D.C. Mun. Regs. tit. 29, § 964
Dental Services
Authority: An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code §1-307.02 (2006 Repl.; & 2011 Supp.)), and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code §7-771.05(6) (2008 Repl.)). Source: Final Rulemaking published at 50 DCR 7549 (September 5, 2003); as amended by Final Rulemaking published at 53 DCR 1699 (March 10, 2006); as amended by Final Rulemaking published at 54 DCR 5593 (June 8, 2007); as amended by Emergency and Proposed Rulemaking published at 58 DCR 7566 (August 19, 2011)[EXPIRED]; as amended by Final Rulemaking published at 59 DCR 2151(March 16, 2012); as corrected by Errata Notice published at 59 DCR 2297 (March 23, 2012); as amended by Final Rulemaking published at 60 DCR 6652 (May 10, 2013); as amended by Final Rulemaking published at 63 DCR 15767 (December 23, 2016).District of Columbia, Office of the Secretary
964.1 The reimbursement rate for dental services provided to eligible Medicaid recipients under the age of twenty-one (21) shall be as follows:
| DESCRIPTION OF SERVICE |
RATE |
| Periodic Dental Screening |
$35.00 |
| Limit Oral Eval Problm Focus |
$50.00 |
| Comprehensive Oral Evaluation |
$77.50 |
| Extensive Oral Eval Prob Focus |
$67.50 |
| Re-Eval Est Pt. Problem Focus |
$45.00 |
| Comp Periodontal Evaluation |
$77.50 |
| Intraor Complete Film Series |
$91.00 |
| Periapical XRay; First Film |
$20.00 |
| Periapical XRay; Each Additional FL |
$16.00 |
| Occlusal XRay |
$29.00 |
| Bitewing, Single First Film |
$21.00 |
| Dental Bitewings Two Films |
$40.00 |
| Dental Bitewings Four Films |
$48.00 |
| P.A. Film |
$100.00 |
| Panorex |
$80.00 |
| Cephalometric Film |
$100.00 |
| Pulp Test |
$39.00 |
| Study Models |
$75.00 |
| Preventive Prophylaxis (Adult) |
$77.50 |
| Preventive Prophylaxis (Child) |
$47.00 |
| Topical Fluor w/o Prophy Chi |
$29.00 |
| Topical Fluor w/o Prophy Adult |
$26.00 |
| Dental Sealants |
$38.00 |
| Fixed Band Type |
$230.00 |
| Fixed, Band Type Bilat (New) |
$325.00 |
| Amalgam One Surface, Primary |
$90.00 |
| Amalgam Two Surfaces, Primary |
$115.00 |
| Amalgam Three Surfaces, Primary |
$139.00 |
| Amalgam Four Surfaces, Primary |
$165.00 |
| Amalgam. One Surface, Permanent |
$90.00 |
| Amalgam Two Surfaces, Permanent |
$115.00 |
| Amalgam Three Surfaces, Permanent |
$139.00 |
| Amalgam Four Surfaces, Permanent |
$165.00 |
| Acrylic or Plastic Restoration,III |
$106.00 |
| Resin Two Surfaces Anterior |
$135.00 |
| Composite Resin 3 Surfaces Restoration |
$165.00 |
| Esthetic Restoration Class IV |
$200.00 |
| Resin-Based Composite One Surface |
$120.00 |
| Resin-Based Composite Two Surface |
$160.00 |
| Resin-Based Composite Three Surface |
$200.00 |
| Resin-Based Composite Four Surface |
$236.00 |
| Acrylic Jacket |
$400.00 |
| Crown Resin |
$500.00 |
| Gold (Full Cast) |
$600.00 |
| Replacement Crown |
$75.00 |
| Pulp Cap Direct, Exclude Final Rest |
$55.00 |
| Pulpotomy |
$134.00 |
| One Canal; Excludes Final Restoration |
$498.00 |
| Two Canals; Excludes Final Restoration |
$591.00 |
| Three Canals; Excludes Final Restoration |
$728.00 |
| Retreatment of Previous Root Canal |
$657.00 |
| Apexification/Recalcification Initial Visit |
$248.00 |
| Apicoectomy |
$467.00 |
| Apicoectomy/Periradicular Surg (Ea Add'l) |
$248.00 |
| Retrograde Amalgam |
$180.00 |
| Gingivectomy or Gingivoplasty, 5 MOR.T |
$446.00 |
| Gingivectomy or Gingiviplasty, 1 T to 3 T |
$160.00 |
| Clinical Crown Lengthening |
$496.00 |
| Bone Replacement Graft 1st |
$452.00 |
| Bone Replacement Graft-Ea add'l site Quad |
$339.00 |
| Deep Scaling |
$181.00 |
| Full Mouth Debridement |
$130.00 |
| Complete Upper Denture |
$1,120.00 |
| Complete Lower Denture |
$1,125.00 |
| Upper Partial |
$375.00 |
| Dentures Maxill Part Resin |
$838.00 |
| Dentures Maxill Part Metal |
$1,200.00 |
| Repair Broken Complete Denture |
$145.00 |
| Replace FX Broken & Tooth on Denture |
$125.00 |
| Extraction Erupted Tooth |
$110.00 |
| Extraction of Tooth, Erupted |
$192.00 |
| Extraction of Tooth, Soft Tiss. Imp |
$210.00 |
| Extraction of Tooth Partial Bony |
$285.00 |
| Extraction of Tooth, Complete Bony, Impac |
$350.00 |
| Root Tips |
$350.00 |
| Replantation of Tooth with Splint |
$375.00 |
| Surgical Exposure of Boney Impaction |
$341.00 |
| Mobilization Erupted |
$352.00 |
| Biopsy of Oral Tissue Soft |
$201.00 |
| Alveolectomy with Extraction |
$200.00 |
| Alveloplasty not in conj w/ext. per quad |
$295.00 |
| Stomatoplasty per arch uncomplicated |
$635.00 |
| Excision of Canula |
$330.00 |
| Incision Drainage Abscess, Intraoral |
$155.00 |
| Incision & Drainage Extraoral |
$250.00 |
| Curettage of Fistulous Tract |
$247.00 |
| Frenulectomy |
$313.00 |
| Bite Plane |
$166.00 |
| Fixed Appliance Therapy |
$677.00 |
| Palliative Treatment of Dental Pain |
$85.00 |
| General Anesthesia |
$260.00 |
| Sedation Ea. Add'l 15 min |
$112.00 |
| Nitrous |
$46.00 |
| Consultation |
$112.50 |
| Hospital Visit |
$33.00 |
| Consultant Evaluation Exam |
$67.50 |
| Occlusal Equilibration by Report |
$40.00 |
| Occlusal Adjustment Ltd |
$116.00 |
| Occlusal Adjustment Complete |
$474.00 |
964.2 The reimbursement rates for dental services provided to eligible Medicaid recipients residing in an intermediate care facility for persons with mental retardation shall be as follows:
| DESCRIPTION OF SERVICE |
RATE |
| Periodic Dental Screening |
$42.00 |
| Limit Oral Eval Problm Focus |
$60.00 |
| Comprehensive Oral Evaluation |
$93.00 |
| Extensive Oral Eval Prob Focus |
$81.00 |
| Re-Eval Est Pt. Problem Focus |
$54.00 |
| Comp Periodontal Evaluation |
$93.00 |
| Intraor Complete Film Series |
$109.20 |
| Periapical XRay; First Film |
$24.00 |
| Periapical XRay; Each Additional FL |
$19.20 |
| Occlusal XRay |
$34.80 |
| Bitewing, Single First Film |
$25.20 |
| Dental Bitewings Two Films |
$48.00 |
| Dental Bitewings Four Films |
$57.60 |
| P.A. Film |
$120.00 |
| Panorex |
$96.00 |
| Cephalometric Film |
$120.00 |
| Pulp Test |
$46.80 |
| Study Models |
$90.00 |
| Preventive Prophylaxis (Adult) |
$93.00 |
| Preventive Prophylaxis (Child) |
$56.40 |
| Topical Fluor w/o Prophy Chi |
$34.80 |
| Topical Fluor w/o Prophy Adult |
$31.20 |
| Dental Sealants |
$45.60 |
| Fixed Band Type |
$276.00 |
| Fixed, Band Type Bilat (New) |
$390.00 |
| Amalgam One Surface, Primary |
$108.00 |
| Amalgam Two Surfaces, Primary |
$138.00 |
| Amalgam Three Surfaces, Primary |
$166.80 |
| Amalgam Four Surfaces, Primary |
$198.00 |
| Amalgam One Surface, Permanent |
$108.00 |
| Amalgam Two Surfaces, Permanent |
$138.00 |
| Amalgam Three Surfaces, Permanent |
$166.80 |
| Amalgam Four Surfaces, Permanent |
$198.00 |
| Acrylic or Plastic Restoration, III |
$127.20 |
| Resin Two Surfaces Anterior |
$162.00 |
| Composite Resin 3 Surfaces Restoration |
$198.00 |
| Esthetic Restoration Class N |
$240.00 |
| Resin-Based Composite One Surface |
$144.00 |
| Resin-Based Composite Two Surface |
$192.00 |
| Resin-Based Composite Three Surface |
$240.00 |
| Resin-Based Composite Four Surface |
$283.20 |
| Acrylic Jacket |
$480.00 |
| Crown Resin |
$600.00 |
| Gold (Full Cast) |
$720.00 |
| Replacement Crown |
$90.00 |
| Pulp Cap Direct, Exclude Final Rest |
$66.00 |
| Pulpotomy |
$160.80 |
| One Canal; Excludes Final Restoration |
$597.60 |
| Two. Canals; Excludes Final Restoration |
$709.20 |
| Three Canals; Excludes Final Restoration |
$873.60 |
| Retreatment of Previous Root Canal |
$788.40 |
| Apexification/Recalcification Initial Visit |
$297.60 |
| Apicoectomy |
$560.40 |
| Apicoectomy/Periradicular Surg (Ea Add'l) |
$297.60 |
| Retrograde Amalgam |
$216.00 |
| Gingivectomy or Gingivoplasty, 5 MOR.T |
$535.20 |
| Gingivectomy or Gingiviplasty, 1 T to 3 T |
$192.00 |
| Clinical Crown Lengthening |
$595.20 |
| Bone Replacement Graft 1st |
$542.40 |
| Bone Replacement Graft-Ea add'l site Quad |
$406.80 |
| Deep Scaling |
$217.20 |
| Full Mouth Debridement |
$156.00 |
| Complete Upper Denture |
$1,344.00 |
| Complete Lower Denture |
$1,350.00 |
| Upper Partial |
$450.00 |
| Dentures Maxill Part Resin |
$1,005.60 |
| Dentures Maxill Part Metal |
$1,440.00 |
| Repair Broken Complete Denture |
$174.00 |
| Replace FX Broken & Tooth on Denture |
$150.00 |
| Extraction Erupted Tooth |
$132.00 |
| Extraction of Tooth, Erupted |
$230.40 |
| Extraction of Tooth, Soft Tiss. Imp |
$252.00 |
| Extraction of Tooth Partial Bony |
$342.00 |
| Extraction of Tooth, Complete Bony, Impac |
$420.00 |
| Root Tips |
$420.00 |
| Replantation of Tooth with Splint |
$450.00 |
| Surgical Exposure of Honey Impaction |
$409.20 |
| Mobilization Erupted |
$422.40 |
| Biopsy of Oral Tissue Soft |
$241.20 |
| Alveolectomy with Extraction |
$240.00 |
| Alveloplasty not in conj w/ext. per quad |
$354.00 |
| Stomatoplasty per arch uncomplicated |
$762.00 |
| Excision of Canula |
$396.00 |
| Incision Drainage Abscess, Intraoral |
$186.00 |
| Incision & Drainage Extraoral |
$300.00 |
| Curettage of Fistulous Tract |
$296.40 |
| Frenulectomy |
$375.60 |
| Bite Plane |
$201.60 |
| Fixed Appliance Therapy |
$812.40 |
| Palliative Treatment of Dental Pain |
$102.00 |
| General Anesthesia |
$312.00 |
| Sedation Ea. Add'l 15 min |
$134.40 |
| Nitrous |
$55.20 |
| Consultation |
$135.00 |
| Hospital Visit |
$39.60 |
| Consultant Evaluation Exam |
$81.00 |
| Occlusal Equilibration by Report |
$48.00 |
| Occlusal Adjustment Ltd |
$139.20 |
| Occlusal Adjustment Complete |
$568.80 |
964.3 The reimbursement rates for dental services provided on or after April 1, 2007, to eligible Medicaid recipients over the age of twenty-one (21) shall be as follows:
| DESCRIPTION OF SERVICE |
RATE |
| Periodic Dental Screening |
$35.00 |
| Limit Oral Eval Problm Focus |
$50.00 |
| Comprehensive Oral Evaluation |
$77.50 |
| Extensive Oral Eval Prob Focus |
$67.50 |
| Re-Eval Est Pt. Problem Focus |
$45.00 |
| Comp Periodontal Evaluation |
$77.50 |
| Intraor Complete Film Series |
$91.00 |
| Periapical X Ray; First Film |
$20.00 |
| Periapical X Ray; Each Additional FL |
$16.00 |
| Occlusal X Ray |
$29.00 |
| Bitewing, Single First Film |
$21.00 |
| Dental Bitewings Two Films |
$40.00 |
| Dental Bitewings Four Films |
$48.00 |
| P.A. Film |
$100.00 |
| Panorex |
$80.00 |
| Cephalometric Film |
$100.00 |
| Pulp Test |
$39.00 |
| Study Models |
$75.00 |
| Preventive Prohylaxis (Adult) |
$77.50 |
| Topical Fluor W/O Prophy Adult |
$26.00 |
| Dental Sealants |
$38.00 |
| Fixed, Band Type |
$230.00 |
| Fixed, Band Type Bilat (New) |
$325.00 |
| Amalgam One Surface, Permanent |
$90.00 |
| Amalgam Two Surfaces, Permanent |
$115.00 |
| Amalgam Three Surfaces, Permanent |
$139.00 |
| Amalgam Four Surfaces, Permanent |
$165.00 |
| Acrylic or Plastic Restoration, III |
$106.00 |
| Resin Two Surfaces Anterior |
$135.00 |
| Composite Resin 3 Surfaces Restoration |
$165.00 |
| Esthetic Restoration Class IV |
$200.00 |
| Resin Based Composite One Surface |
$120.00 |
| Resin Based Composite Two Surface |
$160.00 |
| Resin Based Composite Three Surface |
$200.00 |
| Temporary Crown |
$55.00 |
| Dowel Post |
$45.00 |
| Replacement Crown |
$75.00 |
| Pulp Cap Direct Excluding Final Rest |
$55.00 |
| Pulpotomy |
$134.00 |
| One Canal; Excludes Final Restoration |
$498.00 |
| Two Canals; Excludes Final Restoration |
$591.00 |
| Three Canals; Excludes Final Restoration |
$728.00 |
| Retreatment of Previous Root Canal |
$657.00 |
| Apexification/Recalcification Initial Visit |
$248.00 |
| Apicoectomy |
$467.00 |
| Apicoectomy/Periradicular Surg (Ea Add'l) |
$248.00 |
| Retrograde Amalgam |
$180.00 |
| Gingivectomy or Gingivoplasty, 5 MOR.T |
$446.00 |
| Gingivectomy or Gingiviplasty, 1 T to 3 T |
$160.00 |
| Gingival Flap Proc W/ Planin |
$125.00 |
| Gngvl Flap W Rootplan 1-3 Th |
$125.00 |
| Bone Replacement Graft 1 st |
$452.00 |
| Bone Replacement Graft-Ea add'l site Quad |
$339.00 |
| Deep Scaling |
$181.00 |
| Full Mouth Debridement |
$130.00 |
| Complete Upper Denture |
$1,120.00 |
| Complete Lower Denture |
$1,125.00 |
| Upper Partial |
$375.00 |
| Dentures Maxill Part Resin |
$838.00 |
| Dentures Maxill Part Metal |
$1,200.00 |
| Dentures Mandibl Part Metal |
$1,200.00 |
| Repair Broken Complete Denture |
$145.00 |
| Replace FX Broken & Tooth on Denture |
$125.00 |
| Extraction Erupted Tooth |
$110.00 |
| Extraction of Tooth, Erupted |
$192.00 |
| Extraction of Tooth, Soft Tiss. Imp |
$210.00 |
| Extraction of Tooth Partial Bony |
$285.00 |
| Extraction of Tooth, Complete Bony, Impac |
$350.00 |
| Impact Tooth Rem Bony W/Comp |
REVIEW REQUIRED |
| Root Tips |
$350.00 |
| Replantation Of Tooth With Splint |
$375.00 |
| Surgical Exposure Of Boney Impaction |
$341.00 |
| Mobilization Erupted |
$352.00 |
| Biopsy of Oral Tissue Soft |
$201.00 |
| Alveolectomy with Extraction |
$200.00 |
| Alveloplasty not in conj wlext. per quad |
$295.00 |
| Stomatoplasty per arch uncomplicated |
$635.00 |
| Excision Of Benign Lesion To 1 |
REVIEW REQUIRED |
| Excision Benign Lesion Comp1 |
REVIEW REQUIRED |
| Excision Malig Lesion<=1.25c |
REVIEW REQUIRED |
| Excision Malig Lesion>1.25cm |
REVIEW REQUIRED |
| Excision Malig Les Complicat |
REVIEW REQUIRED |
| Excision of Canula |
$330.00 |
| Incision Drainage Abscess, Intraoral |
$155.00 |
| Incision & Drainage Extraoral |
$250.00 |
| Curettage Of Fistulous Tract |
$247.00 |
| Fx,Open Reduction Maxilla |
REVIEW REQUIRED |
| Fx,Closed Reduction Maxilla |
REVIEW REQUIRED |
| Fx,Open Reduction Mandible |
REVIEW REQUIRED |
| Fx,Closed Reduction Mandible |
REVIEW REQUIRED |
| Fx, Open Reduction Zygomatic A |
REVIEW REQUIRED |
| Closed Reduction Of Dislocation |
$112.50 |
| Condylectomy |
$675.00 |
| Meniscectomy |
$630.00 |
| Arthrotomy |
$450.00 |
| Arthrocentesis |
$ 36.00 |
| Sutures |
$190.00 |
| Debridement & Repair Of Soft Tissue |
$307.00 |
| Osteoplasty(Prognathism,Microg) |
$975.00 |
| Frenulectomy |
$313.00 |
| Intercep Dental Tx Primary |
REVIEW REQUIRED |
| Compre Dental Tx Adolescent |
REVIEW REQUIRED |
| Bite Plane |
$166.00 |
| Fixed Appliance Therapy |
$677.00 |
| Orthodontic Procedure |
REVIEW REQUIRED |
| Palliative Treatment of Dental Pain |
$85.00 |
| General Anesthesia |
$260.00 |
| Sedation Ea. Add'l 15 min |
$112.00 |
| Nitrous |
$ 46.00 |
| Consultation |
$112.50 |
| Hospital Visit |
$33.00 |
| Consultant Evaluation Exam |
$67.50 |
| Occlusal Equilibration by Report |
$40.00 |
| Occlusal Adjustment Ltd |
$116.00 |
| Occlusal Adjustment Complete |
$474.00 |
964.99 DEFINITIONS
When used in this section, the following terms and phrases shall the meanings ascribed:
Intermediate care facility for persons with mental retardation - Shall have the same meaning as set forth in 42 CFR 483.400 et seq.
SOURCE: Final Rulemaking published at 50 DCR 7549 (September 5, 2003); as Final Rulemaking published at 53 DCR 1699 (March 10, 2006); as Final Rulemaking published at 54 DCR 5593 (June 8, 2007).