Revised 04/13/2023
6/7/2022
COMAR 10.09.05
Maryland Medicaid
Dental Fee
Schedule and
Procedure Codes
CDT 2023*
EFFECTIVE DATE April 1, 2023
*The CDT 2023 codes and nomenclature that follow have been obtained, or appears verbatim from the
Current Dental Terminology (CDT) 2023 Dental Procedure Codes (including procedure codes, definitions,
and other data contained therein); copyrighted by the American Dental Association. © 2023 American
Dental Association. All rights reserved. Applicable FARS/DFARS Apply.
Revised 04/13/2023
6/7/2022
Maryland Healthy Smiles Dental Program – 2023 Fee Schedule
Code
Description of CDT Code
Auth
Req
Fee
Diagnostic
Clinical Oral Evaluations
D0120
Periodic Oral Evaluation – Established Patient
31.81
D0140*
Limited Oral Evaluation – Problem Focused
47.26
D0145
Oral Evaluation, Patient Under Three Years of Age and
Counseling with Primary Caregiver
43.76
D0150
Comprehensive Oral Evaluation – New or Established
Patient
56.34
D0160
Detailed and Extensive Oral Evaluation – Problem Focused,
By Report
43.20
* D0140 may be provided via telehealth using the Place of Service 02 to indicate the two-way audio-
visual service delivery.
Diagnostic Imaging (X-Rays)
D0210
Intraoral - Complete Series of Radiographic Images
57.00
D0220
Intraoral – Periapical First Radiographic Image
9.85
D0230
Intraoral – Periapical Each Additional Radiographic Image
6.56
D0240
Intraoral – Occlusal Radiographic Image
9.00
D0250
Extra-oral – 2D Projection Radiographic Image
24.00
D0270
Bitewing – Single Radiographic Image
9.00
D0272
Bitewings – Two Radiographic Images
16.41
D0273
Bitewings – Three Radiographic Images
18.00
D0274
Bitewings – Four Radiographic Images
24.07
D0310
Sialography
57.00
D0320
Temporomandibular Joint Arthrogram, Including Injection
96.00
D0321
Other Temporomandibular Joint Radiographic Images, by
Report
30.00
D0330
Panoramic Radiographic Image
45.95
D0340
2D Cephalometric Radiographic Image
42.00
Tests and Examinations
D0431
Adjunctive Oral Cancer Screening
5.00
D0460
Pulp Vitality Tests
10.00
Preventive
Dental Prophylaxis
D1110
Prophylaxis – Adult
63.62
D1120
Prophylaxis – Child
46.35
Topical Fluoride Treatment (Office Procedure)
D1206
Topical Application of Fluoride Varnish
24.92
D1208
Topical Application of Fluoride – Excluding Varnish
23.00
Other Preventive Services
D1330
Oral Hygiene Instructions
6.00
D1351
Sealant – Per Tooth
33.23
Revised 04/13/2023
6/7/2022
D1352
Preventive Resin Restoration in a Moderate to High Caries
Risk Patient – Permanent Tooth
33.23
D1354
Interim Caries Arresting Medicament Application- Per Tooth
Y*
10.00
*D1354- pre-authorization for ages 7 and above
Space Maintenance (Passive Appliances)
D1510
Space Maintainer – Fixed, Unilateral
84.00
D1516
Space Maintainer – Fixed – Bilateral, Maxillary
144.00
D1517
Space Maintainer – Fixed – Bilateral, Mandibular
144.00
D1520
Space Maintainer – Removable – Unilateral
64.00
D1526
Space Maintainer – Removable – Bilateral, Maxillary
96.00
D1527
Space Maintainer – Removable – Bilateral, Mandibular
96.00
D1553
Re-cement or re-bond unilateral space maintainer- per
quadrant
24.00
D1556
Removal of fixed unilateral space maintainer- per quadrant
25.00
Restorative
Amalgam Restorations (Including Polishing)
D2140
Amalgam – One Surface, Primary or Permanent
70.00
D2150
Amalgam – Two Surfaces, Primary or Permanent
88.00
D2160
Amalgam – Three Surfaces, Primary or Permanent
104.00
D2161
Amalgam – Four or More Surfaces, Primary or Permanent
104.00
Resin-Based Composite Restorations – Direct
D2330
Resin-Based Composite – One Surface, Anterior
91.90
D2331
Resin-Based Composite – Two Surfaces, Anterior
111.59
D2332
Resin-Based Composite – Three Surfaces, Anterior
136.75
D2335
Resin-Based Composite – Four or More Surfaces or
Involving Incisal Angle (Anterior)
165.19
D2390
Resin-Based Composite Crown, Anterior
75.00
D2391
Resin-Based Composite – One Surface, Posterior
101.74
D2392
Resin-Based Composite – Two Surfaces, Posterior
131.28
D2393
Resin-Based Composite – Three Surfaces, Posterior
164.10
D2394
Resin-Based Composite – Four Or More Surfaces, Posterior
164.10
Crowns – Single Restorations Only
D2721
Crown – Resin with Predominantly Base Metal
Y
250.00
D2740
Crown – Porcelain/Ceramic Substrate
Y
328.20
D2750
Crown – Porcelain Fused to High Noble Metal
Y
410.25
D2751
Crown – Porcelain Fused to Predominantly Base Metal
Y
375.00
D2752
Crown – Porcelain Fused to Noble Metal
Y
375.00
D2780
Crown – ¾ Cast High Noble Metal
Y
292.00
D2781
Crown – ¾ Cast Predominantly Base Metal
Y
292.00
D2782
Crown – ¾ Cast Noble Metal
Y
292.00
D2783
Crown – ¾ Porcelain/Ceramic
Y
292.00
D2790
Crown – Full Cast High Noble Metal
Y
292.00
D2791
Crown – Full Cast Predominantly Base Metal
Y
292.00
D2792
Crown – Full Cast Noble Metal
Y
292.00
D2794
Crown – Titanium
Y
292.00
Other Restorative Services
D2910
Re-cement or Re-bond Inlay, Onlay, Veneer or Partial
Coverage Restoration
25.00
Revised 04/13/2023
6/7/2022
D2920
Re-cement or Re-bond Crown
25.00
D2928
Prefabricated porcelain/ceramic crown – Permanent Tooth
180.00
D2929
Prefabricated Porcelain/Ceramic Crown – Primary Tooth
Y
154.00
D2930
Prefabricated Stainless Steel Crown – Primary Tooth
168.48
D2931
Prefabricated Stainless Steel Crown – Permanent Tooth
196.92
D2932
Prefabricated Resin Crown
75.00
D2933
Prefabricated Stainless Steel Crown with Resin Window
81.00
D2934
Prefabricated Esthetic Coated Stainless Steel Crown –
Primary Tooth
168.48
D2940
Protective Restoration
50.00
D2950
Core Buildup, Including Any Pins When Required
Y
81.00
D2951
Pin Retention – Per Tooth, In Addition to Restoration
12.00
D2952
Post and Core In Addition to Crown, Indirectly Fabricated
Y
96.00
D2954
Prefabricated Post and Core In Addition to Crown
Y
70.00
D2955
Post Removal
Y
25.00
D2960
Labial Veneer (Resin Laminate) – Chairside
81.00
D2961
Labial Veneer (Resin Laminate) – Laboratory
81.00
D2962
Labial Veneer (Porcelain Laminate) – Laboratory
Y
108.00
D2980
Crown Repair Necessitated by Restorative Material Failure
93.00
Endodontics
Pulp Capping
D3110
Pulp Cap – Direct Excluding Final Restoration)
15.00
D3120
Pulp Cap – Indirect (Excluding Final Restoration)
35.00
Pulpotomy
D3220
Therapeutic Pulpotomy (Excluding Final Restoration)
65.64
D3221
Pulpal Debridement, Primary and Permanent Teeth
70.00
Endodontic Therapy On Primary Teeth
D3230
Pulpal Therapy (Resorbable Filling) – Anterior,
Primary Tooth (Excluding Final Restoration)
96.00
D3240
Pulpal Therapy (Resorbable Filling) – Posterior, Primary
Tooth (Excluding Final Restoration)
115.00
Endodontic Therapy (Includes Treatment Plan, Procedures And Follow-Up Care)
D3310
Endodontic Therapy, Anterior Tooth (Excluding Final
Restoration)
550.00
D3320
Endodontic Therapy, Bicuspid Tooth (Excluding Final
Restoration)
650.00
D3330
Endodontic Therapy, Molar (Excluding Final Restoration)
748.00
Endodontic Retreatment
D3346*
Retreatment of Previous Root Canal Therapy – Anterior
Y
634.00
D3347*
Retreatment of Previous Root Canal Therapy – Bicuspid
Y
721.00
D3348*
Retreatment of Previous Root Canal Therapy – Molar
Y
829.00
*Not covered when service is provided by the same provider or an associate within two years of
original service.
Revised 04/13/2023
6/7/2022
Apexification/Recalcification
D3351
Apexification/Recalcification – Initial Visit
Y
108.00
D3352
Apexification/Recalcification – Interim Medication
Replacement
Y
67.00
D3353
Apexification/Recalcification – Final Visit
Y
67.00
Apicoectomy/Periradicular Services
D3410
Apicoectomy – Anterior
Y
504.00
D3421
Apicoectomy – Bicuspid (First Root)
Y
570.00
D3425
Apicoectomy – Molar (First Root)
Y
659.00
D3426
Apicoectomy (Each Additional Root)
Y
217.00
D3430
Retrograde Filling – Per Root
Y
100.00
D3450
Root Amputation – Per Root
Y
355.00
D3470
Intentional Re-implantation (Including Necessary Splinting)
Y
629.00
Other Endodontic Procedures
D3920
Hemisection (Including Any Root Removal), Not
Including Root Canal Therapy
Y
221.00
Periodontics
Surgical Services (Including Usual Postoperative Care)
D4210
Gingivectomy or Gingivoplasty – Four or More
Contiguous Teeth or Tooth Bounded Spaces per
Quadrant
Y
108.00
D4211
Gingivectomy or Gingivoplasty – One to Three Contiguous
Teeth or Tooth Bounded Spaces per Quadrant
Y
25.00
D4230
Anatomical Crown Exposure – Four or More Contiguous
Teeth per Quadrant
Y
108.00
D4231
Anatomical Crown Exposure – One to Three Teeth per
Quadrant
Y
25.00
D4240
Gingival Flap Procedure, Including Root Planing – Four or
More Contiguous Teeth or Tooth Bounded Spaces per
Quadrant
Y
63.00
D4241
Gingival Flap Procedure, Including Root Planing – One to
Three Contiguous Teeth or Tooth Bounded Spaces per
Quadrant
Y
75.00
D4249
Clinical Crown Lengthening – Hard Tissue
Y
150.00
D4260
Osseous Surgery – Four or More Contiguous Teeth or Tooth
Bounded Spaces per Quadrant
Y
108.00
D4261
Osseous Surgery – One to Three Contiguous Teeth or Tooth
Bounded Spaces per Quadrant
Y
150.00
Non-Surgical Periodontal Service
D4322
Splint – intra-coronal natural teeth or prosthetic crowns
90.00
D4323
Splint- extra-coronal natural teeth or prosthetic crowns
100.00
D4341
Periodontal Scaling and Root Planing – Four or More Teeth
per Quadrant
Y
75.00
D4342
Periodontal Scaling and Root Planing – One to Three Teeth
per Quadrant
Y
54.00
D4355
Full Mouth Debridement to Enable
Comprehensive Evaluation and Diagnosis
100.00
Revised 04/13/2023
6/7/2022
Other Periodontal Services
D4910
Periodontal Maintenance
Y
54.00
D4920
Unscheduled Dressing Change (By Someone Other Than
Treating Dentist or Their Staff)
Y
24.00
Prosthodontics (Removable)
Complete Dentures (Including Routine Post-Delivery Care)
D5110
Complete Denture – Maxillary
Y
375.00
D5120
Complete Denture – Mandibular
Y
375.00
Partial Dentures (Including Routine Post-Delivery Care)
D5211
Maxillary Partial Denture – Resin Base
Y
225.00
D5212
Mandibular Partial Denture – Resin Base
Y
225.00
D5225
Maxillary Partial Denture – Flexible Base
Y
275.00
D5226
Mandibular Partial Denture – Flexible Base
Y
275.00
Adjustments To Dentures
D5410
Adjust Complete Denture – Maxillary
20.00
D5411
Adjust Complete Denture – Mandibular
20.00
D5421
Adjust Partial Denture – Maxillary
20.00
D5422
Adjust Partial Denture – Mandibular
20.00
Repairs to Complete Dentures
D5511
Repair Broken Complete Denture Base- Mandibular
40.00
D5512
Repair Broken Complete Denture Base- Maxillary
40.00
D5520
Replace Missing Or Broken Teeth-Complete Denture Each
Tooth
20.00
Repairs to Partial Dentures
D5611
Repair Resin Partial Denture Base- Mandibular
63.00
D5612
Repair Resin Partial Denture Base- Maxillary
63.00
D5621
Repair Cast Partial Framework- Mandibular
70.00
D5622
Repair Cast Partial Framework- Maxillary
70.00
D5630
Repair/Replace Broken Clasp – per Tooth
63.00
D5640
Replace Broken Teeth - Per Tooth
20.00
D5650
Add Tooth to Existing Partial Denture
Y
57.00
D5660
Add Clasp To Existing Partial Denture – per Tooth
Y
65.00
Note: aftercare is within the first six months following denture placement and is not reimbursable.
Following the aftercare period these services may be provided once every two years.
Denture Rebase Procedures
D5710
Rebase Complete Maxillary Denture
Y
160.00
D5711
Rebase Complete Mandibular Denture
Y
160.00
D5720
Rebase Maxillary Partial Denture
Y
160.00
D5721
Rebase Mandibular Partial Denture
Y
160.00
D5750
Reline Complete Maxillary Denture (Laboratory)
150.00
D5751
Reline Complete Mandibular Denture (Laboratory)
150.00
D5760
Reline Maxillary Partial Denture (Laboratory)
150.00
D5761
Reline Mandibular Partial Denture (Laboratory)
150.00
Revised 04/13/2023
6/7/2022
Other Removable Prosthetic Services
D5850
Tissue Conditioning, Maxillary
24.00
D5851
Tissue Conditioning, Mandibular
24.00
D5863
Overdenture – Complete Maxillary
Y
325.00
D5864
Overdenture – Partial Maxillary
Y
325.00
D5865
Overdenture – Complete Mandibular
Y
325.00
D5866
Overdenture – Partial Mandibular
Y
325.00
Maxillofacial Prosthetics
D5992
Adjust Maxillofacial Prosthetic Appliance, by Report
Y
20.00
D5993
Maintenance & Cleaning of Maxillofacial Prosthesis (Exta-
or Intra-oral) Other than Required Adjustments, by Report
Y
20.00
Prosthodontics, Fixed
D6930
Re-cement or Re-bond Fixed Partial Denture
32.00
Oral And Maxillofacial Surgery
Extractions
D7111
Extraction, Coronal Remnants – Deciduous Tooth
27.00
D7140
Extraction, Erupted Tooth Or Exposed Root
112.69
D7210
Extraction, Erupted Tooth Requiring Removal of Bone
and/or Sectioning of Tooth, and Including Elevation of
Mucoperiosteal Flap if Indicated
112.69
D7220
Removal of Impacted Tooth – Soft Tissue
157.54
D7230
Removal of Impacted Tooth – Partially Bony
230.83
D7240
Removal of Impacted Tooth – Completely Bony
303.04
D7241
Removal of Impacted Tooth – Completely Bony, with
Unusual Surgical Complications
Y
415.00
D7250
Removal of Residual Tooth Roots (Cutting Procedure)
Y
103.01
D7251
Coronectomy – Intentional Partial Tooth Removal
Y
415.00
Note: Preauthorization is required for multiple extractions in hospitals (other than emergency
conditions) and for extractions requiring replacements.
Other Surgical Procedures
D7260
Oralantral Fistula Closure
Y
125.00
D7270
Tooth Re-implantation and/or Stabilization of Accidentally
Evulsed or Displaced Tooth
Y
64.00
D7272
Tooth Transplantation
Y
27.00
D7280
Exposure of an Unerupted Tooth
Y
369.00
D7285
Incisional Biopsy of Oral Tissue – Hard (Bone, Tooth)
Y
85.00
D7286
Incisional Biopsy of Oral Tissue – Soft
Y
231.00
D7290
Surgical Repositioning of Teeth
Y
165.00
Alveoloplasty
D7310
Alveoloplasty In Conjunction with Extractions - Four or
more teeth or tooth spaces, per Quadrant
Y
90.00
D7311
Alveoloplasty In Conjunction with Extractions -One to Three
Teeth or Tooth Spaces, per Quadrant
Y
50.00
Revised 04/13/2023
6/7/2022
D7320
Alveoloplasty Not in Conjunction with Extractions - Four or
more teeth or Tooth Spaces, per Quadrant
Y
48.00
D7321
Alveoloplasty Not in Conjunction with Extractions - One to
Three Teeth or Tooth Spaces, per Quadrant
Y
95.00
Vestibuloplasty
D7340
Vestibuloplasty – Ridge Extension (Secondary
Epithelialization)
Y
270.00
D7350
Vestibuloplasty – Ridge Extension (Including Soft Tissue
Grafts)
Y
405.00
Excision Of Soft Tissue Lesions
D7410
Excision of Benign Lesion Up To 1.25 cm
Y
84.00
Excision Of Intra-Osseous Lesions
D7440*
Excision of Malignant Tumor – Lesion Diameter Up To 1.25
cm
Y
108.00
D7450*
Removal of Benign Odontogenic Cyst or Tumor – Lesion
Diameter Up To 1.25 cm
Y
97.00
D7451*
Removal of Benign Odontogenic Cyst or Tumor – Lesion
Diameter Greater Than 1.25 cm
Y
125.00
D7460*
Removal of Benign Nonodontogenic Cyst or Tumor – Lesion
Diameter Up To 1.25 cm
Y
95.00
D7461*
Removal of Benign Nonodontogenic Cyst or Tumor – Lesion
Diameter Greater Than 1.25 cm
Y
125.00
*Use CPT codes for these procedures
Excision Of Bone Tissue
D7471
Removal of Lateral Exostosis – (Maxilla or Mandible)
Y
105.00
D7472
Removal of Torus Palatinus
Y
105.00
D7473
Removal of Torus Mandibularis
Y
105.00
Surgical Incision
D7510
Incision & Drainage of Abscess – Intraoral Soft Tissue
48.00
D7520
Incision & Drainage of Abscess – Extraoral Soft Tissue
68.00
D7550
Partial Ostectomy/Sequestrectomy for Removal of Non-
Vital Bone
68.00
Other Repair Procedures
D7961
Buccal/labial frenectomy (frenulectomy)
Y
63.00
D7962
Lingual frenectomy (frenulectomy)
Y
63.00
D7970
Excision of Hyperplastic Tissue – Per Arch
27.00
D7971
Excision of Pericoronal Gingiva
25.00
Orthodontics
Comprehensive Orthodontic Treatment
D8080
Comprehensive Orthodontic Treatment of the
Adolescent Dentition
Y
1035.00
D8090
Comprehensive Orthodontic Treatment of the Adult
Dentition (self-ligating)
Y
900.00
Other Orthodontic Services
D8660
Pre-Orthodontic Treatment Examination to Monitor
Growth and Development
Y
150.00
D8670
Periodic Orthodontic Treatment Visit
Y
75.00
D8680
Orthodontic Retention (Removal of Appliances,
Y
200.00
Revised 04/13/2023
6/7/2022
D8698
Re-cement or re-bonding fixed retainers- Maxillary
Y
40.00
D8699
Re-cement or re-bonding fixed retainers- Mandibular
Y
40.00
D8703
Replacement of lost or broken retainer- Maxillary
Y
140.00
D8704
Replacement of lost or broken retainer- Mandibular
Y
140.00
D8999
Orthodontic Continuation of Care
Y
550.00
*Please refer to the current provider manual for clinical criteria for all orthodontic services.
**Note: CDT D8080, D8090, D8703-D8704 frequency limitations are- 1 per lifetime; and D8698-D8699
frequency limitations are- 1 per member per 24 months.
Adjunctive General Services
Unclassified Treatment
D9110
Palliative (Emergency) Treatment of Dental Pain – Minor
Procedure
20.00
Anesthesia
D9222
Deep Sedation/General Anesthesia- First 15 Minutes
77.67
D9223
Deep Sedation / General Anesthesia – Each 15 Minute
Increment
77.67
D9230
Inhalation of Nitrous Oxide/Analgesia, Anxiolysis
19.69
D9239
Intravenous Moderate (Conscious)Sedation/Analgesia- First
15 Minute
59.00
D9243
Intravenous Moderate (Conscious) Sedation/Analgesia –
Each 15 Minute Increment
59.00
D9248
Non-Intravenous Conscious Sedation
186.91
Professional Consultation
D9310
Consultation – Diagnostic Service Provided by Dentist of
Physician Other than Requesting Dentist of Physician
48.00
Professional Visits
D9410
House/Extended Care Facility Call
Y
15.00
D9420
Hospital or Ambulatory Surgical Center Call
Y
15.00
Miscellaneous Services
D9910
Apply of Desensitizing Medication
10.00
D9941
Fabrication of Athletic Mouthguard
103.00
D9944
Occlusal Guard - Hard Appliance, Full Arch
150.00
D9945
Occlusal Guard - Soft Appliance, Full Arch
150.00
D9946
Occlusal Guard - Hard Appliance, Partial Arch
150.00
D9951
Occlusal Adjustment - Limited
Y
33.00
D9952
Occlusal Adjustment - Complete
Y
66.00
