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: Due to customization, 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 Billing Guidelines & Resources for information about our policies and procedures.
CDT Code | ADA Category | Description of Service | Procedure Guidelines | Submission requirements for BCBSMA-participating providers | Submission requirements for out-of-state & non-par providers |
---|---|---|---|---|---|
Diagnostic |
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 |
Diagnostic |
Limited oral evaluation – problem-focused |
Covered service For specific ACA-compliant small group plans only: Two per calendar year. 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 |
D0145 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Screening of a patient |
Not a covered benefit. |
None |
None |
D0191 |
Diagnostic |
Assessment of a patient |
Not a covered benefit. |
None |
None |
D0210 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Intraoral – occlusal radiographic image |
One film per 6 months per arch. |
Arch identification |
Arch identification |
D0250 |
Diagnostic |
Extra-oral – 2D projection radiographic image created using a stationary radiations source, and detector. |
Not a covered benefit. |
None |
None |
D0251 |
Diagnostic |
Extra-oral posterior dental radiographic image |
Not a covered benefit. |
None |
None |
D0270 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Vertical bitewings – 7 to 8 radiographic images |
One set per 12 month for members age 16+ and no more than two of any bitewings per calendar year (D0270, D0271, D0273, D0274, D0277) For specific ACA-compliant small group plans only: Members age 16+: One set per 12 months. For certain Dental Blue 65 & Medicare Advantage plans with Comprehensive Dental Coverage: |
None |
None |
D0310 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Tomographic survey |
Not a covered benefit. |
None |
None |
D0330 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Cone beam CT capture and interpretation with limited field of view-less than one whole jaw |
Not a covered benefit. |
None |
None |
D0365 |
Diagnostic |
Cone beam CT capture and interpretation with limited field of one full dental arch – mandible |
Not a covered benefit. |
None |
None |
D0366 |
Diagnostic |
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 |
Diagnostic |
Cone beam CT capture and interpretation with field of view of both jaws; with or without cranium |
Not a covered benefit. |
None |
None |
D0368 |
Diagnostic |
Cone beam CT capture and interpretation for TMJ series including two or more exposures |
Not a covered benefit. |
None |
None |
D0369 |
Diagnostic |
Maxillofacial MRI capture and interpretation |
Not a covered benefit. |
None |
None |
D0370 |
Diagnostic |
Maxillofacial ultrasound capture and interpretation |
Not a covered benefit. |
None |
None |
D0371 |
Diagnostic |
Sialoendoscopy capture and interpretation |
Not a covered benefit. |
None |
None |
D0372 |
Diagnostic |
Intraoral tomosynthesis comprehensive series of radiographic images |
Not a covered benefit. |
None |
None |
D0373 |
Diagnostic |
Intraoral tomosynthesis – bitewing radiographic image |
Not a covered benefit. |
None |
None |
D0374 |
Diagnostic |
Intraoral tomosynthesis – periapical radiographic image |
Not a covered benefit. |
None |
None |
D0801 |
Diagnostic |
3D dental surface scan – direct |
Not a covered benefit. |
None |
None |
D0802 |
Diagnostic |
3D dental surface scan – indirect |
Not a covered benefit. |
None |
None |
D0803 |
Diagnostic |
3D facial surface scan – direct |
Not a covered benefit. |
None |
None |
D0804 |
Diagnostic |
3D facial surface scan – indirect |
Not a covered benefit. |
None |
None |
D0380 |
Diagnostic |
Cone beam CT image capture with limited field of view – less than one whole jaw |
Not a covered benefit. |
None |
None |
D0381 |
Diagnostic |
Cone beam CT image capture with field of view of one full dental arch –mandible |
Not a covered benefit. |
None |
None |
D0382 |
Diagnostic |
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 |
Diagnostic |
Cone beam CT image capture with field of view of both jaws, with or without cranium |
Not a covered benefit. |
None |
None |
D0384 |
Diagnostic |
Cone beam CT image capture for TMJ series including two or more exposures |
Not a covered benefit. |
None |
None |
D0385 |
Diagnostic |
Maxillofacial MRI image capture |
Not a covered benefit. |
None |
None |
D0386 |
Diagnostic |
Maxillofacial ultrasound image capture |
Not a covered benefit. |
None |
None |
D0387 |
Diagnostic |
Intraoral tomosynthesis – comprehensive series of radiographic images – image capture only |
Not a covered benefit. |
None |
None |
D0388 |
Diagnostic |
Intraoral tomosynthesis – bitewing radiographic image – image capture only |
Not a covered benefit. |
None |
None |
D0389 |
Diagnostic |
Intraoral tomosynthesis – periapical radiographic image – image capture only |
Not a covered benefit. |
None |
None |
D0701 |
Diagnostic |
Panoramic radiographic image – image capture only |
Not a covered benefit. |
None |
None |
D0702 |
Diagnostic |
2-D cephalometric radiographic image – image capture only |
Not a covered benefit. |
None |
None |
D0703 |
Diagnostic |
2-D oral/facial photographic image obtained intra-orally or extra-orally– image capture only |
Not a covered benefit. |
None |
None |
D0705 |
Diagnostic |
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 |
Diagnostic |
Intraoral – occlusal radiographic image – image capture only |
Not a covered benefit. |
None |
None |
D0707 |
Diagnostic |
Intraoral – periapical radiographic image – image capture only |
Not a covered benefit. |
None |
None |
D0708 |
Diagnostic |
Intraoral – bitewing radiographic image – image capture only. Image axis may be horizonal or vertical |
Not a covered benefit. |
None |
None |
D0709 |
Diagnostic |
Intraoral – comprehensive series of radiographic images – image capture only. |
Not a covered benefit. |
None |
None |
D0391 |
Diagnostic |
Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report |
Not a covered benefit. |
None |
None |
D0393 |
Diagnostic |
Virtual treatment simulation using 3D image volume or surface scan. |
Not a covered benefit. |
None |
None |
D0394 |
Diagnostic |
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 |
Diagnostic |
Fusion of two or more 3D image volumes of one or more modalities. |
Not a covered benefit. |
None |
None |
|
D0396 |
Diagnostic |
3D printing of a 3D dental surface scan |
Not a covered benefit. |
None |
None |
D0411 |
Diagnostic |
HbA1c in-office point of service testing |
Not a covered benefit. |
None |
None |
D0412 |
Diagnostic |
Blood glucose level test — in-office using a glucose meter |
Not a covered benefit. |
None |
None |
D0415 |
Diagnostic |
Collection of microorganisms for culture and sensitivity |
Not a covered benefit. |
None |
None |
D0414 |
Diagnostic |
Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report |
Not a covered benefit. |
None |
None |
D0416 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Assessment of salivary flow by measurement |
Not a covered benefit. |
None |
None |
D0422 |
Diagnostic |
Collection and preparation of genetic sample material for laboratory analysis and report |
Not a covered benefit. |
None |
None |
D0423 |
Diagnostic |
Genetic test for susceptibility to diseases – specimen analysis |
Not a covered benefit. |
None |
None |
D0425 |
Diagnostic |
Caries susceptibility tests. Not to be used for carious dentin staining |
Not a covered benefit |
None |
None |
D0431 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic casts |
One complete set per 60 months. |
None |
None |
D0472 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Caries risk assessment and documentation, with a finding of low risk |
Not a covered benefit. |
None |
None |
D0602 |
Diagnostic |
Caries risk assessment and documentation, with a finding of moderate risk |
Not a covered benefit. |
None |
None |
D0603 |
Diagnostic |
Caries risk assessment and documentation, with a finding of high risk |
Not a covered benefit. |
None |
None |
D0604 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Preventive |
Prophylaxis - adult |
Two per calendar year. There must be at least three months between a periodontal maintenance cleaning and any other cleanings. D1110 and D4346 are considered inclusive of D4341 and D4342 when performed on the same day. 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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
|
D1301 |
Preventive |
Immunization counseling |
Not a covered benefit. |
None |
None |
D1310 |
Preventive |
Nutritional counseling for control of dental disease |
Not a covered benefit. |
None |
None |
D1320 |
Preventive |
Tobacco counseling for control and prevention of oral disease |
Not a covered benefit. |
None |
None |
D1321 |
Preventive |
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 |
Preventive |
Oral hygiene instructions |
Not a covered benefit. |
None |
None |
D1351 |
Preventive |
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 and permanent molars. Reapplication only if process fails within three years. Age 9 to 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 |
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 |
Preventive |
Sealant repair – per tooth |
Not a covered benefit. |
None |
None |
D1354 |
Preventive |
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 |
Preventive |
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 |
Preventive |
Space maintainer – fixed, unilateral – per quadrant |
One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday). Note: Passive appliances are designed to prevent tooth movement. |
Quadrant identification |
Quadrant identification |
D1516 |
Preventive |
Space maintainer – fixed – bilateral, maxillary |
One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday). Note: Passive appliances are designed to prevent tooth movement. |
Arch identification |
Arch identification |
D1517 |
Preventive |
Space maintainer – fixed – bilateral, mandibular |
One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday). Note: Passive appliances are designed to prevent tooth movement. |
Arch identification |
Arch identification |
D1520 |
Preventive |
Space maintainer – removable, unilateral – per quadrant |
One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday). Note: Passive appliances are designed to prevent tooth movement. |
Quadrant identification |
Quadrant identification |
D1526 |
Preventive |
Space maintainer – removable –bilateral, maxillary |
One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday). Note: Passive appliances are designed to prevent tooth movement. |
Arch identification |
Arch identification |
D1527 |
Preventive |
Space maintainer – removable – bilateral, mandibular |
One per arch or quadrant per lifetime for members through age 18 (up to the 19th birthday). Note: Passive appliances are designed to prevent tooth movement. |
Arch identification |
Arch identification |
D1551 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
Distal shoe space maintainer – fixed unilateral, per quadrant |
One per quadrant per lifetime for members through age 18 (up to the 19th birthday). Note: Passive appliances are designed to prevent tooth movement. |
Quadrant identification |
Quadrant identification |
D1701 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
D1999 |
Preventive |
Unspecified preventive procedure, by report |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Detailed narrative |
Detailed narrative |
D2140 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
Resin-based composite – four or more 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 |
D2390 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
|
Tooth identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D2712 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
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:
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 |
Restorative |
Interim crown – further treatment or completion of diagnosis necessary prior to final impression |
Not a covered benefit. |
None |
None |
D2910 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
Reattachment of tooth fragment, incisal edge or cusp |
Not a covered benefit. |
None |
None |
D2928 |
Restorative |
Prefabricated porcelain/ceramic crown – permanent tooth |
Not a covered benefit. |
None |
None |
D2929 |
Restorative |
Prefabricated porcelain/ceramic crown – primary tooth |
One per primary tooth per 24 months as an alternate benefit to D2932. |
Tooth identification |
Tooth identification |
D2930 |
Restorative |
Prefabricated stainless steel crown – primary tooth |
One per primary tooth per 24 months. |
Tooth identification |
Tooth identification |
D2931 |
Restorative |
Prefabricated stainless steel crown – permanent tooth |
One per tooth per 24 months for members through age 15 (up to the 16th birthday). Limited to permanent posterior teeth (#2-5, 12-15, 18-21 and 28-31. |
Tooth identification |
Tooth identification |
D2932 |
Restorative |
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 |
Restorative |
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 |
Restorative |
Prefabricated esthetic coated stainless steel crown – primary tooth |
One per primary tooth per 24 months. |
Tooth identification |
Tooth identification |
D2940 |
Restorative |
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 |
Restorative |
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 |
Restorative foundation for an indirect restoration |
Not a covered benefit. |
Tooth identification |
Tooth identification |
D2950 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
Post removal |
Not a covered benefit. |
None |
None |
D2957 |
Restorative |
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 |
Restorative |
Labial veneer (resin laminate) – direct |
Not a covered benefit. |
Tooth identification |
Tooth identification Detailed narrative Current mounted and dated pre-operative periapical radiographs |
D2961 |
Restorative |
Labial veneer (resin laminate) – indirect |
Not a covered benefit. |
Tooth identification |
Tooth identification Detailed narrative Current mounted and dated pre-operative periapical radiographs |
D2962 |
Restorative |
Labial veneer (porcelain laminate) – indirect |
Not a covered benefit. |
Tooth identification |
Tooth identification Detailed narrative Current mounted and dated pre-operative periapical radiographs |
D2971 |
Restorative |
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 |
Restorative |
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 |
|
D2976 |
Restorative |
Band stabilization – per tooth |
Not a covered benefit. |
None |
None |
D2980 |
Restorative |
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 |
Restorative |
Inlay repair necessitated by restorative material failure |
One per tooth per 12 months. |
Tooth identification |
Tooth identification |
D2982 |
Restorative |
Onlay repair necessitated by restorative material failure |
One per tooth per 12 months. |
Tooth identification |
Tooth identification |
Restorative |
Veneer repair necessitated by restorative material failure |
Not a covered benefit. |
None |
None |
|
D2989 |
Restorative |
Excavation of a tooth resulting in the determination of non-restorability |
Not a covered benefit. |
None |
None |
D2990 |
Restorative |
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) |
D2991 |
Restorative |
Application of hydroxyapatite regeneration medicament – per tooth |
Either D1354 or D2991 covered once per tooth per lifetime For specific ACA-compliant small group plans only: Not a covered benefit. |
Tooth identification |
Tooth identification |
D2999 |
Restorative |
Unspecified restorative procedure, by report |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D3110 |
Endodontics |
Pulp cap – direct (excluding final restoration) |
A separate allowance is not made. Pulp capping is considered part of the final restoration. |
Tooth identification |
Tooth identification |
D3120 |
Endodontics |
Pulp cap – indirect (excluding final restoration) |
A separate allowance is not made. Pulp capping is considered part of the final restoration. |
Tooth identification |
Tooth identification |
D3220 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) |
One per tooth per lifetime. |
Tooth identification |
Tooth identification |
D3240 |
Endodontics |
Pulpal therapy (resorbable filling) – posterior primary tooth (excluding final restoration) |
One per tooth per lifetime. |
Tooth identification |
Tooth identification |
D3310 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
Treatment of root canal obstruction; non-surgical access |
Individual consideration. Note: includes treatment plan, clinical procedures and follow up care. |
Tooth identification Detailed narrative Current dated pre- and post-operative periapical radiographs |
Tooth identification Detailed narrative Current dated pre- and post-operative periapical radiographs |
D3332 |
Endodontics |
Incomplete endodontic therapy; inoperable, unrestorable, or fractured tooth |
Not a covered benefit. |
None |
None |
D3333 |
Endodontics |
Internal root repair of perforation defects |
Not a covered benefit. |
None |
None |
D3346 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
Apexification/recalcification – interim medication replacement |
One per permanent tooth per lifetime. |
Tooth identification |
Tooth identification |
D3353 |
Endodontics |
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 |
Endodontics |
Pulpal regeneration – initial visit |
One per permanent tooth per lifetime. |
Tooth identification |
Tooth identification |
D3356 |
Endodontics |
Pulpal regeneration – interim medication replacement |
One per permanent tooth per lifetime. |
Tooth identification |
Tooth identification |
D3357 |
Endodontics |
Pulpal regeneration – completion of treatment |
One per permanent tooth per lifetime. |
Tooth identification |
Tooth identification |
D3410 |
Endodontics |
Apicoectomy – anterior |
One per tooth root per lifetime. |
Tooth & root identification |
Tooth & root identification |
D3421 |
Endodontics |
Apicoectomy – premolar (first root) |
One per tooth root per lifetime. |
Tooth & root identification |
Tooth & root identification |
D3425 |
Endodontics |
Apicoectomy – molar (first root) |
One per tooth root per lifetime. |
Tooth & root identification |
Tooth & root identification |
D3426 |
Endodontics |
Apicoectomy – (each additional root) |
One per tooth root per lifetime. |
Tooth & root identification |
Tooth & root identification |
D3428 |
Endodontics |
Bone graft in conjunction with periradicular surgery – per tooth, single site |
Not a covered benefit. |
None |
None |
D3429 |
Endodontics |
Bone graft in conjunction with periradicular surgery – each additional contiguous in the same surgical site |
Not a covered benefit. |
None |
None |
D3430 |
Endodontics |
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 |
Endodontics |
Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery |
Not a covered benefit. |
None |
None |
D3432 |
Endodontics |
Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery |
Not a covered benefit. |
None |
None |
D3450 |
Endodontics |
Root amputation – per root |
One per tooth per lifetime for multi-rooted posterior teeth. |
Tooth identification |
Tooth identification |
D3460 |
Endodontics |
Endodontic endosseous implant |
Not a covered benefit. |
None |
None |
D3470 |
Endodontics |
Intentional reimplantation (including necessary splinting) |
Individual consideration. |
Tooth identification Detailed narrative |
Tooth identification Detailed narrative |
D3471 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
Surgical repair of root surface without apicoectomy or repair of root resorption – anterior |
Not a covered benefit. |
None |
None |
D3502 |
Endodontics |
Surgical repair of root surface without apicoectomy or repair of root resorption – premolar |
Not a covered benefit. |
None |
None |
D3503 |
Endodontics |
Surgical repair of root surface without apicoectomy or repair of root resorption – molar |
Not a covered benefit. |
None |
None |
D3910 |
Endodontics |
Surgical procedure for isolation of tooth with rubber dam |
Not a covered benefit. |
None |
None |
D3911 |
Endodontics |
Intraorifice barrier |
Not a covered benefit. |
None |
None |
D3920 |
Endodontics |
Hemisection (including any root removal), not including root canal therapy |
One per posterior tooth per lifetime. |
Tooth identification |
Tooth identification |
D3921 |
Endodontics |
Decoronation or submergence of an erupted tooth |
One per tooth per lifetime (D3921 or D7251). |
Tooth identification |
Tooth identification |
D3950 |
Endodontics |
Canal preparation and fitting of preformed dowel or post |
Not a covered benefit. |
None |
None |
D3999 |
Endodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
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 |
Periodontics |
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. |
Tooth identification |
Tooth identification Current mounted and dated preoperative periapical radiographs. |
D4230 |
Periodontics |
Anatomical crown exposure – four or more contiguous teeth or tooth bounded spaces per quadrant |
Not a covered benefit. |
None |
None |
D4231 |
Periodontics |
Anatomical crown exposure – one to three teeth or tooth bounded spaces per quadrant |
Not a covered benefit. |
None |
None |
D4240 |
Periodontics |
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 |
Periodontics |
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 |
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 |
Periodontics |
Apically repositioned flap |
Not a covered benefit. |
None |
None |
D4249 |
Periodontics |
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 |
Periodontics |
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 radio-graphs is not available, submit current (within last year) bitewing and/or periapical radiographs of the treated area Pre-treatment recommended |
D4261 |
Periodontics |
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 |
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 radio-graphs of the treated area Pre-treatment recommended |
D4263 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
Biologic materials to aid in soft and osseous tissue regeneration, per site |
Not a covered benefit. |
None |
None |
D4266 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
Guided tissue regeneration, edentulous area – resorbable barrier, per site |
Not a covered benefit. |
None |
None |
D7957 |
Periodontics |
Guided tissue regeneration, edentulous area – non-resorbable barrier, per site |
Not a covered benefit. |
None |
None |
D4268 |
Periodontics |
Surgical revision procedure, per tooth |
Not a covered benefit. |
None |
None |
D4270 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Tooth identification Current dated post phase I periodontal charting Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D4275 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
Removal of non-resorbable barrier |
Considered inclusive of D4267, not a covered benefit in any other circumstance. |
Tooth identification |
Tooth identification |
D4322 |
Periodontics |
Splint – intra-coronal; natural teeth or prosthetic crowns |
Not a covered benefit |
None |
None |
D4323 |
Periodontics |
Splint – extra-coronal; natural teeth or prosthetic crowns |
Not a covered benefit |
None |
None |
D4341 |
Periodontics |
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 |
Periodontics |
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 |
Quadrant identification |
D4346 |
Periodontics |
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 |
Periodontics |
Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit |
Not a covered benefit. |
None |
None |
D4381 |
Periodontics |
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 2 teeth per quadrant with 5-6 mm pocket depths and bleeding on probing, subsequent to active and maintained non-surgical periodontal treatment. Should not be used to treat generalized disease. Not covered for treatment of periodontal abscess. |
Detailed narrative Tooth identification |
Detailed narrative Periodontal charting Tooth identification |
D4910 |
Periodontics |
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. D4910 is considered inclusive of D4341 and D4342 when performed on the same day. |
None |
None |
D4920 |
Periodontics |
Unscheduled dressing change (by person other than treating dentist or staff) |
Not a covered benefit. |
None |
None |
D4921 |
Periodontics |
Gingival irrigation with a medicinal agent – per quadrant |
Not a covered benefit. |
None |
None |
D4999 |
Periodontics |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
Immediate denture – maxillary |
One per arch per lifetime. Note: Includes routine post-delivery care. |
Arch identification |
Arch identification |
D5140 |
Prosthodontics (removable) |
Immediate denture – mandibular |
One per arch per lifetime. Note: Includes routine post-delivery care. |
Arch identification |
Arch identification |
D5211 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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. |
Arch identification |
Arch identification |
D5411 |
Prosthodontics (removable) |
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. |
Arch identification |
Arch identification |
D5421 |
Prosthodontics (removable) |
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. |
Arch identification |
Arch identification |
D5422 |
Prosthodontics (removable) |
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. |
Arch identification |
Arch identification |
D5511 |
Prosthodontics (removable) |
Repair broken complete denture base, mandibular |
One per arch per 12 months. |
Arch identification |
Arch identification |
D5512 |
Prosthodontics (removable) |
Repair broken complete denture base, maxillary |
One per arch per 12 months. |
Arch identification |
Arch identification |
D5520 |
Prosthodontics (removable) |
Replace missing or broken teeth – complete denture (each tooth) |
One per tooth per 12 months. |
Tooth identification |
Tooth identification |
D5611 |
Prosthodontics (removable) |
Repair resin partial denture base, mandibular |
One per arch per 12 months. |
Arch identification |
Arch identification |
D5612 |
Prosthodontics (removable) |
Repair resin partial denture base, maxillary |
One per arch per 12 months. |
Arch identification |
Arch identification |
D5621 |
Prosthodontics (removable) |
Repair cast partial framework, mandibular |
One per arch per 12 months. |
Arch identification |
Arch identification |
D5622 |
Prosthodontics (removable) |
Repair cast partial framework, maxillary |
One per arch per 12 months. |
Arch identification |
Arch identification |
D5630 |
Prosthodontics (removable) |
Repair or replace broken retentive clasping materials - per tooth |
One per tooth per 12 months. |
Tooth identification |
Tooth identification |
D5640 |
Prosthodontics (removable) |
Repair broken teeth – per tooth |
One per tooth per 12 months. |
Tooth identification |
Tooth identification |
D5650 |
Prosthodontics (removable) |
Add tooth to existing partial denture |
One per tooth per 12 months. |
Tooth identification |
Tooth identification |
D5660 |
Prosthodontics (removable) |
Add clasp to existing partial denture per tooth |
One per tooth per 12 months. |
Tooth identification |
Tooth identification |
D5670 |
Prosthodontics (removable) |
Replace all teeth and acrylic on cast metal framework (maxillary) |
One per arch per lifetime. |
Arch identification |
Arch identification |
D5671 |
Prosthodontics (removable) |
Replace all teeth and acrylic on cast metal framework (mandibular) |
One per arch per lifetime. |
Arch identification |
Arch identification |
D5710 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
Reline complete maxillary denture (direct) |
One per arch per 24 months. 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 |
Prosthodontics (removable) |
Reline complete mandibular denture (direct) |
One per arch per 24 months. 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 |
Prosthodontics (removable) |
Reline maxillary partial denture (direct) |
One per arch per 24 months. 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 |
Prosthodontics (removable) |
Reline mandibular partial denture (direct) |
One per arch per 24 months. 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 |
Prosthodontics (removable) |
Reline complete maxillary denture (indirect) |
One per arch per 36 months. 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 |
Prosthodontics (removable) |
Reline complete mandibular denture (indirect) |
One per arch per 36 months. 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 |
Prosthodontics (removable) |
Reline maxillary partial denture (indirect) |
One per arch per 36 months. 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 |
Prosthodontics (removable) |
Reline mandibular partial denture (indirect) |
One per arch per 36 months. 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 |
Prosthodontics (removable) |
Interim complete denture (maxillary) |
Not a covered benefit |
None |
None |
D5811 |
Prosthodontics (removable) |
Interim complete denture (mandibular) |
Not a covered benefit |
None |
None |
D5820 |
Prosthodontics (removable) |
Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary |
One per arch per lifetime. Temporary stay-plate covered when inserted immediately after extraction of anterior tooth 6-11 or loss of anterior tooth due to traumatic injury. |
Arch identification |
Arch identification |
D5821 |
Prosthodontics (removable) |
Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular |
One per arch per lifetime. Temporary stay-plate covered when inserted immediately after extraction of anterior tooth 22-27 or loss of anterior tooth due to traumatic injury. |
Arch identification |
Arch identification |
D5765 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
Tissue conditioning, maxillary |
One per arch per 36 months. Not covered if performed within 90 days after the delivery of a full or partial denture, rebase, or reline. |
Arch identification |
Arch identification |
D5851 |
Prosthodontics (removable) |
Tissue conditioning, mandibular |
One per arch per 36 months. Not covered if performed within 90 days after the delivery of a full or partial denture, rebase, or reline. |
Arch identification |
Arch identification |
D5862 |
Prosthodontics (removable) |
Precision attachment, by report |
Not a covered benefit. |
None |
None |
D5863 |
Prosthodontics (removable) |
Overdenture – complete maxillary |
One per 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 |
Prosthodontics (removable) |
Overdenture – partial maxillary |
One per 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 |
Prosthodontics (removable) |
Overdenture – complete mandibular |
One per 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 |
Prosthodontics (removable) |
Overdenture – partial mandibular |
One per 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 |
Prosthodontics (removable) |
Replacement of replaceable part of semi-precision or precision attachment, per attachment |
Not a covered benefit |
None |
None |
D5875 |
Prosthodontics (removable) |
Modification of removable prosthesis following implant surgery. Attachment assemblies are reported using separate codes |
Not a covered benefit. |
None |
None |
D5876 |
Prosthodontics (removable) |
Add metal substructure to acrylic full denture (per arch) |
Not a covered benefit. |
None |
None |
D5899 |
Prosthodontics (removable) |
Unspecified removable prosthodontic procedure, by report |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D5911 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial Prosthetics |
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 |
Maxillofacial Prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial Prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
|
D5952 |
Maxillofacial prosthetics |
Speech aid prosthesis, pediatric |
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 |
D5953 |
Maxillofacial prosthetics |
Speech aid prosthesis, adult |
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 |
D5954 |
Maxillofacial prosthetics |
Palatal augmentation 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 |
D5955 |
Maxillofacial prosthetics |
Palatal lift 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 |
D5958 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
Periodontal medicament carrier with peripheral seal – laboratory processed – maxillary |
Not a covered benefit |
None |
None |
D5996 |
Maxillofacial prosthetics |
Periodontal medicament carrier with peripheral seal – laboratory processed – mandibular |
Not a covered benefit |
None |
None |
D5999 |
Maxillofacial prosthetics |
Unspecified maxillofacial prosthesis, by report |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D6010 |
Implant |
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 |
Implant |
Surgical access to an implant body (Second stage implant surgery) |
One per tooth per 60 months for members age 16+. |
Tooth area identification |
Tooth area identification |
D6012 |
Implant |
Surgical placement of interim implant body for transitional prosthesis: endosteal implant |
Not a covered benefit. |
None |
None |
D6013 |
Implant |
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. |
Tooth area identification |
Tooth area identification Current dated pre-operative periapical radiograph |
D6040 |
Implant |
Surgical placement, eposteal implant |
Not a covered benefit. |
None |
None |
D6050 |
Implant |
Surgical placement, transosteal implant |
Not a covered benefit. |
None |
None |
D6051 |
Implant |
Interim implant abutment placement |
Not a covered benefit. |
None |
None |
D6055 |
Implant |
Connecting bar – implant supported or abutment supported |
Not a covered benefit. |
None |
None |
D6056 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
D6065 |
Implant |
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 |
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 |
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 |
D6068 |
Implant |
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. |
None |
None |
D6069 |
Implant |
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. |
None |
None |
D6070 |
Implant |
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. |
None |
None |
D6071 |
Implant |
Abutment-supported retainer for porcelain fused to metal FPD (noble metal) |
Not a covered benefit, either with or without a rider. |
None |
None |
D6072 |
Implant |
Abutment-supported retainer for cast metal FPD (high noble metal) |
Not a covered benefit, either with or without a rider. |
None |
None |
D6073 |
Implant |
Abutment-supported retainer for cast metal FPD (predominately base metal) |
Not a covered benefit, either with or without a rider. |
None |
None |
D6074 |
Implant |
Abutment-supported retainer for cast metal FPD (noble metal) |
Not a covered benefit, either with or without a rider. |
None |
None |
D6075 |
Implant |
Implant-supported retainer for ceramic FPD |
Not a covered benefit. |
None |
None |
D6076 |
Implant |
Implant-supported retainer for FPD-porcelain fused to high noble alloys |
Not a covered benefit. |
None |
None |
D6077 |
Implant |
Implant-supported retainer for metal FPD – high noble alloys |
Not a covered benefit. |
None |
None |
D6080 |
Implant |
Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments |
Not a covered benefit. |
None |
None |
D6082 | Implant | 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 |
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 |
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 |
D6085 |
Implant |
Interim implant crown |
Not a covered benefit. |
None |
None |
D6086 |
Implant |
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 |
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 |
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 |
D6089 |
Implant |
Accessing and retorquing loose implant screw – per screw |
One per tooth area per 12 months for members age 16+ |
Tooth identification |
Tooth identification |
D6090 |
Implant |
Repair implant supported prosthesis, by report |
One per arch per 6 months for members age 16 and older. |
Arch identification |
Arch identification Detailed narrative |
D6091 |
Implant |
Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment |
Not a covered benefit. |
None |
None |
D6092 |
Implant |
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 |
Implant |
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 |
D6094 |
Implant |
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 |
D6095 |
Implant |
Repair implant abutment, by report |
One per tooth per 6 months for members age 16 and older. |
Tooth area identification |
Tooth area identification |
D6096 |
Implant |
Remove broken implant retaining screw |
Covered under implant rider only. |
Tooth area identification |
Tooth area identification |
D6097 |
Implant |
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 |
D6098 |
Implant |
Implant supported retainer – porcelain fused to predominately base alloys |
Not a covered benefit. |
None |
None |
D6099 |
Implant |
Implant supported retainer for FPD – porcelain fused to noble alloys |
Not a covered benefit. |
None |
None |
D6100 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
Bone graft for repair of peri-implant defect – does not include flap entry and closure |
Not a covered benefit. |
None |
None |
D6104 |
Implant |
Bone graft at time of implant placement |
Not a covered benefit. |
None |
None |
D6105 |
Implant |
Removal of implant body not requiring bone removal or 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 |
Implant |
Guided tissue regeneration – resorbable barrier, per implant |
Not a covered benefit. |
None |
None |
D6107 |
Implant |
Guided tissue regeneration – non-resorbable barrier, per implant |
Not a covered benefit. |
None |
None |
D6110 |
Implant |
Implant/abutment supported removable denture for edentulous arch – maxillary |
Once per 60 months. |
Arch identification |
Arch identification |
D6111 |
Implant |
Implant/abutment supported removable denture for edentulous arch – mandibular |
Once per 60 months. |
Arch identification |
Arch identification |
D6112 |
Implant |
Implant/abutment supported removable denture for partially edentulous arch – maxillary |
Once per 60 months. |
Arch identification |
Arch identification |
D6113 |
Implant |
Implant /abutment supported removable denture for partially edentulous arch – mandibular |
Once per 60 months. |
Arch identification |
Arch identification |
D6114 |
Implant |
Implant/abutment supported fixed denture for edentulous arch – maxillary |
Not a covered benefit. |
None |
None |
D6115 |
Implant |
Implant/abutment supported fixed denture for edentulous arch – mandibular |
Not a covered benefit. |
None |
None |
D6116 |
Implant |
Implant /abutment supported fixed denture for partially edentulous arch – maxillary |
Not a covered benefit. |
None |
None |
D6117 |
Implant |
Implant /abutment supported fixed denture for partially edentulous arch – mandibular |
Not a covered benefit. |
None |
None |
D6118 |
Implant |
Implant/abutment supported interim fixed denture for edentulous arch – mandibular |
Not a covered benefit. |
None |
None |
D6119 |
Implant |
Implant/abutment supported interim fixed denture for edentulous arch – maxillary |
Not a covered benefit. |
None |
None |
D6120 |
Implant |
Implant supported retainer for FPD- porcelain fused to titanium and titanium alloys |
Not a covered benefit. |
None |
None |
D6121 |
Implant |
Implant supported retainer for metal FPD – predominately based alloys |
Not a covered benefit. |
None |
None |
D6122 |
Implant |
Implant supported retainer for metal FPD – noble alloys |
Not a covered benefit. |
None |
None |
D6123 |
Implant |
Implant supported retainer for metal FPD – titanium and titanium alloys |
Not a covered benefit. |
None |
None |
D6190 |
Implant |
Radiographic/surgical implant index, by report |
Not a covered benefit. |
None |
None |
D6191 |
Implant |
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 |
Implant |
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 |
D6194 |
Implant |
Abutment supported retainer crown for FPD – titanium and titanium alloys |
Not a covered benefit. |
None |
None |
D6195 |
Implant |
Abutment supported retainer – porcelain fused to titanium and titanium alloys |
Not a covered benefit. |
None |
None |
D6197 |
Implant |
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 |
D6198 |
Implant |
Remove interim implant component |
Not a covered benefit. |
None |
None |
D6199 |
Implant |
Unspecified implant procedure, by report |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D6205 |
Prosthodontics (fixed) |
Pontic – indirect resin-based composite |
Not a covered benefit. |
None |
None |
D6210 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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. |
Tooth identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6243 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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. |
Tooth identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6250 |
Prosthodontics (fixed) |
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. |
Tooth identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6251 |
Prosthodontics (fixed) |
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. |
Tooth identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6252 |
Prosthodontics (fixed) |
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. |
Tooth identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6253 |
Prosthodontics (fixed) |
Interim pontic – further treatment or completion of diagnosis necessary prior to final impression |
Not a covered benefit. |
None |
None |
D6545 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Retainer inlay –porcelain/ ceramic, two surfaces |
One per tooth per 60 months for members age 16+. |
Tooth identification Surface identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6601 |
Prosthodontics (fixed) |
Retainer inlay – porcelain/ ceramic, three or more surfaces |
One per tooth per 60 months for members age 16+. |
Tooth identification Surface identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6602 |
Prosthodontics (fixed) |
Retainer inlay – cast high noble, two surfaces |
One per tooth per 60 months for members age 16+. |
Tooth identification Surface identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6603 |
Prosthodontics (fixed) |
Retainer inlay – cast high noble metal, three or more surfaces |
One per tooth per 60 months for members age 16+. |
Tooth identification Surface identification |
Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended |
D6604 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Retainer 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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Retainer crown – indirect resin-based composite |
Not a covered benefit. |
None |
None |
D6720 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Retainer crown – porcelain fused to predominantly base metal |
One per tooth per 60 months. 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 |
D6752 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Interim retainer crown – further treatment or completion of diagnosis necessary prior to final impression |
Not a covered benefit. |
None |
None |
D6920 |
Prosthodontics (fixed) |
Connector bar |
Not a covered benefit. |
None |
None |
D6930 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Stress breaker |
Not a covered benefit. |
None |
None |
D6950 |
Prosthodontics (fixed) |
Precision attachment |
Not a covered benefit. |
None |
None |
D6980 |
Prosthodontics (fixed) |
Fixed partial denture repair necessitated by restorative material failure |
One repair per 12 months. |
Quadrant identification |
Quadrant identification |
D6985 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Unspecified fixed prosthodontic procedure, by report |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D7111 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Oroantral fistula closure |
Individual consideration. |
Periapical or panoramic radiograph Operative note Tooth identification |
Periapical or panoramic radiograph Operative note Tooth identification |
D7261 |
Oral & maxillofacial surgery |
Primary closure of a sinus perforation |
Individual consideration. |
Periapical or panoramic radiograph Operative note Tooth identification |
Periapical or panoramic radiograph Operative note Tooth identification |
D7270 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) |
Not a covered benefit. |
None |
None |
D7280 |
Oral & maxillofacial surgery |
Surgical access of unerupted tooth |
One per tooth per lifetime. |
Tooth identification |
Tooth identification |
D7282 |
Oral & maxillofacial surgery |
Mobilization of erupted or mal-positioned tooth to aid eruption |
One per tooth per lifetime. |
Tooth identification |
Tooth identification |
D7283 |
Oral & maxillofacial surgery |
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 |
D7284 |
Oral & maxillofacial surgery |
Excisional biopsy of minor salivary glands |
Individual consideration. |
Pathology report |
Pathology report |
D7285 |
Oral & maxillofacial surgery |
Incisional biopsy of oral tissue – hard (bone, tooth) |
Individual consideration. |
Pathology report |
Pathology report |
D7286 |
Oral & maxillofacial surgery |
Incisional biopsy of oral tissue – soft |
Individual consideration. |
Pathology report |
Pathology report |
D7287 |
Oral & maxillofacial surgery |
Cytology exfoliative sample collection |
Individual consideration. |
Pathology report |
Pathology report |
D7288 |
Oral & maxillofacial surgery |
Brush biopsy – transepithelial sample collection |
Individual consideration. |
Pathology report |
Pathology report |
D7290 |
Oral & maxillofacial surgery |
Surgical repositioning of teeth – grafting procedures are additional |
Individual consideration. |
Tooth identification Detailed narrative |
Tooth identification Detailed narrative |
D7291 |
Oral & maxillofacial surgery |
Transseptal fiberotomy/supra crestal fiberotomy, by report |
Individual consideration. |
Tooth identification Detailed narrative incl orthodontic history |
Tooth identification Detailed narrative incl orthodontic history |
D7292 |
Oral & maxillofacial surgery |
Placement of temporary anchorage device [screw retained plate] requiring flap |
Not a covered benefit. |
None |
None |
D7293 |
Oral & maxillofacial surgery |
Placement of temporary anchorage device requiring flap |
Not a covered benefit. |
None |
None |
D7294 |
Oral & maxillofacial surgery |
Placement of temporary anchorage device without flap |
Not a covered benefit. |
None |
None |
D7295 |
Oral & maxillofacial surgery |
Harvest of bone for use in autogenous grafting procedures |
Not a covered benefit. |
None |
None |
D7296 |
Oral & maxillofacial surgery |
Corticotomy one to three teeth |
Not a covered benefit. |
None |
None |
D7297 |
Oral & maxillofacial surgery |
Corticotomy four or more teeth |
Not a covered benefit. |
None |
None |
D7298 |
Oral & maxillofacial surgery |
Removal of temporary anchorage device [screw retained plate], requiring flap |
Not a covered benefit. |
None |
None |
D7299 |
Oral & maxillofacial surgery |
Removal of temporary anchorage device, requiring flap |
Not a covered benefit. |
None |
None |
D7300 |
Oral & maxillofacial surgery |
Removal of temporary anchorage device without flap |
Not a covered benefit. |
None |
None |
D7310 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 Detailed narrative or progress notes Pre-operative radiographs |
Quadrant identification Detailed narrative or progress notes Pre-operative radiographs |
D7320 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Vestibuloplasty – ridge extension (secondary epithelialization) |
Individual consideration. Not covered in conjunction with implants. |
Arch identification Operative reports |
Arch identification Operative reports |
D7350 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Excision of benign lesion, up to 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7411 |
Oral & maxillofacial surgery |
Excision of benign lesion greater than 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7412 |
Oral & maxillofacial surgery |
Excision of benign lesion, complicated |
Individual consideration. |
Pathology report |
Pathology report |
D7413 |
Oral & maxillofacial surgery |
Excision of malignant lesion up to 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7414 |
Oral & maxillofacial surgery |
Excision of malignant lesion greater than 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7415 |
Oral & maxillofacial surgery |
Excision of malignant lesion, complicated |
Individual consideration. |
Pathology report |
Pathology report |
D7465 |
Oral & maxillofacial surgery |
Destruction of lesion(s) by physical or chemical methods, by report |
Not a covered benefit. |
None |
None |
D7440 |
Oral & maxillofacial surgery |
Excision of malignant tumor – lesion diameter up to 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7441 |
Oral & maxillofacial surgery |
Excision of malignant tumor – lesion diameter greater than 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7450 |
Oral & maxillofacial surgery |
Removal of benign odontogenic cyst or tumor – lesion diameter up to1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7451 |
Oral & maxillofacial surgery |
Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7460 |
Oral & maxillofacial surgery |
Removal of benign non-odontogenic cyst or tumor – lesion diameter up to 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7461 |
Oral & maxillofacial surgery |
Removal of benign nonodontogenic cyst or tumor – lesion diameter greater than 1.25 cm |
Individual consideration. |
Pathology report |
Pathology report |
D7471 |
Oral & maxillofacial surgery |
Removal of lateral exostosis (maxilla or mandible) |
One per arch per lifetime. |
Arch identification |
Arch identification |
D7472 |
Oral & maxillofacial surgery |
Removal of torus palatinus |
One per lifetime. |
Arch identification |
Arch identification |
D7473 |
Oral & maxillofacial surgery |
Removal of torus mandibularis |
One per quadrant per lifetime. |
Quadrant identification |
Quadrant identification |
D7485 |
Oral & maxillofacial surgery |
Reduction of osseous tuberosity |
One per upper quadrant(s) per lifetime. |
Quadrant identification |
Quadrant identification |
D7490 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Marsupialization of odontogenic cyst |
Individual consideration. |
Tooth identification Detailed narrative or Operative report |
Tooth identification Detailed narrative or Operative report |
D7510 |
Oral & maxillofacial surgery |
Incision and drainage of abscess – intraoral soft tissue |
Individual consideration. |
Tooth identification Detailed narrative |
Tooth identification Detailed narrative |
D7511 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Incision and drainage of abscess – extraoral soft tissue |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D7521 |
Oral & maxillofacial surgery |
Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D7530 |
Oral & maxillofacial surgery |
Removal of foreign body, mucosa, skin, or subcutaneous alveolar tissue |
Individual consideration. |
Pathology report Operative report |
Pathology report Operative report |
D7540 |
Oral & maxillofacial surgery |
Removal of reaction-producing foreign bodies, musculoskeletal system |
Individual consideration. |
Pathology report Operative report |
Pathology report Operative report |
D7550 |
Oral & maxillofacial surgery |
Partial ostectomy/sequestrectomy for removal of non-vital bone |
Individual consideration. |
Pathology report Operative report |
Pathology report Operative report |
D7560 |
Oral & maxillofacial surgery |
Maxillary sinusotomy for removal of tooth fragment or foreign body |
Individual consideration. |
Operative report Arch identification |
Operative report Arch identification |
D7610 |
Oral & maxillofacial surgery |
Maxilla – open reduction (teeth immobilized, if present) |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7620 |
Oral & maxillofacial surgery |
Maxilla – closed reduction (teeth immobilized, if present) |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7630 |
Oral & maxillofacial surgery |
Mandible – open reduction (teeth immobilized, if present) |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7640 |
Oral & maxillofacial surgery |
Mandible – closed reduction (teeth immobilized, if present) |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7650 |
Oral & maxillofacial surgery |
Malar and/or zygomatic arch – open reduction |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7660 |
Oral & maxillofacial surgery |
Malar and/or zygomatic arch – closed reduction |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7670 |
Oral & maxillofacial surgery |
Alveolus – closed reduction, may include stabilization of teeth |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7671 |
Oral & maxillofacial surgery |
Alveolus – open reduction, may include stabilization of teeth |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7680 |
Oral & maxillofacial surgery |
Facial bones – complicated reduction with fixation and multiple surgical approaches |
Individual consideration. |
Panoramic radiograph Operative report |
Panoramic radiograph Operative report |
D7710 |
Oral & maxillofacial surgery |
Maxilla – open reduction, stabilization of teeth |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7720 |
Oral & maxillofacial surgery |
Maxilla – closed reduction |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7730 |
Oral & maxillofacial surgery |
Mandible – open reduction |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7740 |
Oral & maxillofacial surgery |
Mandible – closed reduction |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7750 |
Oral & maxillofacial surgery |
Malar and/or zygomatic arch – open reduction |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7760 |
Oral & maxillofacial surgery |
Malar and/or zygomatic arch – closed reduction |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7770 |
Oral & maxillofacial surgery |
Alveolus – open reduction stabilization of teeth |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7771 |
Oral & maxillofacial surgery |
Alveolus – closed reduction, stabilization of teeth |
Individual consideration. |
Panoramic radiograph Operative report Arch identification |
Panoramic radiograph Operative report Arch identification |
D7780 |
Oral & maxillofacial surgery |
Facial bones – complicated reduction with fixation and multiple surgical approaches |
Individual consideration. |
Panoramic radiograph Operative report |
Panoramic radiograph Operative report |
D7810 |
Oral & Maxillofacial |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Occlusal orthotic device adjustment |
Not a covered benefit. |
None |
None |
D7899 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
|
D7939 |
Oral & maxillofacial surgery |
Indexing for osteotomy using dynamic robotic assisted or dynamic navigation |
Not a covered benefit. |
None |
None |
D7940 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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. |
None |
None |
D7961 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Excision of hyperplastic tissue – per arch |
Individual consideration. |
Arch identification Operative report |
Arch identification Operative report |
D7971 |
Oral & maxillofacial surgery |
Excision of pericoronal gingiva |
Individual consideration. |
Tooth identification Operative report |
Tooth identification Operative report |
D7972 |
Oral & maxillofacial surgery |
Surgical reduction of fibrous tuberosity |
One per upper quadrant(s) per lifetime. |
Quadrant identification |
Quadrant identification |
D7979 |
Oral & maxillofacial surgery |
Non-surgical sailolithotomy |
Not a covered benefit. |
None |
None |
D7980 |
Oral & maxillofacial surgery |
Sialolithotomy |
Individual consideration. |
Operative report |
Operative report |
D7981 |
Oral & maxillofacial surgery |
Excision of salivary gland, by report |
Individual consideration. |
Operative report |
Operative report |
D7982 |
Oral & maxillofacial surgery |
Sialodochoplasty |
Individual consideration. |
Operative report |
Operative report |
D7983 |
Oral & maxillofacial surgery |
Closure of salivary fistula |
Individual consideration. |
Operative report |
Operative report |
D7990 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Intraoral placement of a fixation device not in conjunction with a fracture |
Not a covered benefit. |
None |
None |
D7999 |
Oral & maxillofacial surgery |
Unspecified oral surgery procedure, by report |
Individual consideration. |
Tooth identification Detailed narrative Operative report |
Tooth identification Detailed narrative Operative report |
D8010 |
Orthodontics |
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 |
Orthodontics |
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 |
Orthodontics |
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 |
Orthodontics |
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 |
Orthodontics |
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 |
Orthodontics |
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 |
Orthodontics |
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 |
Orthodontics |
Removable appliance therapy |
Available as rider and subject to lifetime maximum and copayment. Considered inclusive of comprehensive orthodontic treatment. For specific ACA-compliant small group plans only: Not covered |
None |
None |
D8220 |
Orthodontics |
Fixed appliance therapy |
Available as rider and subject to lifetime maximum and copayment. Considered inclusive of comprehensive orthodontic treatment. For specific ACA-compliant small group plans only: Not covered |
None |
None |
D8660 |
Orthodontics |
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 |
Orthodontics |
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 |
Orthodontics |
Orthodontic retention (removal of appliances, construction and placement of retainer(s) |
Part of the global fee for the orthodontic outcome. |
None |
None |
D8681 |
Orthodontics |
Occlusal orthotic device adjustment |
Not a covered benefit. |
None |
None |
D8695 |
Orthodontics |
Removal of fixed orthodontic appliances for reasons other than completion of treatment |
Not a covered benefit. |
None |
None |
D8696 |
Orthodontics |
Repair of orthodontic appliance –maxillary |
Not a covered benefit. |
None |
None |
D8697 |
Orthodontics |
Repair of orthodontic appliance – mandibular |
Not a covered benefit. |
None |
None |
D8698 |
Orthodontics |
Re-cement or re-bond fixed retainer – maxillary |
Not a covered benefit. |
None |
None |
D8699 |
Orthodontics |
Re-cement or re-bond retainer – mandibular |
Not a covered benefit. |
None |
None |
D8701 |
Orthodontics |
Repair of fixed retainer, includes reattachment - maxillary |
Not a covered benefit. |
None |
None |
D8702 |
Orthodontics |
Repair of fixed retainer, includes reattachment – mandibular |
Not a covered benefit. |
None |
None |
D8703 |
Orthodontics |
Replacement of lost or broken retainer – maxillary |
Not a covered benefit. |
None |
None |
D8704 |
Orthodontics |
Replacement of lost or broken retainer – mandibular |
Not a covered benefit. |
None |
None |
D8999 |
Orthodontics |
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 |
Adjunctive general |
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 |
Adjunctive General |
Fixed partial denture sectioning |
Not a covered benefit. |
None |
None |
D9130 |
Adjunctive general |
Temporomandibular joint dysfunction – non-invasive physical therapies |
Not a covered benefit. |
None |
None |
D9210 |
Adjunctive general |
Local anesthesia not in conjunction with operative or surgical procedures |
Not a covered benefit. |
None |
None |
D9211 |
Adjunctive general |
Regional block anesthesia |
Not a covered benefit. |
None |
None |
D9212 |
Adjunctive general |
Trigeminal division block anesthesia |
Not a covered benefit. |
None |
None |
D9215 |
Adjunctive general |
Local anesthesia in conjunction with operative or surgical procedures |
Included in the total fee for non-surgical or surgical services. |
None |
None |
D9219 |
Adjunctive general |
Evaluation for moderate sedation, deep sedation, or general anesthesia |
Not a covered benefit. |
None |
None |
D9222 |
Adjunctive general |
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 |
Adjunctive general |
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 |
Adjunctive general |
Administration of nitrous oxide/ analgesia, anxiolysis |
Not a covered benefit. |
None |
None |
D9239 |
Adjunctive general |
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 |
Adjunctive general |
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 |
Adjunctive general |
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 |
Adjunctive general |
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 |
Adjunctive general |
Consultation with a medical health care professional |
Not a covered benefit. |
None |
None |
D9410 |
Adjunctive general |
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 |
Adjunctive general |
Hospital or ambulatory surgical center call |
Not a covered benefit. |
None |
None |
D9430 |
Adjunctive general |
Office visit for observation during regular office hours – no other services performed |
Not a covered benefit. |
None |
None |
D9440 |
Adjunctive general |
Office visit-after regular office hours |
Not a covered benefit. |
None |
None |
D9450 |
Adjunctive general |
Case presentation, subsequent to detailed and extensive treatment planning |
Not a covered benefit. |
None |
None |
D9610 |
Adjunctive general |
Therapeutic parenteral drug, single administration |
Not a covered benefit. |
None |
None |
D9612 |
Adjunctive general |
Therapeutic parenteral drugs, two or more administrations, different meds |
Not a covered benefit. |
None |
None |
D9613 |
Adjunctive general |
Infiltration of sustained-release therapeutic drug, per quadrant |
Not a covered benefit. |
None |
None |
D9630 |
Adjunctive general |
Other drugs/medicaments, by report |
Not a covered benefit. |
None |
None |
D9910 |
Adjunctive general |
Application of desensitizing medicament |
Once within a 12-month period. |
None |
None |
D9911 |
Adjunctive general |
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 |
Adjunctive General |
Pre-visit patient screening |
Not a covered benefit (Included in the primary service that is being rendered). |
None |
None |
D9920 |
Adjunctive general |
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 |
Adjunctive general |
Treatment of complications (post-surgical) – unusual circumstances, by report |
Individual consideration. |
Detailed narrative |
Detailed narrative |
D9932 |
Adjunctive general |
Cleaning and inspection of removable complete denture, maxillary |
Not a covered benefit. |
None |
None |
D9933 |
Adjunctive general |
Cleaning and inspection of removable complete denture, mandibular |
Not a covered benefit. |
None |
None |
D9934 |
Adjunctive general |
Cleaning and inspection of removable partial denture, maxillary |
Not a covered benefit. |
None |
None |
Adjunctive general |
Cleaning and inspection of removable partial denture, mandibular |
Not a covered benefit. |
None |
None |
|
D9938 |
Adjunctive general |
Fabrication of a custom removable clear plastic temporary aesthetic appliance |
Not a covered benefit. |
None |
None |
D9939 |
Adjunctive general |
Placement of a custom removable clear plastic temporary aesthetic appliance |
Not a covered benefit. |
None |
None |
D9941 |
Adjunctive general |
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 |
Adjunctive general |
Repair and/ or reline of occlusal guard |
Covered by rider only. |
None |
None |
D9943 |
Adjunctive general |
Occlusal guard adjustment |
Covered by rider only. |
None |
None |
D9944 |
Adjunctive general |
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 |
Adjunctive general |
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 |
Adjunctive general |
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 |
Sleep apnea |
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 |
Sleep apnea |
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 |
Sleep apnea |
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 |
Adjunctive general |
Occlusion analysis-mounted case |
Not a covered benefit (inclusive of rehabilitative services being performed). |
None |
None |
D9951 |
Adjunctive general |
Occlusal adjustment-limited |
One per quadrant per 24 months. |
Quadrant identification |
Quadrant identification |
D9952 |
Adjunctive general |
Occlusal adjustment-complete |
Once per arch per 24 months. |
Arch identification |
Arch identification |
Sleep apnea |
Reline custom sleep apnea appliance (indirect) |
Not a covered benefit. |
None |
None |
|
D9954 |
Sleep apnea |
Fabrication and delivery of oral appliance therapy (OAT) morning repositioning device |
Not a covered benefit |
None |
None |
D9955 |
Sleep apnea |
Oral appliance therapy (OAT) titration visit |
Not a covered benefit |
None |
None |
D9956 |
Sleep apnea |
Administration of home sleep apnea test |
Not a covered benefit |
None |
None |
D9957 |
Sleep apnea |
Screening for sleep related breathing disorders |
Not a covered benefit |
None |
None |
D9961 |
Adjunctive general |
Duplicate/copy patient’s records |
Not a covered benefit. |
None |
None |
D9970 |
Adjunctive general |
Enamel microabrasion |
Not a covered benefit. |
None |
None |
D9971 |
Adjunctive general |
Odontoplasty - per tooth |
Not a covered benefit. |
None |
None |
D9972 |
Adjunctive general |
External bleaching – per arch – in office |
Not a covered benefit. |
None |
None |
D9973 |
Adjunctive general |
External bleaching – per tooth |
Not a covered benefit. |
None |
None |
D9974 |
Adjunctive general |
Internal bleaching – per tooth |
Not a covered benefit. |
None |
None |
D9975 |
Adjunctive general |
External bleaching – in home – per arch; includes materials & fabrication of custom trays |
Not a covered benefit. |
None |
None |
D9985 |
Adjunctive general |
Sales tax |
Not a covered benefit. |
None |
None |
D9986 |
Adjunctive general |
Missed appointment |
Not a covered benefit. |
None |
None |
D9987 |
Adjunctive general |
Cancelled appointment |
Not a covered benefit. |
None |
None |
D9990 |
Adjunctive general |
Certified translation or sign – language services, per visit |
Not a covered benefit. |
None |
None |
D9991 |
Adjunctive general |
Dental case management – addressing appointment compliance barriers |
Not a covered benefit. |
None |
None |
D9992 |
Adjunctive general |
Dental case management – care coordination |
Not a covered benefit. |
None |
None |
D9993 |
Adjunctive general |
Dental case management – motivational interviewing |
Not a covered benefit. |
None |
None |
D9994 |
Adjunctive general |
Dental case management – patient education |
Not a covered benefit. |
None |
None |
D9995 |
Adjunctive general |
Teledentistry synchronous |
Not a covered benefit. |
None |
None |
D9996 |
Adjunctive general |
Teledentistry nonsynchronous |
Not a covered benefit. |
None |
None |
D9997 |
Adjunctive general |
Dental case management – patients with special health care needs |
Not a covered benefit. |
None |
None |
D9999 |
Adjunctive general |
Unspecified adjunctive procedure by report |
Individual consideration. |
Detailed narrative |
Detailed narrative |
CDT Code | ADA Category | Description of Service | Pediatric EHB Procedure Guidelines Ages 0-19 | Adult EHB Procedure Guidelines Ages 19 & older | Submission Requirements |
---|---|---|---|---|---|
D0120 |
Diagnostic |
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 |
Diagnostic |
Limited oral evaluation – problem-focused |
Two per calendar year. Not a covered benefit when performed on the same day as D9110 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 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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Re-evaluation – post operative office visit |
Not a covered benefit. |
Not a covered benefit. |
None |
D0180 |
Diagnostic |
Comprehensive periodontal evaluation – new or established patient |
Not a covered benefit. |
Once per 60 months per dentist or location. |
None |
D0190 |
Diagnostic |
Screening of a patient |
Not a covered benefit. |
Not a covered benefit. |
None |
D0191 |
Diagnostic |
Assessment of a patient |
Not a covered benefit. |
Not a covered benefit. |
None |
D0210 |
Diagnostic |
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 |
Diagnostic |
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 Endodontics 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 Endodontics therapy, radiographs are included in the fee for the procedure. |
None |
D0230 |
Diagnostic |
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 Endodontics therapy, radiographs are included in the fee for the procedure. |
None |
D0240 |
Diagnostic |
Intraoral - occlusal radiographic image |
Not a covered benefit. |
One film per arch per 6 months. |
None |
D0250 |
Diagnostic |
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 |
D0251 |
Diagnostic |
Extra-oral posterior dental radiographic image |
Not a covered benefit. |
Not a covered benefit. |
None |
D0270 |
Diagnostic |
Bitewing - single radiographic image |
Two per calendar year per patient. |
One per 6 months per patient. |
None |
D0272 |
Diagnostic |
Bitewings - two radiographic images |
Two per calendar year per patient. |
One per 6 months per patient. |
None |
D0273 |
Diagnostic |
Bitewings - three radiographic images |
Two per calendar year per patient. |
One per 6 months per patient. |
None |
D0274 |
Diagnostic |
Bitewings - four radiographic images |
Two per calendar year per patient. |
One per 6 months per patient. |
None |
D0277 |
Diagnostic |
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 |
Diagnostic |
Sialography |
Not a covered benefit. |
Not a covered benefit. |
None |
D0320 |
Diagnostic |
Temporomandibular joint arthrogram, including injection |
Not a covered benefit. |
Not a covered benefit. |
None |
D0321 |
Diagnostic |
Other temporomandibular joint radiographic images, by report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0322 |
Diagnostic |
Tomographic survey |
Not a covered benefit. |
Not a covered benefit. |
None |
D0330 |
Diagnostic |
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 |
Diagnostic |
2D cephalometric radiographic image – acquisition, measurement, and analysis |
Individual consideration for non-orthodontic services. |
Individual consideration for non-orthodontic services. |
None |
D0350 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Cone beam CT capture and interpretation for TMJ series including two or more exposures |
Not a covered benefit. |
Not a covered benefit. |
None |
D0369 |
Diagnostic |
Maxillofacial MRI capture and interpretation |
Not a covered benefit. |
Not a covered benefit. |
None |
D0370 |
Diagnostic |
Maxillofacial ultrasound capture and interpretation |
Not a covered benefit. |
Not a covered benefit. |
None |
D0371 |
Diagnostic |
Sialoendoscopy capture and interpretation |
Not a covered benefit. |
Not a covered benefit. |
None |
D0372 |
Diagnostic |
Intraoral tomosynthesis – comprehensive series of radiographic images |
Not a covered benefit. |
Not a covered benefit. |
None |
D0373 |
Diagnostic |
Intraoral tomosynthesis – bitewing radiographic image |
Not a covered benefit. |
Not a covered benefit. |
None |
D0374 |
Diagnostic |
Intraoral tomosynthesis – periapical radiographic image |
Not a covered benefit. |
Not a covered benefit. |
None |
D0801 |
Diagnostic |
3D dental surface scan – direct |
Not a covered benefit. |
Not a covered benefit. |
None |
D0802 |
Diagnostic |
3D dental surface scan – indirect |
Not a covered benefit. |
Not a covered benefit. |
None |
D0803 |
Diagnostic |
3D facial surface scan – direct |
Not a covered benefit. |
Not a covered benefit. |
None |
D0804 |
Diagnostic |
3D facial surface scan – indirect |
Not a covered benefit. |
Not a covered benefit. |
None |
D0380 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Cone beam CT image capture for TMJ series including two or more exposures |
Not a covered benefit. |
Not a covered benefit. |
None |
D0385 |
Diagnostic |
Maxillofacial MRI image capture |
Not a covered benefit. |
Not a covered benefit. |
None |
D0386 |
Diagnostic |
Maxillofacial ultrasound image capture |
Not a covered benefit. |
Not a covered benefit. |
None |
D0387 |
Diagnostic |
Intraoral tomosynthesis – comprehensive series of radiographic images – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0388 |
Diagnostic |
Intraoral tomosynthesis – bitewing radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0389 |
Diagnostic |
Intraoral tomosynthesis – periapical radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0701 |
Diagnostic |
Panoramic radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0702 |
Diagnostic |
2D cephalometric radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0703 |
Diagnostic |
2D oral/facial photographic image obtained intra-orally or extra-orally – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0705 |
Diagnostic |
Extra-oral posterior dental radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0706 |
Diagnostic |
Intraoral – occlusal radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0707 |
Diagnostic |
Intraoral – periapical radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0708 |
Diagnostic |
Intraoral – bitewing radiographic image – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0709 |
Diagnostic |
Intraoral – comprehensive series of radiographic images – image capture only |
Not a covered benefit. |
Not a covered benefit. |
None |
D0391 |
Diagnostic |
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 |
Diagnostic |
Virtual treatment simulation using 3D image volume or surface scan |
Not a covered benefit. |
Not a covered benefit. |
None |
D0394 |
Diagnostic |
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 |
Diagnostic |
Fusion of two or more 3D image volumes of one or more modalities |
Not a covered benefit. |
Not a covered benefit. |
None |
D0396 |
Diagnostic |
3D printing of a 3D dental surface scan |
Not a covered benefit. |
Not a covered benefit. |
None |
D0411 |
Diagnostic |
HbA1c in-office point-of-service testing |
Not a covered benefit. |
Not a covered benefit. |
None |
D0412 |
Diagnostic |
Blood glucose level test – in-office using a glucose meter |
Not a covered benefit. |
Not a covered benefit. |
None |
D0414 |
Diagnostic |
Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0415 |
Diagnostic |
Collection of microorganisms for culture and sensitivity |
Not a covered benefit. |
Not a covered benefit. |
None |
D0416 |
Diagnostic |
Viral culture. A diagnostic test to identify viral organisms, most often herpes virus. |
Not a covered benefit. |
Not a covered benefit. |
None |
D0417 |
Diagnostic |
Collection and preparation of saliva sample for laboratory diagnostic testing |
Not a covered benefit. |
Not a covered benefit. |
None |
D0418 |
Diagnostic |
Analysis of saliva sample. Chemical or biological analysis of saliva sample for diagnostic purposes. |
Not a covered benefit. |
Not a covered benefit. |
None |
D0419 |
Diagnostic |
Assessment of salivary flow by measurement |
Not a covered benefit. |
Not a covered benefit. |
None |
D0422 |
Diagnostic |
Collection and preparation of genetic sample material for laboratory analysis and report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0423 |
Diagnostic |
Genetic test for susceptibility to diseases – specimen analysis |
Not a covered benefit. |
Not a covered benefit. |
None |
D0425 |
Diagnostic |
Caries susceptibility tests. Not to be used for carious dentin staining. |
Not a covered benefit. |
Not a covered benefit. |
None |
D0431 |
Diagnostic |
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 |
Diagnostic |
Pulp vitality tests |
Not a covered benefit. |
Not a covered benefit. |
None |
D0470 |
Diagnostic |
Diagnostic casts |
Not a covered benefit. |
Not a covered benefit. |
None |
D0472 |
Diagnostic |
Accession of tissue, gross examination, preparation and transmission of written report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0473 |
Diagnostic |
Accession of tissue, gross and microscopic examination, preparation and transmission of written report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0474 |
Diagnostic |
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 |
Diagnostic |
Decalcification procedure |
Not a covered benefit. |
Not a covered benefit. |
None |
D0476 |
Diagnostic |
Special stains for microorganisms |
Not a covered benefit. |
Not a covered benefit. |
None |
D0477 |
Diagnostic |
Special stains, not for microorganisms |
Not a covered benefit. |
Not a covered benefit. |
None |
D0478 |
Diagnostic |
Immunohistochemical stains |
Not a covered benefit. |
Not a covered benefit. |
None |
D0479 |
Diagnostic |
Tissue in-site hybridization, including interpretation |
Not a covered benefit. |
Not a covered benefit. |
None |
D0480 |
Diagnostic |
Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0481 |
Diagnostic |
Electron microscopy |
Not a covered benefit. |
Not a covered benefit. |
None |
D0482 |
Diagnostic |
Direct immunofluorescence |
Not a covered benefit. |
Not a covered benefit. |
None |
D0483 |
Diagnostic |
Indirect immunofluorescence |
Not a covered benefit. |
Not a covered benefit. |
None |
D0484 |
Diagnostic |
Consultation on slides prepared elsewhere |
Not a covered benefit. |
Not a covered benefit. |
None |
D0485 |
Diagnostic |
Consultation, including preparation of slides from biopsy material supplied by referring source |
Not a covered benefit. |
Not a covered benefit. |
None |
D0486 |
Diagnostic |
Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation, and transmission of written report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0502 |
Diagnostic |
Other oral pathology procedures, by report |
Not a covered benefit. |
Not a covered benefit. |
None |
D0600 |
Diagnostic |
Non-ionizing diagnostic procedure capable of quantifying, monitoring and recording changes in structure of enamel, dentin and cementum |
Not a covered benefit. |
Not a covered benefit. |
None |
D0601 |
Diagnostic |
Caries risk assessment and documentation, with a finding of low risk |
Not a covered benefit. |
Not a covered benefit. |
None |
D0602 |
Diagnostic |
Caries risk assessment and documentation, with a finding of moderate risk |
Not a covered benefit. |
Not a covered benefit. |
None |
D0603 |
Diagnostic |
Caries risk assessment and documentation, with a finding of high risk |
Not a covered benefit. |
Not a covered benefit. |
None |
D0604 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
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 |
Diagnostic |
Unspecified diagnostic procedure, by report |
Individual consideration. |
Individual consideration. |
Detailed narrative |
D1110 |
Preventive |
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. D1110 and D4346 are considered inclusive of D4341 and D4342 when performed on the same day. |
None |
D1120 |
Preventive |
Prophylaxis – child |
Two per calendar year. Use D1120 for ages 0 – 13 |
Not a covered benefit. |
None |
D1206 |
Preventive |
Topical application of fluoride varnish |
Once per 90 day(s) of either code D1206 or D1208. |
Not a covered benefit. |
None |
D1208 |
Preventive |
Topical application of fluoride- excluding varnish |
Once per 90 day(s) of either code D1206 or D1208. |
Not a covered benefit. |
None |
D1301 |
Preventive |
Immunization counseling |
Not a covered benefit. |
Not a covered benefit. |
None |
D1310 |
Preventive |
Nutritional counseling for control of dental disease |
Not a covered benefit. |
Not a covered benefit. |
None |
D1320 |
Preventive |
Tobacco counseling for control and prevention of oral disease |
Not a covered benefit. |
Not a covered benefit. |
None |
D1321 |
Preventive |
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 |
Preventive |
Oral hygiene instructions |
Not a covered benefit. |
Not a covered benefit. |
None |
D1351 |
Sealant – per tooth |
Under age 9: Covered for primary and permanent molars. Reapplication only if process fails within three years. Age 9 to under age 19: Covered for permanent non-carious molars for members once every three years per tooth. |
Not a covered benefit. |
Tooth identification
|
|
D1352 |
Preventive |
Preventive resin restoration in a moderate to high caries risk patient-permanent tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D1353 |
Preventive |
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
|
D1354 |
Preventive |
Application of caries- arresting medicament – per tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D1355 |
Preventive |
Caries preventive medicament application – per tooth, for primary prevention or remineralization. |
Not a covered benefit. |
Not a covered benefit. |
None |
D1510 |
Preventive |
Space maintainer – fixed – unilateral – per quadrant |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Not a covered benefit. |
Quadrant identification |
D1516 |
Preventive |
Space maintainer – fixed – bilateral, maxillary |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Not a covered benefit. |
Arch identification |
D1517 |
Preventive |
Space maintainer-fixed-bilateral, mandibular |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Not a covered benefit. |
Arch identification |
D1520 |
Preventive |
Space maintainer – removable –unilateral – per quadrant |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Not a covered benefit. |
Quadrant identification |
D1526 |
Preventive |
Space maintainer – removable – bilateral, maxillary |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Not a covered benefit. |
Arch identification |
D1527 |
Preventive |
Space maintainer – removable – bilateral, mandibular |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Not a covered benefit. |
Arch identification |
D1551 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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. |
Arch identification |
D1556 |
Preventive |
Removal of fixed unilateral space maintainer – per quadrant |
Not a covered benefit. |
Not a covered benefit. |
None |
D1557 |
Preventive |
Removal of fixed bilateral space maintainer – maxillary |
Not a covered benefit. |
Not a covered benefit. |
None |
D1558 |
Preventive |
Removal of fixed bilateral space maintainer – mandibular |
Not a covered benefit. |
Not a covered benefit. |
None |
D1575 |
Preventive |
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 identification |
D1999 |
Preventive |
Unspecified preventive procedure, by report |
Individual consideration. Note: Passive appliances are designed to prevent tooth movement. |
Not a covered benefit. |
Detailed narrative |
D1701 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Preventive |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
Resin-based composite – four or more 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 |
D2390 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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. |
Tooth identification Surface identification |
D2420 |
Restorative |
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. |
Tooth identification Surface identification |
D2430 |
Restorative |
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. |
Tooth identification Surface identification |
D2510 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Tooth identification |
D2720 |
Restorative |
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 |
Tooth identification |
D2721 |
Restorative |
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 |
Tooth identification |
D2722 |
Restorative |
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 |
Tooth identification |
D2740 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Restorative |
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 |
Tooth identification |
D2781 |
Restorative |
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 |
Tooth identification |
D2782 |
Restorative |
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 |
Tooth identification |
D2783 |
Restorative |
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 |
Tooth identification |
D2790 |
Restorative |
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 |
Restorative |
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 |
Tooth identification |
D2792 |
Restorative |
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 |
Tooth identification |
D2794 |
Restorative |
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 |
Tooth identification |
D2799 |
Restorative |
Interim crown – further treatment or completion of diagnosis necessary prior to final impression |
Not a covered benefit. |
Not a covered benefit. |
None |
D2910 |
Restorative |
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 |
Restorative |
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 |
Restorative |
Recement crown |
Once per tooth per 12 months. |
Not covered within 6 months of initial placement. |
Tooth identification |
D2921 |
Restorative |
Reattachment of tooth fragment, incisal edge, or cusp |
Not a covered benefit. |
Not a covered benefit. |
None |
D2928 |
Restorative |
Prefabricated porcelain/ceramic crown – permanent tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D2929 |
Restorative |
Prefabricated porcelain/ceramic crown – primary tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D2930 |
Restorative |
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 |
Restorative |
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 |
Restorative |
Prefabricated resin crown |
One per tooth per 12 months. Maximum of four crowns per date of service. |
Not a covered benefit. |
Tooth identification |
D2933 |
Restorative |
Prefabricated stainless steel crown with resin window |
Not a covered benefit. |
Not a covered benefit. |
None |
D2934 |
Restorative |
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 |
Restorative |
Protective restoration |
Not a covered benefit. |
One per tooth per lifetime. |
Tooth identification |
D2941 |
Restorative |
Interim therapeutic restoration – primary dentition |
Not a covered benefit. |
Not a covered benefit. |
None |
D2949 |
Restorative |
Restorative foundation for an indirect restoration |
Not a covered benefit. |
Not a covered benefit. |
None |
D2950 |
Restorative |
Core buildup, including any pins when required |
Not a covered benefit. |
Once per permanent tooth per 84 months. |
Tooth identification |
D2951 |
Restorative |
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 |
Restorative |
Post and core in addition to crown, indirectly fabricated |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D2953 |
Restorative |
Each additional indirectly fabricated post – same tooth |
Not a covered benefit. |
Once per tooth per lifetime. |
Tooth identification |
D2954 |
Restorative |
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 |
Restorative |
Post removal |
Not a covered benefit. |
Not a covered benefit. |
None |
D2957 |
Restorative |
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 |
Tooth identification |
D2960 |
Restorative |
Labial veneer (resin laminate) – direct |
Not a covered benefit. |
Not a covered benefit. |
None |
D2961 |
Restorative |
Labial veneer (resin laminate) – indirect |
Not a covered benefit. |
Not a covered benefit. |
None |
D2962 |
Restorative |
Labial veneer (porcelain laminate) – indirect |
Not a covered benefit. |
Not a covered benefit. |
None |
D2971 |
Restorative |
Additional procedures to customize a crown to fit under an existing partial denture framework |
Not a covered benefit. |
Individual consideration. |
Tooth identification Detailed narrative |
D2975 |
Restorative |
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 |
D2976 |
Restorative |
Band stabilization – per tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D2980 |
Restorative |
Crown repair necessitated by restorative material failure |
Individual consideration. |
Individual consideration. |
Tooth identification Detailed narrative |
D2981 |
Restorative |
Inlay repair necessitated by restorative material failure |
Not a covered benefit. |
Once per tooth per 12 months. |
Tooth identification |
D2982 |
Restorative |
Onlay repair necessitated by restorative material failure |
Not a covered benefit. |
Once per tooth per 12 months. |
Tooth identification |
D2983 |
Restorative |
Veneer repair necessitated by restorative material failure |
Not a covered benefit. |
Not a covered benefit. |
None |
D2989 |
Restorative |
Excavation of a tooth resulting in the determination of non-restorability |
Not a covered benefit. |
Not a covered benefit. |
None |
D2990 |
Restorative |
Resin infiltration of incipient smooth surface lesions |
Not a covered benefit. |
Once per tooth per 12 months. |
Tooth identification |
D2991 |
Restorative |
Application of hydroxyapatite regeneration medicament – per tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D2999 |
Restorative |
Unspecified restorative procedure, by report |
Individual consideration. |
Individual consideration. |
Detailed narrative |
D3110 |
Endodontics |
Pulp cap – direct (excluding final restoration) |
Not a covered benefit. |
Pulp capping is considered part of the final restoration. |
Tooth identification |
D3120 |
Endodontics |
Pulp cap – indirect (excluding final restoration) |
Not a covered benefit. |
Pulp capping is considered part of the final restoration. |
Tooth identification |
D3220 |
Endodontics |
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 |
Endodontics |
Pulpal debridement, primary & permanent teeth |
Not a covered benefit. |
Once per tooth per lifetime. |
Tooth identification |
D3222 |
Endodontics |
Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development. |
Not a covered benefit. |
Once per tooth per lifetime. |
None |
D3230 |
Endodontics |
Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) |
Not a covered benefit. |
Once per tooth per lifetime. |
None |
D3240 |
Endodontics |
Pulpal therapy (resorbable filling) – posterior primary tooth (excluding final restoration) |
Not a covered benefit. |
Once per tooth per lifetime. |
None |
D3310 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
Treatment of root canal obstruction; non-surgical access |
Not a covered benefit. |
Individual consideration. |
Tooth identification Detailed narrative Current dated pre- and post-operative periapical radiographs |
D3332 |
Endodontics |
Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D3333 |
Endodontics |
Internal root repair of perforation defects |
Not a covered benefit. |
Not a covered benefit. |
None |
D3346 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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. |
Tooth identification |
D3352 |
Endodontics |
Apexification / recalcification – interim medication replacement |
Not a covered benefit. |
Once per permanent tooth per lifetime. |
Tooth identification |
D3353 |
Endodontics |
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. |
Tooth identification |
D3355 |
Endodontics |
Pulpal regeneration – initial visit |
Not a covered benefit. |
Once per permanent tooth per lifetime. |
Tooth identification |
D3356 |
Endodontics |
Pulpal regeneration – interim medication replacement |
Not a covered benefit. |
Once per permanent tooth per lifetime. |
Tooth identification |
D3357 |
Endodontics |
Pulpal regeneration – completion of treatment |
Not a covered benefit. |
Once per permanent tooth per lifetime. |
Tooth identification |
D3410 |
Endodontics |
Apicoectomy – anterior |
One per permanent tooth root per lifetime. |
Once per permanent tooth root per lifetime. |
Tooth and root identification |
D3421 |
Endodontics |
Apicoectomy – premolar (first root) |
One per permanent tooth root per lifetime. |
Once per permanent tooth root per lifetime. |
Tooth and root identification |
D3425 |
Endodontics |
Apicoectomy – molar (first root) |
One per permanent tooth root per lifetime. |
Once per permanent tooth root per lifetime. |
Tooth and root identification |
D3426 |
Endodontics |
Apicoectomy – each additional |
One per permanent tooth root per lifetime. |
Once per permanent tooth root per lifetime. |
Tooth and root identification |
D3428 |
Endodontics |
Bone graft in conjunction with periradicular surgery – per tooth, single site |
Not a covered benefit. |
Not a covered benefit. |
None |
D3429 |
Endodontics |
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 |
Endodontics |
Retrograde filling – per root |
Not a covered benefit. |
Once per permanent tooth per lifetime. |
Tooth and root identification |
D3431 |
Endodontics |
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 |
Endodontics |
Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery |
Not a covered benefit. |
Not a covered benefit. |
None |
D3450 |
Endodontics |
Root amputation – per root |
Not a covered benefit. |
One per tooth per lifetime for multi-rooted posterior teeth. |
Tooth and root identification |
D3460 |
Endodontics |
Endodontic endosseous implant |
Not a covered benefit. |
Not a covered benefit. |
None |
D3470 |
Endodontics |
Intentional reimplantation (including necessary splinting) |
Not a covered benefit. |
Individual consideration. |
Detailed narrative |
D3471 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
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 |
Endodontics |
Surgical repair of root surface without apicoectomy or repair of root resorption – anterior |
Not a covered benefit. |
Not a covered benefit. |
None |
D3502 |
Endodontics |
Surgical repair of root surface without apicoectomy or repair of root resorption – premolar |
Not a covered benefit. |
Not a covered benefit. |
None |
D3503 |
Endodontics |
Surgical repair of root surface without apicoectomy or repair of root resorption – molar |
Not a covered benefit. |
Not a covered benefit. |
None |
D3910 |
Endodontics |
Surgical procedure for isolation of tooth with rubber dam |
Not a covered benefit. |
Not a covered benefit. |
None |
D3911 |
Endodontics |
Intraorifice barrier |
Not a covered benefit. |
Not a covered benefit. |
None |
D3920 |
Endodontics |
Hemisection (including any root removal), not including root canal therapy |
Not a covered benefit. |
One per posterior tooth per lifetime. |
Tooth identification |
D3921 |
Endodontics |
Decoronation or submergence of an erupted tooth |
Not a covered benefit. |
One per tooth per lifetime (D3921 or D7251). |
Tooth identification |
D3950 |
Endodontics |
Canal preparation and fitting of preformed dowel or post |
Not a covered benefit. |
Not a covered benefit. |
None |
D3999 |
Endodontics |
Unspecified endodontic procedure, by report |
Not a covered benefit. |
Individual consideration. |
Tooth identification Detailed narrative Current dated pre- and post-operative periapical radiographs |
D4210 |
Periodontics |
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 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 |
Periodontics |
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 |
Quadrant identification |
D4212 |
Periodontics |
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 |
Tooth identification |
D4230 |
Periodontics |
Anatomical crown exposure – four or more contiguous teeth or tooth-bounded spaces per quadrant |
Not a covered benefit. |
Not a covered benefit. |
None |
D4231 |
Periodontics |
Anatomical crown exposure – one to three teeth or tooth-bounded spaces per quadrant |
Not a covered benefit. |
Not a covered benefit. |
None |
D4240 |
Periodontics |
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 |
Quadrant identification |
D4241 |
Periodontics |
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 |
Quadrant identification |
D4245 |
Periodontics |
Apically repositioned flap |
Not a covered benefit. |
Not a covered benefit. |
None |
D4249 |
Periodontics |
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 |
Tooth identification |
D4260 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
Biologic materials to aid in soft and osseous tissue regeneration, per site |
Not a covered benefit. |
Not a covered benefit. |
None |
D4266 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
Guided tissue regeneration, edentulous area – resorbable barrier, per site |
Not a covered benefit. |
Not a covered benefit. |
None |
D7957 |
Periodontics |
Guided tissue regeneration, edentulous area – non-resorbable barrier, per site |
Not a covered benefit. |
Not a covered benefit. |
None |
D4268 |
Periodontics |
Surgical revision procedure, per tooth |
Not a covered benefit. |
Not a covered benefit. |
None |
D4270 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
Splint – intra-coronal; natural teeth or prosthetic crowns |
Not a covered benefit. |
Not a covered benefit. |
None |
D4323 |
Periodontics |
Splint – extra-coronal; natural teeth or prosthetic crowns |
Not a covered benefit. |
Not a covered benefit. |
|
D4341 |
Periodontics |
Periodontal scaling and root planning – four or more teeth per quadrant |
One per quadrant per 36 months. |
One per quadrant per 24 months. |
Quadrant identification |
D4342 |
Periodontics |
Periodontal scaling and root planning, one to three teeth per quadrant |
One per quadrant per 36 months. |
One per quadrant per 24 months. |
Quadrant identification |
D4346 |
Periodontics |
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 |
Periodontics |
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 |
Periodontics |
Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth |
Not a covered benefit. |
Individual consideration. |
Detailed narrative Periodontal charting Tooth identification |
D4910 |
Periodontics |
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. D4910 is considered inclusive of D4341 and D4342 when performed on the same day. |
None |
D4920 |
Periodontics |
Unscheduled dressing change (by someone other than treating dentist or their staff) |
Not a covered benefit |
Not a covered benefit. |
None |
D4921 |
Periodontics |
Gingival irrigation with a medicinal agent – per quadrant |
Not a covered benefit |
Not a covered benefit. |
None |
D4999 |
Periodontics |
Unspecified periodontal procedure, by report |
Individual consideration. |
Individual consideration. |
Detailed narrative |
D5110 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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. |
Arch identification |
D5411 |
Prosthodontics (removable) |
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. |
Arch identification |
D5421 |
Prosthodontics (removable) |
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. |
Arch identification |
D5422 |
Prosthodontics (removable) |
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. |
Arch identification |
D5511 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 tooth per 12 months. |
Tooth identification |
D5611 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
Replace all teeth and acrylic on cast metal framework (maxillary) |
Not a covered benefit. |
Once per arch per lifetime. |
Arch identification |
D5671 |
Prosthodontics (removable) |
Replace all teeth and acrylic on cast metal framework (mandibular) |
Not a covered benefit. |
Once per arch per lifetime. |
Arch identification |
D5710 |
Prosthodontics (removable) |
Rebase complete maxillary denture |
One per arch 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 arch 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. |
Arch identification |
D5711 |
Prosthodontics (removable) |
Rebase complete mandibular denture |
One per arch 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 arch 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. |
Arch identification |
D5720 |
Prosthodontics (removable) |
Rebase maxillary partial denture |
One per arch 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 arch 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. |
Arch identification |
D5721 |
Prosthodontics (removable) |
Rebase mandibular partial denture |
One per arch 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 arch 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. |
Arch identification |
D5725 |
Prosthodontics (removable) |
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 |
Prosthodontics (removable) |
Reline complete maxillary denture – direct |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Reline complete mandibular denture – direct |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Reline maxillary partial denture –direct |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Reline mandibular partial denture – direct |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Reline complete maxillary denture – indirect |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Reline complete mandibular denture – indirect |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Reline maxillary partial denture – indirect |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Reline mandibular partial denture – indirect |
One per arch 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 arch 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 |
Prosthodontics (removable) |
Interim complete denture (maxillary) |
Not a covered benefit. |
Not a covered benefit. |
None |
D5811 |
Prosthodontics (removable) |
Interim complete denture (mandibular) |
Not a covered benefit. |
Not a covered benefit. |
None |
D5820 |
Prosthodontics (removable) |
Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary |
Not a covered benefit. |
One per arch per lifetime. |
Arch identification |
D5821 |
Prosthodontics (removable) |
Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular |
Not a covered benefit. |
One per arch per lifetime. |
Arch identification |
D5765 |
Prosthodontics (removable) |
Soft liner for complete or partial removable denture – indirect |
Once per arch per 24 months. |
Once per arch per 36 months. |
Arch identification |
D5850 |
Prosthodontics (removable) |
Tissue conditioning, maxillary |
Not a covered benefit. |
One per arch per 36 months. |
Arch identification |
D5851 |
Prosthodontics (removable) |
Tissue conditioning, mandibular |
Not a covered benefit. |
One per arch per 36 months. |
Arch identification |
D5862 |
Prosthodontics (removable) |
Precision attachment, by report |
Not a covered benefit. |
Not a covered benefit. |
None |
D5863 |
Prosthodontics (removable) |
Overdenture – complete maxillary |
Not a covered benefit. |
One per arch per 84 months. |
Arch identification |
D5864 |
Prosthodontics (removable) |
Overdenture – partial maxillary |
Not a covered benefit. |
One per arch per 84 months. |
Arch identification |
D5865 |
Prosthodontics (removable) |
Overdenture – complete mandibular |
Not a covered benefit. |
One per arch per 84 months. |
Arch identification |
D5866 |
Prosthodontics (removable) |
Overdenture – partial mandibular |
Not a covered benefit. |
One per arch per 84 months. |
Arch identification |
D5867 |
Prosthodontics (removable) |
Replacement of replaceable part of semi-precision or precision attachment, per attachment |
Not a covered benefit. |
Not a covered benefit. |
None |
D5875 |
Prosthodontics (removable) |
Modification of removable prosthesis following implant surgery |
Not a covered benefit. |
Not a covered benefit. |
None |
D5876 |
Prosthodontics (removable) |
Add metal substructure to acrylic full denture (per arch) |
Not a covered benefit. |
Not a covered benefit. |
None |
D5899 |
Prosthodontics (removable) |
Unspecified removable prosthodontic procedure, by report |
Individual consideration. |
Individual consideration. |
Detailed narrative |
D5911 |
Maxillofacial prosthetics |
Facial moulage (sectional) |
Not a covered benefit. |
Not a covered benefit. |
None |
D5912 |
Maxillofacial prosthetics |
Facial moulage (complete) |
Not a covered benefit. |
Not a covered benefit. |
None |
D5913 |
Maxillofacial prosthetics |
Nasal prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5914 |
Maxillofacial prosthetics |
Auricula prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5915 |
Maxillofacial prosthetics |
Orbital prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5916 |
Maxillofacial prosthetics |
Ocular prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5919 |
Maxillofacial prosthetics |
Facial prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5922 |
Maxillofacial prosthetics |
Nasal septal prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5923 |
Maxillofacial prosthetics |
Ocular prosthesis, interim |
Not a covered benefit. |
Not a covered benefit. |
None |
D5924 |
Maxillofacial prosthetics |
Cranial prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5925 |
Maxillofacial prosthetics |
Facial augmentation implant prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5926 |
Maxillofacial prosthetics |
Nasal prosthesis, replacement |
Not a covered benefit. |
Not a covered benefit. |
None |
D5927 |
Maxillofacial prosthetics |
Auricular prosthesis, replacement |
Not a covered benefit. |
Not a covered benefit. |
None |
D5928 |
Maxillofacial prosthetics |
Orbital prosthesis, replacement |
Not a covered benefit. |
Not a covered benefit. |
None |
D5929 |
Maxillofacial prosthetics |
Facial prosthesis, replacement |
Not a covered benefit. |
Not a covered benefit. |
None |
D5931 |
Maxillofacial prosthetics |
Obturator prosthesis, surgical |
Not a covered benefit. |
Not a covered benefit. |
None |
D5932 |
Maxillofacial prosthetics |
Obturator prosthesis, definitive |
Not a covered benefit. |
Not a covered benefit. |
None |
D5933 |
Maxillofacial prosthetics |
Obturator prosthesis, modification |
Not a covered benefit. |
Not a covered benefit. |
None |
D5934 |
Maxillofacial prosthetics |
Mandibular resection prosthesis with guide flange |
Not a covered benefit. |
Not a covered benefit. |
None |
D5935 |
Maxillofacial prosthetics |
Mandibular resection prosthesis without guide flange |
Not a covered benefit. |
Not a covered benefit. |
None |
D5936 |
Maxillofacial prosthetics |
Obturator prosthesis, interim |
Not a covered benefit. |
Not a covered benefit. |
None |
D5937 |
Maxillofacial prosthetics |
Trismus appliance (not for TMD treatment) |
Not a covered benefit. |
Not a covered benefit. |
None |
D5951 |
Maxillofacial prosthetics |
Feeding aid |
Not a covered benefit. |
Not a covered benefit. |
None |
D5952 |
Maxillofacial prosthetics |
Speech aid prosthesis, pediatric |
Not a covered benefit. |
Not a covered benefit. |
None |
D5953 |
Maxillofacial prosthetics |
Speech aid prosthesis, adult |
Not a covered benefit. |
Not a covered benefit. |
None |
D5954 |
Maxillofacial prosthetics |
Palatal augmentation prosthesis |
Not a covered benefit. |
Not a covered benefit. |
None |
D5955 |
Maxillofacial prosthetics |
Palatal lift prosthesis, definitive |
Not a covered benefit. |
Not a covered benefit. |
None |
D5958 |
Maxillofacial prosthetics |
Palatal lift prosthesis, interim |
Not a covered benefit. |
Not a covered benefit. |
None |
D5959 |
Maxillofacial prosthetics |
Palatal lift prosthesis, modification |
Not a covered benefit. |
Not a covered benefit. |
None |
D5960 |
Maxillofacial prosthetics |
Speech aid prosthesis, modification |
Not a covered benefit. |
Not a covered benefit. |
None |
D5982 |
Maxillofacial prosthetics |
Surgical stent |
Not a covered benefit. |
Not a covered benefit. |
None |
D5983 |
Maxillofacial prosthetics |
Radiation carrier |
Not a covered benefit. |
Not a covered benefit. |
None |
D5984 |
Maxillofacial prosthetics |
Radiation shield |
Not a covered benefit. |
Not a covered benefit. |
None |
D5985 |
Maxillofacial prosthetics |
Radiation cone locator |
Not a covered benefit. |
Not a covered benefit. |
None |
D5986 |
Maxillofacial prosthetics |
Fluoride gel carrier |
Not a covered benefit. |
Not a covered benefit. |
None |
D5987 |
Maxillofacial prosthetics |
Commissure splint |
Not a covered benefit. |
Not a covered benefit. |
None |
D5988 |
Maxillofacial prosthetics |
Surgical splint |
Not a covered benefit. |
Not a covered benefit. |
None |
D5991 |
Maxillofacial prosthetics |
Vesiculobullous disease medicament carrier |
Not a covered benefit. |
Not a covered benefit. |
None |
D5992 |
Maxillofacial prosthetics |
Adjust maxillofacial prosthetic appliance, by report |
Not a covered benefit. |
Not a covered benefit. |
None |
D5993 |
Maxillofacial prosthetics |
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 |
Maxillofacial prosthetics |
Periodontal medicament carrier with peripheral seal – laboratory processed – maxillary |
Not a covered benefit. |
Not a covered benefit. |
None |
D5996 |
Maxillofacial prosthetics |
Periodontal medicament carrier with peripheral seal – laboratory processed - mandibular |
Not a covered benefit. |
Not a covered benefit. |
None |
D5999 |
Maxillofacial prosthetics |
Unspecified maxillofacial prosthesis, by report |
Individual consideration. |
Individual consideration. |
Detailed narrative |
D6010 |
Implant |
Surgical placement of implant body, endosteal implant |
Not a covered benefit |
Not a covered benefit |
None |
D6011 |
Implant |
Surgical access to an implant body (Second stage implant surgery) |
Not a covered benefit |
Not a covered benefit |
None |
D6012 |
Implant |
Surgical placement of interim implant body for transitional prosthesis: endosteal implant |
Not a covered benefit |
Not a covered benefit |
None |
D6013 |
Implant |
Surgical placement of mini implant |
Not a covered benefit |
Not a covered benefit |
None |
D6040 |
Implant |
Surgical placement: eposteal implant |
Not a covered benefit |
Not a covered benefit |
None |
D6050 |
Implant |
Surgical placement: transosteal implant |
Not a covered benefit |
Not a covered benefit |
None |
D6051 |
Implant |
Interim implant abutment placement |
Not a covered benefit. |
Not a covered benefit. |
None |
D6055 |
Implant |
Connecting bar – implant- supported or abutment-supported |
Not a covered benefit. |
Not a covered benefit. |
None |
D6056 |
Implant |
Prefabricated abutment – includes modification and placement |
Not a covered benefit. |
Not a covered benefit. |
None |
D6057 |
Implant |
Custom fabricated abutment – includes placement |
Not a covered benefit. |
Not a covered benefit. |
None |
D6058 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
D6065 |
Implant |
Implant-supported porcelain/ceramic crown |
Not a covered benefit. |
Not a covered benefit. |
None |
D6066 |
Implant |
Implant supported crown – porcelain fused to high noble alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6067 |
Implant |
Implant-supported crown – high noble alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6068 |
Implant |
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 |
Implant |
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 |
Implant |
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 |
Implant |
Abutment-supported retainer for porcelain fused to metal FPD (noble metal) |
Not a covered benefit. |
Not a covered benefit. |
None |
D6072 |
Implant |
Abutment-supported retainer for cast metal FPD (high noble metal) |
Not a covered benefit. |
Not a covered benefit. |
None |
D6073 |
Implant |
Abutment-supported retainer for cast metal FPD (predominately base metal) |
Not a covered benefit. |
Not a covered benefit. |
None |
D6074 |
Implant |
Abutment-supported retainer for cast metal FPD (noble metal) |
Not a covered benefit. |
Not a covered benefit. |
None |
D6075 |
Implant |
Implant-supported retainer for ceramic FPD |
Not a covered benefit. |
Not a covered benefit. |
None |
D6076 |
Implant |
Implant-supported retainer for FPD – porcelain fused to high noble alloys) |
Not a covered benefit. |
Not a covered benefit. |
None |
D6077 |
Implant |
Implant-supported retainer for cast metal FPD – high noble alloys) |
Not a covered benefit. |
Not a covered benefit. |
None |
D6080 |
Implant |
Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments |
Not a covered benefit. |
Not a covered benefit. |
None |
D6081 |
Implant |
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. |
Not a covered benefit. |
None |
D6082 |
Implant |
Implant-supported crown – porcelain fused to predominately base alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6083 |
Implant |
Implant-supported crown –porcelain fused to noble alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6084 |
Implant |
Implant-supported crown – porcelain fused to titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6085 |
Implant |
Provisional implant crown |
Not a covered benefit. |
Not a covered benefit. |
None |
D6086 |
Implant |
Implant supported crown – predominantly base alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6087 |
Implant |
Implant supported crown – noble alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6088 |
Implant |
Implant-supported crown – titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6089 |
Implant |
Accessing and retorquing loose implant screw – per screw |
Covered by rider only. |
Covered by rider only. |
Tooth identification |
D6090 |
Implant |
Repair implant supported prosthesis, by report |
Not a covered benefit. |
Covered by rider only. |
Arch identification |
D6091 |
Implant |
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 |
Implant |
Recement or re-bond implant/abutment-supported crown |
Not a covered benefit. |
Not a covered benefit. |
None |
D6093 |
Implant |
Recement or re-bond implant/abutment-supported fixed partial denture |
Not a covered benefit. |
Not a covered benefit. |
None |
D6094 |
Implant |
Abutment-supported crown – titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6095 |
Implant |
Repair implant abutment, by report |
Not a covered benefit. |
Covered by rider only. |
Tooth identification |
D6096 |
Implant |
Remove broken implant retaining screw |
Covered by rider only. |
Covered by rider only. |
Tooth identification |
D6097 |
Implant |
Abutment-supported crown – porcelain fused to titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6098 |
Implant |
Implant supported retainer – porcelain fused to predominantly base alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6099 |
Implant |
Implant supported retainer for FPD – porcelain fused to noble alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6100 |
Implant |
Surgical removal of implant body |
Not a covered benefit |
Not a covered benefit |
None |
D6101 |
Implant |
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 |
Implant |
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 |
Implant |
Bone graft for repair of peri-implant defect – not including flap entry and closure |
Not a covered benefit |
Not a covered benefit |
None |
D6104 |
Implant |
Bone graft at time of implant placement |
Not a covered benefit |
Not a covered benefit |
None |
D6105 |
Implant |
Removal of implant body not requiring bone removal or flap elevation |
Not a covered benefit |
Not a covered benefit |
None |
D6106 |
Implant |
Guided tissue regeneration – resorbable barrier, per implant |
Not a covered benefit |
Not a covered benefit |
None |
D6107 |
Implant |
Guided tissue regeneration – non-resorbable barrier, per implant |
Not a covered benefit |
Not a covered benefit |
None |
D6110 |
Implant |
Implant /abutment supported removable denture for edentulous arch – maxillary |
Once per 60 months. |
Once per 60 months. |
Arch identification |
D6111 |
Implant |
Implant /abutment supported removable denture for edentulous arch – mandibular |
Once per 60 months. |
Once per 60 months. |
Arch identification |
D6112 |
Implant |
Implant /abutment supported removable denture for partially edentulous arch – maxillary |
Once per 60 months. |
Once per 60 months. |
Arch identification |
D6113 |
Implant |
Implant /abutment supported removable denture for partially edentulous arch – mandibular |
Once per 60 months. |
Once per 60 months. |
Arch identification |
D6114 |
Implant |
Implant /abutment supported fixed denture for edentulous arch – maxillary |
Not a covered benefit. |
Not a covered benefit. |
None |
D6115 |
Implant |
Implant /abutment supported fixed denture for edentulous arch – mandibular |
Not a covered benefit . |
Not a covered benefit . |
None |
D6116 |
Implant |
Implant /abutment supported fixed denture for partially edentulous arch – maxillary |
Not a covered benefit. |
Not a covered benefit. |
None |
D6117 |
Implant |
Implant /abutment supported fixed denture for partially edentulous arch – mandibular |
Not a covered benefit. |
Not a covered benefit. |
None |
D6118 |
Implant |
Implant/abutment supported interim fixed denture for edentulous arch – mandibular |
Not a covered benefit. |
Not a covered benefit. |
None |
D6119 |
Implant |
Implant/abutment supported interim fixed denture for edentulous arch – maxillary |
Not a covered benefit. |
Not a covered benefit. |
None |
D6120 |
Implant |
Implant supported retainer – porcelain fused to titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6121 |
Implant |
Implant-supported retainer for metal FPD – predominantly base alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6122 |
Implant |
Implant-supported retainer for metal FPD – noble alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6123 |
Implant |
Implant-supported retainer for metal FPD – titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6190 |
Implant |
Radiographic/surgical implant index, by report |
Not a covered benefit |
Not a covered benefit |
None |
D6191 |
Implant |
Semi-precision abutment – placement |
Not a covered benefit. |
Not a covered benefit. |
None |
D6192 |
Implant |
Semi-precision attachment – placement |
Not a covered benefit. |
Not a covered benefit. |
None |
D6194 |
Implant |
Abutment supported retainer crown for FPD – titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6195 |
Implant |
Abutment supported retainer – porcelain fused to titanium and titanium alloys |
Not a covered benefit. |
Not a covered benefit. |
None |
D6197 |
Implant |
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 |
Implant |
Remove interim implant component |
Not a covered benefit. |
Not a covered benefit. |
None |
D6199 |
Implant |
Unspecified implant procedure, by report |
Not a covered benefit. |
Not a covered benefit. |
None |
D6205 |
Prosthodontics (fixed) |
Pontic – indirect resin-based composite |
Not a covered benefit. |
Not a covered benefit. |
None |
D6210 |
Prosthodontics (fixed) |
Pontic – cast high noble |
Not a covered benefit |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6211 |
Prosthodontics (fixed) |
Pontic – cast predominantly base metal |
Not a covered benefit |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6212 |
Prosthodontics (fixed) |
Pontic – cast noble metal |
Not a covered benefit |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6214 |
Prosthodontics (fixed) |
Pontic – titanium and titanium alloys |
Not a covered benefit |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6240 |
Prosthodontics (fixed) |
Pontic – porcelain fused to high noble metal |
Not a covered benefit |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6241 |
Prosthodontics (fixed) |
Pontic – porcelain fused to predominantly base metal |
Once per 60 months per tooth. |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6242 |
Prosthodontics (fixed) |
Pontic – porcelain fused to noble metal |
Not a covered benefit. |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6243 |
Prosthodontics (fixed) |
Pontic – porcelain fused to titanium and titanium alloys |
Not a covered benefit. |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6245 |
Prosthodontics (fixed) |
Pontic – porcelain/ceramic |
Not a covered benefit. |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6250 |
Prosthodontics (fixed) |
Pontic – resin with high noble metal |
Not a covered benefit. |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6251 |
Prosthodontics (fixed) |
Pontic – resin with predominantly base metal |
Not a covered benefit. |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6252 |
Prosthodontics (fixed) |
Pontic – resin with noble metal |
Not a covered benefit. |
One pontic per permanent tooth per 84 months. |
Tooth identification |
D6253 |
Prosthodontics (fixed) |
Interim pontic – further treatment or completion of diagnosis necessary prior to final impression |
Not a covered benefit. |
Not a covered benefit. |
None |
D6545 |
Prosthodontics (fixed) |
Retainer – cast metal for resin-bonded fixed prosthesis |
Not a covered benefit. |
One restoration per permanent tooth per 84 months. |
Tooth identification |
D6548 |
Prosthodontics (fixed) |
Retainer – porcelain/ ceramic for resin-bonded fixed prosthesis |
Not a covered benefit. |
One restoration per permanent tooth per 84 months. |
Tooth identification |
D6549 |
Prosthodontics (fixed) |
Resin retainer – for resin bonded fixed prosthesis |
Not a covered benefit. |
One restoration per permanent tooth per 84 months. |
Tooth identification |
D6600 |
Prosthodontics (fixed) |
Retainer inlay – porcelain/ceramic, two surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6601 |
Prosthodontics (fixed) |
Retainer inlay – porcelain/ceramic, three or more surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6602 |
Prosthodontics (fixed) |
Retainer inlay – cast high noble metal, two surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6603 |
Prosthodontics (fixed) |
Retainer inlay – cast high noble metal, three or more surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6604 |
Prosthodontics (fixed) |
Retainer inlay – cast predominantly base metal, two surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6605 |
Prosthodontics (fixed) |
Retainer inlay – cast predominantly base metal, three or more surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6606 |
Prosthodontics (fixed) |
Retainer inlay – cast noble metal, two surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6607 |
Prosthodontics (fixed) |
Retainer inlay – cast noble metal, three or more surfaces |
Not a covered benefit. |
One restoration per tooth surface per 84 months. |
Tooth identification |
D6608 |
Prosthodontics (fixed) |
Retainer onlay –porcelain/ceramic, two surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6609 |
Prosthodontics (fixed) |
Retainer onlay – porcelain/ ceramic, three or more surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6610 |
Prosthodontics (fixed) |
Retainer onlay – cast high noble metal, two surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6611 |
Prosthodontics (fixed) |
Retainer onlay – cast high noble metal, three or more surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6612 |
Prosthodontics (fixed) |
Retainer onlay – cast predominantly base metal, two surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6613 |
Prosthodontics (fixed) |
Retainer onlay – cast predominantly base metal, three or more surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6614 |
Prosthodontics (fixed) |
Retainer onlay – cast noble metal, two surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6615 |
Prosthodontics (fixed) |
Retainer onlay – cast noble metal, three or more surfaces |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6624 |
Prosthodontics (fixed) |
Retainer inlay – titanium |
Not a covered benefit. |
Not a covered benefit. |
None |
D6634 |
Prosthodontics (fixed) |
Retainer onlay – titanium |
Not a covered benefit. |
Once per tooth per 84 months. |
Tooth identification |
D6710 |
Prosthodontics (fixed) |
Retainer crown – indirect resin-based composite |
Not a covered benefit. |
Not a covered benefit. |
None |
D6720 |
Prosthodontics (fixed) |
Retainer crown – resin with high noble metal |
Not a covered benefit. |
One retainer crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6721 |
Prosthodontics (fixed) |
Retainer crown – resin with predominantly base metal |
Not a covered benefit. |
One retainer crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6722 |
Prosthodontics (fixed) |
Retainer crown – resin with noble metal |
Not a covered benefit. |
One retainer crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6740 |
Prosthodontics (fixed) |
Retainer crown – porcelain/ceramic |
Not a covered benefit. |
One retainer crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6750 |
Prosthodontics (fixed) |
Retainer crown – porcelain fused to high noble |
Not a covered benefit. |
One retainer crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6751 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Retainer crown – ¾ porcelain/ceramic |
Not a covered benefit. |
One retainer crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6784 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Retainer crown – full cast noble metal |
Not a covered benefit. |
One crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6793 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Retainer crown – titanium and titanium alloys |
Not a covered benefit. |
One crown or cast restoration per permanent tooth per 84 months. |
Tooth identification |
D6920 |
Prosthodontics (fixed) |
Connector bar |
Not a covered benefit. |
Not a covered benefit. |
None |
D6930 |
Prosthodontics (fixed) |
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 |
Prosthodontics (fixed) |
Stress breaker |
Not a covered benefit. |
Not a covered benefit. |
None |
D6950 |
Prosthodontics (fixed) |
Precision attachment |
Not a covered benefit. |
Not a covered benefit. |
None |
D6980 |
Prosthodontics (fixed) |
Fixed partial denture repair necessitated by restorative material failure |
Covered. |
One repair per 12 months. |
Quadrant identification Detailed narrative |
D6985 |
Prosthodontics (fixed) |
Pediatric partial denture, fixed |
Not a covered benefit. |
Not a covered benefit. |
None |
D6999 |
Prosthodontics (fixed) |
Unspecified fixed prosthodontic procedure, by report |
Individual consideration. |
Individual consideration. |
Detailed narrative |
D7111 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Removal of impacted tooth – soft tissue |
One per tooth per lifetime. |
One per tooth per lifetime. |
Tooth identification |
D7230 |
Oral & maxillofacial surgery |
Removal of impacted tooth – partially bony |
One per tooth per lifetime. |
One per tooth per lifetime. |
Tooth identification |
D7240 |
Oral & maxillofacial surgery |
Removal of impacted tooth – completely bony |
One per tooth per lifetime. |
One per tooth per lifetime. |
Tooth identification |
D7241 |
Oral & maxillofacial surgery |
Removal of impacted tooth – completely bony, with unusual surgical complications |
Not a covered benefit. |
One per tooth per lifetime. |
Tooth identification |
D7250 |
Oral & maxillofacial surgery |
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 |
Oral & maxillofacial surgery |
Coronectomy – intentional partial tooth removal, impacted teeth only |
Not a covered benefit. |
Once per tooth per lifetime (D3921 or D7251). |
Tooth identification |
D7260 |
Oral & maxillofacial surgery |
Oroantral fistula closure |
Not a covered benefit. |
Individual consideration. |
Periapical or panoramic radiograph Operative note Tooth identification |
D7261 |
Oral & maxillofacial surgery |
Primary closure of a sinus perforation |
Not a covered benefit. |
Individual consideration. |
Periapical or panoramic radiograph Operative note Tooth identification |
D7270 |
Oral & maxillofacial surgery |
Tooth reimplantation and/or stabilization of accidentally avulsed or displaced tooth |
Individual consideration. |
Once per permanent tooth per lifetime. |