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19.15.11 Oral and Maxillofacial Surgery Services
All oral surgery procedures include local anesthesia, suturing, if needed, and visits for routine postoperative care.
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Procedure Code
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Limitations
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Maximum Fee
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D7111
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TIDs A-T and AS-TS. A 1-20
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$12.00
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D7140*
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Replaces procedure codes D7110, D7120, and D7130.
A 1-20, PXR
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$67.04
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Surgical Extractions
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D7210*
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Includes removal of the roots of a previously erupted tooth missing its clinical crown. A 1-20, PXR
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$102.81
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D7220*
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A 1-20, PXR
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$157.50
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D7230*
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A 1-20, PXR
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$180.00
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D7240
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A 1-20, PXR
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$300.00
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D7241
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Document unusual circumstance. A 1-20, N, PXR
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$156.25
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D7250*
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Involves tissue incision and removal of bone to remove a permanent or primary tooth root left in the bone from a previous extraction, caries, or trauma. Usually some degree of soft and/or hard tissue healing has occurred. A 1-20, N, PXR
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$92.50
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Other Surgical Procedures
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D7260
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A 1-20, N, PXR; TIDs 1-16 only.
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$137.50
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D7261
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May not be paid on the same day as D7260; TIDs 1-16 only.
A 1-20
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$137.50
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D7270*
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A 1-20, N, PXR, CCP
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$110.00
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D7272
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Requires prior authorization. A 1-20, N, PXR, CCP
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$150.00
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D7280
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A 1-20, N, PXR
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$62.50
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D7282
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Permanent TIDs 1-32 only; may not be paid on the same day as D7280. A 4-20
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$62.50
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D7283
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A 1-20
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$25.00
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D7285
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A 1-20, PXR, PATH, CCP
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$75.00
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D7286*
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A 1-20, PXR, PATH
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$62.50
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D7287
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Not considered medically necessary.
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NC
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D7290
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A 1-20, N, PXR, CCP
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$137.50
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D7291
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A 4-20, N, PXR, CCP
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$50.00
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Alveoloplasty-Surgical Preparation of Ridge for Dentures
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D7310
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A 1-20, N, PXR, CCP
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$56.25
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D7320
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A 1-20, N, PXR, CCP
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$75.00
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Vestibuloplasty
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D7340
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A 1-20, N, PXR, CCP
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$125.00
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D7350
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A 1-20, N, PXR, CCP
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$250.00
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Surgical Excision of Soft Tissue Lesions
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D7410
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A 1-20, PXR, PATH
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$100.00
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D7411
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A 1-20, PXR, PATH
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$150.00
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D7412
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Not considered medically necessary.
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NC
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D7413
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The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A 1-20, N, PXR, PATH, CCP
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$100.00
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D7414
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The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1-20, N, PXR, PATH, CCP
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$150.00
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D7415
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Not considered medically necessary.
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NC
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Surgical Excision of Intraosseous Lesions
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D7440
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The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1-20, N, PXR, PATH, CCP
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$181.25
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D7441
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The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1-20, N, PXR, PATH, CCP
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$237.50
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D7450
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The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1-20, N, PXR, PATH, CCP
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$118.75
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D7451
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The incidental removal of cysts/lesions attached to the root(s) of an extracted tooth is considered part of the extraction or surgical fee. A 1-20, N, PXR, PATH, CCP
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$162.50
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D7460
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The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A Birth-20, N, PXR, PATH, CCP
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$118.75
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D7461
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The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A Birth-20, N, PXR, PATH, CCP
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$162.50
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D7465
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The incidental removal of cysts/lesions attached to the root(s) of a simple extraction is considered part of the extraction or surgical fee. A 1-20, N, PXR, PATH, CCP
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$68.75
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Excision of Bone Tissue
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D7471
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Denied as global to all extractions
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NC
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D7472
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Prior authorization is required. A 1 -20
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$160.00
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D7473
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Deny as global to other services.
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NC
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D7485
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Deny as global to other services.
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NC
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D7490
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Refer to CPT codes.
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NC
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Surgical Incision
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D7510*
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TID required. A 1-20, PXR
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$37.50
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D7520
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A 1-20, N, PXR, CCP
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$125.00
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D7530
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A 1-20, N, PXR
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$50.00
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D7540
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A 1-20, N, PXR
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$100.00
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D7550*
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A 1-20, N, PXR
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$106.25
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D7560
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A 1-20, N, PXR, CCP
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$125.00
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D7670
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A 1-20, N, PXR, CCP
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$81.25
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D7671
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Not considered medically necessary.
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NC
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D7771
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Not considered medically necessary.
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NC
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Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfunctions
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D7820
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A 1-20, N, PXR
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$81.25
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D7830
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Refer to CPT codes.
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NC
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D7880
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Narrative required on claim form. A 1-20, N, PXR, CCP
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$140.00
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D7899
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Narrative required on claim form. A 1-20, N, PXR, CCP
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Manually priced
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Repair of Traumatic Wounds
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D7910*
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Narrative required on claim form. A 1-20, N, PXR, CCP
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$75.00
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Complicated Suturing
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D7911
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A 1-20, N, PXR, CCP
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$81.25
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D7912
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A 1-20, N, PXR, CCP
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$162.50
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Other Repair Procedures
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D7960
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Narrative required on claim form. A 1-20, N, PXR, CCP
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$105.00
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D7970*
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A 1-20, N, PXR, CCP
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$112.50
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D7971*
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A 1-20, N, PXR, CCP
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$43.75
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D7972
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TIDs 1, 16, 17, and 32 only; may not be paid in addition to D7971 on the same day. A 13-20
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$43.75
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D7980
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A 1-20, N, PXR, CCP
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$193.75
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D7983
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A 1-20, N, PXR, CCP
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$162.50
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D7997*
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Per arch. Prior authorization is required. A 1-20, N, PXR, CCP
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$50.00
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D7999*
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A 1-20, N, PXR, CCP
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Manually priced
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