Texas Medicaid & CHIP Amendment Fee Schedule Current Dental Terminology 2012 American Dental Association. All rights reserved.

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1 D0120 D0140 D0145 D0150 D0160 D0170 D0180 Description PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT LIMITED ORAL EVALUATION-PROBLEM FOCUSED ORAL EVALUATION FOR A PATIENT UNDER THREE YEARS OF AGE AND COUNSELING WITH PRIMARY CAREGIVER COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT DETAILED AND EXTENSIVE ORAL EVAL- PROBLEM FOCUSED, BY REPORT RE-EVALUATION, LIMITED PROBLEM FOCUSED COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR ESTABLISHED PATIENT Description $28.85 D0460 PULP VITALITY TESTS $12.25 $18.78 D0470 DIAGNOSTIC CASTS $22.05 $ D0502 OTHER ORAL PATHOLOGY PROCEDURES, BY REPORT $56.35 $35.32 D1110 PROPHYLAXIS - ADULT $54.88 $14.95 D1120 PROPHYLAXIS - CHILD $36.75 $16.54 D1203 $7.86 D1204 TOPICAL APPLICATION OF FLUORIDE (PROPHYLAXIS NOT INCLUDED) - CHILD TOPICAL APPLICATION OF FLUORIDE (PROPHYLAXIS NOT INCLUDED) - ADULT TOPICAL APPLICATION OF FLUORIDE VARNISH TOPICAL APPLICATION OF FLUORIDE - EXCLUDING VARNISH D0210 INTRAORAL - COMPLETE SERIES OF $70.64 D1206 D0220 INTRAORAL - PERIAPICAL FIRST $12.56 D1208 D0230 INTRAORAL - PERIAPICAL EACH ADDITIONAL $11.51 D1330 ORAL HYGIENE INSTRUCTIONS $12.25 D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE $9.80 D1351 SEALANT - PER TOOTH $28.24 EXTRA-ORAL 2D PROJECTION D0250 CREATED USING A PREVENTIVE RESIN RESTORATION IS $18.38 D1352 STATIONARY RADIATION SOURCE, AND A MOD. TO HIGH CARIES RISK $37.44 DETECTOR D0260 EXTRAORAL - EACH ADDITIONAL SPACE MAINTAINER-FIXED- $12.25 D1510 UNILATERAL $ D0270 BITEWING - SINGLE SPACE MAINTAINER-FIXED- $4.90 D1516 BILATERAL, MAXILLARY $ D0272 BITEWINGS - TWO SPACE MAINTAINER-FIXED- $23.38 D1517 BILATERAL, MANDIBULAR $ D0273 BITEWINGS - THREE SPACE MAINTAINER-REMOVABLE- $29.01 D1520 UNILATERAL $73.50 D0274 BITEWINGS - FOUR SPACE MAINTAINER-REMOVABLE- $34.61 D1526 BILATERAL, MAXILLARY $ D0277 VERTICAL BITEWINGS SPACE MAINTAINER-REMOVABLE- $31.12 D TO 8 FILMS BILATERAL, MANDIBULAR $ D0290 POSTERIOR-ANTERIOR OR LATERAL SKULL RE-CEMENT OR RE-BOND SPACE AND FACIAL BONE SURVEY RADIOGRAPHIC $33.08 D1550 MAINTAINER IMAGE $18.38 D0310 SIALOGRAPHY $44.10 D1555 REMOVAL OF FIXED SPACE MAINTAINER $49.00 D0320 TEMPOROMANDIBULAR JOINT ARTHOGRAM, DISTAL SHOE SPACE MAINTAINER - $73.50 D1575 INCLUDING INJECTION FIXED - UNILATERAL $ D0321 OTHER TEMPOROMANDIBULAR AMALGAM - ONE SURFACE, $34.30 D2140 JOINT FILMS, BY REPORT PERMANENT $62.80 D0322 TOMOGRAPHIC SURVEY $33.08 D2140 AMALGAM - ONE SURFACE, PRIMARY $60.75 D0330 PANORAMIC AMALGAM - TWO SURFACES, $63.78 D2150 PERMANENT $83.57 D0340 CEPHALOMETRIC AMALGAM - TWO SURFACES, $33.08 D2150 PRIMARY $81.24 D0350 2D ORAL/FACIAL PHOTOGRAPHIC IMAGE AMALGAM - THREE SURFACES, $18.38 D2160 OBTAINED INTRA-ORALLY OR EXTRA-ORALLY PERMANENT $ D0360 CONE BEAM CT - CRANIOFACIAL DATA AMALGAM - THREE SURFACES, $ D2160 CAPTURE PRIMARY $88.20 D0362 CONE BEAM AMALGAM - FOUR OR MORE $ D2161 TWO DIMENSIONAL IMAGE SURFACES, PERMANENT $ D0363 CONE BEAM AMALGAM - FOUR OR MORE $ D2161 THREE DIMENSIONAL IMAGE SURFACES, PRIMARY $90.01 D0367 CONE BEAM CT CAPTURE AND RESIN-BASED COMPOSITE - ONE INTERPRETATION WITH FIELD OF VIEW OF $ D2330 SURFACE, ANTERIOR BOTH JAWS, WITH OR WITHOUT CRANIUM $75.81 D0415 BACTERIOLOGIC STUDIES $24.50 D2331 RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR $ Texas Medicaid & CHIP Amendment Schedule Current Dental Terminology 2012 American Dental Association. All rights reserved.

2 Description Description D2332 CROWN - RESIN-BASED COMPOSITE $ D2710 THREE SURFACES, ANTERIOR (INDIRECT) D2335 FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) $ D2720 CROWN-RESIN WITH HIGH NOBLE METAL D2390 RESIN-BASED COMPOSITE CROWN, CROWN - RESIN WITH PREDOMINANTLY $ D2721 ANTERIOR, PERMANENT BASE METAL D2390 RESIN-BASED COMPOSITE CROWN, ANTERIOR, PRIMARY $85.00 D2722 CROWN - RESIN WITH NOBLE METAL D2391 ONE SURFACE, POSTERIOR - PERMANENT $80.34 D2740 CROWN - PORCELAIN/CERAMIC D2391 CROWN - PORCELAIN FUSED TO HIGH $75.45 D2750 ONE SURFACE, POSTERIOR - PRIMARY NOBLE METAL $ D2392 CROWN - PORCELAIN FUSED TO $ D2751 TWO SURFACES, POSTERIOR - PERMANENT PREDOMINANTLY BASE METAL $ D2392 CROWN - PORCELAIN FUSED TO NOBLE $97.01 D2752 TWO SURFACES, POSTERIOR - PRIMARY METAL $ D2393 THREE SURFACES, POSTERIOR - PERMANENT $ D2780 CROWN - ¾ CAST HIGH NOBLE METAL D2393 CROWN - ¾ CAST PREDOMINANTLY BASE $ D2781 THREE SURFACES, POSTERIOR - PRIMARY METAL D2394 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR - PERMANENT $ D2782 CROWN - ¾ CAST NOBLE METAL D2394 RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR - $ D2783 CROWN - ¾ PORCELAIN/CERAMIC PRIMARY D2410 GOLD FOIL - 1 SURFACE $73.50 D2790 CROWN - FULL CAST HIGH NOBLE METAL $ D2420 GOLD FOIL - 2 SURFACES $ D2791 CROWN - FULL CAST PREDOMINANTLY BASE METAL D2430 GOLD FOIL - 3 SURFACES $ D2792 CROWN - FULL CAST NOBLE METAL D2510 INLAY - METALLIC 1 SURFACE $ D2794 CROWN - TITANIUM D2520 RE-CEMENT OR RE-BOND INLAY, ONLAY, INLAY-METALLIC- D2910 VENEER OR PARTIAL COVERAGE 2 SURFACES RESTORATION $17.92 D2530 INLAY-METALLIC- 3+ SURFACES D2915 RE-CEMENT OR RE-BOND INDIRECTLY FABRICATED OR PREFABRICATED POST AND CORE D2542 ONLAY - METALLIC TWO SURFACES D2920 RE-CEMENT OR RE-BOND CROWN $19.11 D2543 ONLAY-METALLIC-3 PREFABRICATED STAINLESS STEEL D2930 SURFACES CROWN - PRIMARY TOOTH $ D2544 ONLAY-METALLIC-4+ PREFABRICATED STAINLESS STEEL D2931 SURFACES CROWN-PERMANENT TOOTH D2610 INLAY-PORCE/CERAMIC-1SURFACE $ D2932 PREFABRICATED RESIN CROWN $65.70 D2620 INLAY-PORCELAIN/CERAMIC- PREFABRICATED STAINLESS STEEL $ D SURFACES CROWN WITH RESIN WINDOW $ D2630 PREFABRICATED ESTHETIC COATED INLAY-PORC/CERAMIC $ D2934 STAINLESS STEEL CROWN - PRIMARY 3+ SURFACES TOOTH $ D2642 ONLAY-PORCELAIN/CERAMIC- 2 SURFACES $ D2940 PROTECTIVE RESTORATION $34.95 D2643 ONLAY-PORCELAIN/CERAMIC- CORE BUILDUP, INCLUDING ANY PINS $ D SURFACES WHEN REQUIRED $43.00 D2644 ONLAY-PORCELAIN/CERAMIC- PIN RETENTION - PER TOOTH, IN ADDITION $ D SURFACES TO RESTORATION $11.94 D2650 INLAY-COMPOSITE/RESIN CAST POST AND CORE IN ADDITION TO D2952 1SURFACE CROWN $83.61 D2651 INLAY-COMPOSITE/RESIN- EACH ADDITIONAL CAST POST - SAME D SURFACES TOOTH $41.81 D2652 INLAY-COMPOSITE/RESIN- PREFABRICATED POST AND CORE IN D SURFACES ADDITION TO CROWN D2662 ONLAY-COMPOSITE/RESIN- POST REMOVAL (NOT IN CONJUNCTION D SURFACES WITH ENDODONTIC THERAPY) D2663 ONLAY-COMPOSITE/RESIN-3 SURFACES D2957 EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH $35.83 D2664 ONLAY-COMPOSITE/RESIN-4+ SURFACES D2960 LABIAL VENEER (LAMINATE)-CHAIR $ $ Texas Medicaid & CHIP Amendment Schedule Current Dental Terminology 2012 American Dental Association. All rights reserved.

3 D2961 D2962 D2971 Description LABIAL VENEER (RESIN LAMINATE) - LABORATORY LABIAL VENEER (PORC LAMINATE) - LABORATORY ADDITIONAL PROCEDURES TO CONSTRUCT NEW CROWN UNDER PARTIAL DENTURE FRAMEWORK Description $ D3430 RETROGRADE FILLING - PER ROOT $47.78 $ D3450 ROOT AMPUTATION - PER ROOT $ D3460 ENDODONTIC ENDOSSEOUS IMPLANT $ D2980 CROWN REPAIR, BY REPORT $47.78 D3470 INTENTIONAL REIMPLANTATION $ D2999 D3110 D3120 UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT PULP CAP - DIRECT (EXLUDING FINAL RESTORATION) PULP CAP - INDIRECT (EXCLUDING FINAL RESTORATION) $0.00 D3910 SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER DAM $17.92 $15.53 D3920 HEMISECTION $77.64 $28.67 D3950 D3220 THERAPEUTIC PULPOTOMY $84.05 D3999 D3230 D3240 PULPAL THERAPY (RESORBABLE FILLING) - ANTERIOR, PRIMARY TOOTH PULPAL THERAPY (RESORBABLE FILLING) - POSTERIOR, PRIMARY TOOTH $37.03 D4210 $42.02 D4211 D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH $ D4230 D3320 ENDODONTIC THERAPY, PREMOLAR TOOTH $ D4231 D3330 ENDODONTIC THERAPY, MOLAR TOOTH $ D4240 D3346 D3347 D3348 D3351 D3352 D3353 RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-ANTERIOR RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - PREMOLAR RETREATMENT OF PREVIOUS ROOT CANAL THERAPY-MOLAR APEXIFICATION/RECALCIFICATION - INITIAL VISIT APEXIFICATION/RECALCIFICATION - INTERIM MEDICATION REPLACEMENT APEXIFICATION/RECALCIFICATION - FINAL VISIT $ D4241 CANAL PREPARATION AND FITTING OF PREFORMED DOWEL OR POST UNSPECIFIED ENDODONTIC PROCEDURE, BY REPORT GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT ANATOMICAL CROWN EXPOSURE - FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TOOTH SPACES PER QUADRANT ANATOMICAL CROWN EXPOSURE - ONE TO THREE TEETH OR BOUNDED TOOTH SPACES PER QUADRANT GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT $47.78 $0.00 $47.78 $93.16 $ $52.55 $ D4245 APICALLY POSITIONED FLAP $ $ D4249 D4260 $47.78 D4261 $95.55 D4266 D3354 PULPAL REGENERATION $98.00 D4267 D3410 APICOECTOMY - ANTERIOR $ D4270 CLINICAL CROWN LENGTHENING - HARD TISSUE OSSEOUS SURGERY FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT OSSEOUS SURGERY ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT GUIDED TISSUE REGENERATE- RESORBABLE BARRIER, PER SITE, PER TOOTH GUIDED TISSUE REGENERATION - NONRESORBABLE BARRIER, PER SITE, PER TOOTH PEDICLE SOFT TISSUE GRAFT PROCEDURE D3421 APICOECTOMY - PREMOLAR (FIRST ROOT) D4271 FREE SOFT TISSUE GRAFT PROCEDURE $ D3425 APICOECTOMY - MOLAR (FIRST ROOT) D4273 D3426 APICOECTOMY (EACH ADDITIONAL ROOT) D4274 SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURE DISTAL OR PROXIMAL WEDGE PROCEDURE $ $64.02 $ $ $ $ $ Texas Medicaid & CHIP Amendment Schedule

4 Description D4275 SOFT TISSUE ALLOGRAFT $ D5520 D4276 D4277 D4278 COMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT FREE SOFT TISSUE GRAFT PROCEDURE FIRST TOOTH OR EDENTULOUS TOOTH POSITION IN GRAFT FREE SOFT TISSUE GRAFT PROCEDURE EACH ADDITIONAL CONTIGUOUS TOOTH OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE $ D5611 $65.70 D5612 Description REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE (EACH TOOTH) REPAIR RESIN PARTIAL DENTURE BASE, MANDIBULAR REPAIR RESIN PARTIAL DENTURE BASE, MAXILLARY $41.81 $68.00 $68.00 $65.70 D5630 REPAIR OR REPLACE BROKEN CLASP $47.78 D4283 AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE EACH ADDITIONAL CONTIGUOUS TOOTH, IMPLANT OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE $65.70 D5640 REPLACE BROKEN TEETH-PER TOOTH $41.81 D4285 NON-AUTOGENOUS CONNECTIVE TISSUE GRAFT PROCEDURE EACH ADDITIONAL CONTIGUOUS TOOTH, IMPLANT OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE $65.70 D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $47.78 D4320 PROVISION SPLINTING - INTRACORONAL $59.72 D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $59.72 D4321 PROVISION SPLINTING - EXTRACORONAL $95.55 D5670 D4341 D4342 PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT PERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH PER QUADRANT $53.75 D5671 REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MAXILLARY) REPLACE ALL TEETH AND ACRYLIC ON CAST METAL FRAMEWORK (MANDIBULAR) $ $ $6.69 D5710 REBASE COMPLETE MAXILLARY DENTURE $ D4355 FULL MOUTH DEBRIDEMENT TO ENABLE A COMPREHENSIVE ORAL EVALUATION AND DIAGNOSIS ON A SUBSEQUENT VISIT D5711 REBASE COMPLETE MANDIBULAR DENTURE $ D4381 LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS $28.67 D5720 REBASE MAXILLARY PARTIAL DENTURE $ D4910 PERIODONTAL MAINTENANCE PROCEDURES $35.83 D5721 REBASE MANDIBULAR PARTIAL DENTURE $ D4920 UNSCHEDULED DRESSING CHANGE $23.89 D5730 D4999 UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORT $0.00 D5731 D5110 COMPLETE DENTURE - MAXILLARY $ D5740 D5120 COMPLETE DENTURE - MANDIBULAR $ D5741 D5130 IMMEDIATE DENTURE - MAXILLARY $ D5750 D5140 IMMEDIATE DENTURE - MANDIBULAR $ D5751 D5211 MAXILLARY PARTIAL DENTURE - RESIN BASE $ D5760 D5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE $ D5761 D5213 D5214 MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) $77.64 $77.64 $ $ $ $ $ D5810 INTERIM COMPLETE DENTURE-MAXILLARY $ $ D5811 INTERIM COMPLETE DENTURE- MANDIBULAR D5410 ADJUST COMPLETE DENTURE - MAXILLARY $17.92 D5820 INTERIM PARTIAL DENTURE (MAXILLARY) D5411 ADJUST COMPLETE DENTURE - MANDIBULAR $17.92 D5821 INTERIM PARTIAL DENTURE-MANDIBULAR D5421 ADJUST PARTIAL DENTURE-MAXILLARY $17.92 D5850 TISSUE CONDITIONING, MAXILLARY $35.83 D5422 ADJUST PARTIAL DENTURE - MANDIBULAR $17.92 D5851 TISSUE CONDITIONING,MANDIBULAR $35.83 D5511 D5512 REPAIR BROKEN COMPLETE DENTURE BASE, MANDIBULAR REPAIR BROKEN COMPLETE DENTURE BASE, MAXILLARY $ $68.00 D5860 OVERDENTURE - COMPLETE, BY REPORT $ $68.00 D5861 OVERDENTURE - PARTIAL, BY REPORT $ Texas Medicaid & CHIP Amendment Schedule

5 Description Description D5862 PRECISION ATTACHMENT, BY REPORT D5954 PALATAL AUGMENT PROSTHESIS $ D5863 OVERDENTURE - COMPLETE MAXILLARY $ D5955 PALATAL LIFT PROSTHESIS, DEFINITIVE $ D5864 OVERDENTURE - PARTIAL MAXILLARY $ D5958 PALATAL LIFT PROSTHESIS, INTERIM $ D5865 OVERDENTURE - COMPLETE MANDIBULAR $ D5959 D5866 OVERDENTURE - PARTIAL MANDIBULAR $ D5960 PALATAL LIFT PROSTHESIS, MODIFICATION SPEECH AID PROSTHESIS, MODIFICATION D5911 FACIAL MOULAGE (SECTIONAL) $47.78 D5982 SURGICAL STENT $ D5912 FACIAL MOULAGE (COMPLETE) $86.00 D5983 RADIATION CARRIER D5913 NASAL PROSTHESIS $ D5984 RADIATION SHIELD D5914 AURICULAR PROSTHESIS $ D5985 RADIATION CONE LOCATOR D5915 ORBITAL PROSTHESIS $ D5986 FLUORIDE GEL CARRIER $47.78 D5916 OCULAR PROSTHESIS $ D5987 COMMISSURE SPLINT $ D5919 FACIAL PROSTHESIS $1, D5922 NASAL SEPTAL PROSTHESIS $ D5992 D5923 OCULAR PROSTHESIS, INTERIM $ D5993 D5924 CRANIAL PROSTHESIS $ D5999 D5925 FACIAL AUGMENT IMPLANT PROSTHESIS $ D6010 D5926 NASAL PROSTHESIS, REPLACEMENT $ D6040 D5927 AURICULAR PROSTHESIS, REPLACE $ D6055 $95.55 $95.55 D5988 SURGICAL SPLINT $ ADJUST MAXILLOFACIAL PROSTHETIC APPLIANCE, BY REPORT MAINTENANCE AND CLEANING OF A MAXILLOFACIAL PROSTHESIS (EXTRA OR INTRAORAL) OTHER THAN REQUIRED ADJUSTMENTS. UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANT SURGICAL PLACEMENT:EPOSTEAL IMPLNT CONNECTING BAR - IMPLANT SUPPORTED OR ABUTMENT SUPPORTED $ $1, $0.00 $1, $1, D5928 ORBITAL PROSTHESIS, REPLACE $ D6056 PREFABRICATED ABUTMENT $ D5929 FACIAL PROSTHESIS, REPLACEMENT $ D6057 CUSTOM ABUTMENT $ D5931 OBTURATOR PROSTHESIS, SURGICAL $ D6080 IMPLANT MAINTENANCE PROCEDURE $42.88 D5932 OBTURATOR PROSTHESIS, DEFINITIVE $1, D5933 OBTURATOR PROSTHESIS, MODIFICATION $ D6092 D5934 D5935 MANDIBULAR RESECTION PROSTHESIS WITH GUIDE FLANGE MANDIBULAR RESECTION PROSTHESIS WITHOUT GUIDE FLANGE $ D6093 $ D6090 REPAIR IMPLANT PROSTHESIS $ RE-CEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED CROWN RE-CEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE $45.91 $45.91 $ D6095 REPAIR IMPLANT ABUTMENT $ D5936 OBTURATOR PROSTHESIS, INTERIM $ D6100 IMPLANT REMOVAL, BY REPORT $ D5937 TRISMUS APPLIANCE (NOT FOR TMD TREATMENT) $ D6210 PONTIC - CAST HIGH NOBLE METAL D5951 FEEDING AID $ D6211 PONTIC-CAST BASE METAL D5952 SPEECH AID PROSTHESIS, PEDIATRIC $ D6212 PONTIC - CAST NOBLE METAL D5953 SPEECH AID PROSTHESIS, ADULT $ D6240 PONTIC-PORCELAIN FUSED-HIGH NOBLE Texas Medicaid & CHIP Amendment Schedule

6 Description Description D6241 PONTIC-PORCELAIN FUSED TO BASE METAL D6975 COPING - METAL $ D6242 PONTIC-PORCELAIN PROSTHODONTICS FIXED, EACH D6976 FUSED-NOBLE METAL ADDITIONAL CAST POST-SAME TOOTH $49.00 D6245 PROSTHODONTICS FIXED, EACH PROSTHODONTICS FIXED, PONTIC - D6977 ADDITIONAL PREFABRICATED POST - SAME PORCELAIN/CERAMIC TOOTH $39.82 D6250 PONTIC-RESIN WITH HIGH NOBLE METAL D6980 FIXED PARTIAL DENTURE REPAIR $65.70 D6251 PONTIC-RESIN WITH BASE METAL D7111 EXTRACTION, CORONAL REMNANTS - PRIMARY TOOTH $11.47 D6252 PONTIC-RESIN WITH NOBLE METAL D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR $64.06 FORCEPS REMOVAL) D6545 RETAINER - CAST METAL FIXED $ D7210 SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH $98.23 D6548 PROSTHODONTICS FIXED, RETAINER - REMOVAL OF IMPACTED TOOTH-SOFT PORCELAIN/CERAMIC FOR RESIN BONDED $ D7220 TISSUE FIXED PROSTHODONTIC $ D6549 RESIN RETAINER-FOR RESIN BONDED FIXED REMOVAL OF IMPACTED TOOTH-PARTIALLY D7230 PROSTHESIS BONY $ D6720 CROWN-RESIN WITH HIGH NOBLE METAL D7240 REMOVAL OF IMPACTED TOOTH- COMPLETELY BONY $ D6721 CROWN-RESIN WITH BASE METAL D7241 REMOVAL OF IMPACTED TOOTH- COMPLETELY BONY, WITH UNUSUAL $ SURGICAL COMPLICATIONS D6722 CROWN-RESIN WITH NOBLE METAL D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) $88.38 D6740 RETAINER CROWN PORCELAIN/CERAMIC D7260 OROANTRAL FISTULA CLOSURE $ D6750 CROWN-PORCELAIN FUSED HIGH NOBLE D7261 PRIMARY CLOSURE OF A SINUS PERFORATION $ D6751 CROWN-PORCELAIN FUSED TO BASE METAL D7270 TOOTH REIMPLANTATION AND/OR STABILIZATION OF ACCIDENTALLY $ EVULSED OR DISPLACED TOOTH D6752 CROWN-PORCELAIN FUSED NOBLE METAL D7272 TOOTH TRANSPLANTATION (INLCUDES REIMPLANTATION FROM ONE SITE TO $ ANOTHER) D6780 CROWN-3/4 CST HIGH NOBLE METAL D7280 SURGICAL ACCESS OF AN UNERUPTED TOOTH $59.72 D6781 PROSTHODONTICS FIXED, CROWN ¾ CAST MOBILIZATION OF ERUPTED OR D7282 PREDOMINANTLY BASED METAL MALPOSITIONED TOOTH TO AID ERUPTION $59.72 D6782 PROSTHODONTICS FIXED, CROWN ¾ CAST PLACEMENT OF DEVICE TO FACILITATE D7283 NOBLE METAL ERUPTION OF IMPACTED TOOTH $23.89 D6783 PROSTHODONTICS FIXED, CROWN ¾ INCISIONAL BIOPSY OF ORAL TISSUE-HARD D7285 PORCELAIN/CERAMIC (BONE, TOOTH) D6790 CROWN-FULL CAST HIGH NOBLE D7286 INCISIONAL BIOPSY OF ORAL TISSUE-SOFT $59.72 D6791 CROWN - FULL CAST BASE METAL D7290 SURGICAL REPOSITIONING OF TEETH $ D6792 CROWN - FULL CAST NOBLE METAL D7291 TRANSSEPTAL FIBEROTOMY, BY REPORT $47.78 D6920 CONNECTOR BAR $ D7310 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT $53.75 D6930 RE-CEMENT OR RE-BOND FIXED PARTIAL DENTURE $35.83 D7320 D6940 STRESS BREAKER $83.61 D7340 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY EPITHELIALIZATION) D6950 PRECISION ATTACHMENT $ D7350 VESTIBULOPLASTY - RIDGE EXTENSION $ D6970 CAST POST/CORE AND FIXED RETAIN $98.00 D7410 RADICAL EXCISION - LESION DIAMETER UP TO 1.25CM $95.55 D6972 PREFABRICATED POST AND CORE EXCISION OF BENIGN LESION GREATER $79.63 D RETAINER THAN 1.25 CM $ D6973 CORE BUILD RETAINER WITH PINS $55.13 D7413 EXCISION OF MALIGNANT LESION UP TO 1.25 CM $95.55 $ Texas Medicaid & CHIP Amendment Schedule

7 D7414 D7440 D7441 D7450 D7451 D7460 D7461 D7465 Description EXCISION OF MALIGNANT LESION GREATER THAN 1.25 CM EXCISION OF MALIGNANT TUMOR - LESION DIAMETER UP TO 1.25CM EXCISION OF MALIGNANT TUMOR - LESION DIAMETER GREATER THAN 1.25CM REMOVAL OF ODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25CM REMOVAL OF ODONTOGENIC CYST OR TUMOR - LESION GREATER THAN 1.25CM REMOVAL OF NONODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25CM REMOVAL OF NONODONTOGENIC CYST OR TUMOR - LESION GREATER THAN 1.25CM DESTRUCTION OF LESION(S) BY PHYSICAL OR CHEMICAL METHOD, BY REPORT $ D7997 $ D7999 $ D8050 $ D8060 D8070 $ D8080 D8090 Description APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED APPLIANCE), INCLUDES REMOVAL OF ARCHBAR UNSPECIFIED ORAL SURGERY PROCEDURE, BY REPORT INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITION $47.78 $0.00 $65.70 D8210 REMOVABLE APPLIANCE THERAPY $ D7472 REMOVAL OF TORUS PALATINUS $ D8220 FIXED APPLIANCE THERAPY $ D7510 D7520 D7530 D7540 D7550 D7560 D7670 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE REMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE REMOVAL OF REACTION-PRODUCING FOREIGN BODIES, MUSCULOSKELETAL SYSTEM PARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NON-VITAL BONE MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN BODY ALVEOLUS STABILIZATION OF TEETH, CLOSED REDUCTION SPLINTING $35.83 D8660 $ D8670 PRE-ORTHODONTIC TREATMENT EXAMINATION TO MONITOR GROWTH AND DEVELOPMENT PERIODIC ORTHODONTIC TREATMENT VISIT $66.74 $47.78 D8680 ORTHODONTIC RETENTION $95.55 D8690 ORTHODONTIC TREATMENT $19.60 $ D8691 REPAIR OF ORTHODONTIC APPLIANCE $75.00 $ D8692 D7820 CLOSED REDUCTION DISLOCATION $77.64 D8999 D7880 OCCLUSAL ORTHOTIC DEVICE, BY REPORT $ D9110 REPLACEMENT OF LOST OR BROKEN RETAINER $ $77.64 D8693 RE-CEMENT OR RE-BOND FIXED RETAINER $49.00 UNSPECIFIED ORTHODONTIC PROCEDURE, BY REPORT PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN - MINOR PROCEDURE D7910 SUTURE SMALL WOUNDS UP TO 5 CM D9120 FIXED PARTIAL DENTURE SECTIONING $19.11 D7911 COMPLICATED SUTURE-UP TO 5 CM $77.64 D9210 LOCAL ANESTHESIA NOT IN CONJUCTION WITH OPERATIVE OR SURGICAL PROCEDURES D7912 COMPLEX SUTURE - GREATER THAN 5CM D9211 REGIONAL BLOCK ANESTHESIA $17.92 D7960 FRENULECTOMY $ D9212 TRIGEMINAL DIVISION BLOCK ANESTHESIA $29.86 D7970 EXCISION OF HYPERPLASTIC TISSUE - PER ARCH $ D9215 D7971 EXCISION OF PERICORONAL GINGIVA $41.81 D9220 D7972 SURGICAL REDUCTION OF FIBROUS TUBEROSITY $41.81 D9221 D7980 SURGICAL SIALOLITHOTOMY $ D9222 D7983 CLOSURE OF SALIVARY FISTULA D9223 LOCAL ANESTHESIA IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURES DEEP SEDATION/GENERAL ANESTHESIA - FIRST 30 MINUTES DEEP SEDATION/GENERAL ANESTHESIA - EACH ADDITIONAL 15 MINUTES DEEP SEDATION/GENERAL ANESTHESIA FIRST 15 MINUTES DEEP SEDATION/GENERAL ANESTHESIA - EACH SUBSEQUENT 15 MINUTE INCREMENT $ $17.92 $11.94 $12.25 $ $35.00 $58.50 $ Texas Medicaid & CHIP Amendment Schedule

8 D9230 D9239 D9241 D9239 D9241 D9242 D9243 D9248 D9310 Description INHALATION OF NITROUS OXIDE/ANALGESIA, ANXIOLYSIS SEDATION/ANALGESIA- FIRST 15 MINUTES SEDATION/ANALGESIA - FIRST 30 MINUTES SEDATION/ANALGESIA- FIRST 15 MINUTES SEDATION/ANALGESIA - FIRST 30 MINUTES SEDATION/ANALGESIA - EACH ADDITIONAL 15 MINUTES SEDATION/ANALGESIA - EACH SUBSEQUENT 15 MINUTE INCREMENT NON-INTRAVENOUS MODERATE (CONSCIOUS) SEDATION CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN REQUESTING DENTIST OR PHYSICIAN $27.11 $57.04 $ $57.04 $ $35.00 $42.78 $ $14.58 D9410 HOUSE/EXTENDED CARE FACILITY CALL $23.89 D9420 D9430 HOSPITAL OR AMBULATORY SURGICAL CENTER CALL OFFICE VISIT FOR OBSERVATION - NO OTHER SERVICES PERFORMED $36.31 $14.33 D9440 OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS $29.86 D9610 THERAPEUTIC DRUG INJECTION, BY REPORT $17.92 D9612 D9630 D9910 THERAPEUTIC DRUG INJECTION - 2 OR MORE MEDICATIONS BY REPORT OTHER DRUGS AND/OR MEDICAMENTS, BY REPORT APPLICATION OF DESENSITIZING MEDICAMENT $35.83 $8.60 $11.94 D9920 BEHAVIOR MANAGEMENT, BY REPORT $47.78 D9930 D9944 TREATMENT OF COMPLICATIONS (POST- SURGICAL) - UNUSUAL CIRCUMSTANCES, BY REPORT OCCLUSAL GUARD HARD APPLIANCE, FULL ARCH $23.89 $ D9950 OCCLUSION ANALYSIS-MOUNTED CASE $53.75 D9951 OCCLUSAL ADJUSTMENT - LIMITED $35.83 D9952 OCCLUSAL ADJUSTMENT - COMPLETE $ D9970 ENAMEL MICROABRASION $53.75 D9974 INTERNAL BLEACHING - PER TOOTH $53.75 D9999 UNSPECIFIED ADJUNCTIVE PROCEDURE, BY REPORT $ Texas Medicaid & CHIP Amendment Schedule

9 ATTACHMENT A-2 TEXAS CHIP FEE SCHEDULE D0120 D0140 D0150 D0210 D0220 D0230 D0270 D0272 D0274 D0330 Description PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT LIMITED ORAL EVALUATION- PROBLEM FOCUSED COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC IMAGES INTRAORAL - PERIAPICAL FIRST INTRAORAL - PERIAPICAL EACH ADDITIONAL BITEWING - SINGLE BITEWINGS - TWO BITEWINGS - FOUR PANORAMIC RADIOGRAPHIC IMAGE $28.85 D2330 $18.78 D2331 $35.32 D2332 $70.64 D2335 $12.56 D2391 $11.51 D2391 $4.90 D2392 $23.38 D2392 $34.61 D2393 $63.78 D2393 D1110 PROPHYLAXIS - ADULT $54.88 D2394 D1120 PROPHYLAXIS - CHILD $36.75 D2394 D1208 TOPICAL APPLICATION OF FLUORIDE - EXCLUDING VARNISH D2710 Description RESIN-BASED COMPOSITE - ONE SURFACE, ANTERIOR RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR RESIN-BASED COMPOSITE - THREE SURFACES, ANTERIOR RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR - PERMANENT RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR - PRIMARY RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR - PERMANENT RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR - PRIMARY RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR - PERMANENT RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR - PRIMARY RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR - PERMANENT RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR - PRIMARY CROWN - RESIN-BASED COMPOSITE (INDIRECT) Texas Medicaid & CHIP Amendment Schedule $75.81 $ $ $ $80.34 $76.25 $ $97.75 $ $ $ $ D1351 SEALANT - PER TOOTH $28.24 D2720 CROWN-RESIN WITH HIGH NOBLE METAL D1510 SPACE MAINTAINER-FIXED- CROWN - RESIN WITH PREDOMINANTLY BASE $ D2721 UNILATERAL METAL D1515 SPACE MAINTAINER - FIXED - BILATERAL $ D2722 CROWN - RESIN WITH NOBLE METAL D1516 SPACE MAINTAINER --FIXED-- BILATERAL, MAXILLARY $ D2740 CROWN - PORCELAIN/CERAMIC D1517 SPACE MAINTAINER --FIXED-- CROWN - PORCELAIN FUSED TO HIGH NOBLE $ D2750 BILATERAL, MANDIBULAR METAL $ D1520 SPACE MAINTAINER- CROWN - PORCELAIN FUSED TO $73.50 D2751 REMOVABLE-UNILATERAL PREDOMINANTLY BASE METAL $ D1525 SPACE MAINTAINER- REMOVABLE-BILATERAL $ D2752 CROWN - PORCELAIN FUSED TO NOBLE METAL $ D1526 SPACE MAINTAINER -- REMOVABLE--BILATERAL, MAXILLARY $ D2790 CROWN - FULL CAST HIGH NOBLE METAL $ D1527 SPACE MAINTAINER -- CROWN - FULL CAST PREDOMINANTLY BASE REMOVABLE--BILATERAL, $ D2791 METAL MANDIBULAR D1575 D2140 D2140 D2150 D2150 D2160 D2160 D2161 D2161 DISTAL SHOE SPACE MAINTAINER - FIXED - UNILATERAL AMALGAM - ONE SURFACE - PERMANENT AMALGAM - ONE SURFACE - PRIMARY AMALGAM - TWO SURFACES - PERMANENT AMALGAM - TWO SURFACES - PRIMARY AMALGAM - THREE SURFACES - PERMANENT AMALGAM - THREE SURFACES - PRIMARY AMALGAM - FOUR OR MORE SURFACES -PERMANENT AMALGAM - FOUR OR MORE SURFACES - PRIMARY $ D2930 $62.80 D2931 $61.25 D3220 $83.57 D3230 $81.75 D3240 PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH PREFABRICATED STAINLESS STEEL CROWN- PERMANENT TOOTH THERAPEUTIC PULPOTOMY - REMOVAL OF PULP CORONAL TO THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT PULPAL THERAPY (RESORBABLE FILLING) - ANTERIOR, PRIMARY TOOTH PULPAL THERAPY (RESORBABLE FILLING) - POSTERIOR, PRIMARY TOOTH $ $84.05 $37.03 $42.02 $ D3310 ENDODONTIC THERAPY, ANTERIOR TOOTH $ $88.75 D3320 ENDODONTIC THERAPY, PREMOLAR TOOTH $ $ D3330 ENDODONTIC THERAPY, MOLAR TOOTH $ $90.01 D4210 GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SPACES PER QUADRANT

10 ATTACHMENT A-2 TEXAS CHIP FEE SCHEDULE Description Description D4341 D4355 PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANT FULL MOUTH DEBRIDEMENT TO ENABLE A COMPREHENSIVE ORAL EVALUATION AND DIAGNOSIS ON A SUBSEQUENT VISIT $53.75 D8680 D8690 D5110 COMPLETE DENTURE - MAXILLARY $ D8691 D5120 COMPLETE DENTURE - MANDIBULAR $ D8692 D5211 D5212 D5213 D5214 D7140 D7210 MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP IF INDICATED $ D8693 $ $ $ $64.06 $98.23 D7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $ D7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY $ D7240 D8010 D8020 D8050 D8060 D8070 D8080 D8090 D8210 D8220 D8660 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DENTITION REMOVABLE APPLIANCE THERAPY (INCLUDES APPLIANCES FOR THUMB SUCKING AND TONGUE THRUSTING) FIXED APPLIANCE THERAPY (INCLUDES APPLIANCES FOR THUMB SUCKING AND TONGUE THRUSTING) PRE-ORTHODONTIC TREATMENT EXAMINATION TO MONITOR GROWTH AND DEVELOPMENT $ $ $ D8670 PERIODIC ORTHODONTIC TREATMENT VISIT $66.74 ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES) ORTHODONTIC TREATMENT (ALTERNATIVE BILLING TO A CONTRACT FEE) REPAIR OF ORTHODONTIC APPLIANCE REPLACEMENT OF LOST OR BROKEN RETAINER RE-CEMENT OR RE-BOND FIXED RETAINER $19.60 $75.00 $ $ Texas Medicaid & CHIP Amendment Schedule

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