(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