N.J. Admin. Code § 10:56-3.6 - D4000 D4999 PERIODONTICS

(a) Surgical services (including usual post-operative services):

				Maximum Fee
HCPCS	Allowance
IND	Code	Mod	Procedure Description	S	$	NS
#	D4210	Gingivectomy or Gingivoplasty--Per	43.60	37.50
Quadrant
*	D4211	Gingivectomy or Gingivoplasty--Per	6.00	5.50
Tooth

NOTE 1: Maximum number of teeth reimbursable--Three.

NOTE 2: D4210 PA required only when exceeding four quadrants, twice annually.

#	D4220	Gingival Curettage, Surgical--Per	22.50	19.50
Quadrant
#	D4260	Osseous Surgery (including Flap	75.00	64.50
Entry and Closure)--Per Quadrant
*	D4261	Osseous, Single Site	56.25	48.40
*	D4263	Bone Replacement Graft First Site	261.00	261.00
in Quadrant
*	D4264	Bone Replacement Graft--Each	130.50	130.50
Additional Site in Quadrant (Use
if Performed on Same Date of
Service)
#	D4270	Pedicle Soft Tissue Graft Procedure	32.00	28.00

NOTE 1: Per site.

NOTE 2: D4220, D4260, D4261, D4270 PA required only for services exceeding four quadrants, twice annually.

#	D4271	Free Soft Tissue Graft Procedure	49.00	42.00
(Including Donor Site)

NOTE: Per site.

*

D4245

Apically Positioned Flap

36.00

31.50

NOTE: Per quadrant.

*	D4249	Clinical Crown Lengthening--Hard	75.00	64.50
Tissue

NOTE: Per quadrant.

*	D4274	Distal or Proximal Wedge Procedure	169.00	153.00
(When Not Performed in Conjunction
with Surgical Procedures in the
same Anatomical Area)

(b) Adjunctive periodontal services:

D4320

Provisional Splinting--Intracoronal

18.00

16.00

NOTE: Per tooth.

D4321

Provisional Splinting--Extracoronal

11.00

10.00

NOTE 1: Per tooth.

NOTE 2: This code may also be used for stabilization of traumatized teeth.

#	D4341	Periodontal Scaling and Root	37.50	34.50
Planing--Per Quadrant
D4355	Full Mouth Debridement to Enable	11.00	10.00
Comprehensive Periodontal
Evaluation and Diagnosis
D4355	76	Full Mouth Debridement to Enable	11.00	10.00
Comprehensive Periodontal
Evaluation and Diagnosis

NOTE 1: Code to replace Y2105-76--additional scaling.

NOTE 2: Code to be used when the beneficiary is developmentally disabled * [on]* *or* neurologically impaired (see N.J.A.C. 10:56-2.9(a)1 ii).

NOTE 3: D4341 PA required for services exceeding four quadrants, twice annually.

d*	D4999	Unspecified Periodontal Procedure,	BR	BR
By Report

Notes

N.J. Admin. Code § 10:56-3.6

Amended by R.1996 d.428, effective 9/16/1996.
See: 28 N.J.R. 3069(a), 28 N.J.R. 4243(a).
Amended by R.2000 d.426, effective 10/16/2000.
See: 32 N.J.R. 2411(a), 32 N.J.R. 3836(a).
In (b), changed Maximum Fee Allowances for Peridontal Scaling and Root Planing--Per Quadrant.
Amended by R.2003 d.16, effective 1/6/2002.
See: 34 N.J.R. 2681(a), 35 N.J.R. 232(a).
Rewrote the section.
Amended by R.2004 d.25, effective 1/20/2004.
See: 35 N.J.R. 4032(a), 36 N.J.R. 568(a).
Rewrote the section.