X. ORAL and Maxillofacial SURGERY EXTRACTIONS - INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED & ROUTINE POSTOPERATIVE CARE D7111 Extraction, Coronal Remnants Deciduous YES YES NO NO $55.00 – D7140 Extraction, Erupted Tooth or exposed Root (elevation YES YES NO NO $91.00 and/or forceps removal) Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under age 21 age 21 & age 21 age 21 & & all over when & all over allowed when residents* 25.04 residents allowed under 25.04 SURGICAL EXTRACTIONS (INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED, & ROUTINE POSTOPERATIVE CARE) – D7210 Surgical Removal of Erupted Tooth Requiring Removal Yes Yes No No Documented need demonstrated $110.00 of Bone and/or Sectioning by X-rays D7220 Removal of Impacted - Soft Tissue Yes Yes No No Documented need demonstrated $95.00 by X-rays D7230 Removal of Impacted Tooth - Partially Bony Yes Yes No No Documented need demonstrated $155.00 by X-rays D7240 Removal of Impacted Tooth Completely Bony Yes Yes No No Documented need demonstrated $185.00 – by X-rays D7241 Removal of Impacted Tooth Completely Bony, with Yes Yes No No Documented need demonstrated $215.00 – Unusual Surgical Complications by X - rays
X. ORAL and Maxillofacial SURGERY EXTRACTIONS - INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED & ROUTINE POSTOPERATIVE CARE D7111 Extraction, Coronal Remnants – Deciduous YES YES NO NO $55.00 D7140 Extraction, Erupted Tooth or exposed Root (elevation and/or forceps removal) YES YES NO NO $91.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed 25.04 age 21 & all residents age 21 & over when allowed under 25.04 SURGICAL EXTRACTIONS – (INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED, & ROUTINE POSTOPERATIVE CARE) D7210 Surgical Removal of Erupted Tooth Requiring Removal of Bone and/or Sectioning Yes Yes No No Documented need demonstrated by X-rays $110.00 D7220 Removal of Impacted - Soft Tissue Yes Yes No No Documented need demonstrated by X-rays $95.00 D7230 Removal of Impacted Tooth - Partially Bony Yes Yes No No Documented need demonstrated by X-rays $155.00 D7240 Removal of Impacted Tooth – Completely Bony Yes Yes No No Documented need demonstrated by X-rays $185.00 D7241 Removal of Impacted Tooth – Completely Bony, with Unusual Surgical Complications Yes Yes No No Documented need demonstrated by X - rays $215.00
c3s025.docx