CDT Dental Procedure Code Lookup

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Medication Look-up

How to check member benefits

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

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

Note: 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.

Step

: During Dental Connect outages, use the member’s ID card to determine the member’s product name and plan type. (Refer to our Change Healthcare Event page for outage updates.)

Step : Choose the member's plan using the information as it appears on the member's ID card.

Step : Type a CDT code (for example, D1206) in the search field for details about the code. To see results for all the codes in a range of services (for example, D0220-D0274) just type the first three characters in the series (for example, D02). Results will appear below.

CDT Code	ADA Category	Description of Service	Procedure Guidelines	Submission requirements for BCBSMA-participating providers	Submission requirements for out-of-state & non-par providers
D0120	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: One per 6 months per patient.	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
D0395	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
D1208	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2543	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2544	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2610	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion. For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2643	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion. For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2644	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion. For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2650	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion. For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2663	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion. For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2664	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion. For specific ACA-compliant small group plans only: Age 16+: One per tooth per 60 months. Note: Onlay refers to a dental restoration made outside the oral cavity that covers one or more cusp tips and adjoining occlusal surfaces, but not the entire external surface.	Tooth identification Surface identification (must include B or L surface)	Tooth identification Surface identification (must include B or L surface) Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2710	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2712	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic or periodontal perspective Periapical pathology or unresolved, incomplete or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2720	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2721	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2722	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2740	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2750	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2751	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2752	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2753	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2780	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2781	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2782	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2783	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: Ages 16+: One per permanent tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2790	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2791	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2792	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2794	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: Untreated bone loss Tooth has poor-to-hopeless prognosis from a restorative, endodontic, or periodontal perspective Periapical pathology or unresolved, incomplete, or failed endodontic therapy Services meant to treat TMJ, increase vertical dimension, or restore occlusion For specific ACA-compliant small group plans only: One per tooth per 60 months.	Tooth identification	Tooth identification Current mounted and dated pre-operative periapical radiographs Pre-treatment recommended
D2799	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
D2975	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
D2983	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
D5951	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
D7922	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
D9935	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
D9953	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 Surface 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 Surface 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.	None
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.	Tooth identification
D7272	Oral & maxillofacial surgery	Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)	Not a covered benefit.	Not a covered benefit.	None
D7280	Oral & maxillofacial surgery	Surgical access of unerupted tooth	Not a covered benefit.	Once per permanent tooth (1 through 32) per lifetime.	Tooth identification
D7282	Oral & maxillofacial surgery	Mobilization of erupted or mal-positioned tooth to aid eruption	Not a covered benefit.	Once per permanent tooth (1 through 32) per lifetime.	Tooth identification
D7283	Oral & maxillofacial surgery	Placement of a device to facilitate eruption of impacted tooth	Once per tooth per lifetime and covered only with approved medically necessary orthodontics.	Once per tooth per lifetime.	Tooth identification
D7284	Oral & maxillofacial surgery	Excisional biopsy of minor salivary glands	Individual consideration.	Individual consideration.	Pathology report
D7285	Oral & maxillofacial surgery