Wisconsin Medicaid-certified providers will be reimbursed the rates listed on this schedule for covered services provided to eligible members.
Note: Effective February 1, 2008, BadgerCare Plus Benchmark Plan members will have different maximum allowable fees and different covered benefits than BadgerCare Plus Standard Plan members. Covered services for BadgerCare Benchmark Plan members are limited to diagnostic, preventative, simple restorative and Temporo-Mandibular Joint (TMJ) procedures. There is an annual limit of $750.00 reimbursement for each member. BadgerCare Plus Benchmark Plan members will be responsible for a $200.00 deductible per enrollment year, except for preventative and diagnostic services. This schedule provides the maximum allowable fee for BadgerCare Plus Benchmark Plan members. To view maximum allowable fees for Standard Plan members, please go to the Dental Maximum Allowable Fee Schedule.
This maximum allowable fee schedule for BadgerCare Plus Benchmark members contains the following information:
| Procedure Code | The procedure code recognized by BadgerCare Plus to identify the service provided. |
| Procedure Description | An abbreviated description of the procedure code. |
| Provider Type | All applicable performing provider types for the procedure code. |
| Maximum Allowable Fee | The uniform rate determined by the Division of Health Care Access and Accountability (DHCAA). |
| Effective Date | The date that the specific maximum allowable fee became effective for the specific procedure code. |
The fee schedule does not address the various coverage limitations routinely applied by BadgerCare Plus before final payment is determined (e.g., member and provider eligibility, billing instructions, frequency of services, third-party liability, copayment, age restrictions, and prior authorization).
For questions about the fee schedule, providers should contact Provider Services at (800) 947-9627 or (608) 221-9883. For questions about rates, providers should contact the DHCAA by writing to the following address:
Policy Analyst
Division of Health Care Access and Accountability
Dental Services
PO Box 309
Madison WI 53701-0309
|
Procedure Code |
Procedure Description |
Provider Type |
Maximum Allowable Fee |
Effective Date |
|
D0120 |
PERIODIC ORAL EVALUATION- ESTABLISHED PATIENT |
27 |
$32.00 |
1/1/2008 |
|
D0140 |
LIMITED ORAL EVALUATION-PROBLEM FOCUSED |
27 |
$47.00 |
1/1/2008 |
|
D0150 |
COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT |
27 |
$50.00 |
1/1/2008 |
|
D0160 |
DETAILED AND EXTENSIVE ORAL EVALUATION |
27 |
$65.00 |
1/1/2008 |
|
D0170 |
RE-EVALUATION-LIMITED, PROBLEM FOCUSED (ESTABLISHED PATIENT; NOT POST-OPERATIVE VISIT) |
27 |
$38.00 |
1/1/2008 |
|
D0210 |
INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) |
27 |
$90.00 |
1/1/2008 |
|
D0220 |
INTRAORAL-FIRST PERIAPICAL FILM |
27 |
$19.00 |
1/1/2008 |
|
D0230 |
INTRAORAL-EA ADD'L PERIAPICAL FILM |
27 |
$15.00 |
1/1/2008 |
|
D0240 |
INTRAORAL- OCCLUSAL FILM |
27 |
$25.00 |
1/1/2008 |
|
D0250 |
EXTRAORAL-FIRST FILM |
27 |
$30.00 |
1/1/2008 |
|
D0260 |
EXTRAORAL-EACH ADD'L FILM |
27 |
Manually Priced |
1/1/2008 |
|
D0270 |
BITEWINGS-SINGLE FILM |
27 |
$20.00 |
1/1/2008 |
|
D0272 |
BITEWINGS-TWO FILMS |
27 |
$30.00 |
1/1/2008 |
|
D0273 |
BITEWINGS- THREE FILMS |
27 |
$36.00 |
1/1/2008 |
|
D0274 |
BITEWINGS- FOUR FILMS |
27 |
$42.00 |
1/1/2008 |
|
D0330 |
PANORAMIC FILM |
27 |
$82.00 |
1/1/2008 |
|
D0340 |
CEPHALOMETRIC FILM |
27 |
$80.00 |
1/1/2008 |
|
D0350 |
ORAL/FACIAL PHOTOGRAPHIC IMAGES |
27 |
$35.00 |
1/1/2008 |
|
D0470 |
DIAGNOSTIC CASTS |
27 |
$66.00 |
1/1/2008 |
|
D0486 |
ACCESSION OF BRUSH BIOPSY SAMPLE,MICROSCOPIC EXAM,PREP & TRANSMISSION OF WRITTEN REPORT |
27 |
$175.00 |
1/1/2008 |
|
D0999 |
UNSPECIFIED DIAGNOSTIC PROCEDURES, BY REPORT |
27 |
$38.00 |
1/1/2008 |
|
D1110 |
PROPHYLAXIS-ADULT/13-99 |
27 |
$60.00 |
1/1/2008 |
|
D1120 |
PROPHYLAXIS-CHILD/00-12 |
27 |
$45.00 |
1/1/2008 |
|
D1203 |
TOP FLUORIDE - CHILD/00-12 (EXCLUDING PROPHYLAXIS |
27 |
$26.00 |
1/1/2008 |
|
D1204 |
TOP FLUORIDE-ADULT/13-99 (EXCLUDING PROPHYLAXIS) |
27 |
$27.00 |
1/1/2008 |
|
D1206 |
TOPICAL FLUORIDE VARNISH;THERAPUTIC APPLICATION FOR MODERATE TO HIGH CARIES RISK PATIENT |
27 |
$27.00 |
1/1/2008 |
|
D1351 |
SEALANT, PER TOOTH |
27 |
$35.00 |
1/1/2008 |
|
D1510 |
SPACE MAINTAIN-FIXED UNILATERAL |
27 |
$210.00 |
1/1/2008 |
|
D1515 |
SPACE MAINTAIN-FIXED-BILATERAL |
27 |
$300.00 |
1/1/2008 |
|
D1550 |
RECEMENT SPACE MAINTAINER |
27 |
$46.00 |
1/1/2008 |
|
D1555 |
REMOVAL OF FIXED SPACE MAINTAINER |
27 |
$25.00 |
1/1/2008 |
|
D2140 |
AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT |
27 |
$85.00 |
1/1/2008 |
|
D2150 |
AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT |
27 |
$103.00 |
1/1/2008 |
|
D2160 |
AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT |
27 |
$125.00 |
1/1/2008 |
|
D2161 |
AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT |
27 |
$150.00 |
1/1/2008 |
|
D2330 |
RESIN-1 SURFACE, ANTERIOR |
27 |
$100.00 |
1/1/2008 |
|
D2331 |
RESIN-2 SURFACES, ANTERIOR |
27 |
$125.00 |
1/1/2008 |
|
D2332 |
RESIN-3 SURFACES, ANTERIOR |
27 |
$151.00 |
1/1/2008 |
|
D2335 |
RESIN, INVOLVE INCISAL ANGLE, ANTERIOR, 4 OR MORE SURFACES |
27 |
$184.00 |
1/1/2008 |
|
D2390 |
RESIN-BASED COMPOSITE CROWN, ANTERIOR |
27 |
$250.00 |
1/1/2008 |
|
D2391 |
RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR |
27 |
$111.00 |
1/1/2008 |
|
D2392 |
RESIN-BASED COMPOSITE-TWO-SURFACES, POSTERIOR |
27 |
$145.00 |
1/1/2008 |
|
D2393 |
RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR |
27 |
$175.00 |
1/1/2008 |
|
D2394 |
RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES, POSTERIOR |
27 |
$204.00 |
1/1/2008 |
|
D4210 |
GINGIVECTOMY OR GINGIVOPLASTY-4 OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES,PER QDT |
27 |
$400.00 |
1/1/2008 |
|
D4211 |
GINGIVECTOMY OR GINGIVOPLASTY-1 TO 3 CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUAD |
27 |
$151.00 |
1/1/2008 |
|
D4341 |
PERIODONTAL SCALING & ROOT PLANING-4 OR MORE TEETH PER QUADRANT |
27 |
$175.00 |
1/1/2008 |
|
D4342 |
PERIODONTAL SCALING AND ROOT PLANING-ONE TO THREE TEETH, PER QUADRANT |
27 |
$105.00 |
1/1/2008 |
|
D4355 |
FULL-MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSIS |
27 |
$123.00 |
1/1/2008 |
|
D4910 |
PERIODONTAL MAINTENANCE |
27 |
$95.00 |
1/1/2008 |
|
D7140 |
EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) |
27 |
$100.00 |
1/1/2008 |
| TMJ Procedures | ||||
|
Procedure Code |
Procedure Description |
Provider Type |
Maximum Allowable Fee |
Effective Date |
|
D7810 |
TMJ-OPEN RDN OF DISLOCATION |
27 |
Manually Priced |
1/1/2008 |
|
D7820 |
TMJ-CLOSED RDN OF DISLOCATION |
27 |
$486.00 |
1/1/2008 |
|
D7830 |
TMJ MANIP UNDER ANESTHESIA |
27 |
$339.00 |
1/1/2008 |
|
D7840 |
CONDYLECTOMY |
27 |
Manually Priced |
1/1/2008 |
|
D7850 |
SURG DISCECTOMY W/WOUT IMPLANT |
27 |
Manually Priced |
1/1/2008 |
|
D7860 |
ARTHROTOMY, TMJ |
27 |
$4,058.00 |
1/1/2008 |
|
D7865 |
ARTHROPLASTY |
27 |
Manually Priced |
1/1/2008 |
|
D7871 |
NON-ARTHROSCOPIC LYSIS AND LAVAGE |
27 |
$766.00 |
1/1/2008 |
|
D7899 |
UNSPECIFIED TMD THERAPY, BY REPORT |
27 |
Manually Priced |
1/1/2008 |
|
20605 |
ARTHROCENTESIS, ASPIRATION/INJECTION, INTERMEDIATE JOINT/BURSA (E.G. WRIST, ELBOW) |
27 |
$82.00 |
1/1/2008 |
|
21050 |
SONDYLECTOMY, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) |
27 |
Manually Priced |
1/1/2008 |
|
21060 |
MENISCECTOMY, PARTIAL OR COMPLETE, TEMPOROMANDIBULAR JOINT (SEPARATE PROCEDURE) |
27 |
Manually Priced |
1/1/2008 |
|
21070 |
CORONOIDECTOMY (SEPARATE PROCEDURE) |
27 |
$2,565.00 |
1/1/2008 |
|
21240 |
ARTHROPLASTY,TEMPOROMANDIBULAR JOINT,WITH OR WITHOUT AUTOGRAFT (INCLUDES OBTAINING GRAFT |
27 |
Manually Priced |
1/1/2008 |
|
21242 |
ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH ALLOGRAFT |
27 |
Manually Priced |
1/1/2008 |
|
21243 |
ARTHROPLASTY, TEMPOROMANDIBULAR JOINT, WITH PROSTHETIC JOINT REPLACEMENT |
27 |
$6,567.00 |
1/1/2008 |
|
21480 |
CLOSED TREATMENT OF TEMPOROMANDIBULAR DISLOCATION; INITIAL OR SUBSEQUENT |
27 |
$369.00 |
1/1/2008 |
|
21485 |
COMPLICATED (EG, RECURRENT REQUIRING INTERMAXILLARY FIXATION OR SPLINTING),INITIAL OR |
27 |
Manually Priced |
1/1/2008 |
|
21490 |
OPEN TREATMENT OF TEMPOROMANDIBULAR DISLOCATION |
27 |
Manually Priced |
1/1/2008 |
|
29800 |
ARTHROSCOPY,TEMPOROMANDIBULAR JOINT,DIAGNOSTIC,WITH OR WITHOUT SYNOVIAL BIOPSY |
27 |
Manually Priced |
1/1/2008 |
|
29804 |
ARTHROSCOPY, TEMPOROMANDIBULAR JOINT, SURGICAL |
27 |
$3,530.00 |
1/1/2008 |