(Amendments to 6 CCR 1015-8,  Rules Pertaining to Services Grants for the Dental Assistance Program, adopted by the State Board of Health on November 19, 2008.  Instructions:  Add new rules regarding allowable procedures and fees for dental services to existing rules following Par. ID 856888)

Allowable Procedures and Fees for Dental Services
2.1	Effective December 31, 2008 through June 30, 2009, a qualified grantee, as defined in Section 1.1 of these regulations, may charge fees, not to exceed the maximum allowable fee, and perform the procedures for an eligible senior as set forth in Section 2.3.  
2.2	Nothing in this part shall prohibit a qualified grantee from charging less than the allowable fee or reducing the amount of the patient co-payment set forth in Section 2.3.  Any reduction in the amount of the patient co-payment shall be a the discretion of the qualified grantee.
2.3	Table of allowable procedures and fees

CDT
2007-2008 	Procedure Description	Maximum Allowable Fee	Program Payment	Maximum Patient Co-pay	
Diagnostic					
0120	Periodic Oral Evaluation – Est. Pt.	$ 20	$ 16	$   4	
0140	Limited Oral Evaluation	$ 31	$ 25	$   6	
0150	Comprehensive Oral Exam	$ 32	$ 26	$   6	
0220, 0230	Periapical – single film; ea. Addtl	$ 12	$ 10	$   2	
0270	Bitewing – single film	$ 12	$ 10	$   2	
0272	Bitewings – two films	$ 19	$ 15	$   4	
0273	Bitewings – three films	$ 23	$ 18	$   5	
0274	Bitewings – four films	$ 27	$ 22	$   5	
0210,0330	Full mouth (periapical or panorex)	$ 53	$ 42	$ 11	
0470	Diagnostic casts	$ 44	$ 35	$   9	
					
Preventive					
1110	Prophylaxis (Adult)	$ 38	$ 30	$   8	
1204	Topical Fluoride (w/out prophy)	$ 16	$ 13	$   3	
1206	Topical Fluoride Varnish	$ 16	$ 13	$   3	
					
Restorative					
2140	Amalgam – one surface	$   27	$   22	$   5	
2150	Amalgam – two surfaces	$   55	$   44	$ 11	
2160	Amalgam – three surfaces	$   82	$   66	$ 16	
2161	Amalgam – four + surfaces	$ 110	$   88	$ 22	
2330	Resin – one surface, anterior	$   44	$   35	$   9	
2331	Resin – two surface, anterior	$   88	$   70	$ 18	
2332	Resin – three surface, anterior	$   98	$   78	$ 20	
2335	Resin – four surface, incisal angle	$ 133	$ 106	$ 27	
2391	Resin – one surface, posterior	$   44	$   35	$   9	
2392	Resin – two surface, posterior	$   88	$   70	$ 18	
2393	Resin – three surface, posterior	$   98	$   78	$ 20	
2394	Resin – four surface, posterior	$ 133	$ 106	$ 27	
					
Periodontics					
4210	Gingivectomy/gingivoplasty 
(Four or more contiguous teeth)	$ 165	$ 132	$ 33	
4211	Gingivectomy/gingivoplasty 
(One to three contiguous teeth)	$   99	$   79	$ 20	
4341	Scaling and Root Planing	$  165	$ 132	$ 33	
4355	Gross Debridement	$   78	$   62	$ 16	
					
Prosthetics  (Patient co-pay for these services are not to exceed 10%)	
5110	Complete denture, maxillary	$ 781	$ 703	$ 78	
5120	Complete denture, mandibular	$ 781	$ 703	$ 78	
5211 	Partial denture, maxillary – resin	$ 594	$ 535	$ 59	
5212	Partial denture, mandibular – resin	$ 594	$ 535	$ 59	
5510, 5610	Repair broken denture/partial base	$   99	$   89	$ 10	
5520, 5640	Replace missing or broken teeth	$   89	$   80	$   9	
5630	Replace or repair broken clasp	$ 129	$ 116	$ 13	
5650	Add tooth to partial	$ 109	$   98	$ 11	
5660	Add clasp to partial	$ 135	$ 122	$ 13	
5710, 5711	Rebase complete denture	$ 282	$ 254	$ 28	
5720, 5721	Rebase partial denture	$ 282	$ 254	$ 28	
5730, 5731,	Reline denture – chair-side	$ 180	$ 162	$ 18	
5740, 5741	Reline partial – chair-side	$ 180	$ 162	$ 18	
5750, 5751	Reline denture – laboratory	$ 229	$ 206	$ 23	
5760, 5761	Reline partial – laboratory	$ 229	$ 206	$ 23	
					
Oral Surgery					
7140	Extraction erupted tooth or exposed root	$   79	$   71	$  8	
7210	Surgical removal of erupted tooth	$ 135	$ 121	$ 14	
7250	Surgical removal of residual tooth roots	$ 128	$ 115	$ 13	
7286	Biopsy, soft tissue	$ 129	$ 103	$ 26	
7310	Alveoloplasty (w/extractions)
(Four or more teeth)	$ 120	$   96	$ 24	
7311	Alveoloplasty (w/extractions)	$ 110	$   99	$ 11	
7320	Alveoloplasty (w/out extractions) 
(Four or more teeth)	$ 120	$   96	$ 24	
7321	Alveoloplasty (w/out extractions) 	$ 110	$   99	$   11	
7510	Incision and drainage of abscess	$   95	$   86	$    9	
9110	Palliative treatment – minor procedure	$   49	$   44	$    5