D7780 Facial Bones - Complicated Reduction with Fixation and Yes Yes No No $1,383.00 Multiple Surgical Approaches REDUCTION OF DISLOCATION AND MANAGEMENT OF TEMPOROMANDIBULAR JOINT DYSFUNCTIONS D7810 Open Reduction of Dislocation NO NO Not Covered D7820 Closed Reduction of Dislocation NO NO Not Covered D7830 Manipulation Under Anesthesia NO NO Not Covered D7840 Condylectomy No No Not Covered D7850 Surgical Discectomy, with/without Implant Yes Yes Yes Yes $1,185.50 Disc Repair No No Not Covered D7854 Synovectomy No No Not Covered Myotomy No No Not Covered D7858 Joint Reconstruction No No Not Covered Covered Service Authorization Additional Limits Max Proc. Description Age/ICF-IID required Code under age 21 age 21 & age 21 age 21 & & all over when & all over allowed when residents* under residents allowed 25.04 under 25.04 D7860 Arthrotomy Yes Yes Yes Yes $1,185.50 D7865 Arthroplasty NO No Not Covered D7870 Arthrocentesis NO NO Not Covered Non-arthroscopic and Lavage NO NO Not Covered D7872 Arthroscopy - Diagnosis, with or without Biopsy NO NO Not Covered D7873 Arthroscopy - Surgical; Lavage and Lysis of Adhesions NO NO Not Covered Arthroscopy Surgical; Disc Repositioning and NO NO Not Covered – Stabilization D7875 Arthroscopy Surgical; Synovectomy NO NO Not Covered – Arthroscopy Surgical; Discectomy NO NO Not Covered –
D7780 Facial Bones - Complicated Reduction with Fixation and Multiple Surgical Approaches Yes Yes No No $1,383.00 REDUCTION OF DISLOCATION AND MANAGEMENT OF TEMPOROMANDIBULAR JOINT DYSFUNCTIONS D7810 Open Reduction of Dislocation NO NO Not Covered D7820 Closed Reduction of Dislocation NO NO Not Covered D7830 Manipulation Under Anesthesia NO NO Not Covered D7840 Condylectomy No No Not Covered D7850 Surgical Discectomy, with/without Implant Yes Yes Yes Yes $1,185.50 Disc Repair No No Not Covered D7854 Synovectomy No No Not Covered Myotomy No No Not Covered D7858 Joint Reconstruction No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Authorization required Additional Limits Max under age 21 & all residents* age 21 & over when allowed under 25.04 age 21 & all residents age 21 & over when allowed under 25.04 D7860 Arthrotomy Yes Yes Yes Yes $1,185.50 D7865 Arthroplasty NO No Not Covered D7870 Arthrocentesis NO NO Not Covered Non-arthroscopic and Lavage NO NO Not Covered D7872 Arthroscopy - Diagnosis, with or without Biopsy NO NO Not Covered D7873 Arthroscopy - Surgical; Lavage and Lysis of Adhesions NO NO Not Covered Arthroscopy – Surgical; Disc Repositioning and Stabilization NO NO Not Covered D7875 Arthroscopy – Surgical; Synovectomy NO NO Not Covered Arthroscopy – Surgical; Discectomy NO NO Not Covered