Osteotomy Mandibular Rami with Bone Graft; Yes Yes Yes Yes $2,529.00 – Includes Obtaining The Graft Osteotomy - Segmented or Subapical Yes Yes Yes Yes $2,213.00 Osteotomy - Body of The Mandible Yes Yes Yes Yes $2,213.00 LeFort I (maxilla - total) Yes Yes Yes Yes $2,213.00 LeFort I (maxilla - segmented) Yes Yes Yes Yes $2,213.00 LeFort II or LeFort III (Osteoplasty of Facial Bones for Yes Yes Yes Yes $2,213.00 Midface Hypoplasia or Retrusion) - without Bone Graft LeFort II or LeFort III with Bone Graft Yes Yes Yes YES $2,529.00 – D7950 Osseous, Osteoperiosteal, or Cartilage of The Yes Yes Yes Yes By Report Mandible or Maxilla - Autogenous or Nonautogenous, by Report D7951 Sinus Augmentation with Bone or Bone Substitutes via a NO NO Not Covered Lateral Open Approach D7952 Sinus Augmentation via a Vertical Approach NO NO Not Covered Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under age 21 age 21 & age age 21 & & all over when 21 & all over allowed ICF-IID when residents* under residents allowed 25.04 under 25.04 D7953 Bone Replacement Graft for Ridge Preservation - Per Site YES YES NO NO Only reimbursable when $325.00 necessary for bone graft for reconstruction of alveolar defect. D7955 Repair of Maxillofacial Soft and/or Hard Tissue Defect Yes Yes No No $412.00 D7960 Frenulectomy (Frenectomy or Frenotomy) - Separate Yes Yes No NO $97.00 Procedure Not Incidental to Another Frenuloplasty YES YES NO NO $125.00
Osteotomy – Mandibular Rami with Bone Graft; Includes Obtaining The Graft Yes Yes Yes Yes $2,529.00 Osteotomy - Segmented or Subapical Yes Yes Yes Yes $2,213.00 Osteotomy - Body of The Mandible Yes Yes Yes Yes $2,213.00 LeFort I (maxilla - total) Yes Yes Yes Yes $2,213.00 LeFort I (maxilla - segmented) Yes Yes Yes Yes $2,213.00 LeFort II or LeFort III (Osteoplasty of Facial Bones for Midface Hypoplasia or Retrusion) - without Bone Graft Yes Yes Yes Yes $2,213.00 LeFort II or LeFort III – with Bone Graft Yes Yes Yes YES $2,529.00 D7950 Osseous, Osteoperiosteal, or Cartilage of The Mandible or Maxilla - Autogenous or Nonautogenous, by Report Yes Yes Yes Yes By Report D7951 Sinus Augmentation with Bone or Bone Substitutes via a Lateral Open Approach NO NO Not Covered D7952 Sinus Augmentation via a Vertical Approach NO NO Not Covered 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 under 25.04 age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D7953 Bone Replacement Graft for Ridge Preservation - Per Site YES YES NO NO Only reimbursable when necessary for bone graft for reconstruction of alveolar defect. $325.00 D7955 Repair of Maxillofacial Soft and/or Hard Tissue Defect Yes Yes No No $412.00 D7960 Frenulectomy (Frenectomy or Frenotomy) - Separate Procedure Not Incidental to Another Yes Yes No NO $97.00 Frenuloplasty YES YES NO NO $125.00
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