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Rule: 24.29.1551 Prev     Up     Next    
Rule Title: DENTAL SPECIALTY AREA FEES FOR SERVICES PROVIDED FROM APRIL 1, 1993, THROUGH DECEMBER 31, 2007
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Department: LABOR AND INDUSTRY
Chapter: WORKERS' COMPENSATION AND OCCUPATIONAL DISEASE
Subchapter: Nonfacility Service Rules and Utilization Rules
 
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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24.29.1551    DENTAL SPECIALTY AREA FEES FOR SERVICES PROVIDED FROM APRIL 1, 1993, THROUGH DECEMBER 31, 2007

(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, through December 31, 2007, 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

History: 39-71-203, MCA; IMP, 39-71-704, MCA; NEW, 1993 MAR p. 404, Eff. 4/1/93; AMD, 1994 MAR p. 680, Eff. 4/1/94; AMD, 2007 MAR p. 1670, Eff. 10/26/07.


 

 
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