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CDT Dental Procedure Code Lookup

How to check member benefits

Member benefits are customized, so it is important to use Change Healthcare’s Dental Connect to check each member’s specific benefits and eligibility before performing services.

Or, you can check member benefits by calling Dental Provider Services at 1-800-882-1178 during business hours.

Note: use of this tool does not guarantee coverage.

Use this tool to look up the procedure guidelines and submission requirements for all CDT codes.

You can refer to our Dental Administrative Guidelines for information about our policies and procedures.

Step : Use Dental Connect to find out the member's plan name and check benefits.
Step : Choose the member's plan using the information as it appears on Dental Connect.
Step : Type a CDT code (for example, D1206) in the search field for details about the code. To see results for all the codes in a range of services (for example, D0220-D0274) just type the first three characters in the series (for example, D02). Results will appear below.

CDT Code Description of Service Procedure Guidelines Submission requirements for BCBSMA-participating providers Submission requirements for out-of-state & non-par providers

D0120

Periodic oral evaluation – established patient

Two per calendar year. Not a covered benefit when performed on the same day as D9110 by the same dentist/dental office.

For specific ACA-compliant small group plans only: Two per calendar year of D0145 or D0120. Not a covered benefit when performed on the same day as D9110 by the same dentist/dental office.

For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage:  Three per 12 months

Note: One evaluation code may be billed per dentist per date of service. Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

None

D0140

Limited oral evaluation – problem-focused

Covered service

For specific ACA-compliant small group plans only: Two per calendar year. Not covered with D9110, D0160 by the same dentist/dental office on the same date of service.

Note: One evaluation code may be billed per dentist per date of service. Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

None

D0145

Oral evaluation for a patient under three years of age and counseling with primary caregiver

One per member per dentist. Maximum 3 per member, up to age 3.

For specific ACA-compliant small group plans only: Two per calendar year of D0145 or D0120. Not covered with D9110 by the same dentist/dental office on the same date of service.

Note: One evaluation code may be billed per dentist per date of service. Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

None

D0150

Comprehensive oral evaluation – new or established patient

Once per 60 months per dentist or location.

 

Note: One evaluation code may be billed per dentist per date of service. Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

None

D0160

Detailed and extensive oral evaluation – problem-focused, by report

Not a covered benefit.

For specific ACA-compliant small group plans only: Two per 12 months. Not covered with D9110 by same dentist/dental office on same date of service.

None

None

D0170

Re-evaluation – limited, problem- focused (established patient; not post-operative visit)

Two per twelve months. Not to be used as a periodontal reevaluation.

 

Note: One evaluation code may be billed per dentist per date of service. Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

None

D0171

Re-evaluation post-operative office visit. 

Considered to be inclusive of the definitive procedure performed previously.   

 

Note: One evaluation code may be billed per dentist per date of service. Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

None

D0180

Comprehensive periodontal evaluation – new or established patient

Once per 60 months per dentist or location.

 

Note: One evaluation code may be billed per dentist per date of service. Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

None

D0190

Screening of a patient

Not a covered benefit.

None  

None

D0191

Assessment of a patient

Not a covered benefit.

None 

None

D0210

Intraoral – comprehensive series of radiographic images

One full mouth series or a panorex (D0330) per 60 months and consists of a minimum of 7 or more radiographs, including bitewings.

For specific ACA-compliant small group plans only: Up to age 19: a full mouth series (including bitewings) or panorex once per three calendar year(s).

None

None

D0220

Intraoral – periapical first radiographic image

A maximum of 6 radiographs per date of service. Any combination of radiographs that exceed 6 will be processed as D0210. If reported with endodontic therapy, radiographs are included in the fee for the procedure.

None

None

D0230

Intraoral – periapical each additional radiographic image

A maximum of 6 radiographs per date of service. Any combination of radiographs that exceed 6 will be processed as D0210. If reported with endodontic therapy, radiographs are included in the fee for the procedure.

None

None

D0240

Intraoral – occlusal radiographic image

One film per 6 months per arch.

Arch identification

Arch identification

D0250

Extra-oral – 2D projection radiographic image created using a stationary radiations source, and detector.

Not a covered benefit.

None

None

D0251

Extra-oral posterior dental radiographic image

Not a covered benefit.

None

None

D0270

Bitewing – single radiographic image

Two per calendar year. Bitewing radiographs reported within 6 months of D0210 are considered included in this procedure and are non-covered. If reported within 6 months of D0330, we will make an allowance for the difference between the payment of the panoramic and a full series of radiographs.

For specific ACA-compliant small group plans only: Up to age 19: Two per calendar year per patient. Ages 19+: One per 6 months per patient. May be a combination of any 2 codes D0270, D0272, D0273, D0274.

For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage:  One per 6 months per patient.

None

None

D0272

Bitewings – two radiographic images

Two per calendar year. Bitewing radiographs reported within 6 months of D0210 are considered included in this procedure and are non-covered. If reported within 6 months of D0330, we will make an allowance for the difference between the payment of the panoramic and a full series of radiographs.

For specific ACA-compliant small group plans only: Up to age 19: Two per calendar year per patient. Ages 19+: One per 6 months per patient. May be a combination of any 2 codes D0270, D0272, D0273, D0274.

For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage:  One per 6 months per patient.

None

None

D0273

Bitewings - three radiographic images

Two per calendar year. Bitewing radiographs reported within 6 months of D0210 are considered included in this procedure and are non-covered. If reported within 6 months of D0330, we will make an allowance for the difference between the payment of the panoramic and a full series of radiographs.

For specific ACA-compliant small group plans only: Up to age 19: Two per calendar year per patient. Ages 19+: One per 6 months per patient. May be a combination of any 2 codes D0270, D0272, D0273, D0274.

For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage:  One per 6 months per patient.

None

None

D0274

Bitewings – four radiographic images

Two per calendar year. Bitewing radiographs reported within 6 months of D0210 are considered included in this procedure and are non-covered. If reported within 6 months of D0330, we will make an allowance for the difference between the payment of the panoramic and a full series of radiographs.

For specific ACA-compliant small group plans only: Up to age 19: Two per calendar year per patient. Ages 19+: One per 6 months per patient. May be a combination of any 2 codes D0270, D0272, D0273, D0274.

For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage:  One per 6 months per patient.

None

None

D0277

Vertical bitewings 7-8 radiographical images

One set per 12 month for members age 16+. Not covered if reported within six months of other bitewing series.

For specific ACA-compliant small group plans only: Members age 16+: One set per 12 months.

None

None

D0310

Sialography

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans.  Please check with patient’s medical insurer for possible coverage.

None

None

D0320

Temporomandibular joint arthrogram, including injection

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans.  Please check with patient’s medical insurer for possible coverage.

None

None

D0321

Other temporomandibular joint radiographic images, by report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans.  Please check with patient’s medical insurer for possible coverage.

None

None

D0322

Tomographic survey

Not a covered benefit.

None

None

D0330

Panoramic radiographic image

Panoramic radiograph or full mouth series (D0210) is limited to one per 60 months.  Submit bitewing radiographs done in conjunction with a panoramic on a separate line; we will pay for the difference between the panorex and a full mouth series of radiographs.

For specific ACA-compliant small group plans only: Up to age 19:  One per three calendar year(s) per member.  

None

None

D0340

Cephalometric radiographic image

Covered only for members with orthodontic benefits. Limited to twice per lifetime.

For specific ACA-compliant small group plans only: Up to age 19: Covered for members without orthodontic benefits.

None

None

D0350

2D oral/facial photographic images obtained intra-orally or extra orally

Covered only when Blue Cross Blue Shield of Massachusetts requests these images to support the claim for another service.

None

None

D0364

Cone beam CT capture and interpretation with limited field of view-less than one whole jaw

Not a covered benefit.

None

None

D0365

Cone beam CT capture and interpretation with limited field of one full dental arch – mandible

Not a covered benefit.

None

None

D0366

Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium

Not a covered benefit.

None

None

D0367

Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium

Not a covered benefit.

None

None

D0368

Cone beam CT capture and interpretation for TMJ series including two or more exposures

Not a covered benefit.

None

None

D0369

Maxillofacial MRI capture and interpretation

Not a covered benefit.

None

None

D0370

Maxillofacial ultrasound capture and interpretation

Not a covered benefit.

None

None

D0371

Sialoendoscopy capture and interpretation

Not a covered benefit.

None  

None

D0372

Intraoral tomosynthesis comprehensive series of radiographic images

Not a covered benefit.

None  

None

D0373

Intraoral tomosynthesis – bitewing radiographic image

Not a covered benefit.

None  

None

D0374

Intraoral tomosynthesis – periapical radiographic image

Not a covered benefit.

None  

None

D0801

3D dental surface scan – direct

Not a covered benefit.

None  

None

D0802

3D dental surface scan – indirect

Not a covered benefit.

None  

None

D0803

3D facial surface scan – direct

Not a covered benefit.

None  

None

D0804

3D facial surface scan – indirect

Not a covered benefit.

None  

None

D0380

Cone beam CT image capture with limited field of view – less than one whole jaw

Not a covered benefit.

None 

None

D0381

Cone beam CT image capture with field of view of one full dental arch –mandible

Not a covered benefit.

None 

None

D0382

Cone beam CT image capture with field of view of one full dental arch –maxilla, with or without cranium

Not a covered benefit.

None 

None

D0383

Cone beam CT image capture with field of view of both jaws, with or without cranium

Not a covered benefit.

None 

None

D0384

Cone beam CT image capture for TMJ series including two or more exposures

Not a covered benefit.

None 

None

D0385

Maxillofacial MRI image capture

Not a covered benefit.

None 

None

D0386

Maxillofacial ultrasound image capture

Not a covered benefit.

None 

None

D0387

Intraoral tomosynthesis – comprehensive series of radiographic images – image capture only

Not a covered benefit.

None 

None

D0388

Intraoral tomosynthesis – bitewing radiographic image – image capture only

Not a covered benefit.

None

None

D0389

Intraoral tomosynthesis – periapical radiographic image – image capture only

Not a covered benefit.

None

None

D0701

Panoramic radiographic image – image capture only

Not a covered benefit.

None

None

D0702

2-D cephalometric radiographic image – image capture only

Not a covered benefit.

None

None

D0703

2-D oral/facial photographic image obtained intra-orally or extra-orally– image capture only

Not a covered benefit.

None

None

D0705

Extra-oral posterior dental radiographic image – image capture only. Image limited to exposure of complete posterior teeth in both dental arches. This is a unique image not derived from another image.

Not a covered benefit.

None

None

D0706

Intraoral – occlusal radiographic image – image capture only

Not a covered benefit.

None

None

D0707

Intraoral – periapical radiographic image – image capture only

Not a covered benefit.

None

None

D0708

Intraoral – bitewing radiographic image – image capture only. Image axis may be horizonal or vertical

Not a covered benefit.

None

None

D0709

Intraoral – comprehensive series of radiographic images – image capture only.

Not a covered benefit.

None

None

D0391

Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

Not a covered benefit.

None 

None

D0393

Virtual treatment simulation using 3D image volume or surface scan.

Not a covered benefit.

None  

None

D0394

Digital subtraction of two or more images or image volumes of the same modality. To demonstrate changes that have occurred over time.

Not a covered benefit.

None  

None

D0395

Fusion of two or more 3D image volumes of one or more modalities.

Not a covered benefit.

None  

None

D0411

HbA1c in-office point of service testing  

Not a covered benefit.                                                                       

None

None

D0412

Blood glucose level test — in-office using a glucose meter

Not a covered benefit.                                                                       

None

None

D0415

Collection of microorganisms for culture and sensitivity

Not a covered benefit.                                                                       

None

None

D0414

Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report

Not a covered benefit.                                                                       

None

None

D0416

Viral culture. A diagnostic test to identify viral organisms, most often herpes virus

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurance for possible coverage.  

None

None

D0417

Collection and preparation of saliva sample for laboratory diagnostic testing

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurance for possible coverage.  

None

None

D0418

Analysis of saliva sample. Chemical or biological analysis of saliva sample for diagnostic purposes

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurance for possible coverage.  

None

None

D0419

Assessment of salivary flow by measurement

Not a covered benefit.

None

None

D0422

Collection and preparation of genetic sample material for laboratory analysis and report

Not a covered benefit.

None

None

D0423

Genetic test for susceptibility to diseases – specimen analysis

Not a covered benefit.

None

None

D0425

Caries susceptibility tests.  Not to be used for carious dentin staining

Not a covered benefit

None

None

D0431

Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures  

Not a routinely covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurance for possible coverage.

None

None

D0460      

Pulp vitality tests

Considered inclusive of other evaluation services performed on the same day. Not a covered benefit in any other circumstances.

None

None

D0470

Diagnostic casts

One complete set per 60 months.

None

None

D0472

Accession of tissue, gross examination, preparation and transmission of written report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0473

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0474

Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0475

Decalcification procedure

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0476

Special stains for microorganisms

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0477

Special stains, not for microorganisms

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0478

Immunohistochemical stains

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0479

Tissue in-site hybridization, including interpretation

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0480

Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0481

Electron microscopy

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0482

Direct immunofluorescence

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

 

None

None

D0483

Indirect immunofluorescence

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0484

Consultation on slides prepared elsewhere

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0485

Consultation, including preparation of slides from biopsy material supplied by referring source

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0486

Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0502

Other oral pathology procedures, by report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0600

Non-ionizing diagnostic procedure capable of quantifying, monitoring and recording changes in structure of enamel, dentin, and cementum

Not a covered benefit.

None

None

D0601

Caries risk assessment and documentation, with a finding of low risk

Not a covered benefit.

None

None

D0602

Caries risk assessment and documentation, with a finding of moderate risk

Not a covered benefit.

None

None

D0603

Caries risk assessment and documentation, with a finding of high risk

Not a covered benefit.

None

None

D0604

Antigen testing for a public health related pathogen including coronavirus

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

 

None

None

D0605

Antibody testing for a public health related pathogen including coronavirus

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0606

Molecular testing for a public health related pathogen, including coronavirus

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D0999

Unspecified diagnostic procedure, by report

Individual consideration.

 

Note: This procedure does not include collection of the tissue sample, which is documented separately.

Detailed narrative

Detailed narrative

D1110

Prophylaxis - adult

Two per calendar year.  There must be at least three months between a periodontal maintenance cleaning and any other cleanings

Use D1110 for ages 14+; use D1120 for ages 0 – 13

For specific ACA-compliant small group plans only: Two per calendar year.

For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage:  Three per 12 months.

None

None

D1120

Prophylaxis - child

Two per calendar year.  There must be at least three months between a periodontal maintenance cleaning and any other cleanings

Use D1110 for ages 14+; use D1120 for ages 0 – 13

For specific ACA-compliant small group plans only: Two per calendar year.

For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage:  Three per 12 months.

None

None

D1206

Topical application of fluoride varnish

Two per calendar year through age 18 (up to the 19th birthday). Benefit will be in place of D1208.

For specific ACA-compliant small group plans only: Up to age 19: Once per 90 days.  Benefit will be in place of D1208.

None

None

D1208

Topical application of fluoride – excluding varnish

Two per calendar year through age 18 (up to the 19th birthday). Benefit will be in place of D1206.

For specific ACA-compliant small group plans only: Up to age 19: Once per 90 days.  Benefit will be in place of D1206.

None

None

D1310

Nutritional counseling for control of dental disease

Not a covered benefit.

None

None

D1320

Tobacco counseling for control and prevention of oral disease

Not a covered benefit.

None

None

D1321

Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use. Counseling services may include patient education about adverse oral, behavioral, and systemic effects associated with high-risk substance use and administration routes. This includes ingesting, injecting, inhaling and vaping. Substances used in a high-risk manner may include but are not limited to alcohol, opioids, nicotine, cannabis, methamphetamine and other pharmaceuticals or chemicals.

Not a covered benefit.

None

None

D1330

Oral hygiene instructions

Not a covered benefit.

None

None

D1351

Sealant – per tooth

One per tooth per 48 months, regardless of the number of surfaces, on premolars and permanent first and second molars. Covered through age 13 (up to the 14th birthday.) No coverage for sealants on a restored surface of a tooth. Preventive resin restorations are considered sealants for benefit purposes.

For specific ACA-compliant small group plans only: Under age 9: Covered for primary molars. Reapplication only if process fails within three years. Under age 19: Covered for permanent non-carious molars for members once every three years per tooth. Ages 19+: Not covered.

Tooth identification

Surface identification

Tooth identification

Surface identification

D1352

Preventive resin restoration in a moderate- to high- caries risk patient – permanent tooth

One per tooth per 48 months, regardless of the number of surfaces, on premolars and permanent first and second molars. Covered through age 13 (up to 14th birthday). No coverage for sealants on a restored surface of a tooth. Preventive resin restorations are considered sealants for benefit purposes.

For specific ACA-compliant small group plans only: Up to 14th birthday: Once per tooth per 48 months, on premolars and permanent first and second molars.

Tooth identification

Surface identification

Tooth identification

Surface identification

Narrative indicating risk criteria

D1353

Sealant repair – per tooth

Not a covered benefit.

None

None

D1354

Application of caries-arresting medicament – per tooth

Covered once per tooth per lifetime.

For specific ACA-compliant small group plans only: Not a covered benefit.

Tooth identification

Tooth identification

D1355

Caries preventive medicament application – per tooth. For primary prevention or remineralization. Medicaments applied do not include topical fluorides.

Not a covered benefit.

None

None

D1510

Space maintainer – fixed, unilateral – per quadrant

One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday).

For specific ACA-compliant small group plans only: Up to age 19: Once per arch or quadrant per lifetime. Ages 19+: not covered.

Note: Passive appliances are designed to prevent tooth movement.

Quadrant identification

Arch identification

Quadrant identification

Arch identification

D1516

Space maintainer – fixed – bilateral, maxillary

One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday).

For specific ACA-compliant small group plans only: Up to age 19: Once per arch or quadrant per lifetime. Ages 19+: not covered.

Note: Passive appliances are designed to prevent tooth movement.

Quadrant identification

Arch identification

Quadrant identification

Arch identification

D1517

Space maintainer – fixed – bilateral, mandibular

One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday).

For specific ACA-compliant small group plans only: Up to age 19: Once per arch or quadrant per lifetime. Ages 19+: not covered.

Note: Passive appliances are designed to prevent tooth movement.

Quadrant identification

Arch identification

Quadrant identification

Arch identification

D1520

Space maintainer – removable, unilateral – per quadrant

One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday).

For specific ACA-compliant small group plans only: Up to age 19: Once per arch or quadrant per lifetime. Ages 19+: not covered.

Note: Passive appliances are designed to prevent tooth movement.

Quadrant identification

Arch identification

Quadrant identification

Arch identification

D1526

Space maintainer – removable –bilateral, maxillary

One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday).

For specific ACA-compliant small group plans only: Up to age 19: Once per arch or quadrant per lifetime. Age 19+: not covered.

Note: Passive appliances are designed to prevent tooth movement.

Arch identification  

Arch identification  

D1527

Space maintainer – removable – bilateral, mandibular

One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday).

For specific ACA-compliant small group plans only: Up to age 19: Once per arch or quadrant per lifetime. Age 19+: not covered.

Note: Passive appliances are designed to prevent tooth movement.

Arch identification  

Arch identification  

D1551

Re-cement or rebond bilateral space maintainer, maxillary

One per arch per 6 months for members through age 18 (up to the 19th birthday).

 

Note: Passive appliances are designed to prevent tooth movement.

Arch identification

Arch identification

D1552

Re-cement or re-bond bilateral space maintainer, mandibular

One per arch per 6 months for members through age 18 (up to the 19th birthday).

 

Note: Passive appliances are designed to prevent tooth movement.

Arch identification

Arch identification

D1553

Re-cement or re-bond unilateral space maintainer, per quadrant

One per arch per 6 months for members through age 18 (up to the 19th birthday).

 

Note: Passive appliances are designed to prevent tooth movement.

Arch identification

Arch identification

D1556

Removal of fixed unilateral space maintainer, per quadrant

Covered only when procedure is performed by a dentist who did not place the original appliance.

 

Note: Passive appliances are designed to prevent tooth movement.

Quadrant identification

Quadrant identification

D1557

Removal of fixed bilateral space maintainer, maxillary

Covered only when procedure is performed by a dentist who did not place the original appliance.

 

Note: Passive appliances are designed to prevent tooth movement.

Arch identification

Arch identification

D1558

Removal of fixed bilateral space maintainer, mandibular

Covered only when procedure is performed by a dentist who did not place the original appliance.

 

Note: Passive appliances are designed to prevent tooth movement.

Arch identification

Arch identification

D1575

Distal shoe space maintainer – fixed unilateral, per quadrant

One per quadrant per lifetime for members through age 18 (up to the 19th birthday).

For specific ACA-compliant small group plans only: Up to age 19: Once per arch or quadrant per lifetime. Age 19+: not covered.

 

Note: Passive appliances are designed to prevent tooth movement.

Quadrant identification

Quadrant identification

D1999

Unspecified preventive procedure, by report

Individual consideration.

 

Note: Passive appliances are designed to prevent tooth movement.

Detailed narrative

Detailed narrative

D1701

Pfizer-BioNTech Covid-19 vaccine administration – first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1702

Pfizer-BioNTech Covid-19 vaccine administration – second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1703

Moderna Covid-19 vaccine administration – first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1704

Moderna Covid-19 vaccine administration – second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1705

AstraZeneca COVID-19 vaccine administration – first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1706

AstraZeneca COVID-19 vaccine administration – second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1707

Janssen COVID-19 vaccine administration

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1708

Pfizer-BioNTech Covid-19 vaccine administration – third dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1709

Pfizer-BioNTech Covid-19 vaccine administration – booster dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1710

Moderna Covid-19 vaccine administration – third dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1711

Moderna Covid-19 vaccine administration – booster dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1712

Janssen Covid-19 vaccine administration – booster dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1713

Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric –first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1714

Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric –second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1781

Vaccine administration – human papillomavirus – Dose 1

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1782

Vaccine administration – human papillomavirus – Dose 2

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D1783

Vaccine administration – human papillomavirus – Dose 3

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D2140

Amalgam – one surface, primary or permanent

One amalgam restoration per tooth surface per 12 months.  We consider contiguous surface amalgam restorations as one multiple-surface restoration.

 

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2150

Amalgam – two surfaces, primary or permanent

One amalgam restoration per tooth surface per 12 months.  We consider contiguous surface amalgam restorations as one multiple-surface restoration.

 

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2160

Amalgam – three surfaces, primary or permanent

One amalgam restoration per tooth surface per 12 months. We consider contiguous surface amalgam restorations as one multiple-surface restoration.

 

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2161

Amalgam – four or more surfaces, primary or permanent

One amalgam restoration per tooth surface per 12 months. We consider contiguous surface amalgam restorations as one multiple-surface restoration.

 

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2330

Resin-based composite – one surface, anterior

One resin restoration per tooth surface per 12 months. Contiguous surface resin restorations are considered one multiple surface restoration.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2331

Resin-based composite – two surfaces, anterior

One resin restoration per tooth surface per 12 months. Contiguous surface resin restorations are considered one multiple surface restoration.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2332

Resin-based composite – three surfaces, anterior

One resin restoration per tooth surface per 12 months. Contiguous surface resin restorations are considered one multiple surface restoration.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2335

Resin-based composite – four or more surfaces or involving incisal angle (anterior)

One resin restoration per tooth surface per 12 months. Contiguous surface resin restorations are considered one multiple surface restoration.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2390

Resin-based composite crown, anterior

Once per tooth per 12 months.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Tooth identification

D2391

Resin-based composite – one surface, posterior

One resin restoration per tooth surface per 12 months. We consider contiguous surface resin restorations one multiple surface restoration. Based on the member’s benefits, posterior composites may pay as an alternate benefit to the corresponding amalgam procedure code. The patient would be responsible for the remainder of the charge. If the member’s plan provides full benefits on posterior resins, you may not balance bill the patient.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2392

Resin-based composite – two surfaces, posterior

One resin restoration per tooth surface per 12 months. We consider contiguous surface resin restorations one multiple surface restoration. Based on the member’s benefits, posterior composites may pay as an alternate benefit to the corresponding amalgam procedure code. The patient would be responsible for the remainder of the charge. If the member’s plan provides full benefits on posterior resins, you may not balance bill the patient.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2393

Resin-based composite – three surfaces, posterior

One resin restoration per tooth surface per 12 months. We consider contiguous surface resin restorations one multiple surface restoration. Based on the member’s benefits, posterior composites may pay as an alternate benefit to the corresponding amalgam procedure code. The patient would be responsible for the remainder of the charge. If the member’s plan provides full benefits on posterior resins, you may not balance bill the patient.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2394

Resin-based composite – four or more surfaces, posterior

One resin restoration per tooth surface per 12 months. We consider contiguous surface resin restorations one multiple surface restoration. Based on the member’s benefits, posterior composites may pay as an alternate benefit to the corresponding amalgam procedure code. The patient would be responsible for the remainder of the charge. If the member’s plan provides full benefits on posterior resins, you may not balance bill the patient.

 

Note: Resin refers to a broad category of materials including, but not limited to, composites. May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration. Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia. Glass ionomers, when used as restorations, should be reported with these codes. If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2410

Gold foil – one surface

One restoration per tooth surface per 12 months. Restoration includes tooth preparation, localized tissue removal, base direct and indirect pulp cap, and polishing. Gold foil restorations will pay as an alternate benefit, based on the corresponding amalgam procedure code. The patient is responsible for the remainder of the charge.

For specific ACA-compliant small group plans only: One per tooth surface per 12 months.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2420

Gold foil – two surfaces

One restoration per tooth surface per 12 months. Restoration includes tooth preparation, localized tissue removal, base direct and indirect pulp cap, and polishing. Gold foil restorations will pay as an alternate benefit, based on the corresponding amalgam procedure code. The patient is responsible for the remainder of the charge.

For specific ACA-compliant small group plans only: One per tooth surface per 12 months.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2430

Gold foil – three surfaces

One restoration per tooth surface per 12 months. Restoration includes tooth preparation, localized tissue removal, base direct and indirect pulp cap, and polishing. Gold foil restorations will pay as an alternate benefit, based on the corresponding amalgam procedure code. The patient is responsible for the remainder of the charge.

For specific ACA-compliant small group plans only: One per tooth surface per 12 months.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2510

Inlay – metallic – one surface

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

 

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2520

Inlay – metallic – two surfaces

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

 

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2530

Inlay – metallic – three or more surfaces

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

 

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2542

Onlay – metallic – two surfaces

One per permanent posterior tooth per 60 months for members ages 16 and older. Includes preparation, impression, temporary, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification

Surface identification (must include B or L surface)

Tooth identification

Surface identification (must include B or L surface)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2543

Onlay – metallic – three surfaces

One per permanent posterior tooth per 60 months for members ages 16 and older. Includes preparation, impression, temporary, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification

Surface identification (must include B or L surface)

Tooth identification

Surface identification (must include B or L surface)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2544

Onlay – metallic – four or more surfaces

One per permanent posterior tooth per 60 months for members ages 16 and older. Includes preparation, impression, temporary, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification

Surface identification (must include B or L surface)

Tooth identification

Surface identification (must include B or L surface)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2610

Inlay – porcelain/ceramic  – one surface

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for porcelain inlays. The patient is responsible for the balance.

 

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2620

Inlay – porcelain/ceramic – two surfaces

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for porcelain inlays. The patient is responsible for the balance.

 

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2630

Inlay – porcelain/ceramic – three or more surfaces

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for porcelain inlays. The patient is responsible for the balance.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays.  The patient is responsible for the balance.

 

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification    

Tooth identification

Surface identification     

D2642

Onlay – porcelain/ceramic – two surfaces

One per posterior tooth per 60 months for members age 16 and older. Includes preparation, impression, temporary restoration, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months.

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification

Surface identification (must include B or L surface) 

Tooth identification

Surface identification (must include B or L surface) 

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2643

Onlay – porcelain/ceramic – three surfaces

One per posterior tooth per 60 months for members age 16 and older. Includes preparation, impression, temporary restoration, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months.

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification

Surface identification (must include B or L surface) 

Tooth identification

Surface identification (must include B or L surface) 

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2644

Onlay – porcelain/ceramic – four or more surfaces

One per posterior tooth per 60 months for members age 16 and older. Includes preparation, impression, temporary restoration and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months.

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification

Surface identification (must include B or L surface) 

Tooth identification

Surface identification (must include B or L surface) 

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2650

Inlay – resin-based composite – one surface

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for composite inlays. The patient is responsible for the balance.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2651

Inlay – resin-based composite – two surfaces

One per tooth per 60 months for members age 16+. Alternate benefit of a corresponding amalgam restoration paid for composite inlays. The patient is responsible for the balance.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2652

Inlay – resin-based composite – three or more surfaces

One per tooth per 60 months for members ages 16 and older. Alternate benefit of a corresponding amalgam restoration paid for composite inlays. The patient is responsible for the balance.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

Note: Inlay refers to an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore and cusp tips.

Tooth identification

Surface identification

Tooth identification

Surface identification

D2662

Onlay – resin-based composite – two surfaces

One per posterior tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy 
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months.

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification 

Surface identification (must include B or L surface)

Tooth identification 

Surface identification (must include B or L surface)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2663

Onlay – resin-based composite – three surfaces

One per posterior tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy 
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months.

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification 

Surface identification (must include B or L surface)

Tooth identification 

Surface identification (must include B or L surface)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2664

Onlay – resin-based composite – four or more surfaces

One per posterior tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and cementation. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy 
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months.

Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.

Tooth identification 

Surface identification (must include B or L surface)

Tooth identification 

Surface identification (must include B or L surface)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2710

Crown – resin-based composite (indirect)

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. Limited to teeth #6-11 and #22-27.  May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2712

Crown – ¾ resin-based composite (indirect) (does not include facial veneers)

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration and insertion. Limited to teeth #6-11 and #22-27.  May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic or periodontal perspective
  • Periapical pathology or unresolved, incomplete or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2720

Crown – resin with high noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration and insertion.  May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2721

Crown – resin with predominantly base metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2722

Crown – resin with noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2740

Crown – porcelain/ceramic substrate

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2750

Crown – porcelain fused to high noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2751

Crown – porcelain fused to predominantly base metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2752

Crown – porcelain fused to noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2753

Crown – porcelain fused to titanium and titanium alloys

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2780

Crown – ¾ cast high noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2781

Crown – ¾ cast predominantly base metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion.  May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2782

Crown – ¾ cast noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2783

Crown – ¾ porcelain/ceramic (does not include facial veneers)

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2790

Crown – full cast, high-noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2791

Crown – full cast, predominantly base metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2792

Crown – full cast, noble metal

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2794

Crown – titanium and titanium alloys

One per permanent tooth per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. May be non-covered if certain conditions are present:

  • Untreated bone loss
  • Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective
  • Periapical pathology or unresolved, incomplete, or failed endodontic therapy
  • Services meant to treat TMJ, increase vertical dimension, or restore occlusion

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D2799

Interim crown – further treatment or completion of diagnosis necessary prior to final impression

Not a covered benefit.

None

None

D2910

Recement or re-bond inlay, onlay, veneer or partial coverage restoration

One per tooth per 12 months for members age 16+.

For specific ACA-compliant small group plans only: Age 16+:   One per tooth per 12 months.

Tooth identification

Tooth identification

D2915

Recement or re-bond indirectly fabricated or prefabricated post and core

One per tooth per 12 months for members age 16+.

For specific ACA-compliant small group plans only: Age 16+:   One per tooth per 12 months.

Tooth identification

Tooth identification

D2920

Recement or re-bond crown

One per tooth per 12 months for members age 16+.

For specific ACA-compliant small group plans only: Age 16+:   One per tooth per 12 months.

Tooth identification

Tooth identification

D2921

Reattachment of tooth fragment, incisal edge or cusp

Not a covered benefit.

None

None

D2928

Prefabricated porcelain/ceramic crown – permanent tooth

Not a covered benefit.

None

None

D2929

Prefabricated porcelain/ceramic crown – primary tooth

One per primary tooth per 24 months as an alternate benefit to D2932.

Tooth identification

Tooth identification

D2930

Prefabricated stainless steel crown – primary tooth

One per primary tooth per 24 months. 

Tooth identification

Tooth identification

D2931

Prefabricated stainless steel crown – permanent tooth

One per first and second molar per 24 months for members through age 15 (up to the 16th birthday)

Tooth identification

Tooth identification

D2932

Prefabricated resin crown

One per permanent anterior tooth per 24 months for members through age 15 (up to the 16th birthday). One per primary tooth per 24 months.

Tooth identification

Tooth identification

D2933

Prefabricated stainless steel crown with resin window

One per 1st molar per 24 months for members through age 15 (up to the 16th birthday). One per primary tooth per 24 months.

Tooth identification

Tooth identification

D2934

Prefabricated esthetic coated stainless steel crown – primary tooth

One per primary tooth per 24 months.

Tooth identification

Tooth identification

D2940

Protective restoration

One per tooth per lifetime. Direct placement of a temporary restorative material to protect tooth and/or tissue form. May be used to relieve pain, promote healing, or prevent further deterioration. Should not be reported as a base or in conjunction with other restorations.

Tooth identification

Tooth identification

D2941

Interim therapeutic restoration – primary dentition

One per tooth per lifetime on primary teeth for members under 3 years of age. Direct placement of a temporary restorative material to protect tooth and/or tissue form. May be used to relieve pain, promote healing, or prevent further deterioration. Should not be reported as a base or in conjunction with other restorations.

Tooth identification

Tooth identification

D2949

Restorative foundation for an indirect restoration

Not a covered benefit.

Tooth identification

Tooth identification

D2950

Core buildup, including any pins when required

One per tooth per 60 months. Not covered if reported with D2952 or D2954. Refers to building up of anatomical crown when restorative crown will be placed, whether or not pins are used. Not intended to be used as a 4-5 surface restoration if crown is not to be considered for a final restoration.

For specific ACA-compliant small group plans only: One per tooth per 60 months.

Tooth identification

Tooth identification

D2951

Pin retention – per tooth, in addition to restoration

Once per tooth per lifetime. Not covered if reported with D2950.

For specific ACA-compliant small group plans only: Up to age 19: Must be billed with two or more surface restorations on a permanent tooth for members. Ages 19+: Once per tooth per lifetime.

Tooth identification

Tooth identification

D2952

Post and core in addition to crown, indirectly fabricated

One per tooth per 60 months. If reported with a restoration or a core buildup on the same service date, the restoration, amalgam, or composite core build-up is considered part of the post- and core procedure. Cast post and core is separate from crown.

For specific ACA-compliant small group plans only: One per tooth per 60 months

Tooth identification

Tooth identification

D2953

Each additional indirectly fabricated post – same tooth

Limited to posterior teeth only (#1-5, 12-16, 17-21 and 28-32).  One per tooth per lifetime. Tooth must be badly broken down and missing at least 3 walls. If reported with a restoration or a core build-up on the same service date, the restoration amalgam or composite core build-up is considered part of the post and core procedure.

Tooth identification

Tooth identification

D2954

Prefabricated post and core in addition to crown

One per tooth per 60 months. If reported with a restoration or a core buildup on the same service date, the restoration amalgam or composite core buildup is considered part of the post and core procedure. Cast restorations submitted on same date of service with this procedure will be non-covered.

Tooth identification

Tooth identification

D2955

Post removal

Not a covered benefit.

None

None

D2957

Each additional prefabricated post – same tooth

Limited to posterior teeth only (#1-5, 12-16, 17-21 and 28-32).  One per tooth per lifetime for members age 16 and older. Tooth must be badly broken down and missing at least 3 walls. If reported with a restoration or a core build-up on the same service date, the restoration, amalgam, or composite core build-up is considered part of the post and core procedure.

For specific ACA-compliant small group plans only: Once per tooth per lifetime for all ages on permanent posterior teeth (#1-5, 12-16, 17-21 and 28-32).

Tooth identification

Tooth identification

D2960

Labial veneer (resin laminate) – direct

Not a covered benefit.

Tooth identification

Tooth identification

Detailed narrative

Current mounted and dated pre-operative periapical radiographs

D2961

Labial veneer (resin laminate) – indirect

Not a covered benefit.

Tooth identification

Tooth identification

Detailed narrative

Current mounted and dated pre-operative periapical radiographs

D2962

Labial veneer (porcelain laminate) – indirect

Not a covered benefit.

Tooth identification

Tooth identification

Detailed narrative

Current mounted and dated pre-operative periapical radiographs

D2971

Additional procedures to customize a crown to fit under an existing partial denture framework

Individual consideration.  One per tooth per 60 months for members age 16 and older - must be reported with individual crown.

For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Must be reported with individual crown.

Tooth identification

Detailed narrative

Tooth identification

Detailed narrative

D2975

Coping – A thin covering of the coronal portion of a tooth, usually devoid of anatomic contour, that can be used as a definitive restoration

Not a covered benefit.

None

None

D2980     

Crown repair necessitated by restorative material failure

One per tooth per 12 months.

For specific ACA-compliant small group plans only: Up to age 19: no limit. Age 19+: one per tooth per 12 months.

Tooth identification

Tooth identification

D2981

Inlay repair necessitated by restorative material failure

One per tooth per 12 months.

Tooth identification

Tooth identification

D2982

Onlay repair necessitated by restorative material failure

One per tooth per 12 months.

Tooth identification

Tooth identification

D2983

Veneer repair necessitated by restorative material failure

Not a covered benefit.

None

None

D2990

Resin infiltration of incipient smooth surface lesions

One per covered tooth surface per 12 months.

Tooth identification

Surface identification (B, L, F surfaces only)

Tooth identification

Surface identification (B, L, F surfaces only)

D2999

Unspecified restorative procedure, by report

Individual consideration.

Detailed narrative

Detailed narrative

D3110

Pulp cap – direct (excluding final restoration)

A separate allowance is not made. Pulp capping is considered part of the final restoration.

None

None

D3120

Pulp cap – indirect (excluding final restoration)

A separate allowance is not made. Pulp capping is considered part of the final restoration.

None

None

D3220

Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to dentinocemental junction and application of medicament

One per tooth per lifetime. Part of endodontic therapy when performed by the same dentist.

Tooth identification

Tooth identification

D3221

Pulpal debridement, primary and permanent teeth

One per tooth per lifetime. Part of endodontic therapy when performed by the same dentist.

Tooth identification

Tooth identification

D3222

Partial pulpotomy for apexogenesis –permanent tooth with incomplete root development

One per tooth per lifetime. Part of endodontic therapy when performed by the same dentist.

Tooth identification

Tooth identification

D3230

Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)

One per tooth per lifetime.

Tooth identification

Tooth identification

D3240

Pulpal therapy (resorbable filling) – posterior primary tooth (excluding final restoration)

One per tooth per lifetime.

Tooth identification

Tooth identification

D3310

Endodontic therapy, anterior tooth (excluding final restoration)

One per permanent tooth per lifetime.

 

Note: includes treatment plan, clinical procedures and follow up care.

Tooth identification

Tooth identification

D3320

Endodontic therapy, premolar tooth (excluding final restoration)

One per permanent tooth per lifetime.

 

Note: includes treatment plan, clinical procedures and follow up care.

Tooth identification

Tooth identification

D3330

Endodontic therapy, molar tooth (excluding final restoration)

One per permanent tooth per lifetime.

 

Note: includes treatment plan, clinical procedures and follow up care.

Tooth identification

Tooth identification

D3331

Treatment of root canal obstruction; non-surgical access

Individual consideration. Once per tooth per lifetime.

 

Note: includes treatment plan, clinical procedures and follow up care.

Tooth identification

Tooth identification
Detailed narrative

Current dated pre- and post-operative periapical radiographs

D3332

Incomplete endodontic therapy; inoperable, unrestorable,, or fractured tooth

Not a covered benefit.

 

None

None

D3333

Internal root repair of perforation defects

Not a covered benefit.

None

None

D3346

Retreatment of previous root canal therapy – anterior

One per tooth per lifetime. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist.

Tooth identification

Tooth identification

D3347

Retreatment of previous root canal therapy – premolar

One per tooth per lifetime. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist.

Tooth identification

Tooth identification

D3348

Retreatment of previous root canal therapy – molar

One per tooth per lifetime. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist.

Tooth identification

Tooth identification

D3351

Apexification/recalcification –initial visit (apical closure/calcific repair of perforations, root resorption, etc.)

One per permanent tooth per lifetime. Includes opening tooth, preparation of canal spaces, first placement of medication and necessary radiographs. (This procedure may include first phase of complete root canal therapy).

Tooth identification

Tooth identification

D3352

Apexification/recalcification – interim medication replacement

One per permanent tooth per lifetime.

Tooth identification

Tooth identification

D3353

Apexification/recalcification - final visit (includes completed root canal therapy –apical closure/calcific repair of perforations, root resorption, etc.)

One per permanent tooth per lifetime.

Tooth identification

Tooth identification

D3355

Pulpal regeneration – initial visit

One per permanent tooth per lifetime.

Tooth identification

Tooth identification

D3356

Pulpal regeneration – interim medication replacement

One per permanent tooth per lifetime.

Tooth identification

Tooth identification

D3357

Pulpal regeneration – completion of treatment

One per permanent tooth per lifetime.

Tooth identification

Tooth identification

D3410

Apicoectomy – anterior

One per tooth root per lifetime.

Tooth & root identification

Tooth & root identification

D3421

Apicoectomy – premolar (first root)

One per tooth root per lifetime.

Tooth & root identification

Tooth & root identification

D3425

Apicoectomy – molar (first root)

One per tooth root per lifetime.

Tooth & root identification

Tooth & root identification

D3426

Apicoectomy – (each additional root)

One per tooth root per lifetime.

Tooth & root identification

Tooth & root identification

D3428

Bone graft in conjunction with periradicular surgery – per tooth, single site

Not a covered benefit.

None

None

D3429

Bone graft in conjunction with periradicular surgery – each additional contiguous in the same surgical site

Not a covered benefit.

None

None

D3430

Retrograde filling – per root

One per tooth root (not canal) per lifetime. Only covered when reported with D3410, D3421, D3425, D3426.  Benefit is paid at a maximum of a one-surface amalgam restoration. If more than one filling is placed per tooth, report additional root (not canal) as D3999 and describe.

Tooth & root identification

Tooth & root identification

For additional retrogrades on the same tooth, include either post-operative periapical radiograph or clinical imaging of finished filling at root end of the tooth and report.

D3431

Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery

Not a covered benefit.

None

None

D3432

Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery

Not a covered benefit.

None

None

D3450

Root amputation – per root

One per tooth per lifetime for multi-rooted posterior teeth.

Tooth identification

Tooth identification

D3460

Endodontic endosseous implant

Not a covered benefit.

None

None

D3470

Intentional reimplantation (including necessary splinting)

Individual consideration.

Tooth identification

Detailed narrative

Tooth identification

Detailed narrative

D3471

Surgical repair of root resorption – anterior

One per tooth root per lifetime. Considered inclusive if submitted with D3410, D3421, D3425, D3426.      

Tooth & root identification

Tooth & root identification

D3472

Surgical repair of root resorption –premolar

One per tooth root per lifetime. Considered inclusive if submitted with D3410, D3421, D3425, D3426.      

Tooth & root identification

Tooth & root identification

D3473

Surgical repair of root resorption–molar

One per tooth root per lifetime. Considered inclusive if submitted with D3410, D3421, D3425, D3426.      

Tooth & root identification

Tooth & root identification

D3501

Surgical repair of root surface without apicoectomy or repair of root resorption – anterior

Not a covered benefit.

None

None

D3502

Surgical repair of root surface without apicoectomy or repair of root resorption – premolar

Not a covered benefit.

None

None

D3503

Surgical repair of root surface without apicoectomy or repair of root resorption – molar

Not a covered benefit.

None

None

D3910

Surgical procedure for isolation of tooth with rubber dam

Not a covered benefit.

None

None

D3911

Intraorifice barrier

Not a covered benefit.

None

None

D3920

Hemisection (including any root removal), not including root canal therapy

One per posterior tooth per lifetime.

Tooth identification

Tooth identification

D3921

Decoronation or submergence of an erupted tooth

One per tooth per lifetime (D3921 or D7251).

Tooth identification

Tooth identification

D3950

Canal preparation and fitting of preformed dowel or post

Not a covered benefit.

None

None

D3999

Unspecified endodontic procedure, by report

Individual consideration.

Tooth identification
Detailed narrative

Current dated pre- and post-operative periapical radiographs

Tooth identification
Detailed narrative

Current dated pre- and post-operative periapical radiographs

D4210

Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth-bounded spaces, per quadrant

One per quadrant per 36 months. An evaluation period of ³ 21 days to assess tissue response must be observed following scaling and root planning before benefits become available for soft tissue procedures. A gingivectomy procedure is unusual in the presence of infrabony defects. If reported at any time in preparation and/or temporization phase of teeth for, or in association with restoration/ prostheses, D4210 is considered to be included as part of the global restorative/prosthetic procedure.

Quadrant identification

Quadrant identification

Current dated post-Phase I periodontal charting

Current mounted and dated preoperative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area)

Pre-treatment recommended

D4211

Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant

One to three teeth per quadrant per 36 months. If reported at any time in preparation and/or temporization phase of tooth for, or in association with restoration/prostheses, D4211 is considered to be included as part of the global restorative/ prosthetic procedure.

Quadrant identification, including teeth numbers

Quadrant identification

Current dated post-Phase I periodontal charting


Current mounted and dated preoperative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area)

Pre-treatment recommended

D4212

Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

One per tooth per quadrant per 36 months. Not covered on same date of service in association with restoration/ prostheses services.

Quadrant identification, including teeth numbers

Quadrant identification, including teeth number

Current mounted and dated preoperative periapical radiographs.  

D4230

Anatomical crown exposure – four or more contiguous teeth or tooth bounded spaces per quadrant

Not a covered benefit.

None

None

D4231

Anatomical crown exposure – one to three teeth or tooth bounded spaces per quadrant

Not a covered benefit.

None

None

D4240

Gingival flap procedure, including root planning – four or more contiguous teeth or tooth-bounded spaces per quadrant

One per quadrant per 36 months. An evaluation period of ³ 28 days to assess tissue response must be observed following scaling and root planning. If scaling and root planning are performed on the same date and in the same quadrant as periodontal surgery, no payment will be made for D4341 or D4342.

Quadrant identification

Quadrant identification

Current dated post-phase I periodontal charting

Current mounted and dated pre-operative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing radiographs and/or periapical radiographs of the treated area

Pre-treatment recommended

D4241

Gingival flap procedure, including root planning – one to three contiguous teeth or tooth bounded spaces per quadrant

One to three teeth per quadrant per 36 months. An evaluation period of ³ 28 days to assess tissue response must be observed following scaling and root planning. If scaling and root planning are performed on the same date and in the same quadrant as periodontal surgery, no payment will be made for D4341 or D4342

Quadrant identification, including teeth numbers

Quadrant identification

Current dated post-phase I periodontal charting

Current mounted and dated pre-operative periapical radiographs.  If a current full mouth set of radiographs is not available, submit current (within last year) bitewing radiographs and/or periapical radiographs of the treated area

Pre-treatment recommended

D4245

Apically repositioned flap

Not a covered benefit.

None

None

D4249

Clinical crown lengthening – hard tissue. This procedure is employed to allow a restorative procedure on a tooth with little or no tooth structure exposed to the oral cavity.

One per tooth per 60 months. Procedure must alter the crown-to-root ratio and be performed in a healthy periodontal environment to be covered. Non-covered when performed on the same day and by the same provider as a crown preparation /insertion or when performed for aesthetic purposes or in conjunction with osseous surgery in the same quadrant.

Tooth identification

Tooth identification

D4260

Osseous surgery (including elevation of a full thickness flap and closure ) – four or more contiguous teeth or tooth-bounded spaces per quadrant

One per quadrant per 36 months. A waiting period of  ³ 28 days should follow periodontal scaling and root planning in order to allow healing and observation of tissue response. If scaling and root planning are performed on the same date and in the same quadrant as periodontal surgery, no payment will be made for D4341 or D4342.

Quadrant identification

Quadrant identification

Current dated post phase I periodontal charting

Current mounted and dated pre-operative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area

Pre-treatment recommended

D4261

Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant

One to three teeth per quadrant per 36 months. A waiting period of ³ 28 days should follow periodontal scaling and root planning to allow healing and observation of tissue response. If scaling and root planning are performed on the same date and in the same quadrant as periodontal surgery, no payment will be made for D4341 or D4342. 

Quadrant identification, including teeth numbers

Quadrant identification

Current dated post phase I periodontal charting

Current mounted and dated pre-operative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area

Pre-treatment recommended

D4263

Bone replacement graft – first site in quadrant

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site or with routine apicoectomy, cystectomy, sinus augmentation, ridge augmentation, mucogingival grafts, or implant procedure.

Tooth identification (edentulous spaces do not qualify for this code)

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D4264

Bone replacement graft – each additional site in quadrant

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site or with routine apicoectomy, cystectomy, sinus augmentation, ridge augmentation, mucogingival grafts or implant procedure.

Tooth identification (edentulous spaces do not qualify for this code)

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D4265

Biologic materials to aid in soft and osseous tissue regeneration, per site

Not a covered benefit.

None

None

D4266

Guided tissue regeneration, natural teeth – resorbable barrier, per site

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site, or with routine apicoectomy, cystectomy, ridge augmentation, mucogingival grafts, or implant procedure.

Tooth identification (edentulous spaces do not qualify for use of this code)

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D4267

Guided tissue regeneration, natural teeth – non-restorable barrier, per site

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site, or with routine apicoectomy, cystectomy, ridge augmentation, mucogingival grafts, or implant procedure.

Tooth identification (edentulous spaces do not qualify for use of this code)

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D7956

Guided tissue regeneration, edentulous area – resorbable barrier, per site

Not a covered benefit.

None

None

D7957

Guided tissue regeneration, edentulous area – non-resorbable barrier, per site

Not a covered benefit.

None

None

D4268

Surgical revision procedure, per tooth

Not a covered benefit.

None

None

D4270

Pedicle soft tissue graft procedure

One per tooth per 36 months. Grafting for cosmetic purposes is non-covered.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingiva indicated

Pre-treatment recommended

D4273

Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft

One per site per 36 months on natural teeth only.

Limited to three teeth per graft site.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingiva indicated

Pre-treatment recommended

D4274

Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures on the same anatomical area)

One per site per 36 months. Must be adjacent to edentulous area.

Tooth identification

Location

Current dated post phase I periodontal charting

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D4275

Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft

One per site per 36 months on natural teeth only. Limited to three teeth per graft site.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingival indicated

Pre-treatment recommended

D4276

Combined connective tissue and pedicle graft, per tooth

One per tooth per 36 months.  Grafting for cosmetic purposes is non-covered.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingival indicated

Pre-treatment recommended

D4277

Free soft tissue graft procedure (including recipient and donor surgical site) first tooth, implant or edentulous tooth position in graft.

One per site per 36 months on natural teeth only. Limited to three teeth per graft site.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingival indicated

Pre-treatment recommended

D4278

Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft

One per site per 36 months on natural teeth only. Limited to three teeth per graft site.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingival indicated

Pre-treatment recommended

D4283

Autogenous connective tissue graft procedure (including donor and recipient surgical sites), each additional contiguous tooth, implant or edentulous tooth position in same graft site

Each additional tooth, up to three teeth total in graft.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingival indicated

Pre-treatment recommended

D4285

Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

Each additional tooth, up to three teeth total in graft.

Tooth identification

Tooth identification

Current periodontal charting with amount of attached gingival indicated

Pre-treatment recommended

D4286

Removal of non-resorbable barrier

Considered inclusive of D4267, not a covered benefit in any other circumstance.

Tooth identification

Tooth identification

D4322

Splint – intra-coronal; natural teeth or prosthetic crowns

Not a covered benefit

None

None

D4323

Splint – extra-coronal; natural teeth or prosthetic crowns

Not a covered benefit

None

None

D4341

Periodontal scaling and root planning – four or more teeth per quadrant

One per quadrant per 24 months. Gross debridement of calculus and polishing of all teeth are considered part of this procedure.

Quadrant identification

Quadrant identification

D4342

Periodontal scaling and root planning – one to three teeth per quadrant

One per quadrant per 24 months. Gross debridement of calculus and polishing of all teeth are considered part of this procedure.

Quadrant identification

Tooth/teeth number(s)

Quadrant identification

Tooth/teeth number(s)

D4346

Scaling in the presence of generalized moderate or severe gingival inflammation – full mouth

Covered interchangeably with D1110.  Held to the same frequencies and allowable as D1110.

None

None

D4355

Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit

Not a covered benefit.

None

None

D4381

Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

One treatment per tooth per 24 months. Up to 3 teeth per quadrant with 5-6 mm pocket depths and bleeding on probing, with or subsequent to active and maintained periodontal treatment. Should not be used to treat generalized disease. Not covered for treatment of periodontal abscess.

Detailed narrative

Detailed narrative

Periodontal charting

Tooth/teeth number(s)

D4910

Periodontal maintenance

One per 3 months following active periodontal treatment. There must be at least three months between a periodontal maintenance cleaning and any other cleanings.

None

None

D4920

Unscheduled dressing change (by person other than treating dentist or staff)

Not a covered benefit.

For specific ACA-compliant small group plans only: One per quadrant per 36 months.

None

None

D4921

Gingival irrigation with a medicinal agent – per quadrant

Not a covered benefit.

None

None

D4999

Unspecified periodontal procedure, by report

Individual consideration. Adjunctive periodontal diagnostic testing (sulcular temperature; biochemical markers, microbiological tests, etc.) is included in fee for diagnostic evaluation, not covered as a separate procedure.

Detailed narrative

Detailed narrative

D5110

Complete denture – maxillary

One per arch per 60 months.  Not covered if D5130, D5211, D5213, D5221, D5223, D5225, or D5227 was reported within 5 years.

 

Note: Includes routine post-delivery care

Arch identification

Arch identification

D5120

Complete denture – mandibular

One per arch per 60 months.  Not covered if D5140, D5212, D5214, D5222, D5224, D5226, or D5228 was reported within 5 years.

 

Note: Includes routine post-delivery care.

Arch identification

Arch identification

D5130

Immediate denture – maxillary

One per arch per lifetime.

 

Note: Includes routine post-delivery care.

Arch identification

Arch identification

D5140

Immediate denture – mandibular

One per arch per lifetime.

 

Note: Includes routine post-delivery care.

Arch identification

Arch identification

D5211

Maxillary partial denture – resin base (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

For specific ACA-compliant small group plans only: One per arch per 60 months.

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5212

Mandibular partial denture – resin base (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

For specific ACA-compliant small group plans only: One per arch per 60 months.

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5213

Maxillary partial denture – cast metal framework with resin denture bases (including retentive /clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

For specific ACA-compliant small group plans only: One per arch per 60 months.

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5214

Mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

For specific ACA-compliant small group plans only: One per arch per 60 months.

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5221

Immediate maxillary partial denture – resin base (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5222

Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5223

Immediate maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5224

Immediate mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5225

Maxillary partial denture – flexible base (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

For specific ACA-compliant small group plans only: One per arch per 60 months.

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5226

Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth)

One per arch per 60 months for members age 16+.

For specific ACA-compliant small group plans only: One per arch per 60 months.

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5227

Immediate maxillary partial denture – flexible base (including any clasps, rests, and teeth)

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5228

Immediate mandibular partial denture – flexible base (including any clasps, rests, and teeth)

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5282

Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5283

Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5284

Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth), per quadrant

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5286

Removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth), per quadrant

One per arch per 60 months for members age 16+.

 

Note: The denture base is presumed to include any conventional clasps, rests, and teeth.

Arch identification

Arch identification

D5410

Adjust complete denture – maxillary

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. One per arch per 12 months.

None

None

D5411

Adjust complete denture – mandibular

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. One per arch per 12 months.

None

None

D5421

Adjust partial denture – maxillary

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. One per arch per 12 months.

None

None

D5422

Adjust partial denture – mandibular

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. One per arch per 12 months.

None

None

D5511

Repair broken complete denture base, mandibular

One per arch per 12 months.

Arch identification

Arch identification

D5512

Repair broken complete denture base, maxillary

One per arch per 12 months.

Arch identification

Arch identification

D5520

Replace missing or broken teeth – complete denture (each tooth)

One per tooth per 12 months.

Tooth identification

Tooth identification

D5611

Repair resin partial denture base, mandibular

One per arch per 12 months.

Arch identification

Arch identification

D5612

Repair resin partial denture base, maxillary

One per arch per 12 months.

Arch identification

Arch identification

D5621

Repair cast partial framework, mandibular

One per arch per 12 months.

Arch identification

Arch identification

D5622

Repair cast partial framework, maxillary

One per arch per 12 months.

Arch identification

Arch identification

D5630

Repair or replace broken retentive clasping materials - per tooth

One per tooth per 12 months.

Tooth identification

Tooth identification

D5640

Repair broken teeth – per tooth

One per tooth per 12 months.

Tooth identification

Tooth identification

D5650

Add tooth to existing partial denture

One per tooth per 12 months.

Tooth identification

Tooth identification

D5660

Add clasp to existing partial denture per tooth

One per tooth per 12 months.

Tooth identification

Tooth identification

D5670

Replace all teeth and acrylic on cast metal framework (maxillary)

One per arch per lifetime.

Arch identification

Arch identification

D5671

Replace all teeth and acrylic on cast metal framework (mandibular)

One per arch per lifetime.

Arch identification

Arch identification

D5710

Rebase complete maxillary denture

One per arch per 36 months. Adjustments are considered part of routine post-delivery care for complete and partial denture rebases for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: One per arch per 24 months per patient. Ages 19+: one per arch per 36 months.

Note: Dental rebase procedures are the process of refitting a denture by replacing the base material.

Arch identification

Arch identification

D5711

Rebase complete mandibular denture

One per arch per 36 months. Adjustments are considered part of routine post-delivery care for complete and partial denture rebases for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: One per arch per 24 months per patient. Ages 19+: one per arch per 36 months.

Note: Dental rebase procedures are the process of refitting a denture by replacing the base material.

Arch identification

Arch identification

D5720

Rebase maxillary partial denture

One per arch per 36 months. Adjustments are considered part of routine post-delivery care for complete and partial denture rebases for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: One per arch per 24 months per patient. Ages 19+: one per arch per 36 months.

Note: Dental rebase procedures are the process of refitting a denture by replacing the base material.

Arch identification

Arch identification

D5721

Rebase mandibular partial denture

One per arch per 36 months. Adjustments are considered part of routine post-delivery care for complete and partial denture rebases for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: One per arch per 24 months per patient. Ages 19+: one per arch per 36 months.

Note: Dental rebase procedures are the process of refitting a denture by replacing the base material.

Arch identification

Arch identification

D5725

Rebase hybrid prosthesis

One per arch per 36 months. Adjustments are considered part of routine post-delivery care for complete and partial denture rebases for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: One per arch per 24 months per patient. Ages 19+: one per arch per 36 months.

Note: Dental rebase procedures are the process of refitting a denture by replacing the base material.

Arch identification

Arch identification

D5730

Reline complete maxillary denture (direct)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5731

Reline complete mandibular denture (direct)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5740

Reline maxillary partial denture (direct)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5741

Reline mandibular partial denture (direct)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5750

Reline complete maxillary denture (indirect)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.


For specific ACA-compliant small group plans only: Up to age 19: one per arch per 24 months. Ages 19+: one per arch per 36 months.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5751

Reline complete mandibular denture (indirect)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: one per arch per 24 months. Ages 19+: one per arch per 36 months.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5760

Reline maxillary partial denture (indirect)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: one per arch per 24 months. Ages 19+: one per arch per 36 months.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5761

Reline mandibular partial denture (indirect)

One per arch per 24 months for direct relines.

One per arch per 36 months for indirect relines.

Adjustments are considered part of routine post-delivery care for complete and partial denture relines for the first 90 days.

For specific ACA-compliant small group plans only: Up to age 19: one per arch per 24 months. Ages 19+: one per arch per 36 months.

Note: Denture reline procedures are the process of resurfacing the tissue side of a denture with new base material.

Arch identification

Arch identification

D5810

Interim complete denture (maxillary)

Not a covered benefit

None.

None.

D5811

Interim complete denture (mandibular)

Not a covered benefit

None

None

D5820

Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary

One per lifetime per arch. Temporary stay-plate covered when inserted immediately after extraction of anterior tooth 6-11 or loss of anterior tooth due to traumatic injury.  

Tooth/teeth being replaced

Tooth/teeth being replaced

D5821

Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular

One per lifetime per arch. Temporary stay-plate covered when inserted immediately after extraction of anterior tooth 22-27 or loss of anterior tooth due to traumatic injury.

Tooth/teeth being replaced

Tooth/teeth being replaced

D5765

Soft liner for complete or partial removable denture – indirect

One per arch per 36 months.

For specific ACA-compliant small group plans only: Up to age 19: one per arch per 24 months. Ages 19+: one per arch per 36 months.

Arch identification

Arch identification

D5850

Tissue conditioning, maxillary

One per denture per 36 months. Not covered if performed within 90 days after the delivery of a full or partial denture, rebase, or reline.

None

None

D5851

Tissue conditioning, mandibular

One per denture per 36 months. Not covered if performed within 90 days after the delivery of a full or partial denture, rebase, or reline.

None

None

D5862

Precision attachment, by report

Not a covered benefit.

None

None

D5863

Overdenture – complete maxillary

One per upper arch per 60 months. Will reject if history of upper complete or upper partial denture in past 60 months. Endodontic therapy or copings placed on remaining teeth are not covered for members age 16+.

Arch identification

Arch identification

D5864

Overdenture – partial maxillary

One per upper arch per 60 months. Will reject if history of upper partial denture in past 60 months. Endodontic therapy or copings placed on remaining teeth are not covered for members age 16+.

Arch identification

Arch identification

D5865

Overdenture – complete mandibular

One per lower arch per 60 months. Will reject if history of lower complete or lower partial denture in past 60 months. Endodontic therapy or copings placed on remaining teeth are not covered for members age 16+.

Arch identification

Arch identification

D5866

Overdenture – partial mandibular

One per lower arch per 60 months. Will reject if history of lower complete or lower partial denture in past 60 months. Endodontic therapy or copings placed on remaining teeth are not covered for members age 16+.

Arch identification

Arch identification

D5867

Replacement of replaceable part of semi-precision or precision attachment, per attachment

Not a covered benefit

None

None

D5875

Modification of removable prosthesis following implant surgery. Attachment assemblies are reported using separate codes

Not a covered benefit.

None

None

D5876

Add metal substructure to acrylic full denture (per arch)

Not a covered benefit.

None

None

D5899

Unspecified removable prosthodontic procedure, by report

Individual consideration.

Detailed narrative

Detailed narrative

D5911

Facial moulage (sectional)

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5912

Facial moulage (complete)

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5913

Nasal prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5914

Auricula prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5915

Orbital prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5916

Ocular prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5919

Facial prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5922

Nasal septal prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5923

Ocular prosthesis, interim

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5924

Cranial prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5925

Facial augmentation implant prosthesis

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5926

Nasal prosthesis, replacement

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5927

Auricular prosthesis, replacement

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5928

Orbital prosthesis, replacement

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5929

Facial prosthesis, replacement

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5931

Obturator prosthesis, surgical

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5932

Obturator prosthesis, definitive

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5933

Obturator prosthesis, modification

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5934

Mandibular resection prosthesis with guide flange

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5935

Mandibular resection prosthesis without guide flange

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5936

Obturator prosthesis, interim

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5937

Trismus appliance (not for TMD treatment)

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5951

Feeding aid

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5958

Palatal lift prosthesis, interim

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5959

Palatal lift prosthesis, modification

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5960

Speech aid prosthesis, modification

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5982

Surgical stent

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5983

Radiation carrier

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5984

Radiation shield

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5985

Radiation cone locator

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5986

Fluoride gel carrier

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5987

Commissure splint

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5988

Surgical splint

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5991

Vesiculobullous disease medicament carrier

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5992

Adjust maxillofacial prosthetic appliance, by report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5993

Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to the patient’s medical plan for possible benefit coverage.

None

None

D5995

Periodontal medicament carrier with peripheral seal – laboratory processed – maxillary

Not a covered benefit

None

None

D5996

Periodontal medicament carrier with peripheral seal – laboratory processed – mandibular

Not a covered benefit

None

None

D5999

Unspecified maxillofacial prosthesis, by report

Individual consideration.

Detailed narrative

Detailed narrative

D6190

Radiographic/surgical implant index, by report

Not a covered benefit.

None

None

D6191

Semi-precision abutment – placement. This procedure is the initial placement or replacement of a semiprecision abutment on the implant body

Not a covered benefit.

None

None

D6192

Semi-precision attachment – placement. This procedure involves the luting of the initial or replacement semiprecision attachment to the removable prosthesis

Not a covered benefit.

None

None

D6010

Surgical placement of implant body, endosteal implant

One per permanent tooth (excluding third molars) per 60 months for members age 16+.

Tooth area identification

Tooth area identification

Current dated pre-operative periapical radiograph

D6011

Surgical access to an implant body (Second stage implant surgery)

One per tooth per 60 months for members age 16+.

For specific ACA-compliant small group plans only: Once per 60 months

Tooth identification

Tooth identification

D6012

Surgical placement of interim implant body for transitional prosthesis: endosteal implant

Not a covered benefit.

None

None

D6013

Surgical placement of mini implant

One per tooth per 60 months for members age 16+. Limit two per arch. Allowed in edentulous arch as components of an overdenture.

For specific ACA-compliant small group plans only: Once per 60 months. Limit two per arch. Allowed in edentulous arch as components of an overdenture for members age 16+.

Tooth identification

Tooth area identification

Current dated pre-operative periapical radiograph

D6040

Surgical placement, eposteal implant

Not a covered benefit.

None

None

D6050

Surgical placement, transosteal implant

Not a covered benefit.

None

None

D6051

Interim implant abutment placement

Not a covered benefit.

None

None

D6055

Connecting bar – implant supported or abutment supported

Covered by rider only.

For specific ACA-compliant small group plans only: Not a covered benefit

 

Note: Implant-supporting prosthetics are considered supporting structures.

Arch identification

Arch identification

Current dated pre-operative periapical radiograph

Detailed narrative

D6081

Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure

Not a covered benefit.

None

None

D6085

Interim implant crown

Not a covered benefit.

None

None

D6096

Remove broken implant retaining screw

Covered under implant rider only.

Tooth area identification

Tooth area identification

D6100

Surgical removal of implant body

One per permanent tooth (excluding third molars) per lifetime for members age 16+ (either D6100 or D6105).

Tooth area identification

Tooth area identification

D6101

Debridement of a peri-implant defect or defects surrounding a single implant and surface cleaning of exposed implant surfaces, including flap entry and closure

Not a covered benefit.

None

None

D6102

Debridement and osseous contouring of a peri-implant defect; or defects surrounding a single implant and includes surface cleaning of exposed implant surfaces including flap entry and closure

Not a covered benefit.

None

None

D6103

Bone graft for repair of peri-implant defect – does not include flap entry and closure

Not a covered benefit.

None

None

D6104

Bone graft at time of implant placement

Not a covered benefit.

None

None

D6105

Removal of implant body not requiring bone removal nor flap elevation

One per permanent tooth (excluding third molars) per lifetime for members age 16+ (either D6100 or D6105).

Tooth area identification

Tooth area identification

D6106

Guided tissue regeneration – resorbable barrier, per implant

Not a covered benefit.

None

None

D6107

Guided tissue regeneration – non-resorbable barrier, per implant

Not a covered benefit.

None

None

D6110

Implant/abutment supported removable denture for edentulous arch – maxillary

Once per 60 months.

Arch identification

Arch identification

D6111

Implant/abutment supported removable denture for edentulous arch – mandibular

Once per 60 months.

Arch identification

Arch identification

D6112

Implant/abutment supported removable denture for partially edentulous arch – maxillary

Once per 60 months.

Arch identification

Arch identification

D6113

Implant /abutment supported removable denture for partially edentulous arch – mandibular

Once per 60 months.

Arch identification

Arch identification

D6114

Implant/abutment supported fixed denture for edentulous arch – maxillary

Covered by rider only.

None

None

D6115

Implant/abutment supported fixed denture for edentulous arch – mandibular

Covered by rider only.

None

None

D6116

Implant /abutment supported fixed denture for partially edentulous arch – maxillary

Covered by rider only.

None

None

D6117

Implant /abutment supported fixed denture for partially edentulous arch – mandibular

Covered by rider only.

None

None

D6118

Implant/abutment supported interim fixed denture for edentulous arch – mandibular

Not a covered benefit.

Arch identification

Arch identification

D6119

Implant/abutment supported interim fixed denture for edentulous arch – maxillary

Not a covered benefit.

Arch identification

Arch identification

D6197

Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant

For members age 16 and older, one per tooth per 6 months when done within 3 months of an implant repair (D6090, D6095 or D6096) on the same tooth.

Tooth identification

Tooth identification

D6056

Prefabricated abutment – includes modification and placement

One per implant per 60 months for members age 16 and older. Includes preparation, impression, temporary restoration and insertion.

 

Note: Implant-supporting prosthetics are considered supporting structures.

Tooth area identification

Tooth area identification

Current dated pre-operative periapical radiograph

Detailed narrative

D6057

Custom fabricated abutment – includes placement

One per implant per 60 months for members age 16 and older. Includes preparation, impression, temporary restoration, and insertion.

 

Note: Implant-supporting prosthetics are considered supporting structures.

Tooth area identification

Tooth area identification

Current dated pre-operative periapical radiograph

Detailed narrative

D6058

Abutment-supported porcelain/ ceramic crown. A single crown restoration that is retained, supported and stabilized by an abutment on an implant

One per implant per 60 months for members age 16+.  Includes preparation, impression, temporary restoration, and insertion.  

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6059

Abutment-supported porcelain fused to metal crown (high noble metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant

One per implant per 60 months for members age 16+.  Includes preparation, impression, temporary restoration and insertion.  

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6060

Abutment-supported porcelain fused to metal crown (predominantly base metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. 

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6061

Abutment-supported porcelain fused to metal crown (noble metal) A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. 

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6062

Abutment-supported cast-metal crown (high noble metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. 

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6063

Abutment-supported cast-metal crown (predominantly base metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. 

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6064

Abutment-supported cast-metal crown (noble metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration and insertion. 

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6094

Abutment supported crown, titanium and titanium alloy

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. 

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6097

Abutment supported crown, porcelain fused to titanium or titanium alloys

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion. 

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

D6065

Implant-supported porcelain/ ceramic crown. A single crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration and insertion.

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6066

Implant-supported crown – porcelain fused to high noble alloys. A single metal-ceramic crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion.

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6067

Implant supported crown – high noble alloys. A single cast metal or milled crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+. Includes preparation, impression, temporary restoration, and insertion.

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6082

Implant supported crown – porcelain fused to predominately base alloys. A single crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+.

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6083

Implant supported crown – porcelain fused to noble alloys. A single crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+.

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6084

Implant supported crown – porcelain fused to titanium and titanium alloys. A single crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+.

Tooth area identification

Tooth area identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6086

Implant supported crown – predominately base alloys. A single crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+.

Tooth identification

Tooth identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6087

Implant supported crown – noble alloys. A single crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+.

Tooth identification

Tooth identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6088

Implant supported crown – titanium and titanium alloys. A single crown restoration that is retained, supported, and stabilized by an implant.

One per implant per 60 months for members age 16+.

Tooth identification

Tooth identification

Current mounted and dated post-implant periapical radiographs

Pre-treatment recommended

Consultant review

D6068

Abutment supported retainer for porcelain/ceramic FPD. A ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant. 

Not a covered benefit, either with or without a rider.

Tooth area identification

Tooth area identification

D6069

Abutment-supported retainer for porcelain fused to metal FPD (high noble metal) A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant. 

Not a covered benefit, either with or without a rider.

Tooth area identification

Tooth area identification

D6070

Abutment-supported retainer for porcelain fused to metal FPD (predominately base metal). A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant.  

Not a covered benefit, either with or without a rider.

Tooth area identification

Tooth area identification

D6071

Abutment-supported retainer for porcelain fused to metal FPD (noble metal)

Not a covered benefit, either with or without a rider.

Tooth area identification

Tooth area identification

D6072

Abutment-supported retainer for cast metal FPD (high noble metal)

Not a covered benefit, either with or without a rider.

Tooth area identification

Tooth area identification

D6073

Abutment-supported retainer for cast metal FPD (predominately base metal)

Not a covered benefit, either with or without a rider.

Tooth area identification

Tooth area identification

D6074

Abutment-supported retainer for cast metal FPD (noble metal)

Not a covered benefit, either with or without a rider.

Tooth area identification

Tooth area identification

D6194

Abutment supported retainer crown for FPD – titanium and titanium alloys

Not a covered benefit.

None

None

D6195

Abutment supported retainer – porcelain fused to titanium and titanium alloys

Not a covered benefit.

None

None

D6075

Implant-supported retainer for ceramic FPD

Not a covered benefit.

Tooth area identification

Tooth area identification

D6076

Implant-supported retainer for FPD-porcelain fused to high noble alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6077

Implant-supported retainer for metal FPD – high noble alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6098

Implant supported retainer – porcelain fused to predominately base alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6099

Implant supported retainer for FPD – porcelain fused to noble alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6120

Implant supported retainer for FPD- porcelain fused to titanium and titanium alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6121

Implant supported retainer for metal FPD – predominately based alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6122

Implant supported retainer for metal FPD – noble alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6123

Implant supported retainer for metal FPD – titanium and titanium alloys

Not a covered benefit.

Tooth area identification

Tooth area identification

D6080

Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments

Covered by rider only.

Arch identification

Arch identification

Current dated pre-operative periapical radiograph

D6090

Repair implant supported prosthesis, by report

One per arch per 6 months for members age 16 and older.

Arch identification

Detailed narrative

D6095

Repair implant abutment, by report

One per tooth per 6 months for members age 16 and older.

Tooth area identification

Tooth area identification

D6091

Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment

Not a covered benefit.

Tooth identification

Tooth identification

D6092

Recement or re-bond implant/abutment-supported crown

One per tooth per 12 months for members age 16 and older.

Tooth identification

Tooth identification

D6093

Recement or re-bond implant/ abutment-supported fixed partial denture

One per bridge per 12 months for members age 16 and older.

Tooth identification

Tooth identification

D6198

Remove interim implant component

Not a covered benefit.

None

None

D6199

Unspecified implant procedure, by report

Individual consideration.

For specific ACA-compliant small group plans only: Not a covered benefit

Detailed narrative

Detailed narrative

D6205

Pontic – indirect resin-based composite

Not a covered benefit.

None

None

D6210

Pontic – cast high noble

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6211

Pontic – cast predominantly base metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6212

Pontic – cast noble metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6214

Pontic – titanium and titanium alloys

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6240

Pontic – porcelain fused to high noble metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6241

Pontic – porcelain fused to predominantly base metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

For specific ACA-compliant small group plans only: Once per 60 months per patient for all ages

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6242

Pontic – porcelain fused to noble metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

For specific ACA-compliant small group plans only: One per absent tooth per 60 months for members age 16+

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6243

Pontic – porcelain fused to titanium and titanium alloys

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6245

Pontic – porcelain/ceramic

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

For specific ACA-compliant small group plans only: One per absent tooth per 60 months for members age 16+

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6250

Pontic – resin with high noble metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar. Not covered when part of an implant-supported fixed prosthesis.

For specific ACA-compliant small group plans only: One per absent tooth per 60 months for members age 16+

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6251

Pontic – resin with predominantly base metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

For specific ACA-compliant small group plans only: One per absent tooth per 60 months for members age 16+

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6252

Pontic – resin with noble metal

One per absent tooth per 60 months for members age 16+. Pontics to replace an impacted tooth or a space beyond the normal complement of teeth due to a diastema or drifting are not covered. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Our current clinical standard of care indicating the utilization of a cantilever pontic in the natural dentition is for the replacement of a missing lateral incisor supported by a natural canine, or canine and premolar.  Not covered when part of an implant-supported fixed prosthesis.

For specific ACA-compliant small group plans only: One per absent tooth per 60 months for members age 16+

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6253

Interim pontic –  further treatment or completion of diagnosis necessary prior to final impression

Individual consideration. Not to be used as a temporary crown/bridge for routine fixed partial denture restorations.

For specific ACA-compliant small group plans only: Not a covered benefit

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Detailed narrative

D6545

Retainer – cast metal for resin-bonded fixed prosthesis

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.  

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Detailed narrative

D6548

Retainer – porcelain/ ceramic for resin-bonded fixed prosthesis

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.  

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Detailed narrative

D6549

Resin retainer – for resin bonded fixed prosthesis

One restoration per permanent tooth per 60 months for members age 16+. Not covered if history of any other prosthetic restoration on the same tooth within 60 months.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6600

Retainer inlay –porcelain/ ceramic, two surfaces

One per tooth per 60 months for members age 16 and older.

Tooth identification

Surface identification 

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6601

Retainer inlay – porcelain/ ceramic, three or more surfaces

One per tooth per 60 months for members age 16 and older.

Tooth identification

Surface identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6602

Retainer inlay – cast high noble, two surfaces

One per tooth per 60 months for members age 16 and older.

Tooth identification

Surface identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6603

Retainer inlay – cast high noble metal, three or more surfaces

One per tooth per 60 months for members age 16 and older.

Tooth identification

Surface identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6604

Retainer inlay – cast predominantly base metal, two surfaces

One per tooth per 60 months for members age 16+. Inlays pay as an alternate benefit to the corresponding amalgam restoration.

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6605

Retainer inlay – cast predominantly base metal, three or more surfaces

One per tooth per 60 months for members age 16+. Inlays pay as an alternate benefit to the corresponding amalgam restoration.

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6606

Retainer inlay – cast noble metal, 2 surfaces

One per tooth per 60 months for members age 16+. Inlays pay as an alternate benefit to the corresponding amalgam restoration.

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6607

Retainer inlay – cast noble metal, three or more surfaces

One per tooth per 60 months for members age 16+. Inlays pay as an alternate benefit to the corresponding amalgam restoration.

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6624

Inlay – titanium

One per tooth per 60 months for members age 16+. Inlays pay as an alternate benefit to the corresponding amalgam restoration.

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6608

Retainer onlay –porcelain/ceramic, two surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification –must include B or L surface

Tooth identification

Surface identification –must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6609

Retainer onlay – porcelain/ ceramic, three or more surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification –must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6610

Retainer onlay – cast high-noble metal, two surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification – must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6611

Retainer onlay – cast high-noble metal, three or more surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification – must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6612

Retainer onlay – cast predominantly base metal, two surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification – must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6613

Retainer onlay – cast predominantly base metal, three or more surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification – must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6614

Retainer onlay – cast noble metal, two surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification – must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6615

Retainer onlay – cast noble metal, three or more surfaces

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification – must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6634

Retainer onlay - titanium

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Tooth identification

Surface identification – must include B or L surface

Tooth identification

Surface identification – must include B or L surface

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6710

Retainer crown – indirect resin-based composite

Not a covered benefit.

None

None

D6720

Retainer crown – resin with high noble metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6721

Retainer crown – resin with predominantly base metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6722

Retainer crown – resin with noble metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6740

Retainer crown – porcelain/ceramic

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6750

Retainer crown – porcelain fused to high noble

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6751

Retainer crown – porcelain fused to predominantly base metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

One per tooth per 60 months for members all ages.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6752

Retainer crown – porcelain fused to noble metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6753

Retainer crown – porcelain fused to titanium and titanium alloys

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6780

Retainer crown – ¾ cast high noble metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6781

Retainer crown – ¾ cast predominately base metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6782

Retainer crown – ¾ cast noble metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6783

Retainer crown – ¾ porcelain/ ceramic

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6784

Retainer crown ¾ titanium and titanium alloys

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed.

Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6790

Retainer crown – full cast high noble metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.  

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6791

Retainer crown – full cast predominantly base metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.  

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6792

Retainer crown – full cast noble metal

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.  

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6794

Retainer crown – titanium and titanium alloys

One per tooth per 60 months for members age 16+. Cast restorations are covered only once within 60 months regardless of the type of restoration placed. Individual consideration required for double abutting of teeth. Appropriate only for prosthetic considerations in specific circumstances, not for periodontal splinting.  

Tooth identification

Tooth identification

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D6793

Interim retainer crown – further treatment or completion of diagnosis necessary prior to final impression

Not a covered benefit.

None

None

D6920

Connector bar

Not a covered benefit. 

None

None

D6930

Recement or rebond fixed partial denture

One re-cementation per 12 months.

For specific ACA-compliant small group plans only: Up to age 19:  Not payable within 6 months of the placement of the fixed partial denture. Ages 19+: One re-cementation per 12 months

Tooth identification

Tooth identification

D6940

Stress breaker

Not a covered benefit. 

None

None

D6950

Precision attachment

Not a covered benefit. 

None

None

D6980

Fixed partial denture repair necessitated by restorative material failure

One repair per 12 months.

For specific ACA-compliant small group plans only: Up to age 19: No limits. Ages 19+: One repair per 12 months.

Tooth identification

Quadrant identification*

Tooth identification

Quadrant identification*

D6985

Pediatric partial denture, fixed

One per arch per lifetime for members through the age 18 (up to the 19th birthday).

Arch identification

Arch identification

D6999

Unspecified fixed prosthodontic procedure, by report

Individual consideration.

Detailed narrative

Detailed narrative

D7111

Extraction – coronal remnants, deciduous tooth

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7140

Extraction – erupted tooth or exposed root (elevation and/or forcep removal)

One per tooth per lifetime.

If performed within 90 days after a D3921, payment for the extraction will be reduced by the payment of D3921.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7210

Surgical removal of an erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated

One per tooth per lifetime.

If performed within 90 days after a D3921, payment for the extraction will be reduced by the payment of D3921.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7220

Removal of impacted tooth – soft tissue

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7230

Removal of impacted tooth – partially bony

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7240

Removal of impacted tooth – completely bony

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7241

Removal of impacted tooth – completely bony, with unusual surgical complications

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7250

Surgical removal of residual tooth roots (cutting procedure)

One per tooth per lifetime.

If performed within 90 days after a D3921, payment for the extraction will be reduced by the payment of D3921.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7251

Coronectomy – intentional partial tooth removal, impacted teeth only

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999).

Tooth identification

Tooth identification

D7260

Oroantral fistula closure

Individual consideration.

Periapical or panoramic radiograph

Operative note

Periapical or panoramic radiograph

Operative note

D7261

Primary closure of a sinus perforation

Individual consideration.

Periapical or panoramic radiograph

Operative note

Periapical or panoramic radiograph

Operative note

D7270

Tooth reimplantation and/or stabilization of accidentally avulsed or displaced tooth

One per tooth per lifetime.

For specific ACA-compliant small group plans only: Up to age 19: No limit. Ages 19+: One tooth per lifetime

Tooth identification

Tooth identification

D7272

Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

Not a covered benefit.

None

None

D7280

Surgical access of unerupted tooth

One per tooth per lifetime.

Tooth identification

Tooth identification

D7282

Mobilization of erupted or mal-positioned tooth to aid eruption

One per tooth per lifetime.

Tooth identification

Tooth identification

D7283

Placement of a device to facilitate eruption of impacted tooth

Only covered in conjunction with D7280. One per tooth per lifetime. Report the surgical exposure separately using D7280.

Tooth identification

Tooth identification

D7285

Incisional biopsy of oral tissue – hard (bone, tooth)

Individual consideration.

Pathology report

Pathology report

D7286

Incisional biopsy of oral tissue –  soft

Individual consideration.

Pathology report

Pathology report

D7287

Cytology exfoliative sample collection

Individual consideration.

Detailed narrative

Detailed narrative

D7288

Brush biopsy – transepithelial sample collection

Individual consideration.

Detailed narrative

Detailed narrative

D7290

Surgical repositioning of teeth – grafting procedures are additional

Individual consideration.

Tooth identification

Detailed narrative

Tooth identification

Detailed narrative

D7291

Transseptal fiberotomy/supra crestal fiberotomy, by report

Individual consideration.

Tooth identification

Detailed narrative incl orthodontic history

Tooth identification

Detailed narrative incl orthodontic history

D7292

Placement of temporary anchorage device [screw retained plate] requiring flap

Not a covered benefit.

None

None

D7293

Placement of temporary anchorage device requiring flap

Not a covered benefit.

None

None

D7294

Placement of temporary anchorage device without flap

Not a covered benefit.

None

None

D7295

Harvest of bone for use in autogenous grafting procedures

Not a covered benefit.

None

None

D7296

Corticotomy one to three teeth

Not a covered benefit.

None

None

D7297

Corticotomy four or more teeth

Not a covered benefit.

None

None

D7298

Removal of temporary anchorage device [screw retained plate], requiring flap

Not a covered benefit.

None

None

D7299

Removal of temporary anchorage device, requiring flap

Not a covered benefit.

None

None

D7300

Removal of temporary anchorage device without flap

Not a covered benefit.

None

None

D7310

Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant

One per quadrant per lifetime. Inclusive when used in conjunction with surgical extractions.

Quadrant identification

Detailed narrative or progress notes

Pre-operative radiographs

Quadrant identification

Detailed narrative or progress notes

Pre-operative radiographs

D7311

Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

One per quadrant per lifetime. Inclusive when used in conjunction with surgical extractions.

Quadrant identification

Tooth spaces identification

Detailed narrative or progress notes

Pre-operative radiographs

Quadrant identification

Tooth spaces identification

Detailed narrative or progress notes

Pre-operative radiographs

D7320

Alveoloplasty not in conjunction with extractions –four or more teeth or tooth spaces, per quadrant

One per quadrant per lifetime. Inclusive when used in conjunction with surgical extractions.

Quadrant identification

Detailed narrative or progress notes

Pre-operative radiographs

Quadrant identification

Detailed narrative or progress notes

Pre-operative radiographs

D7321

Alveoloplasty, not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

One per quadrant per lifetime. Inclusive when used in conjunction with surgical extractions.

Quadrant identification

Tooth spaces identification

Detailed narrative or progress notes

Pre-operative radiographs

Quadrant identification

Tooth spaces identification

Detailed narrative or progress notes

Pre-operative radiographs

D7340

Vestibuloplasty – ridge extension (secondary epithelialization)

Individual consideration. Not covered in conjunction with implants.

Arch identification

Operative reports

Arch identification

Operative reports

D7350

Vestibuloplasty – ridge extension (including soft tissue grafts, muscle re-attachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)

Individual consideration. Not covered in conjunction with implants.

Arch identification

Operative reports

Arch identification

Operative reports

D7410

Excision of benign lesion, up to 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7411

Excision of benign lesion greater than 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7412

Excision of benign lesion, complicated

Individual consideration.

Pathology report

Pathology report

D7413

Excision of malignant lesion up to 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7414

Excision of malignant lesion greater than 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7415

Excision of malignant lesion, complicated

Individual consideration.

Pathology report

Pathology report

D7465

Destruction of lesion(s) by physical or chemical methods, by report

Individual consideration.

Pathology report

Pathology report

D7440

Excision of malignant tumor – lesion diameter up to 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7441

Excision of malignant tumor – lesion diameter greater than 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7450

Removal of benign odontogenic cyst or tumor – lesion diameter up to1.25 cm

Individual consideration.

Pathology report

Pathology report

D7451

Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7460

Removal of benign non-odontogenic cyst or tumor – lesion diameter up to 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7461

Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm

Individual consideration.

Pathology report

Pathology report

D7471

Removal of lateral exostosis (maxilla or mandible)

One per arch per lifetime.

Arch identification

Arch identification

D7472

Removal of torus palatinus

One per lifetime.

Arch identification

Arch identification

D7473

Removal of torus mandibularis

One per quadrant per lifetime.

Quadrant identification

Quadrant identification

D7485

Surgical reduction of osseous tuberosity

One per upper quadrant(s) per lifetime.

Quadrant identification

Quadrant identification

D7490

Radical resection of maxilla or mandible

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Refer to patient’s medical plan for possible benefit coverage.

None

None

D7509

Marsupialization of odontogenic cyst

Individual consideration.

Tooth identification

Detailed narrative or Operative report

Tooth identification

Detailed narrative or Operative report

D7510

Incision and drainage of abscess – intraoral soft tissue

Individual consideration.

Tooth identification

Detailed narrative  

Tooth identification

Detailed narrative  

D7511

Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces)

Individual consideration.

Tooth identification

Detailed narrative  

Tooth identification

Detailed narrative  

D7520

Incision and drainage of abscess – extraoral soft tissue

Individual consideration.

Detailed narrative

Detailed narrative

D7521

Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces)

Individual consideration.

Detailed narrative

Detailed narrative

D7530

Removal of foreign body, mucosa, skin, or subcutaneous alveolar tissue

Individual consideration.

Pathology report

Operative report

Pathology report

Operative report

D7540

Removal of reaction-producing foreign bodies, musculoskeletal system

Individual consideration.

Pathology report

Operative report

Pathology report

Operative report

D7550

Partial ostectomy/sequestrectomy for removal of non-vital bone

Individual consideration.

Pathology report

Operative report

Pathology report

Operative report

D7560

Maxillary sinusotomy for removal of tooth fragment or foreign body

Individual consideration.

Pathology report

Operative report

Pathology report

Operative report

D7610

Maxilla – open reduction (teeth immobilized, if present)

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7620

Maxilla – closed reduction (teeth immobilized, if present)

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7630

Mandible – open reduction (teeth immobilized, if present)

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7640

Mandible – closed reduction (teeth immobilized, if present)

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7650

Malar and/or zygomatic arch – open reduction

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7660

Malar and/or zygomatic arch – closed reduction

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7670

Alveolus – closed reduction, may include stabilization of teeth

Individual consideration.

Panoramic radiograph

Operative report

Arch identification

Panoramic radiograph

Operative report

Arch identification

D7671

Alveolus – open reduction, may include stabilization of teeth

Individual consideration.

Panoramic radiograph

Operative report

Arch identification

Panoramic radiograph

Operative report

Arch identification

D7680

Facial bones – complicated reduction with fixation and multiple surgical approaches

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7710

Maxilla – open reduction, stabilization of teeth

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7720

Maxilla – closed reduction

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7730

Mandible – open reduction

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7740

Mandible – closed reduction

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7750

Malar and/or zygomatic arch – open reduction

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7760

Malar and/or zygomatic arch – closed reduction

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7770

Alveolus – open reduction stabilization of teeth

Individual consideration.

Panoramic radiograph

Operative report

Arch identification

Panoramic radiograph

Operative report

Arch identification

D7771

Alveolus – closed reduction, stabilization of teeth

Individual consideration.

Panoramic radiograph

Operative report

Arch identification

Panoramic radiograph

Operative report

Arch identification

D7780

Facial bones – complicated reduction with fixation and multiple surgical approaches

Individual consideration.

Panoramic radiograph

Operative report

Panoramic radiograph

Operative report

D7810

Open reduction of dislocation

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7820

Closed reduction of dislocation

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7830

Manipulation under anesthesia

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7840

Condylectomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7850

Surgical disectomy; with or without implant

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7852

Disc repair

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7854

Synovectomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7856

Myotomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7858

Joint reconstruction

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7860

Arthrotomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7865

Arthroplasty

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7870

Arthrocentesis

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7871

Non-anthroscopic lysis and lavage

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7872

Arthroscopy – diagnosis, with or without biopsy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7873

Arthroscopy – surgical, lavage and lysis of adhesions

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7874

Arthroscopy – surgical, disc repositioning and stabilization

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7875

Arthroscopy – surgical, synovectomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7876

Arthroscopy – surgical, disectomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7877

Arthroscopy – surgical, debridement

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7880

Occlusal orthotic device, by report

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7881

Occlusal orthotic device adjustment

Not a covered benefit.

None

None

D7899

Unspecified TMD therapy, by report

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7910

Suture of recent small wounds up to 5 cm

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7911

Complicated suture –  up to 5 cm

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7912

Complicated suture – greater than 5 cm

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7920

Skin grafts (identify defect covered, location, and type of graft)

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7921

Collection and application of autologous blood concentrate product

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7922

Placement on intra-socket biological dressing to aid in hemostasis or clot stabilization, per site

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7940

Osteoplasty – for orthognathic deformities

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7941

Osteotomy – mandibular rami

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7943

Osteotomy – mandibular rami with bone graft; includes obtaining the graft

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7944

Osteotomy – segmented or sub-apical, per sextant or quadrant

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7945

Osteotomy – body of mandible

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7946

LeFort I (maxilla – total)

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7947

LeFort I (maxilla – segmented)

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7948

LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) – without bone graft

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7949

LeFort II or LeFort II – with bone graft

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7950

Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones, autogenous or nonautogenous, by report

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7951

Sinus augmentation with bone or bone substitutes via a lateral open approach

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7952

Sinus augmentation via a vertical approach

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7953

Bone replacement graft for ridge preservation – per site

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

None

None

D7955

Repair of maxillofacial soft and/or hard tissue defect

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient’s medical plan for possible benefit coverage.

Pretreatment recommended

Operative report

Appropriate radiographs

Pretreatment recommended

Operative report

Appropriate radiographs

D7961

Buccal/labial frenectomy (frenulectomy)

Covered once per site per lifetime. Covered for members age 6+. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

For specific ACA-compliant small group plans only: Up to age 19:  covered once per site per lifetime. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

Tooth identification

Detailed narrative

Tooth identification

Detailed narrative

D7962

Lingual frenectomy (frenulectomy)

Covered once per site per lifetime. Covered for members age 6+. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

For specific ACA-compliant small group plans only: Up to age 19:  covered once per site per lifetime. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

Tooth identification

Detailed narrative

Tooth identification

Detailed narrative

D7963

Frenuloplasty

Covered once per site per lifetime. Covered for members age 6+. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

For specific ACA-compliant small group plans only: Up to age 19:  covered once per site per lifetime. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

Tooth identification

Detailed narrative

Tooth identification

Detailed narrative

D7970

Excision of hyperplastic tissue – per arch

Individual consideration.

Arch identification

Operative report

Arch identification

Operative report

D7971

Excision of pericoronal gingiva

Individual consideration.

Tooth identification

Operative report

Tooth identification

Operative report

D7972

Surgical reduction of fibrous tuberosity

One per upper quadrant(s) per lifetime.

Quadrant identification

Quadrant identification

D7979

Non-surgical sailolithotomy

Not a covered benefit.

None

None

D7980

Sialolithotomy

Individual consideration.

Operative report

Operative report

D7981

Excision of salivary gland, by report

Individual consideration.

Operative report

Operative report

D7982

Sialodochoplasty

Individual consideration.

Operative report

Operative report

D7983

Closure of salivary fistula

Individual consideration.

Operative report

Operative report

D7990

Emergency tracheotomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient's medical plan for possible benefit coverage.

None

None

D7991

Coronoidectomy

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient's medical plan for possible benefit coverage.

None

None

D7993

Surgical placement of craniofacial implant – extra oral
Surgical placement of a craniofacial implant to aid in retention of an auricular, nasal, or orbital prosthesis.

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient's medical plan for possible benefit coverage.

None

None

D7994

Surgical placement: zygomatic implant. An implant placed in the zygomatic bone and exiting through the maxillary mucosal tissue providing support and attachment of a maxillarydental prosthesis.

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient's medical plan for possible benefit coverage.

None

None

D7995

Synthetic graft – mandible or facial bones, by report

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient's medical plan for possible benefit coverage.

None

None

D7996

Implant – mandible for augmentation purposes (excluding alveolar ridge), by report

Not covered under Blue Cross Blue Shield of Massachusetts dental plans. Please refer to your patient's medical plan for possible benefit coverage.

None

None

D7997

Appliance removal (not by dentist who placed appliance), includes removal of archbar

Individual consideration.

For specific ACA-compliant small group plans only: Not covered

Detailed narrative

Detailed narrative

D7998

Intraoral placement of a fixation device not in conjunction with a fracture

Not a covered benefit.

None

None

D7999

Unspecified oral surgery procedure, by report

Individual consideration.

Tooth identification

Detailed narrative

Operative report

Tooth identification

Detailed narrative

Operative report

D8010

Limited orthodontic treatment of the primary dentition

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: May be covered with traditional orthodontics plan with a rider

None

None

D8020

Limited orthodontic treatment of the transitional dentition

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: May be covered with traditional orthodontics plan with a rider

None

None

D8030

Limited orthodontic treatment of the adolescent dentition

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: Not covered under the Essential Health Benefit, but may be covered with traditional orthodontics rider

None

None

D8040

Limited orthodontic treatment of the adult dentition

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: Not covered under the Essential Health Benefit, but may be covered with traditional orthodontics rider.

None

None

D8070

Comprehensive orthodontic treatment of the transitional dentition

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: Not covered

First date in treatment series

Total treatment charge

First date in treatment series

Total treatment charge

D8080

Comprehensive orthodontic treatment of the adolescent dentition

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: May be covered under traditional orthodontics plan with a rider.

First date in treatment series

Total treatment charge

First date in treatment series

Total treatment charge

D8090

Comprehensive orthodontic treatment of the adult dentition

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: Not covered

First date in treatment series

Total treatment charge

First date in treatment series

Total treatment charge

D8210

Removable appliance therapy

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: Not covered

None

None

D8220

Fixed appliance therapy

Available as rider and subject to lifetime maximum and copayment.

For specific ACA-compliant small group plans only: Not covered

None

None

D8660

Pre-orthodontic treatment examination to monitor growth and development

Not a covered benefit.

For specific ACA-compliant small group plans only: Once per six months. Payable only to a dental provider who is a specialist in orthodontics

None

None

D8670

Periodic orthodontic treatment visit

Use for payment of monthly benefit when a dentist started a case prior to insurance coverage and is now providing services to patient who has become covered. Also used for payment of monthly benefit for services provided by dentist other than original treating dentist. A method of payment between the provider and responsible party for services that reflect an open-ended fee arrangement.

Submit monthly charge; not fee for whole case.

Submit monthly charge; not fee for whole case.

D8680

Orthodontic retention (removal of appliances, construction and placement of retainer(s)

Part of the global fee for the orthodontic outcome.

None

None

D8681

Occlusal orthotic device adjustment

Not a covered benefit.

None

None

D8695

Removal of fixed orthodontic appliances for reasons other than completion of treatment

Not a covered benefit.

None

None

D8696

Repair of orthodontic appliance –maxillary

Not a covered benefit.

None

None

D8697

Repair of orthodontic appliance – mandibular

Not a covered benefit.

None

None

D8698

Re-cement or re-bond fixed retainer – maxillary

Not a covered benefit.

None

None

D8699

Re-cement or re-bond retainer – mandibular

Not a covered benefit.

None

None

D8701

Repair of fixed retainer, includes reattachment - maxillary

Not a covered benefit.

None

None

D8702

Repair of fixed retainer, includes reattachment – mandibular

Not a covered benefit.

None

None

D8703

Replacement of lost or broken retainer – maxillary

Not a covered benefit.

None

None

D8704

Replacement of lost or broken retainer – mandibular

Not a covered benefit.

None

None

D8999

Unspecified orthodontic procedure, by report. Used for procedures not adequately described by a code

Individual consideration. May be covered under traditional ortho with rider.

Detailed narrative

Detailed narrative

D9110

Palliative treatment of dental pain – per visit

Not covered when reported with other definitive services on same treatment date.

For specific ACA-compliant small group plans only: Up to age 19: Other non-emergency medically necessary treatment may be provided during the same visit. Ages 19+: Not covered when reported on same day as definitive services.

None

None

D9120

Fixed partial denture sectioning

Not a covered benefit.

None

None

D9130

Temporomandibular joint dysfunction – non-invasive physical therapies

Not a covered benefit.

None

None

D9210

Local anesthesia not in conjunction with operative or surgical procedures

Not a covered benefit.

None

None

D9211

Regional block anesthesia

Not a covered benefit.

None

None

D9212

Trigeminal division block anesthesia

Not a covered benefit.

None

None

D9215

Local anesthesia in conjunction with operative or surgical procedures

Included in the total fee for non-surgical or surgical services.

None

None

D9219

Evaluation for moderate sedation, deep sedation, or general anesthesia

Not a covered benefit.

None

None

D9222

Deep sedation / general anesthesia first 15 minutes

Covered when provided with covered surgical procedures.

For specific ACA-compliant small group plans only: Up to age 19: no limit

None

None

D9223

Deep sedation/general anesthesia – each 15 minute increment

Covered when provided with covered surgical procedures.

For specific ACA-compliant small group plans only: Up to age 19: no limit

None

None

D9230

Administration of nitrous oxide/ analgesia, anxiolysis

Not a covered benefit.

None

None

D9239

Intravenous moderate (conscious) sedation/analgesia – first 15 minutes

Covered when provided with covered surgical procedures.

For specific ACA-compliant small group plans only: Up to age 19: no limit

None

None

D9243

Intravenous moderate (conscious) sedation/analgesia – each 15 minute increment

Covered when provided with covered surgical procedures.

For specific ACA-compliant small group plans only: Up to age 19: no limit 

None

None

D9248

Non-intravenous (conscious) sedation

Not a covered benefit.

For specific ACA-compliant small group plans only: Up to age 19: No limit

None

None

D9310

Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician

Covered benefit only when documented as used as a second opinion.

Detailed narrative including the referring dentist’s name

Submit with both codes: D9310 at the charge amount and D9999 at no charge on the same claim.

Detailed narrative including the referring dentist’s name

Submit with both codes: D9310 at the charge amount and D9999 at no charge on the same claim.

D9311

Consultation with a medical health care professional

Not a covered benefit.

None

None

D9410

House call/extended care facility call

Not a covered benefit.

For specific ACA-compliant small group plans only: D9410:  Up to age 19: One per facility per date of service. Claim must include place of service codes 03, 04, 12, 13, 14, 31, 32, 33, 34, or 99

None

None

D9420

Hospital or ambulatory surgical center call

Not a covered benefit.

None

None

D9430

Office visit for observation during regular office hours – no other services performed

Not a covered benefit.

None

None

D9440

Office visit-after regular office hours

Not a covered benefit.

None

None

D9450

Case presentation, subsequent to detailed and extensive treatment planning

Not a covered benefit.

None

None

D9610

Therapeutic parenteral drug, single administration

Not a covered benefit.

None

None

D9612

Therapeutic parenteral drugs, two or more administrations, different meds

Not a covered benefit.

None

None

D9613

Infiltration of sustained-release therapeutic drug, per quadrant

Not a covered benefit.

None

None

D9630

Other drugs/medicaments, by report

Not a covered benefit.

None

None

D9910

Application of desensitizing medicament

Once within a 12-month period.

None

None

D9911

Application of desensitizing resin for cervical and/or root surface, per tooth

Once per tooth per 48 months. Limited to age 16 and older.

Tooth identification

Tooth identification

D9912

Pre-visit patient screening

Not a covered benefit (Included in the primary service that is being rendered).

None

None

D9920

Behavior management, by report

Not a covered benefit.

For specific ACA-compliant small group plans only: Up to age 19: One per day per provider or location

None

None

D9930

Treatment of complications (post-surgical) – unusual circumstances, by report

Individual consideration.

Detailed narrative

Detailed narrative

D9932

Cleaning and inspection of removable complete denture, maxillary

Not a covered benefit.

None

None

D9933

Cleaning and inspection of removable complete denture, mandibular

Not a covered benefit.

None

None

D9934

Cleaning and inspection of removable partial denture, maxillary

Not a covered benefit.

None

None

D9935

Cleaning and inspection of removable partial denture, mandibular

Not a covered benefit.

None

None

D9941

Fabrication of athletic mouthguard

Not a covered benefit.

For specific ACA-compliant small group plans only: Up to age 19: Covered with no limit.

None

None

D9942

Repair and/ or reline of occlusal guard

Covered by rider only.

None

None

D9943

Occlusal guard adjustment

Covered by rider only.

None

None

D9944

Occlusal guard hard appliance, full arch

Covered by rider only.

For specific ACA-compliant small group plans only: Up to age 19: One D9944, D9945 or D9946 covered once per calendar year.

None

None

D9945

Occlusal guard – soft appliance, full arch

Covered by rider only.

For specific ACA-compliant small group plans only: Up to age 19: One D9944, D9945 or D9946 covered once per calendar year.

None

None

D9946

Occlusal guard – hard appliance, partial arch

Covered by rider only.

For specific ACA-compliant small group plans only: Up to age 19: One D9944, D9945 or D9946 covered once per calendar year.

None

None

D9947

Custom sleep apnea appliance fabrication and placement

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D9948

Adjustment of custom sleep apnea appliance

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D9949

Repair of custom sleep apnea appliance

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

None

D9950  

Occlusion analysis-mounted case

Not a covered benefit (inclusive of rehabilitative services being performed).

None

None

D9951

Occlusal adjustment-limited

One per quadrant per 24 months.

Quadrant identification

Quadrant identification

D9952

Occlusal adjustment-complete

Once per arch per 24 months.

Arch identification

Arch identification

D9953

Reline custom sleep apnea appliance (indirect)

Not a covered benefit.

None

None

D9961

Duplicate/copy patient’s records

Not a covered benefit.

None

None

D9970

Enamel microabrasion

Not a covered benefit.

None

None

D9971

Odontoplasty - per tooth

Not a covered benefit.

None

None

D9972

External bleaching – per arch – in office

Not a covered benefit.

None

None

D9973

External bleaching – per tooth

Not a covered benefit.

None

None

D9974

Internal bleaching – per tooth

Not a covered benefit.

None

None

D9975

External bleaching  – in home  – per arch; includes materials & fabrication of custom trays

Not a covered benefit.

None

None

D9985

Sales tax

Not a covered benefit.

None

None

D9986

Missed appointment

Not a covered benefit.

None

None

D9987

Cancelled appointment

Not a covered benefit.

None

None

D9990

Certified translation or sign – language services, per visit

Not a covered benefit.

None

None

D9991

Dental case management – addressing appointment compliance barriers

Not a covered benefit.

None

None

D9992

Dental case management – care coordination

Not a covered benefit.

None

None

D9993

Dental case management – motivational interviewing

Not a covered benefit.

None

None

D9994

Dental case management – patient education

Not a covered benefit.

None

None

D9995

Teledentistry synchronous

Not a covered benefit.

None

None

D9996

Teledentistry nonsynchronous

Not a covered benefit.

None

None

D9997

Dental case management – patients with special health care needs

Not a covered benefit.

None

None

D9999

Unspecified adjunctive procedure by report

Individual consideration.

Detailed narrative

Detailed narrative

CDT Code Description of Service Pediatric EHB* Procedure Guidelines
Ages 0-19
Adult EHB* Procedure Guidelines
Ages 19 & older
Submission Requirements

D0120

Periodic oral evaluation – established patient

Two per calendar year of D0145 or D0120. Not a covered benefit when performed on the same day as D9110 by the same dentist/dental office.  

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

Two per calendar year. Not a covered benefit when performed on the same day as D9110 by the same dentist/dental office.  

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

D0140

Limited oral evaluation – problem-focused

Two per calendar year. Not a covered benefit when performed on the same day as D9110 or D0160 by the same dentist.

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

Two per calendar year. Not a covered benefit when performed on the same day as D9110 or D0160 by the same dentist.

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

D0145

Oral evaluation for a patient under three years of age and counseling with primary caregiver

Two per calendar year of D0145 or D0120.

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

Not a covered benefit.

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

D0150

Comprehensive oral evaluation - new or established patient

One per member per lifetime.

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

Once per 60 months per dentist or location. 

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

D0160

Detailed, extensive oral evaluation – problem-focused, by report

Two per twelve months, by report.  Not a covered benefit when performed same day as D9110 by same dentist.

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

Not a covered benefit.

Detailed narrative

D0170

Re-evaluation – limited, problem focused (established patient; not post-operative visit)

Not a covered benefit.

Two per twelve months. Not to be used as a periodontal reevaluation.

Note: One evaluation code may be billed per dentist per date of service.  Evaluations including diagnosis and treatment planning is the responsibility of the dentist.  All evaluations must be completed by a dentist.

None

D0171

Re-evaluation – post operative office visit

Not a covered benefit.

Not a covered benefit.

None

D0180

Comprehensive periodontal evaluation – new or established patient

Not a covered benefit.

Once per 60 months per dentist or location.

None

D0190

Screening of a patient

Not a covered benefit.

Not a covered benefit.

None

D0191

Assessment of a patient

Not a covered benefit.

Not a covered benefit.

None

D0210

Intraoral – comprehensive series of radiographic images

One full mouth series (D0210) or panorex (D0330) per three calendar years and consists of a minimum of 7 or more radiographs, including bitewings.

One full mouth series (D0210) or panorex (D0330) per 60 months and consists of a minimum of 7 or more radiographs, including bitewings.

None

D0220

Intraoral – periapical first radiographic image

One per day per patient per (provider or location). Twelve of (D0220, D0230) per 12 months per patient. If reported with endodontic therapy, radiographs are included in the fee for the procedure.

A maximum of 6 radiographs per date of service.  Any combination of radiographs that exceed 6 will be processed as D0210. If reported with endodontic therapy, radiographs are included in the fee for the procedure.

None

D0230

Intraoral - periapical each additional radiographic image

Three per day per patient per (provider or location). Twelve of (D0220, D0230) per 12 months per patient.

A maximum of 6 radiographs per date of service.  Any combination of radiographs that exceed 6 will be processed as D0210. If reported with endodontic therapy, radiographs are included in the fee for the procedure.

None

D0240

Intraoral - occlusal radiographic image

Not a covered benefit.

One film per arch per 6 months.

None

D0250

Extra-oral – first 2D projection radiographic image created using a stationary radiation source, and detector

Not a covered benefit.

One film per arch per 6 months.

None

D0270

Bitewing - single radiographic image

Two per calendar year per patient.

One per 6 months per patient.

None

D0272

Bitewings - two radiographic images

Two per calendar year per patient.

One per 6 months per patient.

None

D0273

Bitewings - three radiographic images

Two per calendar year per patient.

One per 6 months per patient.

None

D0274

Bitewings - four radiographic images

Two per calendar year per patient.

One per 6 months per patient.

None

D0277

Vertical bitewings – 7 to 8 radiographic images.  This does not constitute a full mouth intraoral radiographic series.

Not a covered benefit.

One set per 12 months.

None

D0310

Sialography

Not a covered benefit.

Not a covered benefit.

None

D0320

Temporomandibular joint arthrogram, including injection

Not a covered benefit.

Not a covered benefit.

None

D0321

Other temporomandibular joint radiographic images, by report

Not a covered benefit.

Not a covered benefit.

None

D0322

Tomographic survey

Not a covered benefit.

Not a covered benefit.

None

D0330

Panoramic radiographic image

One full mouth series (D0210) or panorex (D0330) per three calendar years.

One full mouth series (D0210) or panorex (D0330) per 60 months.

None

D0340

2D cephalometric radiographic image – acquisition, measurement, and analysis

Individual consideration for non-orthodontic services.

Individual consideration for non-orthodontic services.

None

D0350

2D oral/facial photographic image obtained intra-orally or extra-orally 

Not a covered benefit.

Covered only when the Plan requests that photos be submitted for utilization review. Otherwise, not covered. 

None

D0364

Cone beam CT capture and interpretation with limited field of view – less than one whole jaw

Not a covered benefit.

Not a covered benefit.

None

D0365

Cone beam CT capture and interpretation with limited field of one full dental arch – mandible

Not a covered benefit.

Not a covered benefit.

None

D0366

Cone beam CT capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium

Not a covered benefit.

Not a covered benefit.

None

D0367

Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium

Not a covered benefit.

Not a covered benefit.

None

D0368

Cone beam CT capture and interpretation for TMJ series including two or more exposures

Not a covered benefit.

Not a covered benefit.

None

D0369

Maxillofacial MRI capture and interpretation

Not a covered benefit.

Not a covered benefit.

None

D0370

Maxillofacial ultrasound capture and interpretation

Not a covered benefit.

Not a covered benefit.

None

D0371

Sialoendoscopy capture and interpretation

Not a covered benefit.

Not a covered benefit.

None

D0372

Intraoral tomosynthesis – comprehensive series of radiographic images

Not a covered benefit.

Not a covered benefit.

None

D0373

Intraoral tomosynthesis – bitewing radiographic image

Not a covered benefit.

Not a covered benefit.

None

D0374

Intraoral tomosynthesis – periapical radiographic image

Not a covered benefit.

Not a covered benefit.

None

D0801

3D dental surface scan – direct

Not a covered benefit.

Not a covered benefit.

None 

D0802

3D dental surface scan – indirect

Not a covered benefit.

Not a covered benefit.

None 

D0803

3D facial surface scan – direct

Not a covered benefit.

Not a covered benefit.

None 

D0804

3D facial surface scan – indirect

Not a covered benefit.

Not a covered benefit.

None 

D0380

Cone beam CT image capture with limited field of view – less than one whole jaw

Not a covered benefit.

Note: Refers to capture by a practitioner not associated with interpretation and report.

Not a covered benefit.

Note: Refers to capture by a practitioner not associated with interpretation and report.

None 

D0381

Cone beam CT image capture with field of view of one full dental arch – mandible

Not a covered benefit.

Note: Refers to capture by a practitioner not associated with interpretation and report.

Not a covered benefit.

Note: Refers to capture by a practitioner not associated with interpretation and report.

None 

D0382

Cone beam CT image capture with field of view of one full dental arch – maxilla, with or without cranium

Not a covered benefit.

Note: Refers to capture by a practitioner not associated with interpretation and report.

Not a covered benefit.

Note: Refers to capture by a practitioner not associated with interpretation and report.

None 

D0383

Cone beam CT image capture with field of view of both jaws, with or without cranium

Not a covered benefit.

Not a covered benefit.

None 

D0384

Cone beam CT image capture for TMJ series including two or more exposures

Not a covered benefit.

Not a covered benefit.

None 

D0385

Maxillofacial MRI image capture

Not a covered benefit.

Not a covered benefit.

None 

D0386

Maxillofacial ultrasound image capture

Not a covered benefit.

Not a covered benefit.

None 

D0387

Intraoral tomosynthesis – comprehensive series of radiographic images – image capture only

Not a covered benefit.

Not a covered benefit.

None 

D0388

Intraoral tomosynthesis – bitewing radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None 

D0389

Intraoral tomosynthesis – periapical radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None 

D0701

Panoramic radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0702

2D cephalometric radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0703

2D oral/facial photographic image obtained intra-orally or extra-orally – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0705

Extra-oral posterior dental radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0706

Intraoral – occlusal radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0707

Intraoral – periapical radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0708

Intraoral – bitewing radiographic image – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0709

Intraoral – comprehensive series of radiographic images – image capture only

Not a covered benefit.

Not a covered benefit.

None

D0391

Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

Not a covered benefit.

Not a covered benefit.

None 

D0393

Virtual treatment simulation using 3D image volume or surface scan

Not a covered benefit.

Not a covered benefit.

None 

D0394

Digital subtraction of two or more images or image volumes of the same modality to demonstrate changes that occurred over time

Not a covered benefit.

Not a covered benefit.

None 

D0395

Fusion of two or more 3D image volumes of one or more modalities

Not a covered benefit.

Not a covered benefit.

None 

D0411

HbA1c in-office point-of-service testing 

Not a covered benefit.

Not a covered benefit.

None

D0412

Blood glucose level test – in-office using a glucose meter

Not a covered benefit.

Not a covered benefit.

None

D0415

Collection of microorganisms for culture and sensitivity

Not a covered benefit.

Not a covered benefit.

None

D0416

Viral culture. A diagnostic test to identify viral organisms, most often herpes virus.

Not a covered benefit.

Not a covered benefit.

None

D0417

Collection and preparation of saliva sample for laboratory diagnostic testing

Not a covered benefit.

Not a covered benefit.

None

D0418

Analysis of saliva sample. Chemical or biological analysis of saliva sample for diagnostic purposes.

Not a covered benefit.

Not a covered benefit.

None

D0419

Assessment of salivary flow by measurement

Not a covered benefit.

Not a covered benefit.

None

D0425

Caries susceptibility tests.  Not to be used for carious dentin staining.

Not a covered benefit.

Not a covered benefit.

None

D0431

Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures  

Not a covered benefit.

Not a covered benefit.

None

D0460     

Pulp vitality tests

Not a covered benefit.

Not a covered benefit.

None

D0470

Diagnostic casts

Not a covered benefit.

Not a covered benefit.

None

D0472

Accession of tissue, gross examination, preparation and transmission of written report

Not a covered benefit.

Not a covered benefit.

None

D0473

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

Not a covered benefit.

Not a covered benefit.

None

D0474

Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report

Not a covered benefit.

Not a covered benefit.

None

D0475

Decalcification procedure

Not a covered benefit.

Not a covered benefit.

None

D0476

Special stains for microorganisms

Not a covered benefit.

Not a covered benefit.

None

D0477

Special stains, not for microorganisms

Not a covered benefit.

Not a covered benefit.

None

D0478

Immunohistochemical stains

Not a covered benefit.

Not a covered benefit.

None

D0479

Tissue in-site hybridization, including interpretation

Not a covered benefit.

Not a covered benefit.

None

D0480

Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

Not a covered benefit.

Not a covered benefit.

None

D0481

Electron microscopy

Not a covered benefit.

Not a covered benefit.

None

D0482

Direct immunofluorescence

Not a covered benefit.

Not a covered benefit.

None

D0483

Indirect immunofluorescence

Not a covered benefit.

Not a covered benefit.

None

D0484

Consultation on slides prepared elsewhere

Not a covered benefit.

Not a covered benefit.

None

D0485

Consultation, including preparation of slides from biopsy material supplied by referring source

Not a covered benefit.

Not a covered benefit.

None

D0486

Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation, and transmission of written report

Not a covered benefit.

Not a covered benefit.

None

D0502

Other oral pathology procedures, by report

Not a covered benefit.

Not a covered benefit.

None

D0601

Caries risk assessment and documentation, with a finding of low risk

Not a covered benefit.

Not a covered benefit.

None

D0602

Caries risk assessment and documentation, with a finding of moderate risk

Not a covered benefit.

Not a covered benefit.

None

D0603

Caries risk assessment and documentation, with a finding of high risk

Not a covered benefit.

Not a covered benefit.

None

D0604

Antigen testing for a public health-related pathogen including coronavirus

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient's medical insurance for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient's medical insurance for possible coverage.

None

D0605

Antibody testing for a public health-related pathogen including coronavirus

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient's medical insurance for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient's medical insurance for possible coverage.

None

D0606

Molecular testing for a public health-related pathogen, including coronavirus

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient's medical insurance for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient's medical insurance for possible coverage.

None

D0999

Unspecified diagnostic procedure, by report

Individual consideration.

Individual consideration.

Detailed narrative

D1110

Prophylaxis – adult

Two per calendar year. Use D1110 for ages 14+

Two per calendar year.  There must be at least three months between a periodontal maintenance cleaning and any other cleanings.

None

D1120

Prophylaxis – child

Two per calendar year. Use D1120 for ages 0 – 13

Not a covered benefit.

None

D1206

Topical application of fluoride varnish

Once per 90 day(s) of either code D1206 or D1208.

Not a covered benefit.

None

D1208

Topical application of fluoride- excluding varnish

Once per 90 day(s) of either code D1206 or D1208.

Not a covered benefit.

None

D1310

Nutritional counseling for control of dental disease

Not a covered benefit.

Not a covered benefit.

None

D1320

Tobacco counseling for control and prevention of oral disease

Not a covered benefit.

Not a covered benefit.

None

D1321

Counseling for control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use

Not a covered benefit.

Not a covered benefit.

None

D1330

Oral hygiene instructions

Not a covered benefit.

Not a covered benefit.

None

D1351

Sealant – per tooth

Once per tooth per 3 years on primary or permanent first, second, and third non-carious molars.

Not a covered benefit.

Tooth identification


Surface identification

D1352

Preventive resin restoration in a moderate to high caries risk patient-permanent tooth

Not a covered benefit.

Not a covered benefit.

None

D1353

Sealant repair – per tooth

Covered for primary molars for members under age nine. Reapplication only if process fails within three years. Covered for permanent non-carious molars for members under age 17 once every three years per tooth.

Not a covered benefit.

Tooth identification 


Surface identification

D1354

Application of caries- arresting medicament – per tooth

Not a covered benefit.

Not a covered benefit.

None

D1355

Caries preventive medicament application – per tooth, for primary prevention or remineralization.

Not a covered benefit.

Not a covered benefit.

None

D1510

Space maintainer – fixed – unilateral – per quadrant

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Quadrant identification

D1516

Space maintainer – fixed – bilateral, maxillary

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Arch identification

D1517

Space maintainer-fixed-bilateral, mandibular

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Arch identification

D1520

Space maintainer – removable –unilateral – per quadrant

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Quadrant identification

D1526

Space maintainer – removable – bilateral, maxillary

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Arch identification

D1527

Space maintainer – removable – bilateral, mandibular

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Arch identification

D1551

Re-cement or re-bond bilateral space maintainer – maxillary

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Arch identification

D1552

Re-cement or re-bond bilateral space maintainer – mandibular

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Arch identification

D1553

Re-cement or re-bond unilateral space maintainer – per quadrant

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Quadrant identification

D1556

Removal of fixed unilateral space maintainer – per quadrant

Not a covered benefit.

Not a covered benefit.

None

D1557

Removal of fixed bilateral space maintainer – maxillary

Not a covered benefit.

Not a covered benefit.

None

D1558

Removal of fixed bilateral space maintainer – mandibular

Not a covered benefit.

Not a covered benefit.

None

D1575

Distal shoe space maintainer- fixed unilateral – per quadrant

Once per arch or quadrant per lifetime.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Quadrant or arch identification

D1999

Unspecified preventive procedure, by report

Individual consideration.

Note: Passive appliances are designed to prevent tooth movement.

Not a covered benefit.

Detailed narrative

D1701

Pfizer-BioNTech COVID-19 vaccine administration – first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1702

Pfizer-BioNTech COVID-19 vaccine administration – second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1703

Moderna COVID-19 vaccine administration – first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1704

Moderna COVID-19 vaccine administration – second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1705

AstraZeneca COVID-19 vaccine administration – first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1706

AstraZeneca COVID-19 vaccine administration – second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1707

Janssen COVID-19 vaccine administration

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1708

Pfizer-BioNTech Covid-19 vaccine administration – third dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1709

Pfizer-BioNTech Covid-19 vaccine administration – booster dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1710

Moderna Covid-19 vaccine administration – third dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1711

Moderna Covid-19 vaccine administration – booster dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1712

Janssen Covid-19 vaccine administration - booster dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1713

Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – first dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1714

Pfizer-BioNTech Covid-19 vaccine administration tris-sucrose pediatric – second dose

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1781

Vaccine administration – human papillomavirus – Dose 1

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1782

Vaccine administration – human papillomavirus – Dose 2

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D1783

Vaccine administration – human papillomavirus – Dose 3

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

Not a covered benefit under Blue Cross Blue Shield of Massachusetts dental plans. Please check with patient’s medical insurer for possible coverage.

None

D2140

Amalgam – one surface, primary or permanent

One restoration per tooth surface per 12 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2150

Amalgam – two surfaces, primary or permanent

One restoration per tooth surface per 12 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2160

Amalgam – three surfaces, primary or permanent

One restoration per tooth surface per 12 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2161

Amalgam – four or more surfaces, primary or permanent

One restoration per tooth surface per 12 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Amalgam restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap, local anesthesia and all adhesives (including amalgam bonding agents, liners and bases).  These are included as part of the restoration.  If pins are used, they should be reported separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2330

Resin-based composite – one surface, anterior

One restoration per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2331

Resin-based composite – two surfaces, anterior

One restoration per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2332

Resin-based composite – three surfaces, anterior

One restoration per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2335

Resin-based composite – four or more surfaces or involving incisal angle (anterior)

One restoration per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2390

Resin-based composite crown, anterior

One per tooth per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One per tooth per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

D2391

Resin-based composite – one surface, posterior

One per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2392

Resin-based composite – two surfaces, posterior

One per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2393

Resin-based composite – three surfaces, posterior

One per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2394

Resin-based composite – four or more surfaces, posterior

One per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

One restoration per tooth surface per 24 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

Tooth identification

Surface identification

D2410

Gold foil, one surface

Not a covered benefit.

One restoration per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

None

D2420

Gold foil, two surfaces

Not a covered benefit.

One restoration per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

None

D2430

Gold foil, three surfaces

Not a covered benefit.

One restoration per tooth surface per 12 months.

Note: Resin refers to a broad category of materials including, but not limited to composites.  May include bonded composite, light-cured composite, etc.  Light curing, acid-etching, and adhesives (including resin bonding agents) are included as part of the restoration.  Resin restorations include tooth preparation, localized tissue removal, base, direct and indirect pulp cap and local anesthesia.  Glass ionomers, when used as restorations, should be reported with these codes.  If pins are used, please report them separately (see D2951). Restorations are only allowed for fracture or decay.  Restorations for erosion, attrition, abfraction, or abrasion are not covered benefits.

None

D2510

Inlay – metallic, one surface

Not a covered benefit.

One restoration per tooth surface per 84 months. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2520

Inlay – metallic, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2530

Inlay – metallic, three or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months. Alternate benefit of a corresponding amalgam restoration paid for metallic inlays. The patient is responsible for the balance.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2542

Onlay – metallic, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months. Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2543

Onlay – metallic, three surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months. Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2544

Onlay – metallic, four or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months. Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2610

Inlay – porcelain/ceramic, one surface

Not a covered benefit.

One restoration per tooth surface per 84 months.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2620

Inlay – porcelain/ceramic, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2630

Inlay – porcelain/ceramic, three or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2642

Onlay – porcelain/ceramic, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2643

Onlay – porcelain/ceramic, three surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2644

Onlay – porcelain/ceramic, four or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2650

Inlay – resin-based composite, one surface

Not a covered benefit.

One restoration per tooth surface per 84 months.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2651

Inlay – resin-based composite, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2652

Inlay – resin-based composite, three or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Note: an inlay is considered to be an intra-coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusps tips.

Tooth identification

Surface identification

D2662

Onlay – resin-based composite, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2663

Onlay – resin-based composite, three surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2664

Onlay – resin-based composite, four or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

Limited to permanent posterior teeth 1-5, 12-21, 28-32.

Note: An onlay is considered to be a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.  

Tooth identification

Surface identification

D2710

Crown – resin-based composite (indirect)

Once per permanent tooth per 60 months for teeth numbers 3-14 and 19-30.

Once per permanent tooth per 84 months for teeth numbers 3-14 and 19-30.

Note: Subject to a six-month waiting period for members age 19 and over

Tooth identification

D2712

Crown - ¾ resin-based composite (indirect)

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2720

Crown - resin with high noble metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2721

Crown – resin with predominantly base metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2722

Crown – resin with noble metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2740

Crown – porcelain/ceramic substrate

Once per tooth per 60 months for teeth numbers 2-15 and 18-31.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

Tooth identification

D2750

Crown – porcelain fused to high-noble metal

Once per tooth per 60 months for teeth numbers 2-15 and 18-31.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

Tooth identification

D2751

Crown – porcelain fused to predominantly base metal

Once per tooth per 60 months for teeth numbers 2-15 and 18-31.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

Tooth identification

D2752

Crown – porcelain fused to noble metal

Once per tooth per 60 months for teeth numbers 2-15 and 18-31.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

Tooth identification

D2753

Crown – porcelain fused to titanium and titanium alloys

Once per tooth per 60 months for teeth numbers 2-15 and 18-31.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

Tooth identification

D2780

Crown – ¾ cast high noble metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2781

Crown – ¾ cast predominantly base metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2782

Crown – ¾ cast noble metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2783

Crown – ¾ porcelain/ceramic

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2790

Crown – full cast high-noble metal

Once per tooth per 60 months for teeth numbers 2-15 and 18-31.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

Tooth identification

D2791

Crown – full cast predominantly base metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2792

Crown – full cast noble metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2794

Crown – titanium and titanium alloys

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Note: Subject to a six-month waiting period for members age 19 and over

None

D2799

Interim crown – further treatment or completion of diagnosis necessary prior to final impression

Not a covered benefit.

Not a covered benefit.

None

D2910

Recement inlay, onlay, or partial coverage restoration

One per tooth per 12 months. Not covered within 6 months of initial placement.

One per tooth per 12 months.

Not covered within 6 months of initial placement.

Tooth identification

D2915

Recement cast or prefabricated post and core

Not a covered benefit.

One per tooth per 12 months.

Not covered within 6 months of initial placement.

Tooth identification

D2920

Recement crown

Once per tooth per 12 months.

Not covered within 6 months of initial placement.

Tooth identification

D2921

Reattachment of tooth fragment, incisal edge, or cusp

Not a covered benefit.

Not a covered benefit.

None

D2928

Prefabricated porcelain/ceramic crown – permanent tooth

Not a covered benefit.

Not a covered benefit.

None

D2929

Prefabricated porcelain/ceramic crown – primary tooth

Not a covered benefit.

Not a covered benefit.

None

D2930

Prefabricated stainless steel crown – primary tooth

One per tooth per 12 months. Maximum of four crowns per date of service.

One per tooth per 24 months. 

Tooth identification

D2931

Prefabricated stainless steel crown – permanent tooth

One per tooth per 12 months. Maximum of four crowns per date of service. Limited to permanent posterior teeth (#2-5, 12-15, 18-21 and 28-31.

Not a covered benefit.

Tooth identification

D2932

Prefabricated resin crown

One per tooth per 12 months. Maximum of four crowns per date of service.

 Not a covered benefit.

Tooth identification

D2933

Prefabricated stainless steel crown with resin window

Not a covered benefit.

Not a covered benefit.

None

D2934

Prefabricated esthetic coated stainless steel crown – primary tooth

One per tooth per 12 months. Maximum of four crowns per date of service.

One per tooth per 24 months. 

Tooth identification

D2940

Protective restoration

Not a covered benefit.

One per tooth per lifetime.

None

D2941

Interim therapeutic restoration – primary dentition

Not a covered benefit.

Not a covered benefit.

None

D2949

Restorative foundation for an indirect restoration

Not a covered benefit.

Not a covered benefit.

None

D2950

Core buildup, including any pins when required

Not a covered benefit.

Once per permanent tooth per 84 months.

None

D2951

Pin retention – per tooth, in addition to restoration

Covered when billed with a two or more surface restoration on a permanent tooth only.

Limited to three pins per tooth per lifetime.

Tooth identification

D2952

Post and core in addition to crown, indirectly fabricated

Not a covered benefit.

Once per tooth per 84 months.

None

D2953

Each additional indirectly fabricated post – same tooth

Not a covered benefit.

Once per tooth per lifetime.

None

D2954

Prefabricated post and core in addition to crown

Once per tooth per 60 months for teeth numbers 2-15 and 18-31.

Once per tooth per 84 months.

Tooth identification

D2955

Post removal

Not a covered benefit.

Not a covered benefit.

None

D2957

Each additional prefabricated post – same tooth

Not a covered benefit.

Once per tooth per lifetime. Limited to teeth 1-5, 12-21 and 28-32

None

D2960

Labial veneer (resin laminate) – direct

Not a covered benefit.

Not a covered benefit.

None

D2961

Labial veneer (resin laminate) – indirect

Not a covered benefit.

Not a covered benefit.

None

D2962

Labial veneer (porcelain laminate) – indirect

Not a covered benefit.

Not a covered benefit.

None

D2971

Additional procedures to customize a crown to fit under an existing partial denture framework

Not a covered benefit.

Individual consideration.

None

D2975

Coping a thin covering of the coronal portion of the tooth. Usually devoid of anatomic contour that can be used as a definitive restoration 

Not a covered benefit.

Not a covered benefit.

None

D2980     

Crown repair necessitated by restorative material failure

Individual consideration.

Individual consideration.

Detailed narrative

D2981

Inlay repair necessitated by restorative material failure

Not a covered benefit.

Once per tooth per 12 months.

None

D2982

Onlay repair necessitated by restorative material failure

Not a covered benefit.

Once per tooth per 12 months.

None

D2983

Veneer repair necessitated by restorative material failure

Not a covered benefit.

Not a covered benefit.

None

D2990

Resin infiltration of incipient smooth surface lesions

Not a covered benefit.

Once per tooth per 12 months.

None

D2999

Unspecified restorative procedure, by report

Individual consideration.

Individual consideration.

Detailed narrative

D3110

Pulp cap – direct (excluding final restoration)

Not a covered benefit.

Pulp capping is considered part of the final restoration.

None

D3120

Pulp cap – indirect (excluding final restoration)

Not a covered benefit.

Pulp capping is considered part of the final restoration.

None

D3220                   

Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament

One per tooth per lifetime.  Part of endodontic therapy when performed by the same dentist.

One per tooth per lifetime.  Part of endodontic therapy when performed by the same dentist. 

Tooth identification

D3221

Pulpal debridement, primary & permanent teeth

Not a covered benefit.

Once per tooth per lifetime.

None

D3222

Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development.

Not a covered benefit.

Once per tooth per lifetime.

None

D3230

Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration)

Not a covered benefit.

Once per tooth per lifetime.

None

D3240

Pulpal therapy (resorbable filling) –  posterior primary tooth (excluding final restoration)

Not a covered benefit.

Once per tooth per lifetime.

None

D3310

Endodontic therapy, anterior tooth (excluding final restoration)

One per permanent tooth per lifetime.

Note: includes treatment plan, clinical procedures and follow-up care

One per permanent tooth per lifetime.

Note: includes treatment plan, clinical procedures and follow-up care

Tooth identification

D3320

Endodontic therapy, premolar tooth (excluding final restoration)

One per permanent tooth per lifetime excluding third molars.

Note: includes treatment plan, clinical procedures and follow-up care

One per permanent tooth per lifetime excluding third molars.

Note: includes treatment plan, clinical procedures and follow-up care

Tooth identification

D3330

Endodontic therapy, molar (excluding final restoration)

One per permanent tooth per lifetime excluding third molars.

Note: includes treatment plan, clinical procedures and follow-up care

One per permanent tooth per lifetime excluding third molars.

Note: includes treatment plan, clinical procedures and follow-up care

Tooth identification

D3331

Treatment of root canal obstruction; non-surgical access

Not a covered benefit.

Individual consideration.

None

D3332

Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

Not a covered benefit.

Not a covered benefit.

None

D3333

Internal root repair of perforation defects

Not a covered benefit.

Not a covered benefit.

None

D3346

Retreatment of previous root canal therapy – anterior

One per permanent tooth per lifetime excluding third molars. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist or within 24 months. 

One per permanent tooth per lifetime excluding third molars. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist or within 24 months. 

Tooth identification

D3347

Retreatment of previous root canal therapy – premolar

One per permanent tooth per lifetime excluding third molars. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist or within 24 months. 

One per permanent tooth per lifetime excluding third molars. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist or within 24 months. 

Tooth identification

D3348

Retreatment of previous root canal therapy – molar

One per permanent tooth per lifetime excluding third molars. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist or within 24 months. 

One per permanent tooth per lifetime excluding third molars. Coverage is considered when prior root canal failed and re-treatment is performed by another dentist or within 24 months. 

Tooth identification

D3351

Apexification / recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc).

Not a covered benefit.

Once per permanent tooth per lifetime.

None

D3352

Apexification / recalcification – interim medication replacement

Not a covered benefit.

Once per permanent tooth per lifetime.

None

D3353

Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.)

Not a covered benefit.

Once per permanent tooth per lifetime.

None

D3355

Pulpal regeneration – initial visit

Not a covered benefit.

Once per permanent tooth per lifetime.

None

D3356

Pulpal regeneration – interim medication replacement

Not a covered benefit.

Once per permanent tooth per lifetime.

None

D3357

Pulpal regeneration – completion of treatment

Not a covered benefit.

Once per permanent tooth per lifetime.

None

D3410

Apicoectomy – anterior

One per permanent tooth root per lifetime.

Once per permanent tooth root per lifetime.

Tooth and root identification

D3421

Apicoectomy – premolar (first root)

One per permanent tooth root per lifetime.

Once per permanent tooth root per lifetime.

Tooth and root identification

D3425

Apicoectomy – molar (first root)

One per permanent tooth root per lifetime.

Once per permanent tooth root per lifetime.

Tooth and root identification

D3426

Apicoectomy – each additional

One per permanent tooth root per lifetime.

Once per permanent tooth root per lifetime.

Tooth and root identification

D3428

Bone graft in conjunction with periradicular surgery – per tooth, single site

Not a covered benefit.

Not a covered benefit.

None

D3429

Bone graft in conjunction with periradicular surgery – each additional contiguous in the same surgical site

Not a covered benefit.

Not a covered benefit.

None

D3430

Retrograde filling – per root

Not a covered benefit.

Once per permanent tooth per lifetime.

Tooth and root identification

D3431

Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery

Not a covered benefit.

Not a covered benefit.

None

D3432

Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery

Not a covered benefit.

Not a covered benefit.

None

D3450

Root amputation – per root

Not a covered benefit.

One per tooth per lifetime for multi-rooted posterior teeth.

Tooth and root identification

D3460

Endodontic endosseous implant

Not a covered benefit.

Not a covered benefit.

None

D3470

Intentional reimplantation (including necessary splinting)

Not a covered benefit.

Individual consideration.

Detailed narrative 

D3471

Surgical repair of root resorption – anterior

Not a covered benefit.

One per tooth root per lifetime. Considered inclusive if submitted with D3410, D3421, D3425, D3426.

Tooth and root identification

D3472

Surgical repair of root resorption – premolar

Not a covered benefit.

One per tooth root per lifetime. Considered inclusive if submitted with D3410, D3421, D3425, D3426.

Tooth and root identification

D3473

Surgical repair of root resorption – molar

Not a covered benefit.

One per tooth root per lifetime. Considered inclusive if submitted with D3410, D3421, D3425, D3426.

Tooth and root identification

D3501

Surgical repair of root surface without apicoectomy or repair of root resorption – anterior

Not a covered benefit.

Not a covered benefit.

None

D3502

Surgical repair of root surface without apicoectomy or repair of root resorption – premolar

Not a covered benefit.

Not a covered benefit.

None

D3503

Surgical repair of root surface without apicoectomy or repair of root resorption – molar

Not a covered benefit.

Not a covered benefit.

None

D3910

Surgical procedure for isolation of tooth with rubber dam

Not a covered benefit.

Not a covered benefit.

None

D3911

Intraorifice barrier

Not a covered benefit.

Not a covered benefit.

None

D3920

Hemisection (including any root removal), not including root canal therapy

Not a covered benefit.

One per posterior tooth per lifetime.

None

D3921

Decoronation or submergence of an erupted tooth

Not a covered benefit.

One per tooth per lifetime (D3921 or D7251).

None

D3950

Canal preparation and fitting of preformed dowel or post

Not a covered benefit.

Not a covered benefit.

None

D3999

Unspecified endodontic procedure, by report

Not a covered benefit.

Individual consideration.

None

D4210

Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth-bounded spaces, per quadrant

One per quadrant per 36 months. Limited to two quadrants on the same date of service.

Note: Includes usual post-operative services  

One per quadrant per 36 months.  An evaluation period of ³ 21 days to assess tissue response must be observed following scaling and root planning before benefits become available for soft tissue procedures.  A gingivectomy procedure is unusual in the presence of infrabony defects.

If reported at any time in preparation and/or temporization phase of teeth for, or in association with restoration/ prostheses, D4210 is considered to be included as part of the global restorative/prosthetic procedure.

Note: Includes usual post-operative services  

Current dated post-Phase I periodontal charting

Quadrant identification, including tooth numbers

Current mounted and dated preoperative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area)

Pre-treatment recommended

D4211

Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant

One per quadrant per 36 months. Limited to two quadrants on the same date of service.

Note: Includes usual post-operative services  

One to three teeth per quadrant per 36 months.  If reported at any time in preparation and/or temporization phase of tooth for, or in association with restoration/ prostheses, the D4211 is considered to be included as part of the global restorative/ prosthetic procedure.

Note: Includes usual post-operative services  

  • Current dated post phase I periodontal charting
  • Quadrant identification
  • Current mounted and dated pre-operative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area
  • Pre-treatment recommended

D4212

Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

Not a covered benefit.

Once per quadrant per 36 months.

Note: Includes usual post-operative services  

None

D4230

Anatomical crown exposure – four or more contiguous teeth or tooth-bounded spaces per quadrant

Not a covered benefit.

Not a covered benefit.

None

D4231

Anatomical crown exposure – one to three teeth or tooth-bounded spaces per quadrant

Not a covered benefit.

Not a covered benefit.

None

D4240

Gingival flap procedure, including root planning – four or more contiguous teeth or tooth-bounded spaces per quadrant

Not a covered benefit.

Once per quadrant per 36 months.

Note: Includes usual post-operative services  

None

D4241

Gingival flap procedure, including root planning – one to three contiguous teeth or tooth-bounded spaces per quadrant

Not a covered benefit.

Once per quadrant per 36 months.

Note: Includes usual post-operative services  

None

D4245

Apically repositioned flap

Not a covered benefit.

Not a covered benefit.

None

D4249

Clinical crown lengthening – hard tissue. This procedure is employed to allow a restorative procedure on a tooth with little or no tooth structure exposed to the oral cavity.

Not a covered benefit.

One per tooth per 60 months.

Note: Includes usual post-operative services  

None

D4260

Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth-bounded spaces per quadrant

Not a covered benefit.

One per quadrant per 36 months.

Note: Includes usual post-operative services  

Quadrant identification

Current dated post phase I periodontal charting

Current mounted and dated pre-operative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area

Pre-treatment recommended

D4261

Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant

Not a covered benefit.

One per quadrant per 36 months.

Note: Includes usual post-operative services  

Quadrant identification

Current dated post phase I periodontal charting

Current mounted and dated pre-operative periapical radiographs. If a current full mouth set of radiographs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area

Pre-treatment recommended

D4263

Bone replacement graft – first site in quadrant

Not a covered benefit.

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site or with routine apicoectomy, cystectomy, sinus augmentation, ridge augmentation, mucogingival grafts, or implant procedure.

Note: Includes usual post-operative services  

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D4264

Bone replacement graft – each additional site in quadrant

Not a covered benefit.

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site or with routine apicoectomy, cystectomy, sinus augmentation, ridge augmentation, mucogingival grafts, or implant procedure.

Note: Includes usual post-operative services  

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D4265

Biologic materials to aid in soft and osseous tissue regeneration, per site

Not a covered benefit.

Not a covered benefit.

None

D4266

Guided tissue regeneration, natural teeth –  resorbable barrier, per site

Not a covered benefit.

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site, or with routine apicoectomy, cystectomy, ridge augmentation, mucogingival grafts, or implant procedure.

Note: Includes usual post-operative services  

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D4267

Guided tissue regeneration, natural teeth – non-restorable barrier, per site 

Not a covered benefit.

One per site/tooth per 36 months. An allowance will be made in addition to the surgical procedure to cover the cost of the graft material. Not covered when used in an edentulous space, extraction site, or with routine apicoectomy, cystectomy, ridge augmentation, mucogingival grafts, or implant procedure.

Note: Includes usual post-operative services  

Tooth identification (edentulous spaces do not qualify for this code)

Current mounted and dated pre-operative periapical radiographs

Pre-treatment recommended

D7956

Guided tissue regeneration, edentulous area – resorbable barrier, per site

Not a covered benefit.

Not a covered benefit.

None

D7957

Guided tissue regeneration, edentulous area – non-resorbable barrier, per site

Not a covered benefit.

Not a covered benefit.

None

D4268

Surgical revision procedure, per tooth

Not a covered benefit.

Not a covered benefit.

None

D4270

Pedicle soft tissue graft procedure

Not a covered benefit.

Once per tooth per 36 months. Grafting for cosmetic purposes is non-covered.

Note: Includes usual post-operative services  

Tooth identification

D4273

Autogenous  connective tissue graft procedures (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft

Not a covered benefit.

One per site per 36 months on natural teeth only. Limited to three teeth per graft site.

Note: Includes usual post-operative services  

Tooth identification

D4274

Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)

Not a covered benefit.

One per site per 36 months. Must be adjacent to edentulous area.

Note: Includes usual post-operative services  

Tooth identification

D4275

Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft

Not a covered benefit.

One per site per 36 months on natural teeth only. Limited to three teeth per graft site.

Note: Includes usual post-operative services  

Tooth identification

D4276

Combined connective tissue and pedicle graft, per tooth

Not a covered benefit.

One per tooth per 36 months. Grafting for cosmetic purposes is non-covered.

Note: Includes usual post-operative services  

Tooth identification

D4277

Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft

Not a covered benefit.

One per site per 36 months on natural teeth only. Limited to three teeth per graft site.

Note: Includes usual post-operative services  

Tooth identification

D4278

Free soft tissue graft procedure (including recipient and donor surgical sites), each additional contiguous tooth, implant or edentulous tooth position in same graft site

Not a covered benefit.

One per site per 36 months on natural teeth only. Limited to three teeth per graft site.

Note: Includes usual post-operative services  

Tooth identification

D4283

Autogenous connective tissue graft procedure (including donor and recipient surgical sites), each additional contiguous tooth, implant or edentulous tooth position in same graft site

Not a covered benefit.

Each additional tooth, up to three teeth total in graft.

Note: Includes usual post-operative services  

Tooth identification

D4285

Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

Not a covered benefit.

Each additional tooth, up to three teeth total in graft.

Note: Includes usual post-operative services  

Tooth identification

D4286

Removal of non-resorbable barrier

Not a covered benefit.

Considered inclusive of D4267, not a covered benefit in any other circumstance.

Note: Includes usual post-operative services  

Tooth identification


D4322

Splint – intra-coronal; natural teeth or prosthetic crowns

Not a covered benefit.

Not a covered benefit.

None

D4323

Splint – extra-coronal; natural teeth or prosthetic crowns

Not a covered benefit.

Not a covered benefit.



None

D4341

Periodontal scaling and root planning – four or more teeth per quadrant

One per 36 months per quadrant.

Once per quadrant per 24 months.

Quadrant identification

D4342

Periodontal scaling and root planning, one to three teeth per quadrant

One per 36 months per quadrant.

Once per quadrant per 24 months.

Quadrant identification

Tooth/teeth number(s)

D4346

Scaling in the presence of generalized moderate or severe gingival inflammation – full mouth

Covered interchangeably with D1110.  Held to the same frequencies and allowable as D1110.

Covered interchangeably with D1110.  Held to the same frequencies and allowable as D1110.

None

D4355

Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit

Not a covered benefit.

Not a covered benefit.

None

D4381

Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

Not a covered benefit.

Individual consideration.

None

D4910

Periodontal maintenance

Not a covered benefit.

One per 3 months following active periodontal treatment.  There must be at least three months between a periodontal maintenance cleaning and any other cleanings.

None               

D4920

Unscheduled dressing change (by someone other than treating dentist or their staff)

Not a covered benefit

Not a covered benefit.

None

D4921

Gingival irrigation with a medicinal agent – per quadrant

Not a covered benefit

Not a covered benefit.

None

D4999

Unspecified periodontal procedure, by report

Individual consideration. 

Individual consideration. 

Detailed narrative 

D5110

Complete denture – maxillary

One per arch per 84 months.

Note: Includes routine post-delivery care

One per arch per 84 months; not covered if D5130, D5211, D5213, D5221, D5223, D5225, or D5227 was done within 84 months.

Note: Includes routine post-delivery care

Arch identification

D5120

Complete denture – mandibular

One per arch per 84 months.

Note: Includes routine post-delivery care

One per arch per 84 months; not covered if D5140, D5212, D5214, D5222, D5224, D5226, or D5228 was done within 84 months.

Note: Includes routine post-delivery care

Arch identification

D5130

Immediate denture – maxillary

One per arch per lifetime.

Note: Includes routine post-delivery care

One per arch per lifetime.

Note: Includes routine post-delivery care

Arch identification

D5140

Immediate denture – mandibular

One per arch per lifetime.

Note: Includes routine post-delivery care

One per arch per lifetime.

Note: Includes routine post-delivery care

Arch identification

D5211

Maxillary partial denture – resin base (including retentive/clasping materials, rests, and teeth)

One per 84 months.

Note: Includes routine post-delivery care

One per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5212

Mandibular partial denture – resin base (including retentive/clasping materials, rests, and teeth)

One per 84 months.

Note: Includes routine post-delivery care

One per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5213

Maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

One per 84 months.

Note: Includes routine post-delivery care

One per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5214

Mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

One per 84 months.

Note: Includes routine post-delivery care

One per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5221

Immediate maxillary partial denture – resin base (including retentive/ clasping materials, rests, and teeth)

One per arch per 84 months for members age 16+.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5222

Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests, and teeth)

One per arch per 84 months for members age 16+.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5223

Immediate maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

One per arch per 84 months for members age 16+.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5224

Immediate mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests, and teeth)

One per arch per 84 months for members age 16+.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5225

Maxillary partial denture – flexible base (including retentive/clasping materials, rests, and teeth)

One per arch per 84 months.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5226

Mandibular partial denture – flexible base (including retentive/clasping materials, rests, and teeth)

One per arch per 84 months.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5227

Immediate maxillary partial denture – flexible base (including any clasps, rests and teeth)

One per arch per 84 months for members age 16+.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5228

Immediate mandibular partial denture – flexible base (including any clasps, rests and teeth)

One per arch per 84 months for members age 16+.

Note: Includes routine post-delivery care

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5282

Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary

Not a covered benefit.

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5283

Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular

Not a covered benefit.

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5284

Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth), per quadrant

Not a covered benefit.

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5286

Removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth), per quadrant

Not a covered benefit.

One per arch per 84 months.

Note: Includes routine post-delivery care

Arch identification

D5410

Adjust complete denture – maxillary

Not a covered benefit.

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. Once per arch 12 months.

None

D5411

Adjust complete denture – mandibular

Not a covered benefit.

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. Once per arch 12 months.

None

D5421

Adjust partial denture – maxillary

Not a covered benefit.

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. Once per arch 12 months.

None

D5422

Adjust partial denture – mandibular

Not a covered benefit.

Considered part of routine post-delivery care for complete and partial denture for the first 90 days. Once per arch 12 months.

None

D5511

Repair broken complete denture base, mandibular

Not covered if D5110, D5120, D5130 and D5140 have paid within the prior 6 months.

Once per arch 12 months.

Arch identification

D5512

Repair broken complete denture base, maxillary

Not covered if D5110, D5120, D5130 and D5140 have paid within the prior 6 months.

Once per arch 12 months.

Arch identification

D5520

Replace missing or broken teeth - complete denture (each tooth)

Not covered if D5110, D5120, D5130 and D5140 have paid within the prior 6 months.

Once per arch 12 months.

Tooth identification

D5611

Repair resin partial denture base, mandibular

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per arch 12 months.

Arch identification

D5612

Repair resin partial denture base, maxillary

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per arch 12 months.

Arch identification

D5621

Repair cast partial framework, mandibular

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per arch 12 months.

Arch identification

D5622

Repair cast partial framework, maxillary

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per arch 12 months.

Arch identification

D5630   

Repair or replace broken retentive clasping materials, per tooth

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per tooth per 12 months.

Tooth identification

D5640

Repair broken teeth, per tooth

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per tooth per 12 months.

Tooth identification

D5650

Add tooth to existing partial denture

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per tooth per 12 months.

Tooth identification

D5660

Add clasp to existing partial denture

Not covered if D5110, D5120, D5130, D5140, D5211, D5212, D5213 or D5214 have paid within the prior 6 months.

Once per tooth per 12 months.

Tooth identification

D5670

Replace all teeth and acrylic on cast metal framework (maxillary)

Not a covered benefit.

Once per arch per partial denture.

Arch identification

D5671

Replace all teeth and acrylic on cast metal framework (mandibular)

Not a covered benefit.

Once per arch per partial denture.

Arch identification

Tooth identification

D5710

Rebase complete maxillary denture

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

None

D5711

Rebase complete mandibular denture

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

None

D5720

Rebase maxillary partial denture

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

None

D5721

Rebase mandibular partial denture

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

None

D5725

Rebase hybrid prosthesis

Once per arch per 24 months.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

Once per arch per 36 months.

Note: Dental rebase procedures are considered to be the process of refitting a denture by replacing the base material.

Arch identification

D5730

Reline complete maxillary denture – direct

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5731

Reline complete mandibular denture – direct

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5740

Reline maxillary partial denture –direct

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5741

Reline mandibular partial denture – direct

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5750

Reline complete maxillary denture – indirect

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5751

Reline complete mandibular denture – indirect

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5760

Reline maxillary partial denture – indirect

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5761

Reline mandibular partial denture – indirect

Once per 24 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

One per 36 months; adjustments are considered part of routine post-delivery care for complete and partial denture rebases within 6 months of dispensing date of denture.

Note: Denture reline procedures are considered to be the process of resurfacing the tissue side of a denture with new base material.

Arch identification

D5810

Interim complete denture (maxillary)

Not a covered benefit.

Not a covered benefit.

None

D5811

Interim complete denture (mandibular)

Not a covered benefit.

Not a covered benefit.

None

D5820

Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary

Not a covered benefit.

One per upper arch per lifetime.

None

D5821

Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular

Not a covered benefit.

One per lower arch per lifetime.

None

D5765

Soft liner for complete or partial removable denture – indirect

Once per arch per 24 months.

Once per arch per 36 months.

Arch identification

D5850

Tissue conditioning, maxillary

Not a covered benefit.

One per denture per 36 months.

None

D5851

Tissue conditioning, mandibular

Not a covered benefit.

One per denture per 36 months.

None

D5862

Precision attachment, by report

Not a covered benefit.

Not a covered benefit.

None

D5863

Overdenture – complete maxillary

Not a covered benefit.

One per arch per 84 months.

None

D5864

Overdenture – partial maxillary

Not a covered benefit.

One per arch per 84 months.

None

D5865

Overdenture – complete mandibular

Not a covered benefit.

One per arch per 84 months.

None

D5866

Overdenture – partial mandibular

Not a covered benefit.

One per arch per 84 months.

None

D5867

Replacement of replaceable part of semi-precision or precision attachment, per attachment

Not a covered benefit.

Not a covered benefit.

None

D5875

Modification of removable prosthesis following implant surgery

Not a covered benefit.

Not a covered benefit.

None

D5876

Add metal substructure to acrylic full denture (per arch)

Not a covered benefit.

Not a covered benefit.

None

D5899

Unspecified removable prosthodontic procedure, by report

Individual consideration.

Individual consideration.

Detailed narrative 

D5911

Facial moulage (sectional)

Not a covered benefit.

Not a covered benefit.

None

D5912

Facial moulage (complete)

Not a covered benefit.

Not a covered benefit.

None

D5913

Nasal prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5914

Auricula prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5915

Orbital prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5916

Ocular prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5919

Facial prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5922

Nasal septal prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5923

Ocular prosthesis, interim

Not a covered benefit.

Not a covered benefit.

None

D5924

Cranial prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5925

Facial augmentation implant prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5926

Nasal prosthesis, replacement

Not a covered benefit.

Not a covered benefit.

None

D5927

Auricular prosthesis, replacement

Not a covered benefit.

Not a covered benefit.

None

D5928

Orbital prosthesis, replacement

Not a covered benefit.

Not a covered benefit.

None

D5929

Facial prosthesis, replacement

Not a covered benefit.

Not a covered benefit.

None

D5931

Obturator prosthesis, surgical

Not a covered benefit.

Not a covered benefit.

None

D5932

Obturator prosthesis, definitive

Not a covered benefit.

Not a covered benefit.

None

D5933

Obturator prosthesis, modification

Not a covered benefit.

Not a covered benefit.

None

D5934

Mandibular resection prosthesis with guide flange

Not a covered benefit.

Not a covered benefit.

None

D5935

Mandibular resection prosthesis without guide flange

Not a covered benefit.

Not a covered benefit.

None

D5936

Obturator prosthesis, interim

Not a covered benefit.

Not a covered benefit.

None

D5937

Trismus appliance (not for TMD treatment)

Not a covered benefit.

Not a covered benefit.

None

D5951

Feeding aid

Not a covered benefit.

Not a covered benefit.

None

D5952

Speech aid prosthesis, pediatric

Not a covered benefit.

Not a covered benefit.

None

D5953

Speech aid prosthesis, adult

Not a covered benefit.

Not a covered benefit.

None

D5954

Palatal augmentation prosthesis

Not a covered benefit.

Not a covered benefit.

None

D5955

Palatal lift prosthesis, definitive

Not a covered benefit.

Not a covered benefit.

None

D5958

Palatal lift prosthesis, interim

Not a covered benefit.

Not a covered benefit.

None

D5959

Palatal lift prosthesis, modification

Not a covered benefit.

Not a covered benefit.

None

D5960

Speech aid prosthesis, modification

Not a covered benefit.

Not a covered benefit.

None

D5982

Surgical stent

Not a covered benefit.

Not a covered benefit.

None

D5983

Radiation carrier              

Not a covered benefit.

Not a covered benefit.

None

D5984

Radiation shield

Not a covered benefit.

Not a covered benefit.

None

D5985

Radiation cone locator

Not a covered benefit.

Not a covered benefit.

None

D5986

Fluoride gel carrier

Not a covered benefit.

Not a covered benefit.

None

D5987

Commissure splint

Not a covered benefit.

Not a covered benefit.

None

D5988

Surgical splint

Not a covered benefit.

Not a covered benefit.

None

D5991

Vesiculobullous disease medicament carrier

Not a covered benefit.

Not a covered benefit.

None

D5992

Adjust maxillofacial prosthetic appliance, by report

Not a covered benefit.

Not a covered benefit.

None

D5993

Maintenance and cleaning of a maxillofacial prosthesis (extra or intraoral) other than required adjustments, by report

Not a covered benefit.

Not a covered benefit.

None

D5995

Periodontal medicament carrier with peripheral seal – laboratory processed – maxillary

Not a covered benefit.

Not a covered benefit.

None

D5996

Periodontal medicament carrier with peripheral seal – laboratory processed - mandibular

Not a covered benefit.

Not a covered benefit.

None

D5999

Unspecified maxillofacial prosthesis, by report

Not a covered benefit.

Not a covered benefit.

None

D6190

Radiographic/surgical implant index, by report

Not a covered benefit

Not a covered benefit

None

D6010

Surgical placement of implant body, endosteal implant

Not a covered benefit

Not a covered benefit

None

D6011

Surgical access to an implant body (Second stage implant surgery)

Not a covered benefit

Not a covered benefit

None

D6012

Surgical placement of interim implant body for transitional prosthesis: endosteal implant

Not a covered benefit

Not a covered benefit

None

D6013

Surgical placement of mini implant

Not a covered benefit

Not a covered benefit

None

D6040

Surgical placement: eposteal implant

Not a covered benefit

Not a covered benefit

None

D6050

Surgical placement: transosteal implant

Not a covered benefit

Not a covered benefit

None

D6100

Surgical removal of implant body

Not a covered benefit

Not a covered benefit

None

D6101

Debridement of a peri-implant defect and surface cleaning of exposed implant surfaces, including flap entry and closure

Not a covered benefit

Not a covered benefit

None

D6102

Debridement and osseous contouring of a peri-implant defect; includes surface cleaning of exposed implant surfaces and flap entry

Not a covered benefit

Not a covered benefit

None

D6103

Bone graft for repair of peri-implant defect – not including flap entry and closure

Not a covered benefit

Not a covered benefit

None

D6104

Bone graft at time of implant placement

Not a covered benefit

Not a covered benefit

None

D6105

Removal of implant body not requiring bone removal nor flap elevation

Not a covered benefit

Not a covered benefit

None

D6106

Guided tissue regeneration – resorbable barrier, per implant

Not a covered benefit

Not a covered benefit

None

D6107

Guided tissue regeneration – non-resorbable barrier, per implant

Not a covered benefit

Not a covered benefit

None

D6110

Implant /abutment supported removable denture for edentulous arch – maxillary

Once per 60 months.

Once per 60 months.

None

D6111

Implant /abutment supported removable denture for edentulous arch – mandibular

Once per 60 months.

Once per 60 months.

None

D6112

Implant /abutment supported removable denture for partially edentulous arch – maxillary

Once per 60 months.

Once per 60 months.

None

D6113

Implant /abutment supported removable denture for partially edentulous arch – mandibular

Once per 60 months.

Once per 60 months.

None

D6114

Implant /abutment supported fixed denture for edentulous arch – maxillary

Covered by rider only.

Covered by rider only.

None

D6115

Implant /abutment supported fixed denture for edentulous arch – mandibular

Covered by rider only.

Covered by rider only.

None

D6116

Implant /abutment supported fixed denture for partially edentulous arch – maxillary

Covered by rider only.

Covered by rider only.

None

D6117

Implant /abutment supported fixed denture for partially edentulous arch – mandibular

Covered by rider only.

Covered by rider only.

None

D6118

Implant/abutment supported interim fixed denture for edentulous arch – mandibular

Covered by rider only.

Covered by rider only.

None

D6119

Implant/abutment supported interim fixed denture for edentulous arch – maxillary

Covered by rider only.

Covered by rider only.

None

D6051

Interim implant abutment placement

Not a covered benefit.

Not a covered benefit.

None

D6055

Connecting bar – implant- supported or abutment-supported

Not a covered benefit.

Not a covered benefit.

None

D6056

Prefabricated abutment – includes modification and placement

Not a covered benefit.

Not a covered benefit.

None

D6057

Custom fabricated abutment – includes placement

Not a covered benefit.

Not a covered benefit.

None

D6078

Implant/abutment-supported fixed denture, completely edentulous arch

Not a covered benefit.

Not a covered benefit.

None

D6079

Implant/abutment-supported fixed denture, partially edentulous arch

Not a covered benefit.

Not a covered benefit.

None

D6058

Abutment-supported porcelain/ ceramic crown. A single crown restoration that is retained, supported, and stabilized by an abutment on an implant

Not a covered benefit.

Not a covered benefit.

None

D6059

Abutment-supported porcelain fused to metal crown (high noble metal) A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant

Not a covered benefit.

Not a covered benefit.

None

D6060

Abutment supported porcelain fused to metal crown (predominantly base metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

Not a covered benefit.

Not a covered benefit.

None

D6061

Abutment-supported porcelain fused to metal crown (noble metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

Not a covered benefit.

Not a covered benefit.

None

D6062

Abutment-supported cast metal crown (high noble metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

Not a covered benefit.

Not a covered benefit.

None

D6063

Abutment-supported cast metal crown (predominantly base metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

Not a covered benefit.

Not a covered benefit.

None

D6064

Abutment-supported cast metal crown (noble metal). A single metal-ceramic crown restoration that is retained, supported, and stabilized by an abutment on an implant.

Not a covered benefit.

Not a covered benefit.

None

D6094

Abutment-supported crown – titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6097

Abutment-supported crown – porcelain fused to titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6065

Implant-supported porcelain/ceramic crown

Not a covered benefit.

Not a covered benefit.

None

D6066

Implant supported crown – porcelain fused to high noble alloys

Not a covered benefit.

Not a covered benefit.

None

D6067

Implant-supported crown – high noble alloys

Not a covered benefit.

Not a covered benefit.

None

D6082

Implant-supported crown – porcelain fused to predominately base alloys

Not a covered benefit.

Not a covered benefit.

None

D6083

Implant-supported crown –porcelain fused to noble alloys

Not a covered benefit.

Not a covered benefit.

None

D6084

Implant-supported crown – porcelain fused to titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6085

Provisional implant crown

Not a covered benefit.

Not a covered benefit.

None

D6086

Implant supported crown – predominantly base alloys

Not a covered benefit.

Not a covered benefit.

None

D6087

Implant supported crown – noble alloys

Not a covered benefit.

Not a covered benefit.

None

D6088

Implant-supported crown – titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6068

Abutment supported retainer for porcelain/ceramic FPD. A ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant. 

Not a covered benefit.

Not a covered benefit.

None

D6069

Abutment-supported retainer for porcelain fused to metal FPD (high noble metal). A metal- ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant. 

Not a covered benefit.

Not a covered benefit.

None

D6070

Abutment-supported retainer for porcelain fused to metal FPD (predominately base metal) A metal-ceramic retainer for a fixed partial denture that gains retention, support, and stability from an abutment on an implant. 

Not a covered benefit.

Not a covered benefit.

None

D6071

Abutment-supported retainer for porcelain fused to metal FPD (noble metal)

Not a covered benefit.

Not a covered benefit.

None

D6072

Abutment-supported retainer for cast metal FPD (high noble metal)

Not a covered benefit.

Not a covered benefit.

None

D6073

Abutment-supported retainer for cast metal FPD (predominately base metal)

Not a covered benefit.

Not a covered benefit.

None

D6074

Abutment-supported retainer for cast metal FPD (noble metal)

Not a covered benefit.

Not a covered benefit.

None

D6191

Semi-precision abutment – placement

Not a covered benefit.

Not a covered benefit.

None

D6192

Semi-precision attachment – placement

Not a covered benefit.

Not a covered benefit.

None

D6194

Abutment supported retainer crown for FPD – titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6195

Abutment supported retainer – porcelain fused to titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6075

Implant-supported retainer for ceramic FPD

Not a covered benefit.

Not a covered benefit.

None

D6076

Implant-supported retainer for FPD – porcelain fused to high noble alloys)

Not a covered benefit.

Not a covered benefit.

None

D6077

Implant-supported retainer for cast metal FPD – high noble alloys)

Not a covered benefit.

Not a covered benefit.

None

D6098

Implant supported retainer – porcelain fused to predominantly base alloys

Not a covered benefit.

Not a covered benefit.

None

D6099

Implant supported retainer for FPD – porcelain fused to noble alloys

Not a covered benefit.

Not a covered benefit.

None

D6120

Implant supported retainer – porcelain fused to titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6121

Implant-supported retainer for metal FPD – predominantly base alloys

Not a covered benefit.

Not a covered benefit.

None

D6122

Implant-supported retainer for metal FPD – noble alloys

Not a covered benefit.

Not a covered benefit.

None

D6123

Implant-supported retainer for metal FPD – titanium and titanium alloys

Not a covered benefit.

Not a covered benefit.

None

D6080

Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments

Not a covered benefit.

Not a covered benefit.

None

D6090

Repair implant supported prosthesis, by report

Not a covered benefit.

Covered by rider only.

Arch identification

D6091

Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment

Not a covered benefit.

Not a covered benefit.

None

D6092

Recement or re-bond implant/abutment-supported crown

Not a covered benefit.

Not a covered benefit.

None

D6093

Recement or re-bond implant/abutment-supported fixed partial denture

Not a covered benefit.

Not a covered benefit.

None

D6095

Repair implant abutment, by report

Not a covered benefit.

Covered by rider only.

Tooth identification

D6096

Remove broken implant retaining screw

Not a covered benefit.

Covered by rider only.

Tooth identification

D6197

Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant

Not a covered benefit.

One per tooth per 6 months when done within 3 months of an implant repair (D6095 or D6096) on the same tooth.

Tooth identification

D6198

Remove interim implant component

Not a covered benefit.

Not a covered benefit.

None

D6199

Unspecified implant procedure, by report

Not a covered benefit.

Not a covered benefit.

None

D6205

Pontic – indirect resin-based composite

Not a covered benefit.

Not a covered benefit.

None

D6210

Pontic – cast high noble

Not a covered benefit

One pontic per permanent tooth per 84 months.

None

D6211

Pontic – cast predominantly base metal

Not a covered benefit

One pontic per permanent tooth per 84 months.

None

D6212

Pontic – cast noble metal

Not a covered benefit

One pontic per permanent tooth per 84 months.

None

D6214

Pontic – titanium and titanium alloys

Not a covered benefit

One pontic per permanent tooth per 84 months.

None

D6240

Pontic – porcelain fused to high noble metal

Not a covered benefit

One pontic per permanent tooth per 84 months.

None

D6241

Pontic – porcelain fused to predominantly base metal

Once per 60 months per tooth.

One pontic per permanent tooth per 84 months.

Tooth identification

D6242

Pontic – porcelain fused to noble metal

Not a covered benefit.

One pontic per permanent tooth per 84 months.

None

D6243

Pontic – porcelain fused to titanium and titanium alloys

Not a covered benefit.

One pontic per permanent tooth per 84 months.

None

D6245

Pontic – porcelain/ceramic

Not a covered benefit.

One pontic per permanent tooth per 84 months.

None

D6250

Pontic – resin with high noble metal       

Not a covered benefit.

One pontic per permanent tooth per 84 months.

None

D6251

Pontic – resin with predominantly base metal

Not a covered benefit.

One pontic per permanent tooth per 84 months.

None

D6252

Pontic – resin with noble metal

Not a covered benefit.

One pontic per permanent tooth per 84 months.

None

D6253

Interim pontic – further treatment or completion of diagnosis necessary prior to final impression

Not a covered benefit.

Individual consideration.

Tooth identification

D6545

Retainer – cast metal for resin-bonded fixed prosthesis

Not a covered benefit.

One restoration per permanent tooth per 84 months.

Tooth identification

D6548

Retainer – porcelain/ ceramic for resin-bonded fixed prosthesis

Not a covered benefit.

One restoration per permanent tooth per 84 months.

Tooth identification

D6549

Resin retainer – for resin bonded fixed prosthesis

Not a covered benefit.

One restoration per permanent tooth per 84 months.

Tooth identification

D6600

Retainer inlay – porcelain/ceramic, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6601

Retainer inlay – porcelain/ceramic, three or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6602

Retainer inlay – cast high noble metal, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6603

Retainer inlay – cast high noble metal, three or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6604

Retainer inlay – cast predominantly base metal, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6605

Retainer inlay – cast predominantly base metal, three or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6606

Retainer inlay – cast noble metal, two surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6607

Retainer inlay – cast noble metal, three or more surfaces

Not a covered benefit.

One restoration per tooth surface per 84 months.

None

D6608

Retainer onlay –porcelain/ceramic, two surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6609

Retainer onlay – porcelain/ ceramic, three or more surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6610

Retainer onlay – cast high noble metal, two surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6611

Retainer onlay – cast high noble metal, three or more surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6612

Retainer onlay – cast predominantly base metal, two surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6613

Retainer onlay – cast predominantly base metal, three or more surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6614

Retainer onlay – cast noble metal, two surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6615

Retainer onlay – cast noble metal, three or more surfaces

Not a covered benefit.

Once per tooth per 84 months.

None

D6624

Retainer inlay – titanium

Not a covered benefit.

Not a covered benefit.

None

D6634

Retainer onlay – titanium

Not a covered benefit.

Once per tooth per 84 months.

None

D6710

Retainer crown – indirect resin-based composite

Not a covered benefit.

Not a covered benefit.

None

D6720

Retainer crown – resin with high noble metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

None

D6721

Retainer crown – resin with predominantly base metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

None

D6722

Retainer crown – resin with noble metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

None

D6740

Retainer crown – porcelain/ceramic

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

None

D6750

Retainer crown – porcelain fused to high noble

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

None

D6751

Retainer crown – porcelain fused to predominantly base metal

Once per 60 months per tooth.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6752

Retainer crown – porcelain fused to noble metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6753

Retainer crown – porcelain fused to titanium and titanium alloys

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6780

Retainer crown – ¾ cast high noble metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6781

Retainer crown – ¾ cast predominately base metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6782

Retainer crown – ¾ cast noble metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6783

Retainer crown – ¾ porcelain/ceramic

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6784

Retainer crown ¾ – titanium and titanium alloys

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6790

Retainer crown – full cast high noble metal

Not a covered benefit.

One retainer crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6791

Retainer crown – full cast predominantly base metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6792

Retainer crown – full cast noble metal

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6793

Interim retainer crown – further treatment or completion of diagnosis necessary prior to final impression

Not a covered benefit.

Not a covered benefit.

Tooth identification

D6794

Retainer crown – titanium and titanium alloys

Not a covered benefit.

One crown or cast restoration per permanent tooth per 84 months.

Tooth identification

D6920

Connector bar

Not a covered benefit.

Not a covered benefit.

None

D6930

Recement or re-bond fixed partial denture

Not payable within 6 months of the placement of the fixed partial denture.

One re-cementation per 12 months.

Tooth identification

D6940

Stress breaker

Not a covered benefit.

Not a covered benefit.

None

D6950

Precision attachment

Not a covered benefit.

Not a covered benefit.

None

D6980

Fixed partial denture repair necessitated by restorative material failure

Covered.

One repair per 12 months.

Quadrant identification

Detailed narrative

D6985

Pediatric partial denture, fixed

Not a covered benefit.

Not a covered benefit.

None

D6999

Unspecified fixed prosthodontic procedure, by report

Individual consideration.

Individual consideration.

Detailed narrative  

D7111

Extraction – coronal remnants, deciduous tooth

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999)

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999)

Tooth identification

D7140

Extraction – erupted tooth or exposed root (elevation and/or forcep removal)

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999)

One per tooth per lifetime.

If D7140, D7210, or D7250 is performed within 90 days after a D3921, payment for the extraction will be reduced by the payment of D3921.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999)

Tooth identification

D7210

Surgical removal of an erupted tooth requiring removal of bone and/or sectioning of tooth and including elevation of mucoperiosteal flap if indicated

One per tooth per lifetime.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999)

One per tooth per lifetime.

If D7140, D7210 or D7250 is performed within 90 days after a D3921, payment for the extraction will be reduced by the payment of D3921.

Note: Includes local anesthesia, suturing, if needed, and routine post-operative care. Bone grafts (D4263, D4264, D4265) and GTR membranes (D4266, D4267) are not covered in conjunction with oral surgery codes (D7000-D7999)

Tooth identification

D7220

Removal of impacted tooth – soft tissue

One per tooth per lifetime.

One per tooth per lifetime.

Tooth identification

D7230

Removal of impacted tooth – partially bony

One per tooth per lifetime.

One per tooth per lifetime.

Tooth identification

D7240

Removal of impacted tooth – completely bony

One per tooth per lifetime.

One per tooth per lifetime.

Tooth identification

D7241

Removal of impacted tooth – completely bony, with unusual surgical complications

Not a covered benefit.

One per tooth per lifetime.

Tooth identification

D7250

Surgical removal of residual tooth roots (cutting procedure)

Only covered for teeth that are symptomatic, carious or pathologic.

One per tooth per lifetime.

If D7140, D7210 or D7250 is performed within 90 days after a D3921, payment for the extraction will be reduced by the payment of D3921.

Tooth identification

D7251

Coronectomy – intentional partial tooth removal, impacted teeth only

Not a covered benefit.

Once per tooth per lifetime (D3921 or D7251).

None

D7260

Oroantral fistula closure

Not a covered benefit.

Individual consideration.

Periapical or panoramic radiograph

Operative note

D7261

Primary closure of a sinus perforation

Not a covered benefit.

Individual consideration.

Periapical or panoramic radiograph

Operative note

D7270

Tooth reimplantation and/or stabilization of accidentally avulsed or displaced tooth

Individual consideration.

Once per permanent tooth per lifetime.

Tooth identification

D7272

Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

Not a covered benefit.

Not a covered benefit.

None

D7280

Surgical access of unerupted tooth

Not a covered benefit.

Once per permanent tooth (1 through 32) per lifetime.

None

D7282

Mobilization of erupted or mal-positioned tooth to aid eruption

Not a covered benefit.

Once per permanent tooth (1 through 32) per lifetime.

None

D7283

Placement of a device to facilitate eruption of impacted tooth

Once per tooth per lifetime and covered only with approved medically necessary orthodontics.

Once per tooth per lifetime.

Tooth identification

D7285

Incisional biopsy of oral tissue – hard (bone, tooth)

Not a covered benefit.

Individual consideration.

Pathology report

D7286

Incisional biopsy of oral tissue – soft

Not a covered benefit.

Individual consideration.

 Pathology report

D7287

Cytology exfoliative sample collection

Not a covered benefit.

Individual consideration.

Detailed narrative

D7288

Brush biopsy – transepithelial sample collection

Not a covered benefit.

Individual consideration.

Detailed narrative

D7290

Surgical repositioning of teeth – grafting procedures are additional

Not a covered benefit.

Individual consideration.

Tooth identification

Detailed narrative

D7291

Transseptal fiberotomy/supra crestal fiberotomy, by report

Not a covered benefit.

Individual consideration.

Tooth identification

Detailed narrative

Include orthodontic history

D7292

Placement of temporary anchorage device [screw retained plate] requiring flap

Not a covered benefit.

Not a covered benefit.

None

D7293

Placement of temporary anchorage device requiring flap

Not a covered benefit.

Not a covered benefit.

None

D7294

Placement of temporary anchorage device without flap

Not a covered benefit.

Not a covered benefit.

None

D7295

Harvest of bone for use in autogenous grafting procedures

Not a covered benefit.

Not a covered benefit.

None

D7298

Removal of temporary anchorage device [screw retained plate], requiring flap

Not a covered benefit.

Not a covered benefit.

None

D7299

Removal of temporary anchorage device, requiring flap

Not a covered benefit.

Not a covered benefit.

None

D7300

Removal of temporary anchorage device without flap

Not a covered benefit.

Not a covered benefit.

None

D7310

Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant

Once per quadrant per lifetime.

Once per quadrant per lifetime.

Quadrant Identification

Detailed narrative or progress notes

Pre-operative radiographs

D7311

Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

Once per quadrant per lifetime.

Once per quadrant per lifetime.

Quadrant Identification

Tooth spaces identification

Detailed narrative or progress notes

Pre-operative radiographs

D7320

Alveoloplasty not in conjunction with extractions –four or more teeth or tooth spaces, per quadrant

Once per quadrant per lifetime.

Once per quadrant per lifetime.

Quadrant Identification

Detailed narrative or progress notes

Pre-operative radiographs

D7321

Alveoloplasty, not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

Once per quadrant per lifetime.

Once per quadrant per lifetime.

Quadrant Identification

Tooth spaces identification

Detailed narrative or progress notes

Pre-operative radiographs

D7340

Vestibuloplasty – ridge extension (secondary epithelialization)

Individual consideration. Services must be rendered by an oral surgeon for benefit coverage.

Individual consideration. Services must be rendered by an oral surgeon for benefit coverage.

Arch identification

D7350

Vestibuloplasty – ridge extension (incl. soft tissue grafts, muscle re-attachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)

Individual consideration. Services must be rendered by an oral surgeon for benefit coverage.

Individual consideration. Services must be rendered by an oral surgeon for benefit coverage.

Arch identification

D7410

Excision of benign lesion, up to 1.25 cm

Individual consideration.

Individual consideration.

Detailed narrative

D7411

Excision of benign lesion greater than 1.25 cm

Individual consideration.

Individual consideration.

Detailed narrative

D7412

Excision of benign lesion, complicated

Not a covered benefit.

Individual consideration.

Pathology report

D7413

Excision of malignant lesion up to 1.25 cm

Not a covered benefit.

Individual consideration.

Pathology report

D7414

Excision of malignant lesion greater than 1.25 cm

Not a covered benefit.

Individual consideration.

Pathology report

D7415

Excision of malignant lesion, complicated

Not a covered benefit.

Individual consideration.

None

D7440

Excision of malignant tumor – lesion diameter up to 1.25 cm

Not a covered benefit.

Individual consideration.

Pathology report

D7441

Excision of malignant tumor – lesion diameter greater than 1.25 cm

Not a covered benefit.

Individual consideration.

Pathology report

D7450

Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm

Individual consideration; services must be rendered by an oral surgeon for benefit coverage.

Individual consideration.

Pathology report

D7451

Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm

Individual consideration; services must be rendered by an oral surgeon for benefit coverage.

Individual consideration.

Pathology report

D7460

Removal of benign nonodontogenic cyst or tumor – lesion diameter up to 1.25 cm

Individual consideration; services must be rendered by an oral surgeon for benefit coverage.

Individual consideration.

Pathology report

D7461

Removal of benign nonodontogenic cyst or tumor– lesion diameter greater than 1.25 cm

Individual consideration; services must be rendered by an oral surgeon for benefit coverage.

Individual consideration.

Pathology report

D7465

Destruction of lesion(s) by physical or chemical methods, by report

Not a covered benefit.

Individual consideration.

Pathology report

D7471

Removal of lateral exostosis (maxilla or mandible)

Individual consideration. Services must be rendered by an oral surgeon for benefit coverage.

Once per arch per lifetime.

Arch identification

D7472

Removal of torus palatinus

Not a covered benefit.

Once per arch per lifetime

Arch identification

D7473

Removal of torus mandibularis

Not a covered benefit.

Once per quadrant per lifetime.

Quadrant identification

D7485

Surgical reduction of osseous tuberosity

Not a covered benefit.

Once per upper quadrant per lifetime.

Quadrant identification

D7490

Radical resection of maxilla or mandible

Not a covered benefit.

Not a covered benefit.

None

D7509

Marsupialization of odontogenic cyst

Not a covered benefit.

Individual consideration.

Tooth identification

Detailed narrative or operative report

D7510

Incision and drainage of abscess – intraoral soft tissue

Not a covered benefit.

Individual consideration.

Tooth identification

Detailed narrative

D7511

Incision and drainage of abscess – intraoral soft tissue, complicated (includes drainage of multiple fascial spaces)

Not a covered benefit.

Individual consideration.

Tooth identification

Detailed narrative

D7520

Incision and drainage of abscess – extraoral soft tissue

Not a covered benefit.

Individual consideration.

Detailed narrative

D7521

Incision and drainage of abscess – extraoral soft tissue, complicated (includes drainage of multiple fascial spaces)

Not a covered benefit.

Individual consideration.

Detailed narrative

D7530

Removal of foreign body, mucosa, skin, or subcutaneous alveolar tissue

Not a covered benefit.

Individual consideration.

Pathology report

Operative report

D7540

Removal of reaction-producing foreign bodies, musculoskeletal system

Not a covered benefit.

Individual consideration.

Pathology report

Operative report

D7550

Partial ostectomy/ sequestrectomy for removal of non-vital bone

Not a covered benefit.

Individual consideration.

Pathology report

Operative report

D7560

Maxillary sinusotomy for removal of tooth fragment or foreign body

Not a covered benefit.

Individual consideration.

Operative report

D7610

Maxilla – open reduction (teeth immobilized, if present)

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

D7620

Maxilla – closed reduction (teeth immobilized, if present)

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

D7630

Mandible – open reduction (teeth immobilized, if present)

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

D7640

Mandible – closed reduction (teeth immobilized, if present)

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

D7650

Malar and/or zygomatic arch – open reduction

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

D7660

Malar and/or zygomatic arch – closed reduction

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

D7670

Alveolus – closed reduction, may include stabilization of teeth

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

Arch identification

D7671

Alveolus – open reduction, may include stabilization of teeth

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

Arch identification

D7680

Facial bones – complicated reduction with fixation and multiple surgical approaches

Not a covered benefit.

Individual consideration.

Panoramic radiograph

Operative report

D7710

Maxilla – open reduction, stabilization of teeth

Not a covered benefit.

Individual consideration.

None

D7720

Maxilla – closed reduction

Not a covered benefit.

Individual consideration.

None

D7730

Mandible – open reduction

Not a covered benefit.

Individual consideration.

None

D7740

Mandible – closed reduction

Not a covered benefit.

Individual consideration.

None

D7750

Malar and/or zygomatic arch – open reduction

Not a covered benefit.

Individual consideration.

None

D7760

Malar and/or zygomatic arch – closed reduction

Not a covered benefit.

Individual consideration.

None

D7770

Alveolus – open reduction stabilization of teeth

Not a covered benefit.

Individual consideration.

None

D7771

Alveolus – closed reduction, stabilization of teeth

Not a covered benefit.

Individual consideration.

None

D7780

Facial bones – complicated reduction with fixation and multiple surgical approaches

Not a covered benefit.

Individual consideration.

None

D7810

Open reduction of dislocation

Not a covered benefit.

Not a covered benefit.

None

D7820

Closed reduction of dislocation

Not a covered benefit.

Not a covered benefit.

None

D7830

Manipulation under anesthesia

Not a covered benefit.

Not a covered benefit.

None

D7840

Condylectomy

Not a covered benefit.

Not a covered benefit.

None

D7850

Surgical disectomy; with or without implant

Not a covered benefit.

Not a covered benefit.

None

D7852

Disc repair

Not a covered benefit.

Not a covered benefit.

None

D7854

Synovectomy

Not a covered benefit.

Not a covered benefit.

None

D7856

Myotomy

Not a covered benefit.

Not a covered benefit.

None

D7858

Joint reconstruction

Not a covered benefit.

Not a covered benefit.

None

D7860

Arthrotomy

Not a covered benefit.

Not a covered benefit.

None

D7865

Arthroplasty

Not a covered benefit.

Not a covered benefit.

None

D7870

Arthrocentesis

Not a covered benefit.

Not a covered benefit.

None

D7871

Non-anthroscopic lysis and lavage

Not a covered benefit.

Not a covered benefit.

None

D7872

Arthroscopy – diagnosis, with or without biopsy

Not a covered benefit.

Not a covered benefit.

None

D7873

Arthroscopy – surgical, lavage and lysis of adhesions

Not a covered benefit.

Not a covered benefit.

None

D7874

Arthroscopy – surgical, disc repositioning and stabilization

Not a covered benefit.

Not a covered benefit.

None

D7875

Arthroscopy – surgical, synovectomy

Not a covered benefit.

Not a covered benefit.

None

D7876

Arthroscopy – surgical, disectomy

Not a covered benefit.

Not a covered benefit.

None

D7877

Arthroscopy – surgical, debridement

Not a covered benefit.

Not a covered benefit.

None

D7880

Occlusal orthotic device, by report

Not a covered benefit.

Not a covered benefit.

None

D7881

Occlusal orthotic device adjustment

Not a covered benefit.

Not a covered benefit.

None

D7899

Unspecified TMD therapy, by report

Not a covered benefit.

Not a covered benefit.

None

D7910

Suture of recent small wounds up to 5 cm

Not a covered benefit.

Not a covered benefit.

None

D7911

Complicated suture – up to 5 cm

Not a covered benefit.

Not a covered benefit.

None

D7912

Complicated suture – greater than 5 cm

Not a covered benefit.

Not a covered benefit.

None

D7920

Skin grafts (identify defect covered, location, and type of graft)

Not a covered benefit.

Not a covered benefit.

None

D7921

Collection and application of autologous blood concentrate product

Not a covered benefit.

Not a covered benefit.

None

D7922

Placement on intra-socket biological dressing to aid in hemostasis or clot stabilization, per site

Not a covered benefit.

Not a covered benefit.

None

D7940

Osteoplasty – for orthognathic deformities

Not a covered benefit.

Not a covered benefit.

None

D7941

Osteotomy – mandibular rami

Not a covered benefit.

Not a covered benefit.

None

D7943

Osteotomy – mandibular rami with bone graft; includes obtaining the graft

Not a covered benefit.

Not a covered benefit.

None

D7944

Osteotomy – segmented or sub-apical, per sextant or quadrant

Not a covered benefit.

Not a covered benefit.

None

D7945

Osteotomy – body of mandible

Not a covered benefit.

Not a covered benefit.

None

D7946

LeFort I (maxilla – total)

Not a covered benefit.

Not a covered benefit.

None

D7947

LeFort I (maxilla – segmented)

Not a covered benefit.

Not a covered benefit.

None

D7948

LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) – without bone graft

Not a covered benefit.

Not a covered benefit.

None

D7949

LeFort II or LeFort II – with bone graft

Not a covered benefit.

Not a covered benefit.

None

D7950

Osseous, osteoperiosteal, or cartilage graft of the mandible or facial bones, autogenous or nonautogenous, by report

Not a covered benefit.

Not a covered benefit.

None

D7951

Sinus augmentation with bone or bone substitutes via a lateral open approach

Not a covered benefit.

Not a covered benefit.

None

D7952

Sinus augmentation via a vertical approach

Not a covered benefit.

Not a covered benefit.

None

D7953

Bone replacement graft for ridge preservation – per site

Not a covered benefit.

Not a covered benefit.

None

D7955

Repair of maxillofacial soft and/or hard tissue defect

Not a covered benefit.

Not a covered benefit.

None

D7961

Buccal/labial frenectomy (frenulectomy)

D7961, D7962 or D7963 covered once per site per lifetime. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

D7961 or D7962 covered once per site per lifetime. Covered for members 6 years and older. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

Tooth identification

Detailed narrative

D7962

Lingual frenectomy (frenulectomy)

D7961, D7962 or D7963 covered once per site per lifetime. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

D7961 or D7962 covered once per site per lifetime. Covered for members 6 years and older. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

Tooth identification

Detailed narrative

D7963

Frenuloplasty

D7961, D7962 or D7963 covered once per site per lifetime. Not allowed when performed in conjunction with soft tissue graft; same site and same date of service.

Individual consideration.

Tooth identification

Detailed narrative

D7970

Excision of hyperplastic tissue – per arch

Not payable on the same date of service as an extraction in the same area.

Individual consideration.

Arch identification

D7971

Excision of pericoronal gingiva

Not a covered benefit.

Once per upper quadrant per lifetime.

None

D7972

Surgical reduction of fibrous tuberosity

Not a covered benefit.

Once per upper quadrant per lifetime.

None

D7979

Non-surgical sailolithotomy

Not a covered benefit.

Not a covered benefit.

None

D7980

Sialolithotomy

Not a covered benefit.

Individual consideration.

Detailed narrative

D7981

Excision of salivary gland, by report

Not a covered benefit.

Individual consideration.

Detailed narrative

D7982

Sialodochoplasty

Not a covered benefit.

Individual consideration.

Detailed narrative

D7983

Closure of salivary fistula

Not a covered benefit.

Individual consideration.

Detailed narrative

D7990

Emergency tracheotomy

Not a covered benefit.

Not a covered benefit.

None

D7991

Coronoidectomy

Not a covered benefit.

Not a covered benefit.

None

D7993

Surgical placement of craniofacial implant – extra oral

Not a covered benefit.

Not a covered benefit.

None

D7994

Surgical placement: zygomatic implant

Not a covered benefit.

Not a covered benefit.

None

D7995

Synthetic graft – mandible or facial bones, by report

Not a covered benefit.

Not a covered benefit.

None

D7996

Implant – mandible for aumentation purposes (excluding alveolar ridge), by report

Not a covered benefit.

Not a covered benefit.

None

D7997

Appliance removal (not by dentist who placed appliance), includes removal of archbar

Not a covered benefit.

Individual consideration.

Detailed narrative

D7998

Intraoral placement of a fixation device not in conjunction with a fracture

Not a covered benefit.

Not a covered benefit.

None

D7999

Unspecified oral surgery procedure, by report

Individual consideration.

Individual consideration.

Tooth identification

Detailed narrative
Operative report

D8010

Limited orthodontic treatment of the primary dentition

Once per child per lifetime; services must be provided by an orthodontist.

Not a covered benefit.

Prior authorization

D8020

Limited orthodontic treatment of the transitional dentition

Once per child per lifetime; services must be provided by an orthodontist.

Not a covered benefit.

Prior authorization

D8030

Limited orthodontic treatment of the adolescent dentition

Not a covered benefit.

Not a covered benefit.

None

D8040

Limited orthodontic treatment of the adult dentition

Not a covered benefit.

Not a covered benefit.

None

D8070

Comprehensive orthodontic treatment of transitional dentition

Not a covered benefit.

Not a covered benefit.

None

D8080

Comprehensive orthodontic treatment of adolescent dentition

Once per child per lifetime; services must be provided by an orthodontist.

Not a covered benefit.

Prior authorization.

D8090

Comprehensive orthodontic treatment of the adult dentition

Not a covered benefit.

Not a covered benefit.

None

D8210

Removable appliance therapy

Not a covered benefit.

Not a covered benefit.

None

D8220

Fixed appliance therapy

Not a covered benefit.

Not a covered benefit.

None

D8660

Pre-orthodontic treatment examination to monitor growth and development

Use for orthodontic work-up. Services must be rendered by orthodontist. Covered when prior auth for codes D8010, D8020 and D8080 is denied. Not covered and considered inclusive of D8010, D8020 and D8080 when prior auth for orthodontics is approved. 

Not a covered benefit.

None

D8670

Periodic orthodontic treatment visit

Included in the allowance for the comprehensive treatment.  Also covered for previously approved EHB take-over cases.

Not a covered benefit.

None

D8680

Orthodontic retention (removal of appliances, construction and placement of retainer(s)

Included in the allowance for the comprehensive treatment.

Not a covered benefit.

None

D8681

Removable orthodontic retainer adjustment

Not a covered benefit.

Not a covered benefit.

None

D8696

Repair of orthodontic appliance  – maxillary

Not a covered benefit.

Not a covered benefit.

None

D8697

Repair of orthodontic appliance  – mandibular

Not a covered benefit.

Not a covered benefit.

None

D8698

Re-cement or re-bond fixed retainer – maxillary

Not a covered benefit.

Not a covered benefit.

None

D8699

Re-cement or re-bond retainer – mandibular

Not a covered benefit.

Not a covered benefit.

None

D8701

Repair of fixed retainer, includes reattachment – maxillary

Not a covered benefit.

Not a covered benefit.

None

D8702

Repair of fixed retainer, includes reattachment – mandibular

Not a covered benefit.

Not a covered benefit.

None

D8703

Replacement of lost or broken retainer – maxillary

Individual consideration.

Not a covered benefit.

Prior authorization

Detailed narrative

D8704

Replacement of lost or broken retainer – mandibular

Individual consideration.

Not a covered benefit.

Prior authorization

Detailed narrative