Ambulatory Surgical Center Services

An Ambulatory Surgical Center is a distinct entity that operates exclusively to provide surgical services to beneficiaries not requiring hospitalization. Approved services are based on the Code of Federal Regulations (42 CFR 416).

Fee Schedules

Billing for Dental Facility Charges By An Ambulatory Surgical Center

An Ambulatory Surgical Center (ASC) must submit claims for dental facility use with an electronic claim in NCTracks. Paper claims are no longer accepted. These claims will be reimbursed based on the total time for each case, as follows:

ASC Group

Total Time



Up to 30 minutes



31–60 minutes



61–90 minutes



Over 90 minutes


Providers must complete the claim as instructed below:

  1. Enter the place of service code as “24” for the ASC.
  2. Enter the dental procedure codes (Code on Dental Procedures and Nomenclature CDT-2015) for the services provided by the dentist.
  3. Note: All dental codes begin with the “D” prefix. Only the dental procedure codes (CDT-2015) listed in the clinical coverage policy 4A, Dental Services, subsection 5.3, Limitations or Requirements, are valid for billing in ASC cases.
  4. Enter modifier SG for each procedure code.
  5. Enter all charges on detail line 1 of the claim.
  6. Enter the total operating room time on detail line 1 of the claim (one unit = one minute).
  7. For all remaining detail lines, enter the number of times (units) each dental procedure was provided with zero charges
  8. Submit all dental procedure codes on one electronic claim for the surgery date. 


Medical Assistance Clinical Section
Phone: 919-855-4260
Fax: 919-733-2796

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