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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