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Montana Medicaid - Fee Schedule Oral Surgeon Definitions:

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  • 1. Montana Medicaid - Fee Schedule Oral SurgeonDefinitions: Modifier – When a modifier is present, this indicates system may have different reimbursement or code edits for that procedure code/modifier combination. For example: 26 = professional component TC = technical component Description – Procedure code short description. You must refer to the appropriate official CPT-4, HCPCS or CDT-5 coding manual for complete definitions in order to assure correct coding. Effective – This is the first date of service for which the listed fee is applicable. Fees for drugs, radiopharmaceuticals, blood products, immune globins, vaccines, and toxoids are reviewed and updated quarterly -- effective dates that are greater than three months old indicate that there has been no fee change since that date. Method – Source of fee determination Fee Sched: Based on Relative Value for Dentists (RVD) X Montana Medicaid Dental Conversion Factor. Conversion factor for fiscal year 2009 is $31.27. Medicare: Medicare-prevailing fee. By Report (BR): Equals 45% of billed charges for CPT codes; Equals 85% of billed charges for CDT codes. Anes Value: Number of anesthesia base value units. This is added to the 15 min. time increment units and multiplied by the anesthesia conversion factor of $26.25. RBRVS: Based on Medicare Relative Value Units (RVU’s) x Montana Medicaid conversion factor x policy adjuster. Conversion factor for fiscal year 2009 is $26.15. *If a valid, current code is not present, that code may be a non-covered service Fees The facility rate is paid to physicians/practitioners providing services in the following sites: hospitals, emergency rooms, ambulatory surgery centers, IHS provider based and IHS 638 free standing facilities, skilled nursing and nursing facilities, hospice, ambulance, inpatient psychiatric and partial psychiatric hospitals, psychiatric residential treatment centers, comprehensive inpatient rehab facilities, birthing centers and military treatment facilities. All other sites of service receive the office rate. Procedures not normally done in the office are shown with the same facility rate, while those done in both locations have different rates. Bundled services, which are covered but paid as part of a related service, are shown with an RBRVS method and a fee of $0.00. Policy adjustments are applied to certain codes to increase or decrease reimbursement for the service. Vaccines covered by the Vaccines for Children (VFC) program are not reimbursable for individuals under 19. Please refer to the Medicaid Provider website for the list of VFC vaccines. NOTE: Mid-level practitioners do not get 100% of the fee shown in all cases. Please refer to your provider manual for more information. Global Days – Global surgery indicator. Global surgery periods are pre- and post-operative time frames assigned to surgical procedures. 000: Same day as procedure 010: Same day and ten days following procedure 090: One day prior to and ninety days following procedure MMM: In maternity cases, the global period is per the CPT-4 code description ZZZ: Add-on code, global period does not apply. An add-on code must be billed with its associated primary code Space: Global concept does not apply to this code PA – Prior Authorization Indicators Y: Prior authorization is required Mult - Multiple surgery guidelines do apply Space - this indicator does not apply to this code Bilat - Bilateral. The procedure can be done bilaterally Assist - Assistant. An assistant is allowed for this procedure Co-Surg - Co-Surgery. A co-surgeon is allowed for this procedure Team - A team of surgeons is allowed for this procedure Related - The procedure code listed is separately billable Y - indicator is applicable to this code Space - this indicator does not apply to this code Policy Adjust - M = Maternity, P = Mental Health, D = Profess. Differential, F = Family Planning Relative Values for Dentists (RVD) - copyright 2006. Published by Relative Value Studies, Inc., Broomfield, Colorado CPT codes, descriptors, and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply.Please see first page for a complete description 1of information contained in the fee schedules. Fees as of July 2008
  • 2. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team AdjustA4550 SURGICAL TRAYS 7/1/2003 RBRVS $0.00 $0.00D0120 PERIODIC ORAL EVALUATION 7/1/2008 FEE SCHED $21.89 $0.00D0140 LIMIT ORAL EVAL PROBLM FOCUS 7/1/2008 FEE SCHED $31.27 $0.00D0150 COMPREHENSVE ORAL EVALUATION 7/1/2008 FEE SCHED $31.27 $0.00D0210 INTRAOR COMPLETE FILM SERIES 7/1/2008 FEE SCHED $62.54 $0.00D0220 INTRAORAL PERIAPICAL FIRST F 7/1/2008 FEE SCHED $15.64 $0.00D0230 INTRAORAL PERIAPICAL EA ADD 7/1/2008 FEE SCHED $7.82 $0.00D0240 INTRAORAL OCCLUSAL FILM 7/1/2008 FEE SCHED $18.76 $0.00D0250 EXTRAORAL FIRST FILM 7/1/2008 FEE SCHED $31.27 $0.00D0260 EXTRAORAL EA ADDITIONAL FILM 7/1/2008 FEE SCHED $21.89 $0.00D0270 DENTAL BITEWING SINGLE FILM 7/1/2008 FEE SCHED $15.64 $0.00D0272 DENTAL BITEWINGS TWO FILMS 7/1/2008 FEE SCHED $18.76 $0.00D0273 BITEWINGS - THREE FILMS 7/1/2008 FEE SCHED $25.02 $0.00D0274 DENTAL BITEWINGS FOUR FILMS 7/1/2008 FEE SCHED $31.27 $0.00D0275 BITEWINGS-EACH ADDITIONAL FILM 7/1/2008 FEE SCHED $7.82 $0.00D0277 VERT BITEWINGS-SEV TO EIGHT 7/1/2008 FEE SCHED $37.52 $0.00D0330 DENTAL PANORAMIC FILM 7/1/2008 FEE SCHED $50.03 $0.00D0340 DENTAL CEPHALOMETRIC FILM 7/1/2008 FEE SCHED $62.54 $0.00D0350 ORAL/FACIAL PHOTO IMAGES 7/1/2008 FEE SCHED $31.27 $0.00D0360 CONE BEAM CT 1/1/2007 BY REPORT $0.00 $0.00D0362 CONE BEAM, TWO DIMENSIONAL 1/1/2007 BY REPORT $0.00 $0.00D0363 CONE BEAM, THREE DIMENSIONAL 1/1/2007 BY REPORT $0.00 $0.00D0460 PULP VITALITY TEST 7/1/2008 FEE SCHED $25.02 $0.00D0470 DIAGNOSTIC CASTS 7/1/2008 FEE SCHED $39.09 $0.00D0486 ACCESSION OF BRUSH BIOPSY 1/1/2007 BY REPORT $0.00 $0.00D1110 DENTAL PROPHYLAXIS ADULT 7/1/2008 FEE SCHED $46.91 $0.00D1120 DENTAL PROPHYLAXIS CHILD 7/1/2008 FEE SCHED $31.27 $0.00D1203 TOPICAL FLUOR W/O PROPHY CHI 7/1/2008 FEE SCHED $15.64 $0.00D1204 TOPICAL FLUOR W/O PROPHY ADU 7/1/2008 FEE SCHED $15.64 $0.00D1206 TOPICAL FLUORIDE VARNISH 7/1/2008 FEE SCHED $28.16 $0.00D1351 DENTAL SEALANT PER TOOTH 7/1/2008 FEE SCHED $25.02 $0.00D1510 SPACE MAINTAINER FXD UNILAT 7/1/2008 FEE SCHED $125.08 $0.00D1515 FIXED BILAT SPACE MAINTAINER 7/1/2008 FEE SCHED $187.62 $0.00D1550 RECEMENT SPACE MAINTAINER 7/1/2008 FEE SCHED $37.52 $0.00D1555 REMOVE FIX SPACE MAINTAINER 1/1/2007 BY REPORT $0.00 $0.00D2140 AMALGAM ONE SURFACE PERMANEN 7/1/2008 FEE SCHED $62.54 $0.00D2150 AMALGAM TWO SURFACES PERMANE 7/1/2008 FEE SCHED $68.79 $0.00D2160 AMALGAM THREE SURFACES PERMA 7/1/2008 FEE SCHED $84.43 $0.00D2161 AMALGAM 4 OR > SURFACES PERM 7/1/2008 FEE SCHED $103.19 $0.00D2330 RESIN ONE SURFACE-ANTERIOR 7/1/2008 FEE SCHED $62.54 $0.00D2331 RESIN TWO SURFACES-ANTERIOR 7/1/2008 FEE SCHED $93.81 $0.00D2332 RESIN THREE SURFACES-ANTERIO 7/1/2008 FEE SCHED $109.45 $0.00D2335 RESIN 4/> SURF OR W INCIS AN 7/1/2008 FEE SCHED $125.08 $0.00D2390 ANT RESIN-BASED CMPST CROWN 7/1/2008 FEE SCHED $212.64 $0.00D2391 POST 1 SRFC RESINBASED CMPST 7/1/2008 FEE SCHED $62.54 $0.00D2392 POST 2 SRFC RESINBASED CMPST 7/1/2008 FEE SCHED $125.08 $0.00D2393 POST 3 SRFC RESINBASED CMPST 7/1/2008 FEE SCHED $168.86 $0.00 Please see first page for a complete description 2 of information contained in the fee schedules. Fees as of July 2008
  • 3. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team AdjustD2394 POST >=4SRFC RESINBASE CMPST 7/1/2008 FEE SCHED $178.24 $0.00D2710 CROWN RESIN-BASED INDIRECT 7/1/2008 FEE SCHED $312.70 $0.00D2712 CROWN 3/4 RESIN-BASED COMPOS 7/1/2008 FEE SCHED $462.80 $0.00D2720 CROWN RESIN W/ HIGH NOBLE ME 7/1/2008 FEE SCHED $625.40 $0.00D2721 CROWN RESIN W/ BASE METAL 7/1/2008 FEE SCHED $469.05 $0.00D2722 CROWN RESIN W/ NOBLE METAL 7/1/2008 FEE SCHED $531.59 $0.00D2740 CROWN PORCELAIN/CERAMIC SUBS 7/1/2008 FEE SCHED $625.40 $0.00D2750 CROWN PORCELAIN W/ H NOBLE M 7/1/2008 FEE SCHED $687.94 $0.00 YD2751 CROWN PORCELAIN FUSED BASE M 7/1/2008 FEE SCHED $500.32 $0.00 YD2752 CROWN PORCELAIN W/ NOBLE MET 7/1/2008 FEE SCHED $562.86 $0.00D2780 CROWN 3/4 CAST HI NOBLE MET 7/1/2008 FEE SCHED $562.86 $0.00D2781 CROWN 3/4 CAST BASE METAL 7/1/2008 FEE SCHED $406.51 $0.00 YD2782 CROWN 3/4 CAST NOBLE METAL 7/1/2008 FEE SCHED $469.05 $0.00D2783 CROWN 3/4 PORCELAIN/CERAMIC 7/1/2008 FEE SCHED $594.13 $0.00D2790 CROWN FULL CAST HIGH NOBLE M 7/1/2008 FEE SCHED $594.13 $0.00D2791 CROWN FULL CAST BASE METAL 7/1/2008 FEE SCHED $437.78 $0.00 YD2792 CROWN FULL CAST NOBLE METAL 7/1/2008 FEE SCHED $500.32 $0.00D2794 CROWN-TITANIUM 7/1/2008 FEE SCHED $499.69 $0.00D2799 PROVISIONAL CROWN 7/1/2008 FEE SCHED $312.70 $0.00D2910 RECEMENT INLAY ONLAY OR PART 7/1/2008 FEE SCHED $46.91 $0.00D2920 DENTAL RECEMENT CROWN 7/1/2008 FEE SCHED $46.91 $0.00D2930 PREFAB STNLSS STEEL CRWN PRI 7/1/2008 FEE SCHED $125.08 $0.00D2931 PREFAB STNLSS STEEL CROWN PE 7/1/2008 FEE SCHED $187.62 $0.00D2932 PREFABRICATED RESIN CROWN 7/1/2008 FEE SCHED $150.10 $0.00D2933 PREFAB STAINLESS STEEL CROWN 7/1/2008 FEE SCHED $140.72 $0.00D2940 DENTAL SEDATIVE FILLING 7/1/2008 FEE SCHED $46.91 $0.00D2950 CORE BUILD-UP INCL ANY PINS 7/1/2008 FEE SCHED $125.08 $0.00D2951 TOOTH PIN RETENTION 7/1/2008 FEE SCHED $31.27 $0.00D2952 POST AND CORE CAST + CROWN 7/1/2008 FEE SCHED $250.16 $0.00D2953 EACH ADDTNL CAST POST 7/1/2008 FEE SCHED $203.26 $0.00D2954 PREFAB POST/CORE + CROWN 7/1/2008 FEE SCHED $156.35 $0.00D2957 EACH ADDTNL PREFAB POST 7/1/2008 FEE SCHED $109.45 $0.00D2960 LAMINATE LABIAL VENEER 7/1/2008 FEE SCHED $187.62 $0.00D2961 LAB LABIAL VENEER RESIN 7/1/2008 FEE SCHED $312.70 $0.00D2962 LAB LABIAL VENEER PORCELAIN 7/1/2008 FEE SCHED $450.28 $0.00D2970 TEMPORARY- FRACTURED TOOTH 1/1/2008 BY REPORT $0.00 $0.00D2980 CROWN REPAIR 7/1/2008 FEE SCHED $128.21 $0.00D2999 DENTAL UNSPEC RESTORATIVE PR 7/1/2001 BY REPORT $0.00 $0.00D3110 PULP CAP DIRECT 7/1/2008 FEE SCHED $39.09 $0.00D3120 PULP CAP INDIRECT 7/1/2008 FEE SCHED $31.27 $0.00D3220 THERAPEUTIC PULPOTOMY 7/1/2008 FEE SCHED $93.81 $0.00D3221 GROSS PULPAL DEBRIDEMENT 7/1/2008 FEE SCHED $125.08 $0.00D3230 PULPAL THERAPY ANTERIOR PRIM 7/1/2008 FEE SCHED $103.19 $0.00D3240 PULPAL THERAPY POSTERIOR PRI 7/1/2008 FEE SCHED $115.70 $0.00D3310 ANTERIOR 7/1/2008 FEE SCHED $318.95 $0.00D3320 ROOT CANAL THERAPY 2 CANALS 7/1/2008 FEE SCHED $359.61 $0.00D3330 ROOT CANAL THERAPY 3 CANALS 7/1/2008 FEE SCHED $437.78 $0.00 Please see first page for a complete description 3 of information contained in the fee schedules. Fees as of July 2008
  • 4. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team AdjustD3331 NON-SURG TX ROOT CANAL OBS 7/1/2008 FEE SCHED $315.83 $0.00D3346 RETREAT ROOT CANAL ANTERIOR 7/1/2008 FEE SCHED $343.97 $0.00D3347 RETREAT ROOT CANAL BICUSPID 7/1/2008 FEE SCHED $419.02 $0.00D3348 RETREAT ROOT CANAL MOLAR 7/1/2008 FEE SCHED $515.96 $0.00D3410 APICOECT/PERIRAD SURG ANTER 7/1/2008 FEE SCHED $284.56 $0.00D3421 ROOT SURGERY BICUSPID 7/1/2008 FEE SCHED $328.34 $0.00D3425 ROOT SURGERY MOLAR 7/1/2008 FEE SCHED $365.86 $0.00D3426 ROOT SURGERY EA ADD ROOT 7/1/2008 FEE SCHED $303.32 $0.00D3430 RETROGRADE FILLING 7/1/2008 FEE SCHED $93.81 $0.00D4210 GINGIVECTOMY/PLASTY PER QUAD 7/1/2008 FEE SCHED $297.07 $0.00D4211 GINGIVECTOMY/PLASTY PER TOOT 7/1/2008 FEE SCHED $256.41 $0.00D4230 ANA CROWN EXP 4 OR> PER QUAD 1/1/2007 BY REPORT $0.00 $0.00D4231 ANA CROWN EXP 1-3 PER QUAD 1/1/2007 BY REPORT $0.00 $0.00D4240 GINGIVAL FLAP PROC W/ PLANIN 7/1/2008 FEE SCHED $340.84 $0.00D4241 GNGVL FLAP W ROOTPLAN 1-3 TH 7/1/2008 FEE SCHED $96.94 $0.00D4260 OSSEOUS SURGERY PER QUADRANT 7/1/2008 FEE SCHED $500.32 $0.00D4261 OSSEOUS SURGL-3TEETHPERQUAD 7/1/2008 FEE SCHED $250.16 $0.00D4270 PEDICLE SOFT TISSUE GRAFT PR 7/1/2008 FEE SCHED $381.49 $0.00D4271 FREE SOFT TISSUE GRAFT PROC 7/1/2008 FEE SCHED $394.00 $0.00D4320 PROVISION SPLNT INTRACORONAL 7/1/2008 FEE SCHED $212.64 $0.00D4321 PROVISIONAL SPLINT EXTRACORO 7/1/2008 FEE SCHED $185.10 $0.00D4341 PERIODONTAL SCALING & ROOT 7/1/2008 FEE SCHED $156.35 $0.00D4342 PERIODONTAL SCALING 1-3TEETH 7/1/2008 FEE SCHED $84.43 $0.00D4355 FULL MOUTH DEBRIDEMENT 7/1/2008 FEE SCHED $78.18 $0.00D4910 PERIODONTAL MAINT PROCEDURES 7/1/2008 FEE SCHED $62.54 $0.00D4920 UNSCHEDULED DRESSING CHANGE 7/1/2008 FEE SCHED $40.65 $0.00D4999 UNSPECIFIED PERIODONTAL PROC 7/1/2001 BY REPORT $0.00 $0.00D5110 DENTURES COMPLETE MAXILLARY 7/1/2008 FEE SCHED $781.75 $0.00D5120 DENTURES COMPLETE MANDIBLE 7/1/2008 FEE SCHED $781.75 $0.00D5130 DENTURES IMMEDIAT MAXILLARY 7/1/2008 FEE SCHED $859.93 $0.00D5140 DENTURES IMMEDIAT MANDIBLE 7/1/2008 FEE SCHED $859.93 $0.00D5211 DENTURES MAXILL PART RESIN 7/1/2008 FEE SCHED $531.59 $0.00D5212 DENTURES MAND PART RESIN 7/1/2008 FEE SCHED $553.48 $0.00D5213 DENTURES MAXILL PART METAL 7/1/2008 FEE SCHED $938.10 $0.00D5214 DENTURES MANDIBL PART METAL 7/1/2008 FEE SCHED $938.10 $0.00D5225 MAXILLARY PART DENTURE FLEX 7/1/2008 FEE SCHED $686.69 $0.00D5226 MANDIBULAR PART DENTURE FLEX 7/1/2008 FEE SCHED $687.94 $0.00D5410 DENTURES ADJUST CMPLT MAXIL 7/1/2008 FEE SCHED $37.52 $0.00D5411 DENTURES ADJUST CMPLT MAND 7/1/2008 FEE SCHED $37.52 $0.00D5421 DENTURES ADJUST PART MAXILL 7/1/2008 FEE SCHED $37.52 $0.00D5422 DENTURES ADJUST PART MANDBL 7/1/2008 FEE SCHED $37.52 $0.00D5510 DENTUR REPR BROKEN COMPL BAS 7/1/2008 FEE SCHED $93.81 $0.00D5520 REPLACE DENTURE TEETH COMPLT 7/1/2008 FEE SCHED $62.54 $0.00D5610 DENTURES REPAIR RESIN BASE 7/1/2008 FEE SCHED $93.81 $0.00D5620 REP PART DENTURE CAST FRAME 7/1/2008 FEE SCHED $128.21 $0.00D5630 REP PARTIAL DENTURE CLASP 7/1/2008 FEE SCHED $115.70 $0.00D5640 REPLACE PART DENTURE TEETH 7/1/2008 FEE SCHED $93.81 $0.00 Please see first page for a complete description 4 of information contained in the fee schedules. Fees as of July 2008
  • 5. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team AdjustD5650 ADD TOOTH TO PARTIAL DENTURE 7/1/2008 FEE SCHED $93.81 $0.00D5660 ADD CLASP TO PARTIAL DENTURE 7/1/2008 FEE SCHED $156.35 $0.00D5710 DENTURES REBASE CMPLT MAXIL 7/1/2008 FEE SCHED $312.70 $0.00D5711 DENTURES REBASE CMPLT MAND 7/1/2008 FEE SCHED $312.70 $0.00D5720 DENTURES REBASE PART MAXILL 7/1/2008 FEE SCHED $187.62 $0.00D5721 DENTURES REBASE PART MANDBL 7/1/2008 FEE SCHED $250.16 $0.00D5730 DENTURE RELN CMPLT MAXIL CH 7/1/2008 FEE SCHED $187.62 $0.00D5731 DENTURE RELN CMPLT MAND CHR 7/1/2008 FEE SCHED $187.62 $0.00D5740 DENTURE RELN PART MAXIL CHR 7/1/2008 FEE SCHED $156.35 $0.00D5741 DENTURE RELN PART MAND CHR 7/1/2008 FEE SCHED $156.35 $0.00D5750 DENTURE RELN CMPLT MAX LAB 7/1/2008 FEE SCHED $250.16 $0.00D5751 DENTURE RELN CMPLT MAND LAB 7/1/2008 FEE SCHED $250.16 $0.00D5760 DENTURE RELN PART MAXIL LAB 7/1/2008 FEE SCHED $250.16 $0.00D5761 DENTURE RELN PART MAND LAB 7/1/2008 FEE SCHED $250.16 $0.00D5820 DENTURE INTERM PART MAXILL 7/1/2008 FEE SCHED $312.70 $0.00D5821 DENTURE INTERM PART MANDBL 7/1/2008 FEE SCHED $312.70 $0.00D5850 TISSUE CONDITIONING, MAXILLARY 7/1/2008 FEE SCHED $81.30 $0.00D5851 TISSUE CONDITIONING, MANDIBULAR 7/1/2008 FEE SCHED $81.30 $0.00D5899 REMOVABLE PROSTHODONTIC PROC 1/1/1998 BY REPORT $0.00 $0.00D6205 PONTIC-INDIRECT RESIN BASED 7/1/2008 FEE SCHED $464.67 $0.00D6210 PROSTHODONT HIGH NOBLE METAL 7/1/2008 FEE SCHED $625.40 $0.00D6211 BRIDGE BASE METAL CAST 7/1/2008 FEE SCHED $437.78 $0.00D6212 BRIDGE NOBLE METAL CAST 7/1/2008 FEE SCHED $500.32 $0.00D6214 PONTIC TITANIUM 7/1/2008 FEE SCHED $487.81 $0.00D6240 BRIDGE PORCELAIN HIGH NOBLE 7/1/2008 FEE SCHED $687.94 $0.00D6241 BRIDGE PORCELAIN BASE METAL 7/1/2008 FEE SCHED $562.86 $0.00D6242 BRIDGE PORCELAIN NOBEL METAL 7/1/2008 FEE SCHED $625.40 $0.00D6245 BRIDGE PORCELAIN/CERAMIC 7/1/2008 FEE SCHED $472.18 $0.00D6250 BRIDGE RESIN W/HIGH NOBLE 7/1/2008 FEE SCHED $625.40 $0.00D6251 BRIDGE RESIN BASE METAL 7/1/2008 FEE SCHED $437.78 $0.00D6252 BRIDGE RESIN W/NOBLE METAL 7/1/2008 FEE SCHED $562.86 $0.00D6710 CROWN-INDIRECT RESIN BASED 7/1/2008 FEE SCHED $503.45 $0.00D6720 RETAIN CROWN RESIN W HI NBLE 7/1/2008 FEE SCHED $625.40 $0.00D6721 CROWN RESIN W/BASE METAL 7/1/2008 FEE SCHED $469.05 $0.00D6722 CROWN RESIN W/NOBLE METAL 7/1/2008 FEE SCHED $531.59 $0.00D6740 CROWN PORCELAIN/CERAMIC 7/1/2008 FEE SCHED $500.32 $0.00D6750 CROWN PORCELAIN HIGH NOBLE 7/1/2008 FEE SCHED $750.48 $0.00D6751 CROWN PORCELAIN BASE METAL 7/1/2008 FEE SCHED $437.78 $0.00D6752 CROWN PORCELAIN NOBLE METAL 7/1/2008 FEE SCHED $562.86 $0.00D6780 CROWN 3/4 HIGH NOBLE METAL 7/1/2008 FEE SCHED $594.13 $0.00D6781 CROWN 3/4 CAST BASED METAL 7/1/2008 FEE SCHED $487.81 $0.00D6782 CROWN 3/4 CAST NOBLE METAL 7/1/2008 FEE SCHED $490.94 $0.00D6783 CROWN 3/4 PORCELAIN/CERAMIC 7/1/2008 FEE SCHED $494.07 $0.00D6790 CROWN FULL HIGH NOBLE METAL 7/1/2008 FEE SCHED $594.13 $0.00D6791 CROWN FULL BASE METAL CAST 7/1/2008 FEE SCHED $437.78 $0.00D6792 CROWN FULL NOBLE METAL CAST 7/1/2008 FEE SCHED $531.59 $0.00D6794 CROWN TITANIUM 7/1/2008 FEE SCHED $459.67 $0.00 Please see first page for a complete description 5 of information contained in the fee schedules. Fees as of July 2008
  • 6. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team AdjustD6930 DENTAL RECEMENT BRIDGE 7/1/2008 FEE SCHED $62.54 $0.00D6950 PRECISION ATTACHMENT 7/1/2008 FEE SCHED $250.16 $0.00D6980 BRIDGE REPAIR 7/1/2008 FEE SCHED $162.60 $0.00D6999 FIXED PROSTHODONTIC PROC 1/1/1998 BY REPORT $0.00 $0.00D7111 EXTRACTION CORONAL REMNANTS 7/1/2008 FEE SCHED $62.54 $0.00D7140 EXTRACTION ERUPTED TOOTH/EXR 7/1/2008 FEE SCHED $68.79 $0.00D7210 REM IMP TOOTH W MUCOPER FLP 7/1/2008 FEE SCHED $125.08 $0.00D7220 IMPACT TOOTH REMOV SOFT TISS 7/1/2008 FEE SCHED $143.84 $0.00D7230 IMPACT TOOTH REMOV PART BONY 7/1/2008 FEE SCHED $187.62 $0.00D7240 IMPACT TOOTH REMOV COMP BONY 7/1/2008 FEE SCHED $225.14 $0.00D7241 IMPACT TOOTH REM BONY W/COMP 7/1/2008 FEE SCHED $312.70 $0.00D7250 TOOTH ROOT REMOVAL 7/1/2008 FEE SCHED $125.08 $0.00D7270 TOOTH REIMPLANTATION 7/1/2008 FEE SCHED $225.14 $0.00D7280 EXPOSURE IMPACT TOOTH ORTHOD 7/1/2008 FEE SCHED $187.62 $0.00D7282 MOBILIZE ERUPTED/MALPOS TOOT 7/1/2008 FEE SCHED $62.54 $0.00D7310 ALVEOPLASTY W/ EXTRACTION 7/1/2008 FEE SCHED $131.33 $0.00D7320 ALVEOPLASTY W/O EXTRACTION 7/1/2008 FEE SCHED $165.73 $0.00D7321 ALVEOLOPLASTY NOT W/EXTRACTS 7/1/2008 FEE SCHED $240.78 $0.00D7510 I&D ABSC INTRAORAL SOFT TISS 7/1/2008 FEE SCHED $84.43 $0.00D7511 INCISION/DRAIN ABSCESS INTRA 7/1/2008 FEE SCHED $138.21 $0.00D7520 I&D ABSCESS EXTRAORAL 7/1/2008 FEE SCHED $187.62 $0.00D7521 INCISION/DRAIN ABSCESS EXTRA 7/1/2008 FEE SCHED $222.64 $0.00D7540 REMOVAL OF FB REACTION 7/1/2008 FEE SCHED $265.80 $0.00D7550 REMOVAL OF SLOUGHED OFF BONE 7/1/2008 FEE SCHED $218.89 $0.00D7560 MAXILLARY SINUSOTOMY 7/1/2008 FEE SCHED $406.51 $0.00D7910 DENT SUTUR RECENT WND TO 5CM 7/1/2008 FEE SCHED $431.53 $0.00D7911 DENTAL SUTURE WOUND TO 5 CM 7/1/2008 FEE SCHED $168.86 $0.00D7912 SUTURE COMPLICATE WND > 5 CM 7/1/2008 FEE SCHED $250.16 $0.00D7951 SINUS AUG W BONE/BONE SUP 1/1/2007 BY REPORT $0.00 $0.00D7970 EXCISION HYPERPLASTIC TISSUE 7/1/2008 FEE SCHED $1,500.96 $0.00D7998 INTRAORAL PLACE OF FIX DEV 1/1/2007 BY REPORT $0.00 $0.00D8050 INTERCEP DENTAL TX PRIMARY 10/1/2007 BY REPORT $0.00 $0.00 YD8060 INTERCEP DENTAL TX TRANSITN 10/1/2007 BY REPORT $0.00 $0.00 YD8070 COMPRE DENTAL TX TRANSITION 10/1/2007 BY REPORT $0.00 $0.00 YD8080 COMPRE DENTAL TX ADOLESCENT 10/1/2007 BY REPORT $0.00 $0.00 YD8090 COMPRE DENTAL TX ADULT 10/1/2007 BY REPORT $0.00 $0.00 YD8220 FIXED APPLIANCE THERAPY HABT 7/1/2008 BY REPORT $0.00 $0.00D8670 PERIODIC ORTHODONTC TX VISIT 10/1/2007 BY REPORT $0.00 $0.00 YD9110 TX DENTAL PAIN MINOR PROC 7/1/2008 FEE SCHED $62.54 $0.00D9220 GENERAL ANESTHESIA 7/1/2008 FEE SCHED $171.99 $0.00D9221 GENERAL ANESTHESIA EA AD 15M 7/1/2008 FEE SCHED $62.54 $0.00D9230 ANALGESIA 7/1/2008 FEE SCHED $28.14 $0.00D9241 INTRAVENOUS SEDATION 7/1/2008 FEE SCHED $187.62 $0.00D9242 IV SEDATION EA AD 30 M 7/1/2008 FEE SCHED $70.36 $0.00D9248 SEDATION (NON-IV) 7/1/2008 FEE SCHED $139.15 $0.00D9310 DENTAL CONSULTATION 7/1/2008 FEE SCHED $50.03 $0.00D9410 DENTAL HOUSE CALL 7/1/2008 FEE SCHED $93.81 $0.00 Please see first page for a complete description 6 of information contained in the fee schedules. Fees as of July 2008
  • 7. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team AdjustD9420 HOSPITAL CALL 7/1/2008 FEE SCHED $93.81 $0.00D9440 OFFICE VISIT AFTER HOURS 7/1/2008 FEE SCHED $62.54 $0.00D9612 THERA PAR DRUGS 2 OR > ADMIN 7/1/2008 FEE SCHED $62.54 $0.00D9630 OTHER DRUGS/MEDICAMENTS 7/1/2008 FEE SCHED $15.64 $0.00D9920 BEHAVIOR MANAGEMENT 7/1/2008 FEE SCHED $50.03 $0.00D9940 DENTAL OCCLUSAL GUARD 7/1/2008 FEE SCHED $312.70 $0.0000170 ANESTHESIA FOR INTRAORAL PROCEDUR 10/1/2007 ANES VALU 5.00 0.0010060 DRAINAGE OF SKIN ABSCESS 7/1/2008 RBRVS $84.75 $73.56 010 Y10180 COMPLEX DRAINAGE, WOUND 7/1/2008 RBRVS $181.95 $142.62 010 Y11010 DEBRIDE SKIN FX 7/1/2008 RBRVS $370.79 $231.31 010 Y11100 BIOPSY SKIN LESION 7/1/2008 RBRVS $76.32 $38.54 000 Y11101 BIOPSY, SKIN ADD-ON 7/1/2008 RBRVS $25.38 $19.59 ZZZ11310 SHAVE SKIN LESION 7/1/2008 RBRVS $64.18 $34.42 000 Y11311 SHAVE SKIN LESION 7/1/2008 RBRVS $80.29 $49.88 000 Y11312 SHAVE SKIN LESION 7/1/2008 RBRVS $93.26 $57.45 000 Y11313 SHAVE SKIN LESION 7/1/2008 RBRVS $118.30 $77.34 000 Y11440 EXC FACE-MM B9+MARG 0.5 < CM 7/1/2008 RBRVS $101.89 $76.59 010 Y11441 EXC FACE-MM B9+MARG 0.6-1 CM 7/1/2008 RBRVS $126.73 $99.88 010 Y11442 EXC FACE-MM B9+MARG 1.1-2 CM 7/1/2008 RBRVS $142.54 $111.19 010 Y11443 EXC FACE-MM B9+MARG 2.1-3 CM 7/1/2008 RBRVS $172.19 $137.93 010 Y11444 EXC FACE-MM B9+MARG 3.1-4 CM 7/1/2008 RBRVS $217.47 $177.15 010 Y11446 EXC FACE-MM B9+MARG > 4 CM 7/1/2008 RBRVS $293.03 $250.14 010 Y12011 REPAIR SUPERFICIAL WOUND(S) 7/1/2008 RBRVS $125.75 $85.74 010 Y12013 REPAIR SUPERFICIAL WOUND(S) 7/1/2008 RBRVS $138.31 $97.99 010 Y12014 REPAIR SUPERFICIAL WOUND(S) 7/1/2008 RBRVS $162.82 $117.70 010 Y12015 REPAIR SUPERFICIAL WOUND(S) 7/1/2008 RBRVS $204.91 $147.95 010 Y12016 REPAIR SUPERFICIAL WOUND(S) 7/1/2008 RBRVS $243.03 $180.33 010 Y12017 REPAIR SUPERFICIAL WOUND(S) 7/1/2008 RBRVS $217.96 $217.96 010 Y12018 REPAIR SUPERFICIAL WOUND(S) 7/1/2008 RBRVS $261.00 $261.00 010 Y Y Y12051 LAYER CLOSURE OF WOUND(S) 7/1/2008 RBRVS $202.60 $138.61 010 Y12052 LAYER CLOSURE OF WOUND(S) 7/1/2008 RBRVS $222.99 $157.71 010 Y12053 LAYER CLOSURE OF WOUND(S) 7/1/2008 RBRVS $244.51 $164.82 010 Y12054 LAYER CLOSURE OF WOUND(S) 7/1/2008 RBRVS $262.74 $177.60 010 Y12055 LAYER CLOSURE OF WOUND(S) 7/1/2008 RBRVS $321.66 $221.21 010 Y12056 LAYER CLOSURE OF WOUND(S) 7/1/2008 RBRVS $396.39 $273.55 010 Y12057 LAYER CLOSURE OF WOUND(S) 7/1/2008 RBRVS $427.78 $312.28 010 Y Y Y13131 REPAIR OF WOUND OR LESION 7/1/2008 RBRVS $278.05 $216.94 010 Y13132 REPAIR OF WOUND OR LESION 7/1/2008 RBRVS $435.31 $360.46 010 Y13133 REPAIR WOUND/LESION ADD-ON 7/1/2008 RBRVS $131.27 $106.61 ZZZ13150 REPAIR OF WOUND OR LESION 7/1/2008 RBRVS $284.29 $218.37 010 Y13151 REPAIR OF WOUND OR LESION 7/1/2008 RBRVS $315.38 $252.03 010 Y13152 REPAIR OF WOUND OR LESION 7/1/2008 RBRVS $429.48 $339.55 010 Y13153 REPAIR WOUND/LESION ADD-ON 7/1/2008 RBRVS $146.17 $117.05 ZZZ15120 SKN SPLT A-GRFT FAC/NCK/HF/G 7/1/2008 RBRVS $734.01 $624.56 090 Y15121 SKN SPLT A-GRFT F/N/HF/G ADD 7/1/2008 RBRVS $222.00 $145.23 ZZZ Y15240 SKIN FULL GRFT FACE/GENIT/HF 7/1/2008 RBRVS $703.98 $617.94 090 Y15241 SKIN FULL GRAFT ADD-ON 7/1/2008 RBRVS $145.34 $93.19 ZZZ Please see first page for a complete description 7 of information contained in the fee schedules. Fees as of July 2008
  • 8. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust15260 SKIN FULL GRAFT EEN & LIPS 7/1/2008 RBRVS $752.39 $667.30 090 Y15261 SKIN FULL GRAFT ADD-ON 7/1/2008 RBRVS $167.47 $117.54 ZZZ15574 FORM SKIN PEDICLE FLAP 7/1/2008 RBRVS $707.73 $605.35 090 Y15576 FORM SKIN PEDICLE FLAP 7/1/2008 RBRVS $628.98 $532.35 090 Y15620 SKIN GRAFT 7/1/2008 RBRVS $353.01 $249.35 090 Y15630 SKIN GRAFT 7/1/2008 RBRVS $360.92 $270.34 090 Y15822 REVISION OF UPPER EYELID 7/1/2008 RBRVS $330.43 $290.76 090 Y Y Y17000 DESTROY BENIGN/PREMLG LESION 7/1/2008 RBRVS $58.73 $41.11 010 Y17003 DESTROY LESIONS, 2-14 7/1/2008 RBRVS $5.98 $4.05 ZZZ17280 DESTRUCTION OF SKIN LESIONS 7/1/2008 RBRVS $102.87 $68.64 010 Y17281 DESTRUCTION OF SKIN LESIONS 7/1/2008 RBRVS $131.27 $95.72 010 Y17282 DESTRUCTION OF SKIN LESIONS 7/1/2008 RBRVS $152.15 $110.89 010 Y17283 DESTRUCTION OF SKIN LESIONS 7/1/2008 RBRVS $184.90 $139.44 010 Y17284 DESTRUCTION OF SKIN LESIONS 7/1/2008 RBRVS $216.25 $166.33 010 Y17286 DESTRUCTION OF SKIN LESIONS 7/1/2008 RBRVS $277.49 $226.62 010 Y17999 SKIN TISSUE PROCEDURE 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y20000 INCISION OF ABSCESS 7/1/2008 RBRVS $162.55 $127.04 010 Y20005 INCISION OF DEEP ABSCESS 7/1/2008 RBRVS $240.50 $194.09 010 Y20200 MUSCLE BIOPSY 7/1/2008 RBRVS $151.02 $76.13 000 Y20205 DEEP MUSCLE BIOPSY 7/1/2008 RBRVS $207.56 $120.53 000 Y20245 BONE BIOPSY, EXCISIONAL 7/1/2008 RBRVS $512.91 $512.91 010 Y20605 DRAIN/INJECT JOINT/BURSA 7/1/2008 RBRVS $47.92 $34.79 000 Y Y20670 REMOVAL OF SUPPORT IMPLANT 7/1/2008 RBRVS $354.41 $124.39 010 Y20680 REMOVAL OF SUPPORT IMPLANT 7/1/2008 RBRVS $474.26 $327.75 090 Y20690 APPLY BONE FIXATION DEVICE 7/1/2008 RBRVS $409.82 $409.82 090 Y20692 APPLY BONE FIXATION DEVICE 7/1/2008 RBRVS $754.32 $754.32 090 Y Y Y20694 REMOVE BONE FIXATION DEVICE 7/1/2008 RBRVS $353.13 $274.72 090 Y20900 REMOVAL OF BONE FOR GRAFT 7/1/2008 RBRVS $492.64 $379.37 090 Y Y Y20902 REMOVAL OF BONE FOR GRAFT 7/1/2008 RBRVS $496.46 $496.46 090 Y Y Y21010 INCISION OF JAW JOINT 7/1/2008 RBRVS $591.54 $591.54 090 Y Y21025 EXCISION OF BONE, LOWER JAW 7/1/2008 RBRVS $785.79 $678.60 090 Y21026 EXCISION OF FACIAL BONE(S) 7/1/2008 RBRVS $460.12 $389.09 090 Y21029 CONTOUR OF FACE BONE LESION 7/1/2008 RBRVS $591.81 $505.39 090 Y21030 EXCISE MAX/ZYGOMA B9 TUMOR 7/1/2008 RBRVS $384.14 $323.32 090 Y21031 REMOVE EXOSTOSIS, MANDIBLE 7/1/2008 RBRVS $294.47 $230.78 090 Y21032 REMOVE EXOSTOSIS, MAXILLA 7/1/2008 RBRVS $299.99 $227.68 090 Y21040 EXCISE MANDIBLE LESION 7/1/2008 RBRVS $385.39 $317.57 090 Y21044 REMOVAL OF JAW BONE LESION 7/1/2008 RBRVS $711.32 $711.32 090 Y Y Y21045 EXTENSIVE JAW SURGERY 7/1/2008 RBRVS $988.92 $988.92 090 Y Y Y21050 REMOVAL OF JAW JOINT 7/1/2008 RBRVS $690.71 $690.71 090 Y Y21060 REMOVE JAW JOINT CARTILAGE 7/1/2008 RBRVS $638.55 $638.55 090 Y Y Y Y21070 REMOVE CORONOID PROCESS 7/1/2008 RBRVS $520.44 $520.44 090 Y Y21073 MNPJ OF TMJ W/ANESTH 7/1/2008 RBRVS $293.86 $191.79 090 Y Y21079 PREPARE FACE/ORAL PROSTHESIS 7/1/2008 RBRVS $1,366.36 $1,202.87 090 Y21080 PREPARE FACE/ORAL PROSTHESIS 7/1/2008 RBRVS $1,553.49 $1,357.36 090 Y21081 PREPARE FACE/ORAL PROSTHESIS 7/1/2008 RBRVS $1,414.47 $1,231.46 090 Y21082 PREPARE FACE/ORAL PROSTHESIS 7/1/2008 RBRVS $1,298.97 $1,135.13 090 Y Please see first page for a complete description 8 of information contained in the fee schedules. Fees as of July 2008
  • 9. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust21083 PREPARE FACE/ORAL PROSTHESIS 7/1/2008 RBRVS $1,233.99 $1,050.00 090 Y21085 PREPARE FACE/ORAL PROSTHESIS 7/1/2008 RBRVS $565.33 $486.59 010 Y21087 PREPARE FACE/ORAL PROSTHESIS 7/1/2008 RBRVS $1,469.84 $1,332.55 090 Y21089 PREPARE FACE/ORAL PROSTHESIS 7/1/2003 BY REPORT $0.00 $0.00 09021100 MAXILLOFACIAL FIXATION 7/1/2008 RBRVS $576.76 $318.86 090 Y21110 INTERDENTAL FIXATION 7/1/2008 RBRVS $566.58 $494.31 090 Y21116 INJECTION, JAW JOINT X-RAY 7/1/2008 RBRVS $136.68 $36.23 000 Y21120 RECONSTRUCTION OF CHIN 7/1/2008 RBRVS $499.15 $401.53 090 Y Y Y21121 RECONSTRUCTION OF CHIN 7/1/2008 RBRVS $596.04 $516.70 090 Y Y Y21122 RECONSTRUCTION OF CHIN 7/1/2008 RBRVS $576.26 $576.26 090 Y Y Y21123 RECONSTRUCTION OF CHIN 7/1/2008 RBRVS $681.48 $681.48 090 Y Y Y Y21125 AUGMENTATION, LOWER JAW BONE 7/1/2008 RBRVS $2,268.82 $597.06 090 Y Y Y21127 AUGMENTATION LOWER JAW BONE 7/1/2008 RBRVS $2,477.40 $703.26 090 Y Y Y Y21141 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,087.25 $1,087.25 090 Y Y Y Y21142 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,068.79 $1,068.79 090 Y Y Y Y21143 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,122.99 $1,122.99 090 Y Y Y Y21145 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,261.71 $1,261.71 090 Y Y Y21146 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,259.67 $1,259.67 090 Y Y Y Y21147 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,351.08 $1,351.08 090 Y Y Y21150 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,429.86 $1,429.86 090 Y Y Y21151 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,533.60 $1,533.60 090 Y Y Y21154 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,711.92 $1,711.92 090 Y Y Y Y21155 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $1,975.26 $1,975.26 090 Y Y Y21159 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $2,305.81 $2,305.81 090 Y Y Y Y21160 RECONSTRUCT MIDFACE, LEFORT 7/1/2008 RBRVS $2,418.55 $2,418.55 090 Y Y Y21188 RECONSTRUCTION OF MIDFACE 7/1/2008 RBRVS $1,329.30 $1,329.30 090 Y Y Y21193 RECONST LWR JAW W/O GRAFT 7/1/2008 RBRVS $1,015.32 $1,015.32 090 Y Y Y Y21194 RECONST LWR JAW W/GRAFT 7/1/2008 RBRVS $1,155.48 $1,155.48 090 Y Y Y21195 RECONST LWR JAW W/O FIXATION 7/1/2008 RBRVS $1,091.98 $1,091.98 090 Y Y Y21196 RECONST LWR JAW W/FIXATION 7/1/2008 RBRVS $1,185.85 $1,185.85 090 Y Y Y Y21198 RECONSTR LWR JAW SEGMENT 7/1/2008 RBRVS $925.53 $925.53 090 Y Y Y Y21206 RECONSTRUCT UPPER JAW BONE 7/1/2008 RBRVS $901.74 $901.74 090 Y Y Y Y21208 AUGMENTATION OF FACIAL BONES 7/1/2008 RBRVS $1,273.02 $666.39 090 Y Y21209 REDUCTION OF FACIAL BONES 7/1/2008 RBRVS $634.01 $513.37 090 Y Y Y21210 FACE BONE GRAFT 7/1/2008 RBRVS $1,492.83 $670.85 090 Y Y21215 LOWER JAW BONE GRAFT 7/1/2008 RBRVS $2,470.89 $699.93 090 Y Y Y21240 RECONSTRUCTION OF JAW JOINT 7/1/2008 RBRVS $909.04 $909.04 090 Y Y Y Y Y21242 RECONSTRUCTION OF JAW JOINT 7/1/2008 RBRVS $834.20 $834.20 090 Y Y Y Y Y21243 RECONSTRUCTION OF JAW JOINT 7/1/2008 RBRVS $1,361.48 $1,361.48 090 Y Y Y Y Y21244 RECONSTRUCTION OF LOWER JAW 7/1/2008 RBRVS $837.07 $837.07 090 Y Y Y Y21245 RECONSTRUCTION OF JAW 7/1/2008 RBRVS $900.23 $737.98 090 Y Y Y21246 RECONSTRUCTION OF JAW 7/1/2008 RBRVS $707.46 $707.46 090 Y Y Y21247 RECONSTRUCT LOWER JAW BONE 7/1/2008 RBRVS $1,325.21 $1,325.21 090 Y Y Y Y21248 RECONSTRUCTION OF JAW 7/1/2008 RBRVS $838.24 $712.83 090 Y Y21249 RECONSTRUCTION OF JAW 7/1/2008 RBRVS $1,180.14 $1,017.58 090 Y Y21299 CRANIO/MAXILLOFACIAL SURGERY 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y21315 TREATMENT OF NOSE FRACTURE 7/1/2008 RBRVS $203.85 $119.06 010 Y Please see first page for a complete description 9 of information contained in the fee schedules. Fees as of July 2008
  • 10. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust21320 TREATMENT OF NOSE FRACTURE 7/1/2008 RBRVS $195.72 $111.87 010 Y21325 TREATMENT OF NOSE FRACTURE 7/1/2008 RBRVS $387.28 $387.28 090 Y21330 TREATMENT OF NOSE FRACTURE 7/1/2008 RBRVS $473.47 $473.47 090 Y21335 TREATMENT OF NOSE FRACTURE 7/1/2008 RBRVS $593.32 $593.32 090 Y21336 TREAT NASAL SEPTAL FRACTURE 7/1/2008 RBRVS $516.24 $516.24 090 Y21337 TREAT NASAL SEPTAL FRACTURE 7/1/2008 RBRVS $307.78 $225.56 090 Y21340 TREATMENT OF NOSE FRACTURE 7/1/2008 RBRVS $642.86 $642.86 090 Y21343 TREATMENT OF SINUS FRACTURE 7/1/2008 RBRVS $942.17 $942.17 090 Y Y Y21344 TREATMENT OF SINUS FRACTURE 7/1/2008 RBRVS $1,220.64 $1,220.64 090 Y Y Y21345 TREAT NOSE/JAW FRACTURE 7/1/2008 RBRVS $632.99 $527.40 090 Y21346 TREAT NOSE/JAW FRACTURE 7/1/2008 RBRVS $761.24 $761.24 090 Y Y21347 TREAT NOSE/JAW FRACTURE 7/1/2008 RBRVS $913.01 $913.01 090 Y Y Y21348 TREAT NOSE/JAW FRACTURE 7/1/2008 RBRVS $976.32 $976.32 090 Y Y Y21355 TREAT CHEEK BONE FRACTURE 7/1/2008 RBRVS $340.72 $254.34 010 Y21360 TREAT CHEEK BONE FRACTURE 7/1/2008 RBRVS $425.55 $425.55 090 Y Y21365 TREAT CHEEK BONE FRACTURE 7/1/2008 RBRVS $891.64 $891.64 090 Y Y Y21366 TREAT CHEEK BONE FRACTURE 7/1/2008 RBRVS $1,006.24 $1,006.24 090 Y Y Y21385 TREAT EYE SOCKET FRACTURE 7/1/2008 RBRVS $574.45 $574.45 090 Y Y Y21400 TREAT EYE SOCKET FRACTURE 7/1/2008 RBRVS $135.13 $111.46 090 Y21406 TREAT EYE SOCKET FRACTURE 7/1/2008 RBRVS $434.85 $434.85 090 Y Y Y21421 TREAT MOUTH ROOF FRACTURE 7/1/2008 RBRVS $553.76 $485.31 090 Y21422 TREAT MOUTH ROOF FRACTURE 7/1/2008 RBRVS $543.66 $543.66 090 Y Y Y21423 TREAT MOUTH ROOF FRACTURE 7/1/2008 RBRVS $643.89 $643.89 090 Y Y Y21431 TREAT CRANIOFACIAL FRACTURE 7/1/2008 RBRVS $591.62 $591.62 090 Y Y21432 TREAT CRANIOFACIAL FRACTURE 7/1/2008 RBRVS $538.82 $538.82 090 Y Y21433 TREAT CRANIOFACIAL FRACTURE 7/1/2008 RBRVS $1,365.49 $1,365.49 090 Y Y Y21435 TREAT CRANIOFACIAL FRACTURE 7/1/2008 RBRVS $1,072.58 $1,072.58 090 Y Y21436 TREAT CRANIOFACIAL FRACTURE 7/1/2008 RBRVS $1,542.60 $1,542.60 090 Y Y Y21440 TREAT DENTAL RIDGE FRACTURE 7/1/2008 RBRVS $389.85 $332.89 090 Y21445 TREAT DENTAL RIDGE FRACTURE 7/1/2008 RBRVS $566.62 $483.45 090 Y Y21450 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $408.49 $355.70 090 Y21451 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $548.69 $480.54 090 Y21452 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $481.71 $251.35 090 Y21453 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $633.26 $582.69 090 Y21454 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $442.76 $442.76 090 Y Y21461 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $1,374.91 $723.46 090 Y Y21462 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $1,507.96 $796.07 090 Y Y Y21465 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $738.47 $738.47 090 Y Y Y21470 TREAT LOWER JAW FRACTURE 7/1/2008 RBRVS $958.36 $958.36 090 Y Y Y21480 RESET DISLOCATED JAW 7/1/2008 RBRVS $73.94 $26.93 000 Y Y21485 RESET DISLOCATED JAW 7/1/2008 RBRVS $484.85 $428.20 090 Y Y21490 REPAIR DISLOCATED JAW 7/1/2008 RBRVS $744.94 $744.94 090 Y Y Y Y21497 INTERDENTAL WIRING 7/1/2008 RBRVS $486.37 $427.48 090 Y21499 HEAD SURGERY PROCEDURE 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y29800 JAW ARTHROSCOPY/SURGERY 7/1/2008 RBRVS $427.71 $427.71 090 Y Y Y29804 JAW ARTHROSCOPY/SURGERY 7/1/2008 RBRVS $529.18 $529.18 090 Y Y Y Y Y30580 REPAIR UPPER JAW FISTULA 7/1/2008 RBRVS $494.57 $407.55 090 Y Please see first page for a complete description 10 of information contained in the fee schedules. Fees as of July 2008
  • 11. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust30600 REPAIR MOUTH/NOSE FISTULA 7/1/2008 RBRVS $455.92 $359.93 090 Y31020 EXPLORATION, MAXILLARY SINUS 7/1/2008 RBRVS $377.22 $274.84 090 Y Y31030 EXPLORATION, MAXILLARY SINUS 7/1/2008 RBRVS $556.56 $415.76 090 Y Y31032 EXPLORE SINUS REMOVE POLYPS 7/1/2008 RBRVS $454.22 $454.22 090 Y Y31299 SINUS SURGERY PROCEDURE 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y40490 BIOPSY OF LIP 7/1/2008 RBRVS $99.09 $58.77 000 Y40500 PARTIAL EXCISION OF LIP 7/1/2008 RBRVS $385.54 $287.92 090 Y40510 PARTIAL EXCISION OF LIP 7/1/2008 RBRVS $377.94 $286.41 090 Y40520 PARTIAL EXCISION OF LIP 7/1/2008 RBRVS $396.96 $291.40 090 Y40650 REPAIR LIP 7/1/2008 RBRVS $332.36 $231.27 090 Y40652 REPAIR LIP 7/1/2008 RBRVS $391.78 $285.84 090 Y40654 REPAIR LIP 7/1/2008 RBRVS $454.71 $341.44 090 Y40800 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $150.33 $100.11 010 Y40801 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $232.67 $175.41 010 Y40804 REMOVAL, FOREIGN BODY, MOUTH 7/1/2008 RBRVS $157.97 $102.30 010 Y40805 REMOVAL FOREIGN BODY MOUTH 7/1/2008 RBRVS $249.54 $183.28 010 Y40806 INCISION OF LIP FOLD 7/1/2008 RBRVS $79.04 $26.89 000 Y40808 BIOPSY OF MOUTH LESION 7/1/2008 RBRVS $134.00 $83.43 010 Y40810 EXCISION OF MOUTH LESION 7/1/2008 RBRVS $151.13 $99.92 010 Y40812 EXCISE/REPAIR MOUTH LESION 7/1/2008 RBRVS $214.02 $156.73 010 Y40814 EXCISE/REPAIR MOUTH LESION 7/1/2008 RBRVS $291.48 $242.54 090 Y40816 EXCISION OF MOUTH LESION 7/1/2008 RBRVS $306.12 $253.32 090 Y40818 EXCISE ORAL MUCOSA FOR GRAFT 7/1/2008 RBRVS $268.37 $215.91 090 Y40819 EXCISE LIP OR CHEEK FOLD 7/1/2008 RBRVS $230.44 $185.32 090 Y40820 TREATMENT OF MOUTH LESION 7/1/2008 RBRVS $192.01 $130.25 010 Y40830 REPAIR MOUTH LACERATION 7/1/2008 RBRVS $186.11 $127.57 010 Y40831 REPAIR MOUTH LACERATION 7/1/2008 RBRVS $246.25 $179.99 010 Y40840 RECONSTRUCTION OF MOUTH 7/1/2008 RBRVS $634.39 $518.25 090 Y Y40842 RECONSTRUCTION OF MOUTH 7/1/2008 RBRVS $641.77 $517.30 090 Y40843 RECONSTRUCTION OF MOUTH 7/1/2008 RBRVS $812.71 $656.90 090 Y Y40844 RECONSTRUCTION OF MOUTH 7/1/2008 RBRVS $1,078.85 $913.73 090 Y Y40845 RECONSTRUCTION OF MOUTH 7/1/2008 RBRVS $1,193.94 $1,039.37 090 Y40899 MOUTH SURGERY PROCEDURE 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y41000 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $123.26 $89.03 010 Y41005 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $166.67 $100.11 010 Y41006 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $277.60 $210.09 090 Y41007 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $276.28 $200.45 090 Y41008 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $282.93 $216.37 090 Y41009 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $301.54 $236.26 090 Y41010 INCISION OF TONGUE FOLD 7/1/2008 RBRVS $153.28 $86.76 010 Y41015 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $327.14 $269.88 090 Y41016 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $335.05 $278.39 090 Y41017 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $337.92 $280.32 090 Y41018 DRAINAGE OF MOUTH LESION 7/1/2008 RBRVS $389.09 $327.67 090 Y41100 BIOPSY OF TONGUE 7/1/2008 RBRVS $129.84 $89.52 010 Y41105 BIOPSY OF TONGUE 7/1/2008 RBRVS $129.12 $89.75 010 Y41108 BIOPSY OF FLOOR OF MOUTH 7/1/2008 RBRVS $110.28 $72.24 010 Y Please see first page for a complete description 11 of information contained in the fee schedules. Fees as of July 2008
  • 12. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust41110 EXCISION OF TONGUE LESION 7/1/2008 RBRVS $158.54 $104.80 010 Y41112 EXCISION OF TONGUE LESION 7/1/2008 RBRVS $251.69 $199.24 090 Y41113 EXCISION OF TONGUE LESION 7/1/2008 RBRVS $276.16 $221.78 090 Y41114 EXCISION OF TONGUE LESION 7/1/2008 RBRVS $515.90 $515.90 090 Y41115 EXCISION OF TONGUE FOLD 7/1/2008 RBRVS $180.63 $118.26 010 Y41116 EXCISION OF MOUTH LESION 7/1/2008 RBRVS $243.79 $174.65 090 Y41120 PARTIAL REMOVAL OF TONGUE 7/1/2008 RBRVS $842.97 $842.97 090 Y Y Y41130 PARTIAL REMOVAL OF TONGUE 7/1/2008 RBRVS $1,031.62 $1,031.62 090 Y Y Y41150 TONGUE, MOUTH, JAW SURGERY 7/1/2008 RBRVS $1,755.76 $1,755.76 090 Y Y Y41153 TONGUE, MOUTH, NECK SURGERY 7/1/2008 RBRVS $1,895.65 $1,895.65 090 Y Y Y41250 REPAIR TONGUE LACERATION 7/1/2008 RBRVS $171.93 $110.85 010 Y41251 REPAIR TONGUE LACERATION 7/1/2008 RBRVS $187.17 $132.14 010 Y41252 REPAIR TONGUE LACERATION 7/1/2008 RBRVS $238.68 $173.06 010 Y41500 FIXATION OF TONGUE 7/1/2008 RBRVS $366.66 $366.66 090 Y41510 TONGUE TO LIP SURGERY 7/1/2008 RBRVS $345.79 $345.79 090 Y41520 RECONSTRUCTION, TONGUE FOLD 7/1/2008 RBRVS $262.62 $205.67 090 Y41599 TONGUE AND MOUTH SURGERY 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y41800 DRAINAGE OF GUM LESION 7/1/2008 RBRVS $160.36 $96.37 010 Y41805 REMOVAL FOREIGN BODY GUM 7/1/2008 RBRVS $161.53 $123.14 010 Y41806 REMOVAL FOREIGN BODY JAWBONE 7/1/2008 RBRVS $247.80 $199.16 010 Y41820 EXCISION, GUM, EACH QUADRANT 7/1/2003 BY REPORT $0.00 $0.00 000 Y41821 EXCISION OF GUM FLAP 7/1/2003 BY REPORT $0.00 $0.00 000 Y41822 EXCISION OF GUM LESION 7/1/2008 RBRVS $222.65 $143.00 010 Y41823 EXCISION OF GUM LESION 7/1/2008 RBRVS $321.05 $252.60 090 Y41825 EXCISION OF GUM LESION 7/1/2008 RBRVS $155.29 $106.65 010 Y41826 EXCISION OF GUM LESION 7/1/2008 RBRVS $203.47 $158.05 010 Y41827 EXCISION OF GUM LESION 7/1/2008 RBRVS $322.64 $240.76 090 Y41828 EXCISION OF GUM LESION 7/1/2008 RBRVS $237.74 $184.94 010 Y41830 REMOVAL OF GUM TISSUE 7/1/2008 RBRVS $295.00 $227.79 010 Y41850 TREATMENT OF GUM LESION 7/1/2003 BY REPORT $0.00 $0.00 000 Y41870 GUM GRAFT 7/1/2003 BY REPORT $0.00 $0.00 000 Y41872 REPAIR GUM 7/1/2008 RBRVS $277.37 $208.58 090 Y41874 REPAIR TOOTH SOCKET 7/1/2008 RBRVS $280.36 $206.76 090 Y41899 DENTAL SURGERY PROCEDURE 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y42000 DRAINAGE MOUTH ROOF LESION 7/1/2008 RBRVS $123.67 $82.41 010 Y42100 BIOPSY ROOF OF MOUTH 7/1/2008 RBRVS $115.62 $87.78 010 Y42104 EXCISION LESION MOUTH ROOF 7/1/2008 RBRVS $155.06 $108.66 010 Y42106 EXCISION LESION MOUTH ROOF 7/1/2008 RBRVS $197.38 $146.82 010 Y42107 EXCISION LESION, MOUTH ROOF 7/1/2008 RBRVS $350.97 $277.07 090 Y42120 REMOVE PALATE/LESION 7/1/2008 RBRVS $770.24 $770.24 090 Y Y Y42140 EXCISION OF UVULA 7/1/2008 RBRVS $188.68 $123.41 090 Y42145 REPAIR PALATE, PHARYNX/UVULA 7/1/2008 RBRVS $563.40 $563.40 090 Y42160 TREATMENT MOUTH ROOF LESION 7/1/2008 RBRVS $190.76 $126.13 010 Y42180 REPAIR PALATE 7/1/2008 RBRVS $188.95 $149.28 010 Y42182 REPAIR PALATE 7/1/2008 RBRVS $258.92 $219.89 010 Y42200 RECONSTRUCT CLEFT PALATE 7/1/2008 RBRVS $731.36 $731.36 090 Y Y42205 RECONSTRUCT CLEFT PALATE 7/1/2008 RBRVS $754.74 $754.74 090 Y Y Please see first page for a complete description 12 of information contained in the fee schedules. Fees as of July 2008
  • 13. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust42210 RECONSTRUCT CLEFT PALATE 7/1/2008 RBRVS $882.91 $882.91 090 Y Y42215 RECONSTRUCT CLEFT PALATE 7/1/2008 RBRVS $583.37 $583.37 090 Y Y42220 RECONSTRUCT CLEFT PALATE 7/1/2008 RBRVS $469.23 $469.23 090 Y Y42225 RECONSTRUCT CLEFT PALATE 7/1/2008 RBRVS $800.04 $800.04 090 Y Y42226 LENGTHENING OF PALATE 7/1/2008 RBRVS $779.58 $779.58 090 Y Y42227 LENGTHENING OF PALATE 7/1/2008 RBRVS $767.59 $767.59 090 Y Y42235 REPAIR PALATE 7/1/2008 RBRVS $627.02 $627.02 090 Y Y42260 REPAIR NOSE TO LIP FISTULA 7/1/2008 RBRVS $675.39 $565.98 090 Y Y42280 PREPARATION, PALATE MOLD 7/1/2008 RBRVS $122.01 $86.46 010 Y42281 INSERTION PALATE PROSTHESIS 7/1/2008 RBRVS $157.33 $123.75 010 Y42299 PALATE/UVULA SURGERY 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y Y42300 DRAINAGE OF SALIVARY GLAND 7/1/2008 RBRVS $161.83 $123.44 010 Y42305 DRAINAGE OF SALIVARY GLAND 7/1/2008 RBRVS $351.73 $351.73 090 Y42310 DRAINAGE OF SALIVARY GLAND 7/1/2008 RBRVS $126.70 $100.49 010 Y42320 DRAINAGE OF SALIVARY GLAND 7/1/2008 RBRVS $193.56 $144.93 010 Y42330 REMOVAL OF SALIVARY STONE 7/1/2008 RBRVS $180.93 $133.28 010 Y42335 REMOVAL OF SALIVARY STONE 7/1/2008 RBRVS $285.35 $210.51 090 Y42340 REMOVAL OF SALIVARY STONE 7/1/2008 RBRVS $363.41 $277.98 090 Y42400 BIOPSY OF SALIVARY GLAND 7/1/2008 RBRVS $84.79 $48.30 000 Y42405 BIOPSY OF SALIVARY GLAND 7/1/2008 RBRVS $240.12 $186.38 010 Y42408 EXCISION OF SALIVARY CYST 7/1/2008 RBRVS $355.43 $268.07 090 Y42410 EXCISE PAROTID GLAND/LESION 7/1/2008 RBRVS $511.55 $511.55 090 Y Y Y42415 EXCISE PAROTID GLAND/LESION 7/1/2008 RBRVS $923.03 $923.03 090 Y Y Y42420 EXCISE PAROTID GLAND/LESION 7/1/2008 RBRVS $1,060.09 $1,060.09 090 Y Y Y42425 EXCISE PAROTID GLAND/LESION 7/1/2008 RBRVS $698.91 $698.91 090 Y Y Y42426 EXCISE PAROTID GLAND/LESION 7/1/2008 RBRVS $1,134.90 $1,134.90 090 Y Y Y42440 EXCISE SUBMAXILLARY GLAND 7/1/2008 RBRVS $378.99 $378.99 090 Y Y Y42450 EXCISE SUBLINGUAL GLAND 7/1/2008 RBRVS $356.08 $292.08 090 Y42500 REPAIR SALIVARY DUCT 7/1/2008 RBRVS $338.07 $277.90 090 Y42505 REPAIR SALIVARY DUCT 7/1/2008 RBRVS $443.78 $374.64 090 Y42507 PAROTID DUCT DIVERSION 7/1/2008 RBRVS $415.15 $415.15 090 Y Y42508 PAROTID DUCT DIVERSION 7/1/2008 RBRVS $584.96 $584.96 090 Y Y42509 PAROTID DUCT DIVERSION 7/1/2008 RBRVS $701.79 $701.79 090 Y42510 PAROTID DUCT DIVERSION 7/1/2008 RBRVS $515.75 $515.75 090 Y Y Y42550 INJECTION FOR SALIVARY X-RAY 7/1/2008 RBRVS $129.57 $55.33 000 Y42600 CLOSURE OF SALIVARY FISTULA 7/1/2008 RBRVS $376.91 $287.02 090 Y42650 DILATION OF SALIVARY DUCT 7/1/2008 RBRVS $64.56 $48.26 000 Y42660 DILATION OF SALIVARY DUCT 7/1/2008 RBRVS $83.36 $64.18 000 Y42665 LIGATION OF SALIVARY DUCT 7/1/2008 RBRVS $234.82 $167.92 090 Y42699 SALIVARY SURGERY PROCEDURE 7/1/2008 BY REPORT $0.00 $0.00 010 Y Y Y Y42900 REPAIR THROAT WOUND 7/1/2008 RBRVS $286.94 $286.94 010 Y64600 INJECTION TREATMENT OF NERVE 7/1/2008 RBRVS $356.00 $172.04 010 Y64612 DESTROY NERVE, FACE MUSCLE 7/1/2008 RBRVS $130.71 $108.32 010 Y Y64732 INCISION OF BROW NERVE 7/1/2008 RBRVS $295.64 $295.64 090 Y Y64734 INCISION OF CHEEK NERVE 7/1/2008 RBRVS $334.25 $334.25 090 Y64738 INCISION OF JAW NERVE 7/1/2008 RBRVS $377.82 $377.82 090 Y Y64740 INCISION OF TONGUE NERVE 7/1/2008 RBRVS $375.48 $375.48 090 Y Y Please see first page for a complete description 13 of information contained in the fee schedules. Fees as of July 2008
  • 14. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust70100 X-RAY EXAM OF JAW 7/1/2008 RBRVS $26.13 $26.1370100 TC X-RAY EXAM OF JAW 7/1/2008 RBRVS $18.19 $18.1970100 26 X-RAY EXAM OF JAW 7/1/2008 RBRVS $7.98 $7.9870300 X-RAY EXAM OF TEETH 7/1/2008 RBRVS $12.75 $12.7570300 TC X-RAY EXAM OF TEETH 7/1/2008 RBRVS $7.94 $7.9470300 26 X-RAY EXAM OF TEETH 7/1/2008 RBRVS $4.80 $4.8070328 X-RAY EXAM OF JAW JOINT 7/1/2008 RBRVS $25.49 $25.4970328 TC X-RAY EXAM OF JAW JOINT 7/1/2008 RBRVS $17.55 $17.5570328 26 X-RAY EXAM OF JAW JOINT 7/1/2008 RBRVS $7.98 $7.9870330 X-RAY EXAM OF JAW JOINTS 7/1/2008 RBRVS $40.01 $40.0170330 TC X-RAY EXAM OF JAW JOINTS 7/1/2008 RBRVS $29.61 $29.6170330 26 X-RAY EXAM OF JAW JOINTS 7/1/2008 RBRVS $10.40 $10.4070332 X-RAY EXAM OF JAW JOINT 7/1/2008 RBRVS $81.50 $81.50 Y70332 TC X-RAY EXAM OF JAW JOINT 7/1/2008 RBRVS $57.90 $57.90 Y70332 26 X-RAY EXAM OF JAW JOINT 7/1/2008 RBRVS $23.60 $23.60 Y70350 X-RAY HEAD FOR ORTHODONTIA 7/1/2008 RBRVS $18.76 $18.7670350 TC X-RAY HEAD FOR ORTHODONTIA 7/1/2008 RBRVS $11.16 $11.1670350 26 X-RAY HEAD FOR ORTHODONTIA 7/1/2008 RBRVS $7.60 $7.6070355 PANORAMIC X-RAY OF JAWS 7/1/2008 RBRVS $22.96 $22.9670355 TC PANORAMIC X-RAY OF JAWS 7/1/2008 RBRVS $13.96 $13.9670355 26 PANORAMIC X-RAY OF JAWS 7/1/2008 RBRVS $9.00 $9.0070380 X-RAY EXAM OF SALIVARY GLAND 7/1/2008 RBRVS $31.81 $31.8170380 TC X-RAY EXAM OF SALIVARY GLAND 7/1/2008 RBRVS $24.20 $24.2070380 26 X-RAY EXAM OF SALIVARY GLAND 7/1/2008 RBRVS $7.60 $7.6076100 X-RAY EXAM OF BODY SECTION 7/1/2008 RBRVS $101.24 $101.2476100 TC X-RAY EXAM OF BODY SECTION 7/1/2008 RBRVS $75.64 $75.6476100 26 X-RAY EXAM OF BODY SECTION 7/1/2008 RBRVS $25.60 $25.6076499 RADIOGRAPHIC PROCEDURE 7/1/2003 BY REPORT $0.00 $0.0076499 TC RADIOGRAPHIC PROCEDURE 7/1/2003 BY REPORT $0.00 $0.0076499 26 RADIOGRAPHIC PROCEDURE 7/1/2003 BY REPORT $0.00 $0.0093040 RHYTHM ECG WITH REPORT 7/1/2008 RBRVS $12.03 $12.0395873 GUIDE NERV DESTR ELEC STIM 7/1/2008 RBRVS $35.10 $35.10 ZZZ95873 TC GUIDE NERV DESTR ELEC STIM 7/1/2008 RBRVS $17.85 $17.85 ZZZ95873 26 GUIDE NERV DESTR ELEC STIM 7/1/2008 RBRVS $17.25 $17.25 ZZZ95874 GUIDE NERV DESTR NEEDLE EMG 7/1/2008 RBRVS $34.45 $34.45 ZZZ95874 TC GUIDE NERV DESTR NEEDLE EMG 7/1/2008 RBRVS $17.21 $17.21 ZZZ95874 26 GUIDE NERV DESTR NEEDLE EMG 7/1/2008 RBRVS $17.25 $17.25 ZZZ99070 SPECIAL SUPPLIES 7/1/2003 RBRVS $0.00 $0.0099201 OFFICE/OUTPATIENT VISIT, NEW 7/1/2008 RBRVS $31.88 $20.0499202 OFFICE/OUTPATIENT VISIT, NEW 7/1/2008 RBRVS $55.07 $38.7399203 OFFICE/OUTPATIENT VISIT, NEW 7/1/2008 RBRVS $80.86 $59.4599204 OFFICE/OUTPATIENT VISIT, NEW 7/1/2008 RBRVS $124.13 $99.1699205 OFFICE/OUTPATIENT VISIT, NEW 7/1/2008 RBRVS $156.20 $129.0099211 OFFICE/OUTPATIENT VISIT, EST 7/1/2008 RBRVS $17.21 $7.6099212 OFFICE/OUTPATIENT VISIT, EST 7/1/2008 RBRVS $32.87 $20.0499213 OFFICE/OUTPATIENT VISIT, EST 7/1/2008 RBRVS $53.33 $38.3199214 OFFICE/OUTPATIENT VISIT, EST 7/1/2008 RBRVS $80.29 $59.83 Please see first page for a complete description 14 of information contained in the fee schedules. Fees as of July 2008
  • 15. Montana Medicaid - Fee Schedule Oral Surgeon Fees Global Indicators Policy Proc Mod Description Effective Method Office Facility Days PA Mult Bilat Assist CoSurg Team Adjust99215 OFFICE/OUTPATIENT VISIT, EST 7/1/2008 RBRVS $108.77 $85.7499221 INITIAL HOSPITAL CARE 7/1/2008 RBRVS $77.68 $77.6899222 INITIAL HOSPITAL CARE 7/1/2008 RBRVS $106.80 $106.8099223 INITIAL HOSPITAL CARE 7/1/2008 RBRVS $157.07 $157.0799231 SUBSEQUENT HOSPITAL CARE 7/1/2008 RBRVS $32.30 $32.3099232 SUBSEQUENT HOSPITAL CARE 7/1/2008 RBRVS $57.79 $57.7999233 SUBSEQUENT HOSPITAL CARE 7/1/2008 RBRVS $82.90 $82.9099238 HOSPITAL DISCHARGE DAY 7/1/2008 RBRVS $58.70 $58.7099241 OFFICE CONSULTATION 7/1/2008 RBRVS $42.40 $28.6399242 OFFICE CONSULTATION 7/1/2008 RBRVS $79.23 $60.3699243 OFFICE CONSULTATION 7/1/2008 RBRVS $108.88 $84.2699244 OFFICE CONSULTATION 7/1/2008 RBRVS $160.43 $132.2699245 OFFICE CONSULTATION 7/1/2008 RBRVS $198.06 $166.0799251 INPATIENT CONSULT 7/1/2008 RBRVS $41.72 $41.7299252 INPATIENT CONSULT 7/1/2008 RBRVS $66.07 $66.0799253 INPATIENT CONSULT 7/1/2008 RBRVS $98.75 $98.7599254 INPATIENT CONSULT 7/1/2008 RBRVS $142.58 $142.5899255 INPATIENT CONSULT 7/1/2008 RBRVS $175.60 $175.6099281 EMERGENCY DEPT VISIT 7/1/2008 RBRVS $17.85 $17.8599282 EMERGENCY DEPT VISIT 7/1/2008 RBRVS $33.62 $33.6299283 EMERGENCY DEPT VISIT 7/1/2008 RBRVS $54.01 $54.0199284 EMERGENCY DEPT VISIT 7/1/2008 RBRVS $100.00 $100.0099285 EMERGENCY DEPT VISIT 7/1/2008 RBRVS $149.20 $149.2099381 PREV VISIT, NEW, INFANT 7/1/2008 RBRVS $103.25 $72.5899382 PREV VISIT, NEW, AGE 1-4 7/1/2008 RBRVS $110.21 $80.1499383 PREV VISIT, NEW, AGE 5-11 7/1/2008 RBRVS $108.92 $80.1499384 PREV VISIT, NEW, AGE 12-17 7/1/2008 RBRVS $117.20 $88.4699385 PREV VISIT, NEW, AGE 18-39 7/1/2008 RBRVS $92.17 $65.3299386 PREV VISIT, NEW, AGE 40-64 7/1/2008 RBRVS $108.09 $80.2599387 PREV VISIT, NEW, 65 & OVER 7/1/2008 RBRVS $117.66 $87.2599391 PREV VISIT, EST, INFANT 7/1/2008 RBRVS $84.75 $64.6399392 PREV VISIT, EST, AGE 1-4 7/1/2008 RBRVS $92.70 $72.5899393 PREV VISIT, EST, AGE 5-11 7/1/2008 RBRVS $92.05 $72.5899394 PREV VISIT, EST, AGE 12-17 7/1/2008 RBRVS $99.66 $80.1499395 PREV VISIT, EST, AGE 18-39 7/1/2008 RBRVS $78.17 $58.0299396 PREV VISIT, EST, AGE 40-64 7/1/2008 RBRVS $85.78 $65.3299397 PREV VISIT, EST, 65 & OVER 7/1/2008 RBRVS $95.68 $72.9599420 HEALTH RISK ASSESSMENT TEST 7/1/2008 RBRVS $7.34 $7.3499429 UNLISTED PREVENTIVE SERVICE 7/1/2003 BY REPORT $0.00 $0.0099499 UNLISTED E&M SERVICE 7/1/2003 BY REPORT $0.00 $0.00 Please see first page for a complete description 15 of information contained in the fee schedules. Fees as of July 2008