D4278 Free soft tissue graft procedure (including donor site YES NO YES Must be reported in conjunction $125.00 surgery), each additional contiguous tooth or edentulous with D4277 tooth position in the same graft site NON-SURGICAL PERIODONTAL SERVICES Provisional Splinting - Intracoronal NO NO Not Covered Provisional Splinting Extracoronal No No Not Covered – Covered Service Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code age 21 age 21 & under age age 21 & & all over when 21 & all over allowed ICF-IID when residents* 25.04 residents allowed under 25.04 D4341 Periodontal Scaling and Root Planing Four or More Yes Yes Yes Yes No PA required for diagnosis $40.00 – Per Quadrant code 101 and the Department may authorize payment for Diagnosis Code 101 retroactively. D4342 Periodontal Scaling and Root Planing One to Three No no Not Covered – Teeth, Per Quadrant Full Mouth Debridement to Enable Comprehensive Yes Yes YES YES Once per year per provider. $100.00 Evaluation and Diagnosis Dental Hygienists practicing under PHS and IPDHs practicing under PHS may use this code. D4381 Localized Delivery of Antimicrobial Agents Via a No NO Not Covered Controlled Release Vehicle into Diseased Crevicular Tissue, Per Tooth
D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in the same graft site YES NO YES Must be reported in conjunction with D4277 $125.00 NON-SURGICAL PERIODONTAL SERVICES Provisional Splinting - Intracoronal NO NO Not Covered Provisional Splinting – Extracoronal No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D4341 Periodontal Scaling and Root Planing – Four or More Per Quadrant Yes Yes Yes Yes No PA required for diagnosis code 101 and the Department may authorize payment for Diagnosis Code 101 retroactively. $40.00 D4342 Periodontal Scaling and Root Planing – One to Three Teeth, Per Quadrant No no Not Covered Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis Yes Yes YES YES Once per year per provider. Dental Hygienists practicing under PHS and IPDHs practicing under PHS may use this code. $100.00 D4381 Localized Delivery of Antimicrobial Agents Via a Controlled Release Vehicle into Diseased Crevicular Tissue, Per Tooth No NO Not Covered
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