Crown--Permanent Tooth










NOTE: Reimbursable only for permanent posterior teeth up to and including 17 years of age.




D2932




Prefabricated Resin Crown

40.00




35.00

NOTE: For example, Polycarbonate--Reimbursable only for primary and permanent anterior teeth up to and including 15 years of age.




D2933




Prefabricated Stainless Steel

135.50




124.00










Crown with Resin window













D2940




Sedative Filling

10.00




9.00




D2950




Core Buildup including any Pins

49.00




45.00

NOTE 1: And/or post.

NOTE 2: Core of composite or amalgam.






D2951




Pin Retention--Per Tooth, In

6.00




5.00










Addition to Restoration










NOTE 1: Per pin.

NOTE 2: Maximum reimbursable--three pins.

NOTE 3: Not in conjunction with Procedure Code D3950 and D3950 22.




D2952




Cast Post and Core In Addition to

75.00




68.00










Crown










NOTE 1: Post and core fabricated (cast) and cemented as a separate unit from crown.

NOTE 2: Preparatory to crown restoration only.

NOTE 3: Not in conjunction with Procedure Code D3950 and D3950 22.




D2954




Prefabricated Post and Core In

49.00




45.00










Addition to Crown










NOTE 1: Preparatory to crown restoration only.

NOTE 2: Not in conjunction with Procedure Code D3950 and D3950 22.






D2970




Temporary Crown (Fractured Tooth)

29.00




25.00

NOTE: A preformed artificial crown which is fitted over a damaged tooth as an immediate protective device in tooth injury.

*

D2980




Crown Repair, By Report

BR




BR

*

D2999




Unspecified Restorative Procedure,

BR




BR










By Report










38 of 46 DOCUMENTS


NEW JERSEY ADMINISTRATIVE CODE

Copyright © 2014 by the New Jersey Office of Administrative Law


*** This file includes all Regulations adopted and published through the ***

*** New Jersey Register, Vol. 46 No. 11, June 2, 2014 ***


TITLE 10. HUMAN SERVICES

CHAPTER 56. MANUAL FOR DENTAL SERVICES



SUBCHAPTER 3. HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS)
N.J.A.C. 10:56-3.5 (2014)
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