Dental Codes

CDT 2020
Dental Procedure codes and

Nomenclature
Hawaii Procedure Guidelines
TABLE OF CONTENTS
About This Guidebook ................................................................................................ 3
Utilization Management .............................................................................................. 4
Diagnostic Services .................................................................................................... 6
Preventive Services .................................................................................................. 20
Restorative Services ................................................................................................. 24
Endodontic Services ................................................................................................. 40
Periodontal Services ................................................................................................. 48
Procedure Billing Guidelines .................................................................................. 48
Payment for Surgical Services ............................................................................... 48
Prosthodontics, Removable ..................................................................................... 58
Implant Services ....................................................................................................... 71
Coverage ............................................................................................................... 71
Prosthodontics, Fixed............................................................................................... 81
Oral and Maxillofacial Surgery ................................................................................. 91
Orthodontic Services .............................................................................................. 111
Orthodontic Benefit Administration....................................................................... 111
How to Submit Claims - Please follow these guidelines when submitting claims
for orthodontic treatment: ..................................................................................... 111
Adjunctive General Services ................................................................................. 115
Edition 1: 01-2020
2
ABOUT THIS GUIDEBOOK
This guide is organized according to the latest and most current edition of the American Dental
Association (ADA) Current Dental Terminology (CDT) procedure codes. We accept only coding
that is consistent with the verbal descriptors of CDT. However, the presence of a code in CDT
does not mean that a subscriber has coverage available. We determine member benefits on the
basis of our administrative policies and the terms of the subscriber’s certificate. As always, we
remind you to check benefits and eligibility before performing services.
Some of the categories of service have introductory sections to explain what information you need to
provide to facilitate our claim processing. For a more complete description of procedures, please refer to
the American Dental Association, Current Dental Terminology – 2020.
We’ve designed these administrative guidelines and policies to promote our members’ long-term oral
health. We review our policies on an ongoing basis to determine clinical appropriateness and to reflect
significant technical advances.
For each code, we have provided specific guidelines and recommendations with respect to time, age, or
other contractual limitations or exclusions. We have also noted when procedures are not covered
benefits. We also indicate procedure codes that require radiographic (X-ray) imaging documentation and
other supplementary documentation. Please use this guide to determine the correct code to describe the
service you provided to your patient. We hope that making our policies and guidelines clear and easily
available will enable your office to receive the appropriate compensation for the services provided to our
members, your patients.
If you need additional information on how to submit a claim, you can:
 Refer to the Dental Administrative Manual

 Go to .hmsadental.com/providers to access administrative information
 Call the Dental Call Center at 808-948-6440 on Oahu or 1-800-792-4672 toll-free on the Neighbor
Islands
If you need additional information on how to submit a medical claim, you can:
 Refer to the Dental Administrative Manual/How to submit a Medical claim

 Go to hmsa.com/provider/portal/ to access administrative information
 Call the Dental Call Center at 808-948-6440 on Oahu or 1-800-792-4672 toll-free on the Neighbor
Islands.
3
UTILIZATION MANAGEMENT
While we continue to conduct utilization review on submitted claims, we will no longer routinely
require submission of radiographs or periodontal charting from participating HMSA PPO and HMO
providers. Please refer to the Submission Requirements column for any specific requirements
needed when submitting claims for treatment.
What is “Necessary and Appropriate Treatment?”

Our members’ subscriber certificates specify that all dental care must be “necessary and appropriate to
diagnose or treat your dental condition” and defines dental care as inclusive of services, procedures,
supplies, and appliances.” The member’s subscriber certificates identify the following criteria used to
determine whether dental care is necessary and appropriate for the member. The dental care must be:
 Consistent with the prevention and treatment of oral disease or with the diagnosis and treatment of
teeth that are decayed or fractured, or where the supporting structure is weakened by disease
(including periodontal, endodontic, and related diseases).
 Furnished in accordance with standards of good dental practice.

 Not solely for the member’s or dentist’s convenience.
How Do We Determine Necessity and Appropriateness of Treatment?
Based on a review of the submitted procedure documentation, our dental consultants determine available
benefits for certain types of procedures, including, but not limited to, cast restorations, periodontal
services, oral surgery services, and fixed and removable prosthetics. A dental consultant reviews the
treatment plan objectively and determines whether the services are within the scope of benefits, and
whether these services appear to be necessary and appropriate for the member. Based on these
findings, we may determine that a service is not necessary and appropriate for the member, even if a
dentist has recommended, approved, prescribed, ordered, or furnished the service.
Services That Are Non-covered Due to Contractual Limitations

There are situations in which specific services are not covered regardless of whether the procedure is a
covered benefit. These are considered contractual limitations and are outlined in the Subscriber
Certificate under “Limitations and Exclusions.” Examples include a service performed for cosmetic
purposes rather than for tooth decay or fracture or a service that is exploratory in nature.
4
Information We Need to Review a Procedure
We review procedures including, but not limited to, cast restorations, periodontal services, oral surgery
services, and fixed and removable prosthetics. To thoroughly review a procedure, we may need pertinent
documentation supporting your patient’s treatment. This Guide identifies the information you must submit
for each procedure that requires review. In cases where we request a detailed narrative, please
supply details about the patient’s condition that will help us evaluate your claim and reimburse
you appropriately.
When Documentation Is Requested

While we continue to conduct utilization review on submitted claims, we will no longer routinely
require submission of radiographs or periodontal charting from participating HMSA PPO and HMO
providers. Please refer to the Submission Requirements column for any specific requirements needed
when submitting claims for treatment.
When we do request documentation, please remember that radiographs must be:
 Preoperative radiographic images that are current and dated

 Labeled “left” or “right” side if they are duplicates
 Mounted if they are a full series
 Of diagnostic quality
Please remember to include:
 The Member’s name and ID

 The Dentist’s name and Address
Refer to the specific code listing to determine what additional documentation is required.
5
CDT: DIAGNOSTIC SERVICES
DIAGNOSTIC SERVICES
Submission
Procedure Guidelines or Limitations, Exclusions and Integral Requirements:
CDT Code Description of Service
Frequency Limitation Considerations Participating
Providers
CLINICAL ORAL EVALUATIONS: One (1) evaluation code may be billed per dentist per date of service. Evaluations, including diagnosis and treatment planning, are the
responsibility of the dentist. A dentist must complete all evaluations. Only two (2) evaluation codes in any combination are allowed per member per calendar year.
D0120 Periodic oral evaluation Only two (2) evaluation codes in any This includes an oral cancer evaluation and None
combination are allowed per periodontal screening where indicated, and may
member per calendar year. require interpretation of information acquired
through additional diagnostic procedures. Report
additional diagnostic procedures separately.
D0140 Limited oral evaluation: problem-focused These may require interpretation of information
acquired through additional diagnostic procedures.
Definitive procedures may be required on the same
date as the evaluation.
D0145 Oral evaluation for a patient less than 3 Preferably within the first six (6) months of the
years of age and counseling with primary eruption of the first primary tooth, including
caregiver recording the oral and physical health history,
especially of caries susceptibility, development of an
appropriate preventive oral health regime and
communication with and counseling of the child’s
parent, legal guardian and/or primary caregiver.
NOTE: These CDT Procedure Guidelines are to be used as a reference for claim submission based on the level of benefits for each subscriber’s plan. Particular
6 details will vary from plan to plan. Verification of eligibility and individual plan benefits is required to determine the specific level of benefit coverage.
Submission
Providers
D0150 Comprehensive oral evaluation, new or Only two (2) evaluation codes in The exam is a thorough evaluation and recording of None
established patient any combination are allowed per the extraoral hard and soft tissues. This includes an
member per calendar year. evaluation for oral cancer where indicted, the
evaluation and recording of the patient’s dental and
medical history and a general health assessment.
In addition, the exam would include the evaluation
and recording of dental caries, missing or
unerupted teeth, restorations, existing prostheses,
occlusal relationships, periodontal conditions
(including periodontal screening and/or charting),
hard and soft tissue anomalies, etc. It may also
require interpretation of information acquired
through additional diagnostic procedures. This
procedure applies to new patients or established
patients who have been absent from active
treatment three (3) or more years. The procedure
also applies to established patients who have had a
significant change in health conditions or other
unusual circumstances.
Submission
Providers
D0160 Detailed, extensive oral evaluation: Only two (2) evaluation codes in any A problem focused examination that entails None
problem-focused, by report combination are allowed per extensive diagnostic and cognitive modalities based
member per calendar year. on the findings of a comprehensive oral evaluation.
Integration of more extensive diagnostic modalities
to develop a treatment plan for a specific problem is
required. The condition requiring this type of
evaluation should be described and documented.
Examples of conditions requiring this type of
evaluation may include dentofacial anomalies,
complicated perio‐prosthetic conditions, complex
temporomandibular dysfunction, facial pain of
unknown origin, conditions requiring
multidisciplinary consultation, etc.
D0170 Re-evaluation: limited, problem focused Not a covered benefit None

(established patient, not post-operative
visit)
D0171 Re-evaluation - post-operative office visit
D0180 Comprehensive periodontal evaluation: Only two (2) evaluation codes in any Indicated for patients showing signs or symptoms of
new or established patient combination are allowed per periodontal disease and for patients with risk factors
member per calendar year. such as smoking or diabetes. It includes evaluation
of periodontal conditions, probing and charting,
evaluation and recording of the patient’s dental and
medical history and general health assessment. It
may also include the evaluation and recording or
dental caries, missing or unerupted teeth,
restorations, occlusal relationships and oral cancer
evaluation.
Submission
Providers
PRE-DIAGNOSTIC SERVICES
D0190 Screening of a patient Not a covered benefit A screening, including state or federally mandated None
screenings, to determine an individual’s need to be
seen by a dentist for diagnosis.
D0191 Assessment of a patient A limited clinical inspection that is performed to

identify possible signs of oral or systemic disease,
malformation, or injury, and the potential need for
referral for diagnosis and treatment.
DIAGNOSTIC IMAGING - Should be taken only for clinical reasons as determined by the patient’s dentist. Should be of diagnostic quality and properly identified and
dated. Is a part of the patient’s clinical record and the original images should be retained by the dentist. Originals should not be used to fulfill requests made by patients or
third-parties for copies of records.
IMAGE CAPTURE WITH INTERPRETATION
D0210 Intraoral complete series of radiographic One (1) in a three (3) year period Covered based on the last service date once every None
images D0210 or D0330 three (3) years, with the exception of the Federal
plan which is covered once every five (5) years,
based on the last service date.
D0220 Intraoral periapical – first radiographic 1 per day (no waiting period) Periapical films, for diagnostic purposes, are
image covered as needed. Intra‐operative “working”
radiographs are included with complete root canal
therapy.
 Periapical film taken with Panoramic film on the
same day will deny, and will be non-billable to
the patient.
Submission
Providers
D0230 Intraoral periapical – each additional Not to exceed five (5) films per date Periapical films, for diagnostic purposes, are None
radiographic image of service. (No waiting period) covered as needed. Intra‐operative “working”
radiographs are included with complete root canal
therapy.
 Periapical film taken with Panoramic film on the
same day will deny, and will be non-billable to
the patient.
D0240 Intraoral occlusal radiographic image By report Not payable as a substitute for children’s complete Arch identification
series of intraoral radiographs.
D0250 Extraoral – 2D projection radiographic Not a covered benefit None None

image created using a stationary
radiation source, and detector
D0251 Extraoral posterior dental radiographic

image
D0270 Bitewing – single radiographic image One (1) set per calendar year Any of these codes constitute a set of bitewings.
When bitewings are taken within 12 months of a
FMX, these guidelines apply.
D0272 Bitewings – two (2) radiographic images  If bitewings have been taken prior to a FMX, no
limitation applies and both procedures will be
paid.
D0273 Bitewings – three (3) radiographic  If bitewings are submitted within 12 months after
images a FMX has been paid, then the bitewings are
denied due to the 1 in 12 month limitation for
bitewings. The member will be responsible for
D0274 Bitewings – four (4) radiographic images the cost of the bitewings.
Submission
Providers
Vertical bitewings constitute a set of bitewings.

D0277 Vertical bitewings – seven (7) to eight (8) One (1) set per calendar year, for None
patients 15 years and older. When bitewings are taken within 12 months of a FMX,
radiographic images these guidelines apply.
 If bitewings have been taken prior to a FMX, no
limitation applies and both procedures will be paid.
 If bitewings are submitted within 12 months after a
FMX has been paid, then the bitewings are denied
due to the 1 in 12 month limitation for
bitewings. The member will be responsible for the
cost of the bitewings
D0310 Sialography Not a covered benefit None
D0320 Temporomandibular joint arthrogram,

including injection
D0321 Other temporomandibular joint films, by

report
D0322 Tomographic survey
D0330 Panoramic radiographic images Once in a three (3) year period Panoramic film is allowable in place of a complete
D0210 or D0330 series (D0210) based on the last service date, with
the frequency depending upon the terms of the
dental plan. Allowance for a complete series varies
among dental plans and ranges from one (1) per
calendar year to one (1) every five (5) years.
Additional panoramic film may be allowed for oral
surgeons, provided any previous panoramic film is
more than twelve (12) months old.
Submission
Providers
D0340 Cephalometric radiographic images Not a covered benefit None None
D0350 2D oral/facial photographic image

obtained intra-orally or extra-orally
D0351 3D photographic image
D0364 Cone beam CT capture and

interpretation with limited field of view –
less than one whole jaw.

interpretation with field of view of one full
dental arch - mandible

dental arch – maxilla, with or without
cranium.

interpretation with field of view of both
jaws, with or without cranium.
Submission
Providers
D0368 Cone beam CT capture and Not a covered benefit None None
interpretation for TMJ series including
two or more exposures.
D0369 Maxillofacial MRI capture and

interpretation.
D0370 Maxillofacial ultrasound capture and

interpretation.
D0371 Sialoendoscopy capture and

interpretation
IMAGE CAPTURE ONLY – Capture by a Practitioner not associated with Interpretation and Report
D0380 Cone bean CT image capture with limited Not a covered benefit None None
field of view – less than one whole jaw.

dental arch – mandible
Submission
Providers
D0382 Cone beam CT capture and Not a covered benefit None None
dental arch – maxilla, with or without
cranium.

interpretation with field of view of both
jaws, with or without cranium.

interpretation for TMJ series including
two or more exposures.
D0385 Maxillofacial MRI capture and

interpretation.
D0386 Maxillofacial ultrasound capture and

interpretation.
INTERPRETATION AND REPORT ONLY – Interpretation and Report by a Practitioner not associated with Image Capture
None None
D0391 Interpretation of diagnostic image by a Not a covered benefit
practitioner not associated with capture
of the image, including report.
Submission
Providers
POST PROCESSING OF IMAGE OR IMAGE SETS
None None
D0393 Treatment simulation using 3D image Not a covered benefit
volume
D0394 Digital subtraction of two or more images

or image volumes of the same modality
D0395 Fusion of two or more 3D image volumes

of one or more modalities
TESTS AND EXAMINATIONS
D0411 HbA1c in-office point of service testing Not a covered benefit None Submit to
medical carrier
D0412 Blood glucose level test for payment
determination.
D0414 Laboratory processing of microbial Not a covered benefit None None

specimen to include culture and
sensitivity studies, preparation and
transmission of written report
D0415 Collection of microorganisms for culture

and sensitivity
D0416 Viral Culture
D0417 Collection and preparation of saliva

sample for laboratory diagnostic testing
Submission
Providers
D0418 Analysis of saliva sample Not a covered benefit None None
D0422 Collection and preparation of genetic

sample material for laboratory analysis
and report
D0423 Genetic test for susceptibility to diseases None

– specimen analysis
D0425 Caries susceptibility tests
D0431 Adjunctive pre-diagnostic test that aids in Note: If member has oral cancer or Sjögren's
syndrome and is enrolled in Oral Health for Total
detection of mucosal abnormalities
Health, D0431 is covered once every six months.
including premalignant and malignant
lesions; does not include cytology or
biopsy procedures
D0460 Pulp vitality tests One (1) per member calendar year May be billed in conjunction with evaluation codes
or root canal therapy (D3310, D3320, and D3330).
If more than one tooth has pulp vitality testing on the
same date of service only one will be paid.
Not a covered benefit Not a covered benefit

D0470 Diagnostic casts
Submission
Procedure Guidelines or imitations, Exclusions and Integral Requirements:
Providers
ORAL PATHOLOGY LABORATORY (Use Codes D0472 – D0502) – These procedures do not include collection of the tissue sample, which is documented
separately.
D0472 Accession of tissue, gross examination, Not a covered benefit Not a covered benefit None
including preparation and transmission of
written report
D0473 Accession of tissue, gross and

microscopic examination, preparation
and transmission of written report
D0474 Accession of tissue, gross and None

microscopic examination, including
assessment of surgical margins for
presence of disease, preparation and
D0475 Decalcification procedure
D0476 Special stains for microorganisms
D0477 Special stains, not for microorganisms
D0478 Immunohistochemical stains
Submission
Providers
Not a covered benefit None None

D0479 Tissue in-site hybridization, including
interpretation
D0480 Processing and interpretation of

exfoliative cytologic smears, including
preparation and transmission of written
report
D0481 Electron microscopy
D0482 Direct immunofluorescence
D0483 Indirect immunofluorescence
D0484 Consultation on slides prepared

elsewhere
D0485 Consultation, including preparation of

slides from biopsy material supplied by
referring source
D0486 Laboratory accession of transepithelial

cytologic sample, microscopic
examination, preparation and
Submission
Providers

D0502 Other oral pathology procedures, by
report
D0600 Non-ionizing diagnostic procedure

capable of quantifying, monitoring, and
recording changes in structure of enamel,
dentin and cementum
D0601 Caries risk assessment and

documentation, with a finding of low risk

documentation, with a finding of
moderate risk

documentation, with a finding of high risk
D0999 Unspecified diagnostic procedure, by By report Individual Consideration. Detailed narrative Detailed narrative
report required.
CDT: PREVENTIVE SERVICES
PREVENTIVE SERVICES
Submission
Providers
DENTAL PROPHYLAXIS
D1110 Prophylaxis – adult Twice per calendar year age 13 and Covered according to the terms of dental plan. None
older Code D1110 may be used for member’s age13 and
older. Code D1120 should be used for children age
twelve (12) and younger.
D1120 Prophylaxis – child Twice per calendar year age 12 and Note: If member is enrolled in Oral Health for Total
younger Health, D1110/D1120 or D4346 or D4910 is
covered once every three months.
TOPICAL FLUORIDE TREATMENT OFFICE PROCEDURE
D1206 Topical application of fluoride varnish Twice per calendar year through Coverage is twice per calendar year for FFS/PPO None
age eighteen (18). Dental Plans. Fluoride varnish, code D1206, can be
used in combination with D1208 up to a total of two
(2), topical or varnish fluoride applications per
calendar year. The patient must be age eighteen
(18) or younger. Fluoride applications usually
accompany prophylaxis and/or oral evaluations.
Note: If member has oral cancer or Sjögren's

Health, D1206 or D1208 is covered once every
three months.
Submission
Providers
D1208 Topical application of fluoride – excluding Twice per calendar year through Coverage is twice per calendar year for FFS/PPO None
varnish age eighteen (18). Dental Plans. Topical application of fluoride, code
D1208, can be used in combination with D1206 up
to a total of two (2), topical or varnish fluoride
applications per calendar year. The patient must be
age eighteen (18) or younger. Fluoride applications
usually accompany prophylaxis and/or oral
evaluations.
Note: If member has oral cancer or Sjögren's

Health, D1206 or D1208 is covered once every
three months.
OTHER PREVENTIVE SERVICES
D1310 Nutritional counseling for control of dental Not a covered benefit None None
disease
D1320 Tobacco counseling for control and

prevention of oral disease
D1330 Oral hygiene instructions
Submission
Providers
D1351 Sealant – per tooth Once per tooth per lifetime up to age Sealants are a benefit of most dental plans, with a Tooth
sixteen (16). Limited to permanent few exceptions. When covered, sealants are Identification
molars. allowed for permanent molars only. The occlusal
surface must be free from overt dentinal caries and
restoration. Once per tooth per lifetime, 16 years
and under.
D1352 Preventive resin restoration in a Covered according to the terms of dental plan.
moderate to high caries-risk patient; Permanent molars only. Once per tooth per lifetime.
permanent tooth 16 years and under.
Not a covered benefit

D1353 Sealant repair – per tooth None None
Once per tooth per lifetime

D1354 Interim caries arresting medicament
application – per tooth
Submission
Providers
SPACE MAINTENANCE (PASSIVE APPLIANCES): Designed to prevent tooth movement
D1510 Space maintainer – fixed, unilateral

Once per arch per lifetime age The procedure codes listed are not to be used to Arch identification
thirteen (13) and younger. claim for the temporary replacement of teeth for
D1516 Space maintainer – fixed, bilateral
adults. Once per lifetime. For most dental plans, the
maxillary patient must be age 13 or younger. This limitation
D1517 Space maintainer – fixed, bilateral may vary depending on the terms of the patient's
mandibular dental plan.
D1520 Space maintainer – removable, bilateral

maxillary

mandibular
D1550 Re-cement or re-bond space maintainer

Once in a twelve (12) month period. Re‐cementation is allowed if more than six (6)
months have passed since insertion.
D1555 Removal of fixed space maintainer

Once per space maintainer; no age Removal of fixed space maintainer by the practice
limit where the appliance was originally delivered to the
patient is not a benefit.
Distal shoe space maintainer – fixed – This codes shares frequency limitation with Code
D1575 unilateral Once per arch per lifetime age
D1510. Member benefit will cover either D1510 or
thirteen (13) and younger.
D1575, and not both.
Unspecified preventive procedure, by By report Individual Consideration. Detailed narrative Detailed narrative
D1999 report required.
CDT: RESTORATIVE SERVICES
RESTORATIVE SERVICES
Submission
Providers
AMALGAM RESTORATIONS (INCLUDING POLISHING): Amalgam restorations include tooth preparation, localized tissue removal, base, indirect pulp cap, local
anesthesia and all adhesives (including amalgam bonding agents, liners and bases) included as part of the restoration. If used, pins should be reported separately (see
D2951). Restorations only allowed for fracture or decay. Restorations for erosion, attrition, or abrasion are not covered benefits.
Tooth
D2140 Amalgam – 1 surface, permanent or One (1) restoration per surface per Coverage includes polishing. Limited to one (1)
primary tooth per twelve (12) month period surface (O, M, D, B, and L) per twelve (12) month identification,
period regardless of materials used and how many Surface
separate restorations share the same surface. identification
There is a twelve (12) month waiting period between
services
D2150 Amalgam – 2 surfaces, permanent or

primary
D2160 Amalgam – 3 surfaces, permanent or

primary
D2161 Amalgam – 4 or more surfaces,

permanent or primary
Submission
Providers
RESIN-BASED COMPOSITE RESTORATIONS: 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, 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.
D2330 Resin-based composite, 1 surface, One (1) restoration per surface per Limited to one (1) surface (I, M, D, B, and L) per Tooth
anterior tooth per twelve (12) month period twelve (12) month period regardless of materials identification,
used and how many separate restorations share the Surface
same surface identification
D2331 Resin-based composite, 2 surfaces,
anterior
D2332 Resin-based composite, 3 surfaces,

anterior
D2335 Resin-based composite, 4 or more

surfaces or involving incisal angle,
anterior
D2390 Resin-based composite crown, anterior Most plans cover as an alternate Covered according to the terms of the member’s Tooth
benefit; D2930 or D2931. One (1) dental plan. If the member elects to have a resin‐ identification
per tooth per three (3) years. based composite crown the member will be
responsible for the difference between the stainless
steel crown allowance and the dentist's billed
charge. There is a three‐year waiting period
between services.
Submission
Providers
D2391 Resin-based composite, 1 surface, Most plans cover as an alternate Covered according to the terms of the member’s Tooth
posterior, permanent or primary benefit; D2140, D2150, D2160, dental plan. Stand‐alone single facial restorations identification,
D2161. One (1) restoration per on bicuspids will be considered as exceptions and Surface
surface per tooth per twelve (12) will be covered as composites. Specify surfaces and identification
D2392 Resin-based composite, 2 surfaces, months tooth numbers. Limited to one (1) surface (O, M, D,
posterior, permanent, or primary B, L) per twelve (12) month period regardless of
materials used and how many separate restorations
D2393 Resin-based composite, 3 surface, share the same surface. Example: Two (2)
posterior, permanent, or primary separate restorations, an MO and DO. The MO will
be paid as a D2392 and the D will be paid
separately as a D2391. There is a twelve (12)
D2394 Resin-based composite, 4 or more month waiting period between services. If a
surfaces, posterior permanent, or primary member elects to have a resin‐based composite
restoration on a posterior tooth, the member will be
responsible for the difference between the alternate
amalgam allowance and the dentist's charge.
GOLD FOIL RESTORATIONS
D2410 Gold foil, 1 surface Not a covered benefit None None
D2420 Gold foil, 2 surfaces
D2430 Gold foil, 3 surfaces
Submission
Providers
INLAY/ONLAY RESTORATIONS
 Inlay: An intra‐coronal dental restoration, made outside the oral cavity to conform to the prepared cavity, which does not restore any cusp tips.
 Onlay: 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
When services are covered:

 To restore fractured or severely diseased teeth that cannot properly be restored by direct amalgam or resin restorations.
 Teeth must be endodontically and periodontally sound.
 Onlays are defined as needing buccal and or lingual cusp reduction and coverage.
When services are not covered:

 Cosmetic purposes or to restore or treat complications of non-covered procedures.
 To treat TMJ dysfunction.
 Increase vertical dimension.
 Restore occlusion lost through erosion, abrasion, or attrition.
 Correction of congenital or developmental abnormalities.
Benefit criteria and limitations:

 Restoration is covered only once every five (5) years.
 Members fifteen (15) years or older.
 Permanent teeth only.
 Service or completion date is the cementation date.
 Service includes preparation of teeth, indirect pulp caps, bases, liners, laboratory costs, temporary crowns/bridges, cementation and local anesthesia.
 If an alternate benefit is paid, the member is responsible for the difference between The Plan allowance and provider’s billed charge.
 Gingivectomy performed in conjunction with an inlay/onlay is considered a part of the procedure and cannot be billed separately.
Submission
Providers
D2510 Inlay – metallic, 1 surfaces One (1) per tooth per five (5) years. Metallic inlays may be covered when clinical Tooth
See benefit criteria and limitations at conditions such as extensive caries or fractures do identification,
the beginning of this section. not permit a direct restoration. Coverage is for Surface
D2520 Inlay – metallic, 2 surfaces permanent teeth only. Frequency limitations: There identification
is a five (5) year waiting between services. The
patient must be age fifteen (15) or older. Service or
D2530 Inlay – metallic, 3 or more surfaces completion date is the cementation date.
D2542 Onlay – metallic, 2 surfaces
D2543 Onlay – metallic, 3 surfaces
D2544 Onlay – metallic, 4 or more surfaces
Submission
Providers
D2610 Inlay – porcelain/ceramic, 1 surface One (1) per tooth per five (5) years. Porcelain/ceramic inlays are considered cosmetic Tooth
Alternate benefit; D2510, D2520, and are not a benefit of The Plan. However, an identification,
D2530 alternate benefit of an equivalent metallic inlay will Surface
D2620 Inlay – porcelain/ceramic, 2 surfaces be considered for payment when clinical conditions identification
of extensive caries or fracture do not permit a direct
restoration. Coverage is for permanent teeth only. If
D2630 Inlay – porcelain/ceramic, 3 or more an alternate payment is made the member is
surfaces responsible for any copayments and the difference
between The Plans allowance and the provider’s
actual charge. There is a five (5) year waiting
period between services. The patient must be age
fifteen (15) or older.
D2642 Onlay – porcelain/ceramic, 2 surfaces One (1) per tooth per five (5) years. Porcelain/ceramic onlays are considered cosmetic
Alternate benefit; D2542, D2543, and are not a benefit of The Plan. However, an
D2544 alternate benefit of an equivalent metallic onlay will
D2643 Onlay – porcelain/ceramic, 3 surfaces be considered for payment when clinical conditions
of extensive buccal or lingual cusp coverage caries
or fracture do not permit a direct restoration for
D2644 Onlay – porcelain/ceramic, 4 or more permanent teeth only. If an alternate payment is
surfaces made the member is responsible for any
copayments and the difference between The Plan’s
allowance and the provider’s actual charge. There
is a five (5) year waiting period between services.
The patient must be age fifteen (15) or older.
Service or completion date is the cementation date.
Submission
Providers
D2650 Inlay – resin-based composite, 1 surface One (1) per tooth per five (5) years. Resin‐based composite inlays are considered Tooth
Alternate benefit; D2510, D2520, cosmetic and are not a benefit of The Plan. identification,
D2530. However, an alternate benefit of an equivalent Surface
D2651 Inlay – resin-based composite, 2 metallic inlay will be considered for payment when identification
surfaces clinical conditions of extensive caries or fracture do
not permit a direct restoration. Coverage is for
permanent teeth only. If an alternate payment is
D2652 Inlay – resin-based composite, 3 or more made the member is responsible for any
surfaces copayments and the difference between The Plans
allowance and the provider’s actual charge. There
is a five (5) year waiting period between services.
D2662 Onlay – resin-based composite, 2 One (1) per tooth per five (5) years. Resin‐based composite onlays are considered
surfaces Alternate benefit; D2542, D2543, cosmetic and are not a benefit of The Plan.
D2544 However, an alternate benefit of an equivalent
metallic onlay will be considered for payment when
Onlay – resin-based composite, 3 clinical conditions of buccal or lingual cusp
D2663
surfaces coverage extensive caries or fracture do not permit
a direct restoration. Coverage is for permanent
D2664 Onlay – resin-based composite, 4 or
more surfaces teeth only. If an alternate payment is made the
member is responsible for any copayments and the
difference between The Plans allowance and the
provider’s actual charge. There is a five (5) year
waiting period between services. The patient must
be age fifteen (15) or older. Service or completion
date is the cementation date.
Submission
Providers
CROWNS, SINGLE RESTORATIONS ONLY

 To restore fractured or severely diseased teeth which cannot properly be restored by direct amalgam or resin restorations.
 Teeth must be endodontically and periodontally sound.

 Correction of congenital or developmental abnormalities

 Service includes preparation of teeth, indirect pulp cap, bases, liners, laboratory costs, temporary crowns/bridges, cementation and local anesthesia.
 Gingivectomy performed in conjunction with a crown is considered a part of the procedure and cannot be billed separately.
Submission
Providers
Once per tooth per five (5) years for Crowns are covered when as a result of extensive Tooth
D2710 Crown – resin-based composite (indirect)
permanent teeth only. caries or fracture; the tooth cannot be restored with identification
a direct restoration. Porcelain/ceramic, porcelain
fused to metal, resin, and resin with metal and metal
crowns are covered for anterior and bicuspid teeth
D2712 Crown - ¾ resin-based composite
meeting policy guidelines. Resin/porcelain crowns
(indirect), does not include facial veneers
or resin/porcelain on metal crowns placed fused to
molars are covered as an alternate benefit at the full
D2720 Crown – resin with high-noble metal metal crown rate. The member is responsible for the
difference between allowance and the provider's
billed charge. Indirect crowns placed on primary
D2721 Crown – resin with predominantly base
teeth are paid at the stainless steel rate, except
metal
where the permanent tooth is congenitally missing.
Five (5) year waiting period between services.
D2722 Crown – resin with noble metal Patient must be age fifteen (15) or older. Service or
completion date is the cementation date.
D2740 Crown – porcelain/ceramic substrate
D2750 Crown – porcelain fused to high-noble

metal
D2751 Crown – porcelain fused to

predominantly base metal
Submission
Providers
Once per tooth per five (5) years for Crowns are covered when as a result of extensive Tooth
D2752 Crown – porcelain fused to noble metal
permanent teeth only. caries or fracture; the tooth cannot be restored with identification
a direct restoration. Porcelain/ceramic, porcelain
D2780 Crown – ¾ cast high noble metal fused to metal, resin, and resin with metal and metal
D2781 Crown – ¾ cast predominantly base meeting policy guidelines. Resin/porcelain crowns
metal or resin/porcelain on metal crowns placed fused to
molars are covered as an alternate benefit at the full
D2782 Crown – ¾ cast noble metal metal crown rate. The member is responsible for the
difference between allowance and the provider's
billed charge. Indirect crowns placed on primary
D2783 Crown – ¾ porcelain/ceramic (not
veneers) teeth are paid at the stainless steel rate, except
where the permanent tooth is congenitally missing.
D2790 Crown – full cast high-noble metal Five (5) year waiting period between services.
Patient must be age fifteen (15) or older. Service or
D2791 Crown – full cast predominantly base
metal
D2792 Crown – full cast noble metal
D2794 Crown – titanium
D2799 Provisional crown - further treatment or Not a covered benefit None

completion of diagnosis necessary prior
to final impression.
Submission
Providers
OTHER RESTORATIVE SERVICES
D2910 Re-cement or re-bond inlay, onlay, Maximum two (2) in a five (5) year Coverage is for two (2) re-cementations per Tooth
veneer or partial coverage restoration period. Age fifteen (15) or older inlay/onlay, crown, fixed partial denture, or cast or identification
prefabricated post and core. Re-cementation of
D2915 Re-cement or re-bond indirectly inlays, onlays, and fixed partial dentures may be
fabricated or prefabricated post and core performed on permanent teeth only. Crowns may be
re-cemented on both primary and permanent teeth.
Re-cementation is allowable if six (6) months have
D2920 Re-cement or re-bond crown Maximum two (2) in a five (5) year
passed since the original cementation date.
period.
There is a twelve (12) month waiting period
between re-cementations. The member must be
age fifteen (15) or older except for crown re-
cementation.
D2921 Reattachment of tooth fragment, incisal Not a covered benefit None None
edge or cusp
D2929 Prefabricated porcelain/ceramic crown- Alternate benefit: D2930 One (1) per Coverage includes bases, liners and local Tooth
primary tooth tooth per three (3) year period anesthesia. Prefabricated stainless steel or resin identification
crowns are not covered if used as temporary
crowns. There is a three (3) year waiting period
between services. Alternate benefit D2930.
Submission
Providers
Prefabricated stainless steel crown – Once per tooth per three (3) years Coverage includes indirect pulp caps, bases, liners Tooth
D2930
primary tooth and local anesthesia. Prefabricated stainless steel identification
or resin crowns are not covered if used as
Prefabricated stainless steel crown – temporary crowns. There is a three (3) year waiting
D2931 period between services. Service or completion date
permanent tooth
is the cementation date.
D2932 Prefabricated resin crown
D2933 Prefabricated stainless steel crown with Not a covered benefit None None
resin window
D2934 Prefabricated esthetic coated stainless Alternate benefit: D2930 One (1) per Coverage includes bases, liners and local Tooth
steel crown – primary tooth tooth per three (3) year period anesthesia. Prefabricated stainless steel or resin identification
crowns are not covered, if used as temporary
crowns. There is a three (3) year waiting period
between services. Alternate benefit D2930 Service
or completion date is the cementation date.
D2940 Protective restoration Not a covered benefit None None
D2941 Interim therapeutic restoration – primary

dentition
Submission
Providers
D2949 Restorative foundation for an indirect Not a covered benefit. Always Integral to Restorative Procedure None
restoration integral
D2950 Core buildup, including any pins when One (1) per tooth per five (5) years Core buildup is allowed for endodontically-treated Tooth
required for permanent teeth only. Age teeth. Core buildup is covered for vital teeth when identification
fifteen (15) or older more than 50 percent of the coronal tooth structure
is missing. Core build up should not be reported
when the procedure only involves a filler to eliminate
any undercut, box form, or concave irregularity in
the preparation. One (1) every five (5) years. Age
limitations: The patient must be age fifteen (15) or
older. When combined in a claim with a cast or
prefabricated post and core (D2952, D2954), core
buildup (D2950) is not paid separately.
D2951 Pin retention – per tooth, in addition to Up to two (2) pins per tooth as a Pins are covered for permanent teeth only.
restoration lifetime maximum
Pin retention is not covered separately when
claimed with cast-post and core, prefabricated-post
and core, and core buildup (D2952, D2954, and
D2950).
To be eligible for payment, services must occur 12

months apart.
Submission
Providers
D2952 Post and core in addition to crown; One (1) per tooth per five (5) years. Post and core are not included as part of a crown Tooth
indirectly fabricated Age fifteen (15) or older and are eligible for separate payment. Post and identification
core are covered for permanent teeth that have
received root canal therapy. Replacement once
every five (5) years as needed. The patient must be
age fifteen (15) or older. Core build-up (D2950) and
pin retention (D2951) are not covered separately if
claimed with D2952, D2954, D6970 or D6972 on
same tooth. Service or completion date is the
cementation date.
D2953 Each additional cast post – same tooth; Not a covered benefit None None
indirectly fabricated
D2954 Prefabricated post and core in addition to One (1) per tooth per five (5) years Prefabricated post and core are not included as part Tooth
crown for permanent teeth only. Age fifteen of a crown and are eligible for separate payment. identification
(15) or older Prefabricated post and core are covered for
permanent teeth that have received root canal
therapy. Replacement once every five (5) years as
needed. The patient must be age fifteen (15) or
older. Core build-up (D2950) and pin retention
(D2951) are not covered separately if claimed with
D2952, D2954, D6970 or D6972 on same tooth.
Submission
Providers
D2955 Post removal Not a covered benefit None None
D2957 Each additional prefabricated post –

same tooth
D2960 Labial veneer (resin laminate) – chair

side
D2961 Labial veneer (resin laminate) – By report Age fifteen (15) or older. Labial veneers are covered when the tooth, as a Tooth
laboratory Once per tooth per five (5) years result of extensive caries, fracture or root canal identification
permanent teeth only. therapy, cannot be restored with a direct restoration
D2962 Labial veneer (porcelain laminate) – on permanent teeth only. Only veneers on anterior
laboratory teeth (#6 through #11, #22 through #27) are
covered. Labial veneers are not a benefit if used on
bicuspids or molars.
Labial veneers are not a benefit if performed for
cosmetic purposes or when normal dental attrition
occurs. Five (5) year waiting period between
services. The patient must be age fifteen (15) or
older. Service or completion date is the cementation
date.
Submission
Providers
D2971 Additional procedures to construct new One (1) per tooth per five (5) years. One (1) per tooth per five (5) years. For members Tooth
crown under existing partial denture Permanent teeth only. Age fifteen age fifteen (15) and older. Must be reported with identification
framework (15) or older individual crown.
D2975 Coping Not a covered benefit None None
D2980 Crown repair necessitated by restorative Once in five (5) years. Age fifteen (15) or older. Tooth
material failure. identification
D2981 Inlay repair necessitated by restorative

material failure
D2982 Onlay repair necessitated by restorative

material failure
D2983 Veneer repair necessitated by restorative

material failure
D2990 Resin infiltration of incipient smooth One (1) per tooth surface per 12 Allowed on the smooth surface (buccal or lingual) of
months. Permanent teeth only. B permanent teeth only. One (1) per tooth surface per
surface lesions
or L surfaces(smooth surfaces only) 12 months. Permanent teeth only. B or L surfaces
(smooth surfaces only)
D2999 Unspecified restorative procedure, by By report Individual Consideration. Detailed narrative Tooth
report required. identification,
Detailed narrative
CDT: ENDODONTIC SERVICES
ENDODONTIC SERVICES
Please note the following:
 Endodontic procedures include exams, pulp tests, pulpotomy, pulpectomy, extirpation of pulp, and pre-operative, operative, and post-operative
radiographs/diagnostic images, filling of canals, bacteriologic cultures and local anesthesia.
 Endodontic therapy performed specifically for coping or overdenture is not covered.
 Please bill claims for multiple-stage procedures only on the date of completion/insertion.
 Payment for endodontic services does not mean that benefits will be available for subsequent restorative services. Coverage for those services is still
subject to exclusions listed under major restorative guidelines.
Submission
Providers
PULP CAPPING
D3110 Pulp cap direct (excluding final Once per tooth per lifetime Allowance for direct pulp cap may be made for Tooth
restoration) exposure of a vital pulp. The service is limited to identification
one (1) pulp cap per tooth, and the member is
responsible for payment of charges for any repeat
procedures. Once per tooth per lifetime. May be
billed in conjunction with restorative codes.
D3120 Pulp cap indirect (excluding final Not a covered benefit None None
restoration)
Submission
Providers
PULPOTOMY: Therapeutic pulpotomy (excluding final restoration)
D3220 Therapeutic pulpotomy (excluding final Once per tooth per lifetime To be performed on primary and permanent teeth. Tooth
restoration) – removal of pulp coronal to Not to be construed as the first stage of root canal identification
dentinocemental junction and application therapy. Not to be construed as an emergency
of medicament (not to be used for procedure to relieve pain or "open and broach."
apexogenesis) Once per tooth per lifetime. If root canal therapy is
performed on the same tooth, there is no separate
coverage for the therapeutic pulpotomy.
D3221 Pulpal debridement, primary and The patient must not have been previously
permanent teeth not to be used for appointed for the problem and has been "added-in"
apexogenesis to render emergent care only. Coverage includes
local anesthetic. Pulpal debridement will not be paid
if root canal therapy is completed the same day.
None
D3222 Partial pulpotomy for apexogenesis – Not a covered benefit None
permanent tooth with incomplete root
development.
Submission
Providers
ENDODONTIC THERAPY ON PRIMARY TEETH
D3230 Pulpal therapy (resorbable filling) Not a covered benefit None None
anterior, primary tooth (excluding final
restoration)
D3240 Pulpal therapy (resorbable filling)

posterior primary tooth (excluding final
restoration)
ENDODONTIC THERAPY (including treatment plan, clinical procedures and follow up care)
Tooth
D3310 Anterior tooth (excluding final restoration) One (1) per tooth per lifetime. Pulpectomy, D3221, is considered part of the root
canal therapy and is not paid separately. Root canal identification
treatment does not include diagnostic evaluation
D3320 Bicuspid tooth (excluding final and necessary diagnostic radiographs. These may
restoration) be billed separately. If a root canal is not completed
allowance for palliative treatment (D9110) may be
made. Once per permanent tooth.
D3330 Molar tooth (excluding final restoration)
Submission
Providers
D3331 Treatment of root canal obstruction; non- Not a covered benefit None None
surgical access in lieu of surgery.
Root canal blocked by foreign bodies or

calcification of 50% or more of root.
D3332 Incomplete endodontic therapy; Benefit for Federal plan only. Tooth
Services are not covered when performed on
inoperable, unrestorable, or fractured Please check with the Plan for primary teeth identification
tooth member’s eligibility for this service.
D3333 Internal root repair of perforation defects None

Not a covered benefit None
ENDODONTIC RETREATMENT
D3346 Retreatment of previous root canal Once per tooth per lifetime. Due to its complexity non-surgical root canal re- Tooth
therapy, anterior, by report treatment is most frequently performed by identification
endodontists. Coverage includes post-operative
care and local anesthesia. Payable twelve (12)
D3347 Retreatment of previous root canal
months post treatment following codes D3310,
therapy, bicuspid, by report
D3320, D3330. Once per tooth per lifetime. Re-
treatment of previous root canal therapy is not
D3348 Retreatment of previous root canal payable with apicoectomy/periradicular services
therapy, molar, by report (D3410, D3421, D3425, D3426, and D3430) and
apexification/re-calcification procedures. Post
removal (D2955) not to be used with endodontic re-
treatment (D3346, D3347, D3348).
Submission
Providers
APEXIFICATION/RECALCIFICATION
D3351 Apexification/recalcification: initial visit Once per tooth per lifetime. Apexification/recalcification (D3351, initial visit) Tooth
(apical closure/ calcific repair of includes opening tooth, preparation of canal spaces, identification
perforations, root resorption, etc.) first placement of medication and any necessary
radiographs/diagnostic images. Permanent teeth
only. (This procedure may include first phase of
complete root canal therapy.
D3352 Apexification/recalcification regeneration: Apexification/recalcification (D3352, interim

interim medication replacement medication replacement) includes visits in which the
intra-canal medication is replaced with new
medication and any necessary
radiographs/diagnostic images. Once per tooth.
Permanent teeth only. (This procedure includes
final root canal therapy).
D3353 Apexification/recalcification: final visit Apexification/recalcification (D3353, final visit)

(includes completed root canal therapy – includes removal of intra-canal medication and
apical closure/calcific repair of procedures necessary to place final root canal filling
perforations, root resorption, etc.) material, including any necessary
radiographs/diagnostic images. Once per tooth.
Permanent teeth only. (This procedure includes last
phase of complete root canal).
Submission
Providers
D3355 Pulpal regeneration - initial visit Once per tooth per lifetime. Once per tooth per lifetime. Not paid if claimed Tooth
same day or if history of D3310, D3320, D3330 identification
D3410, D3426 or D3430 on file.
D3356 Pulpal regeneration - interim medication
replacement
D3357 Pulpal regeneration - completion of

treatment
APICOECTOMY/PERIRADICULAR SERVICES: Includes all pre-operative radiographs, bacteriologic cultures, local anesthesia and routine follow-up care
D3410 Apicoectomy – anterior Once per permanent tooth root per Apicoectomy (D3410, D3421, D3425, D3426) or Tooth
lifetime. retrograde filling (D3430) reported within 30 days identification
after a root canal will deny as integral.
D3421 Apicoectomy – bicuspid (first root)
D3425 Apicoectomy – molar (first root)
D3426 Apicoectomy (each additional root)
Submission
Providers
D3427 Periradicular surgery without Once per permanent tooth root per Apicoectomy (D3410, D3421, D3425, D3426) or Tooth
apicoectomy lifetime. retrograde filling (D3430) reported within 30 days identification
D3428
Bone graft in conjunction with Not a covered benefit None None
periradicular surgery – per tooth, single
site
D3429 Bone graft in conjunction with

periradicular surgery – each additional
contiguous tooth in the same surgical site
Tooth and root

D3430 Retrograde filling – per root Once per permanent tooth root per Apioectomy (D3410, D3421, D3425, D3426) or
lifetime retrograde filling (D3430) reported within 30 days identification
D3431 Biologic materials to aid in soft and Not a covered benefit None None
osseous tissue regeneration in
conjunction with periradicular surgery
D3432 Guided tissue regeneration, resorbable

barrier, per site, in conjunction with
periradicular surgery
Submission
Providers
D3450 Root amputation – per root Once per permanent tooth root per Apicoectomy (D3410, D3421, D3425, D3426) or Tooth
lifetime. retrograde filling (D3430) reported within 30 days identification
D3460 Endodontic endosseous implant Not a covered benefit None None
D3470 Intentional reimplantation (including

necessary splinting)
D3910 Surgical procedure for isolation of tooth

with rubber dam
D3920 Hemisection (including any root removal), One (1) per tooth per lifetime. Allowance is for permanent teeth only. Root canal therapy Tooth
not including root canal therapy for the remaining root is covered separately. May be identification
performed once per tooth. Root canal therapy may be
completed before hemisection services are claimed. A
crown/retainer may be allowed for the remaining crown
segment, but a pontic for the resected portion of the tooth
and root will not be allowed.
D3950 Canal preparation and fitting of Not a covered benefit. None None
preformed dowel or post
Individual Consideration. Detailed narrative Tooth

D3999 Unspecified endodontic procedure, by By report.
Detailed narrative
CDT: PERIODONTAL SERVICES
PERIODONTAL SERVICES
Procedure Billing Guidelines
 A quadrant is defined as four (4) or more contiguous teeth in a quadrant. A partial quadrant is defined as one (1) to three (3) teeth in a quadrant.
 For billing purposes, a sextant is not a recognized designation by the American Dental Association.
 Periodontal services are benefits when performed for the treatment of periodontal disease around natural teeth. There are no benefits for these
procedures when billed in conjunction with or in preparation for implants, ridge augmentation, extractions sites and endodontic surgeries.
 Benefits for all periodontal services are limited to two (2) quadrants per date of service. If you wish to request an exception due to a medical condition that
may require your patient to receive extended treatment, please include a detailed narrative including general or intravenous anesthesia record, medical
condition and length of appointment time for consideration.
Payment for Services

 Payment for definitive periodontal service includes follow-up evaluation for both surgical and non-surgical procedures.
 To be covered, alveolar crestal bone loss and subgingival calculus must be evident radiographically for scaling and root planing.
 When more than one (1) periodontal service is completed within the same site or quadrant on the same date of service, the Plan will pay for the more
extensive treatment as payment for the total service.
 If scaling and root planing are performed on the same date and in the same quadrant as periodontal surgery, no payment will be made for scaling and
root planing. The liability will fall on the provider.
 Codes D4266, D4267are considered adjunctive services for individual teeth and will not be included in the surgical quadrant code count above. These
codes should be a benefit only when they are covered services, only when submitted in addition to periodontal surgery codes (D4240,D4241,D4260, and
D4261), and only when placed around natural teeth (not a benefit around implants, extraction sites, endodontic surgery, or edentulous areas). If denied,
the liability will be on the member.
 We provide payment only for one (1) surgical procedure per quadrant per thirty-six (36) months. No more than two (2) quadrants of surgical or non-
surgical services may be covered when done on the same date of service.
 Any type of restorative prosthetic service (including crown, inlay, onlay, restoration or extraction) done on same date of service and in the same area as
periodontal surgery (4240, 4241, 4260, 4261, 4212) are covered as integral to the restorative service.
Submission
Providers
SURGICAL SERVICES (INCLUDING USUAL POST-OPERATIVE SERVICES)

Coverage includes placement and removal of periodontal pack, suture removal, local anesthesia and postoperative care.
D4210 Gingivectomy or gingivoplasty – 4 or One (1) per quadrant in a three (3) Gingivectomy (D4210, D4211, D4212) reported for Quadrant
more contiguous teeth or tooth-bounded year period. the same date of service, same provider, same identification
spaces, per quadrant area as any crown, inlay, onlay, restoration or
extraction will deny as integral. Patient must be
eighteen (18) years or older.
D4211 Gingivectomy or gingivoplasty – one (1) Tooth
to three (3) contiguous teeth or tooth identification
bounded spaces per quadrant
D4212 Gingivectomy or gingivoplasty to allow One (1) per tooth in a three (3) year Tooth
access for restorative procedure, per period. identification
tooth.
D4230 Anatomical crown exposure – four (4) or Not a covered benefit None None
more contiguous teeth
D4231 Anatomical crown exposure – one (1) to

three (3) teeth
Submission
Providers
D4240 Gingival flap procedure, including root One (1) per quadrant in a three (3) Coverage of D4240 is allowed when four (4) or Quadrant
planing – four (4) or more contiguous year period. more teeth in a quadrant have periodontal pockets identification
teeth or tooth-bounded spaces per measuring 5 mm or greater. If less than four (4)
quadrant teeth are involved, use CDT code D4241. Other
procedures may be required concurrent to D4240
and should be reported separately using their own
unique codes. May be performed once every three
(3) years if needed. Patient must be eighteen (18)
years or older.
D4241 Gingival flap procedure - one (1) to three One (1) per quadrant in a three (3) Coverage of D4241 is allowed when one (1) to Tooth
(3) contiguous teeth or tooth bounded year period. three (3) in a quadrant have periodontal pockets identification
spaces per quadrant measuring 5 mm or greater. Other procedures
may be required concurrent to D4241 and should
be reported separately using their own unique
codes. May be performed once every three (3)
years if needed. Patient must be eighteen (18)
years or older.
D4245 Apically repositioned flap Not a covered benefit None Quadrant

identification
Submission
Providers
D4249 Clinical crown lengthening - hard tissue Subject to clinical necessity in Coverage is provided for crown lengthening as a Tooth
conjunction with a covered result of a crown fracture or extensive caries identification
restorative procedure. resulting in insufficient tooth volume to support a
restoration without impinging upon the biologic width
of the periodontal attachment of the tooth.
Procedure should be performed in a healthy
periodontal environment. May be performed once in
a three (3) year period. Patient must be age
eighteen (18) or older. If performed on the same
day of any restorative procedure, the service will
deny as integral, and be provider liability.
D4260 Osseous surgery (including elevation of a One (1) per quadrant in a three (3) Osseous surgery is a benefit when four (4) or more Quadrant
full thickness flap and closure) – four (4) year period. teeth in a quadrant have periodontal pockets identification
or more contiguous teeth or tooth- measuring 5 mm or greater. May be performed
bounded spaces per quadrant once in a three (3)-year period. Patient must be
eighteen (18) years or older. Other procedures
may be required concurrent to D4260 or D4261
and should be reported using their own unique
codes.
D4261 Osseous surgery (including elevation of a One (1) per quadrant in a three (3) Osseous surgery is a benefit when one (1) to three Tooth
full thickness flap and closure) - one (1) year period. (3) teeth in a quadrant have periodontal pockets identification
to three (3) contiguous teeth or tooth measuring 5 mm or greater. May be performed
bounded spaces per quadrant once in a three (3) year period. Patient must be
eighteen (18) years or older. Other procedures
may be required concurrent to D4260 or D4261
and should be reported using their own unique
codes.
Submission
Providers
D4263 Bone replacement graft – first site in Not a covered benefit None None
quadrant
D4264 Bone replacement graft – each additional

site in quadrant
D4265 Biologic materials to aid in soft and

osseous tissue regeneration
D4266 Guided tissue regeneration Resorbable One (1) per site in a three (3) year Coverage is allowable once per site per three (3) Tooth
barrier, per site period. year period. Services covered in conjunction with identification
natural teeth and only in conjunction with covered
periodontal surgical services. The patient must be
D4267 Guided tissue regeneration non- age eighteen (18) or older.
resorbable barrier, per site (includes
membrane removal)
If performed on same day and in the same area as
codes D4277 or D4278, it will be member liability.
D4268 Surgical revision procedure, per tooth Not a covered benefit None None
D4270 Pedicle soft tissue graft procedure
Submission
Providers
D4273 Autogenous connective tissue graft Not a covered benefit None None
procedures (including donor and recipient
surgical sites) first tooth, implant, or
edentulous tooth position in graft
D4274 Distal or proximal wedge procedure

(when not performed in conjunction with
surgical procedures on the same
anatomical area)
D4275 Non-autogenous connective tissue graft

(including recipient and donor material)
first tooth, implant, or edentulous tooth
position in graft
D4276 Combined connective tissue and double

pedicle graft, per tooth
D4277 Free soft tissue graft procedure Once per tooth per lifetime Narrative/remarks describing the procedure and Tooth
(including recipient and donor surgical tooth numbers are required with the claim. The identification
sites), first tooth, implant, or edentulous patient must be age eighteen (18) or older.
tooth position in graft.
D4278 Free soft tissue graft procedure

(including recipient and donor surgical
sites), each additional contiguous tooth,
implant or edentulous tooth position in
same graft site.
Submission
Providers
D4283 Autogenous connective tissue graft None

Not a covered benefit None
procedure (including donor and recipient
surgical sites) - each additional
contiguous tooth, implant or edentulous
tooth position in same graft site.
D4285 Non-autogenous connective tissue graft

procedure (including recipient surgical
sites and donor material) - each
additional contiguous tooth, implant or
edentulous tooth position in same graft
site.
NON-SURGICAL PERIODONTAL SERVICES
D4320 Provisional splinting – intracoronal Not a covered benefit None None
D4321 Provisional splinting – extracoronal
Submission
CDT Code Description of Service Considerations
Frequency Limitation Participating
Providers
D4341 Periodontal scaling and root planing, 4 or One (1) per quadrant in a two (2) Periodontal scaling and root planing may be used as Quadrant
more teeth per quadrant year period, age eighteen (18) and a definitive treatment in some stages of periodontal identification
older disease and/or as a part of pre-surgical procedures in
others. D4341 is a benefit when four (4) or more
teeth in a quadrant have periodontal pockets
measuring 4 mm or greater. D4342 is a benefit when
less than four (4) teeth in a quadrant have periodontal
pockets measuring 4mm or greater. Once every two
(2) years. Patient must be eighteen (18) years and
older. Must demonstrate radiographic alveolar bone
loss and subgingival calculus to be a benefit.
Note: If member has diabetes, CAD, stroke or is

pregnant and is enrolled in Oral Health for Total
Health, D4341 or D4342 is covered once per quadrant
every 24 months.
D4342 Periodontal scaling and root planing, 1 - 3 One (1) per quadrant in a two (2) Periodontal scaling and root planing may be used as Tooth
teeth per quadrant year period, age eighteen (18) and a definitive treatment in some stages of periodontal identification
older disease and/or as a part of pre-surgical procedures in
others. D4341 is a benefit when four (4) or more
teeth in a quadrant have periodontal pockets
measuring 4 mm or greater. D4342 is a benefit when
less than four (4) teeth in a quadrant have periodontal
pockets measuring 4mm or greater. Once every two
(2) years. Patient must be eighteen (18) years and
older. Must demonstrate radiographic alveolar bone
loss and subgingival calculus to be a benefit.
Note: If member has diabetes, CAD, stroke or is

pregnant and is enrolled in Oral Health for Total
Health, D4341 or D4342 is covered once per quadrant
every 24 months.
Submission
CDT Code Description of Service Considerations
Frequency Limitation Participating
Providers
D4346 Scaling in presence of generalized This code will be interchangeable with code D1110.
moderate or severe gingival inflammation Twice per calendar year age 13 and The code will be covered as a preventative service and None
– full mouth, after oral evaluation older will share the same frequency limitations, processing
guidelines, relationship to other codes, provider /
member liability as code D1110.
Note: If member is enrolled in Oral Health for Total

Health, D1110/D1120 or D4346 or D4910 is covered
once every three months.
D4355 Full mouth debridement to enable a Not a covered benefit None None
comprehensive oral evaluation and
diagnosis on a subsequent visit
D4381 Localized delivery of antimicrobial agents Benefit for Federal plan only. One treatment per tooth per 24 months. Up to 3 Detailed Narrative
via a controlled-release vehicle into teeth per quadrant or 10 teeth overall with 5-6 mm
diseased crevicular tissue, per tooth pocket depths and bleeding on probing with, or Tooth/teeth
subsequent to active and maintained periodontal identification(s)
treatment. This treatment should not be used to
treat generalized disease. Not covered for
treatment of periodontal abscess or in conjunction
with periodontal surgery. If denied for above
criteria not being met, it is a member liability.
Patient must be 18 years and older.
Submission
Providers
OTHER PERIODONTAL SERVICES
D4910 Periodontal maintenance Two (2) per calendar year in Periodontal maintenance includes removal of the None
addition to regular prophy. bacterial plaque and calculus from supragingival and
subgingival regions, site-specific scaling and root
planing where indicated, and polishing the teeth. If
new or recurring periodontal disease appears,
additional diagnostic and treatment procedures must
be considered. Periodontal maintenance is covered
two (2) times per calendar year following surgical and
definitive non-surgical therapy. The patient must be
age eighteen (18) or older. Periodontal maintenance
should not be performed on same day as periodontal
surgery.
Note: If member is enrolled in Oral Health for Overall

Health, D1110/D1120 or D4346 or D4910 is covered
once every three months.
D4920 Unscheduled dressing change (by Not a covered benefit None

someone other than treating dentist or
their staff)
D4921 Gingival irrigation – per quadrant
D4999 Unspecified periodontal procedure, by report By report Individual Consideration. Detailed narrative required Detailed narrative
CDT: PROSTHODONTICS, REMOVABLE
PROSTHODONTICS, REMOVABLE
Please bill claims for multiple-stage procedures on the date of completion/insertion. Services may be non-covered for the following conditions:
 Untreated bone loss: An abutment tooth has poor-to-hopeless prognosis from either a restorative or periodontal perspective
 Periapical pathology or unresolved, incomplete, or failed endodontic therapy
 Treatment of TMJ to increase vertical dimension or restore occlusion
Submission
Providers
COMPLETE DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)
D5110 Complete denture – maxillary One (1) in five (5) years Complete denture coverage includes routine post- None
delivery care.
D5120 Complete denture – mandibular
D5130 Immediate denture – maxillary Immediate dentures are not considered temporary
dentures. Coverage includes routine follow-up care.
Once every five (5) years. The patient must be age
D5140 Immediate denture – mandibular fifteen (15) years or older.
Submission
Providers
PARTIAL DENTURES: For the following codes, denture base presumed to include any conventional clasps, rests, and teeth
D5211 Maxillary partial denture – resin base One (1) in five (5) years, age fifteen Partial denture includes acrylic resin-based denture Tooth
(15) and older. with resin or wrought wire clasps. Coverage identification
includes routine post-delivery care. Precision
D5212 Mandibular partial denture – resin base attachments are not a benefit for removable partial
dentures. One (1) partial denture, per arch, in a five
(5)-year period. The patient must be age fifteen (15)
D5213 Maxillary partial denture – cast metal or older
framework with resin denture bases
D5214 Mandibular partial denture – cast metal

framework with resin denture bases
D5221 Immediate maxillary partial denture –

resin base (including any conventional
clasps, rests and teeth)
D5222 Immediate mandibular partial denture –

resin base (including any conventional
clasps, rests and teeth)
D5223 Immediate maxillary partial denture –

cast metal framework with resin denture
bases (including any conventional clasps,
rests and teeth)
Submission
Providers
D5224 Immediate mandibular partial denture – One (1) in five (5) years, age fifteen Partial denture includes acrylic resin-based denture Tooth
cast metal framework with resin denture (15) and older. with resin or wrought wire clasps. Coverage identification
bases (including any conventional clasps, includes routine post-delivery care. Precision
rests and teeth) attachments are not a benefit for removable partial
dentures. One (1) partial denture, per arch, in a five
(5)-year period. The patient must be age fifteen (15)
D5225 Maxillary partial denture - flexible base or older
D5226 Mandibular partial denture - flexible base
D5282 Removable unilateral partial denture –

one (1) piece cast metal maxillary
D5283 Removable unilateral partial denture –

one (1) piece cast metal mandibular
D5410 Adjust complete denture – maxillary Two (2) per calendar year, age Coverage is available six (6) months after the date None
fifteen (15) and older. of insertion of the complete or partial denture. Two
(2) adjustments are allowed per arch per calendar
D5411 Adjust complete denture – mandibular
year. Patient must be age fifteen (15) or older.
D5421 Adjust partial denture – maxillary
D5422 Adjust partial denture – mandibular
Submission
Providers
REPAIRS TO DENTURES
D5511 Repair broken complete denture base, One (1) per calendar year, age Six (6) months must have elapsed since insertion of None
mandibular fifteen (15) and older. the denture, or the services will be disallowed. One
(1) repair per year. The patient must be age fifteen
Repair broken complete denture base,
(15) or older.
D5512 maxillary
D5520 Replace missing or broken teeth Once per denture tooth per year Six (6) months must have elapsed since insertion of Tooth
(complete denture), each tooth the denture, or the services will be disallowed. identification
Once per denture tooth per year. The patient must
be age fifteen (15) or older.
D5611 Repair resin partial denture base, Six (6) months must have elapsed since insertion of None
One (1) per calendar year, age
mandibular the denture, or the services will be disallowed.
fifteen (15) and older.
Coverage will be paid according to plan benefits, or
D5612 Repair resin partial denture base, once a year if the plan does not have another
maxillary limitation. The patient must be age fifteen (15) or
older.
D5621 Repair cast partial framework,

One (1) per calendar year, age Six (6) months must have elapsed since insertion of None
mandibular
fifteen (15) and older. the denture, or the services will be disallowed.
D5622 Repair cast partial framework, maxillary once a year if the plan does not have another
limitation. The patient must be age fifteen (15) or
older.
Submission
Providers
D5630 Repair or replace broken clasp One (1) per calendar year, age Six (6) months must have elapsed since insertion of None
fifteen (15) and older. the denture, or the services will be disallowed.
Coverage for code D5630 includes repair of rests.
Coverage for code D5640 includes repair of broken
D5640 Repair broken teeth – per tooth Once per tooth per calendar year, tooth. Coverage will be paid according to plan Tooth
age fifteen (15) and older. benefits, or once a year if the plan does not have identification
another limitation. The patient must be age fifteen
(15) or older.
D5650 Add tooth to existing partial denture Six (6) months must have elapsed since insertion of
the denture, or the services will be disallowed.
D5660 Add clasp to existing partial denture once a year if the plan does not have another
limitation. The patient must be age fifteen (15) or
older.
D5670 Replace all teeth and acrylic on cast Not a covered benefit None None
metal framework – maxillary
D5671 Replace all teeth and acrylic on cast

metal framework – mandibular
Submission
Providers
DENTURE REBASE PROCEDURES: process of refitting a denture by replacing the base material
D5710 Rebase complete maxillary denture One (1) in a three (3) year period, Coverage of a rebase is available six (6) months None
age fifteen (15) and older. after the date of insertion of the denture. One (1)
rebase is allowed per arch per thirty-six (36)
D5711 Rebase complete mandibular denture months. Patient must be age fifteen (15) or older.
D5720 Rebase maxillary partial denture
D5721 Rebase mandibular partial denture
DENTURE RELINE PROCEDURES: The process of resurfacing the tissue side of a denture with new base material
Reline complete maxillary denture (chair One (1) in a three (3) year period, Coverage of a reline is available beginning six (6) None
D5730
side) age fifteen (15) and older. months after the date of insertion of the denture.
One (1) reline is allowed per arch per thirty-six (36)
months. Patient must be age fifteen (15) or older.
Reline complete mandibular denture
D5731
(chair side)
Reline maxillary partial denture (chair

D5740
side)
Submission
Providers
Reline mandibular partial denture (chair One (1) in a three (3) year period, Coverage of a reline is available beginning six (6) None
D5741
side) age fifteen (15) and older. months after the date of insertion of the denture.
One (1) reline is allowed per arch per thirty-six (36)
Reline complete maxillary denture months. Patient must be age fifteen (15) or older.
D5750
(laboratory)
Reline complete mandibular denture

D5751
(laboratory)
Reline upper maxillary denture

D5760
(laboratory)
Reline mandibular partial denture

D5761
(laboratory)
OTHER REMOVABLE PROSTHETIC SERVICES
D5810 Interim complete denture (maxillary) Not a covered benefit None None
D5811 Interim complete denture (mandibular)
D5820 Interim partial denture (maxillary)
Submission
Providers
D5821 Interim partial denture (mandibular) Not a covered benefit None None
D5850 Tissue conditioning, maxillary Twice per calendar year, age fifteen A maximum of two (2) tissue conditioning treatment
(15) and older. per arch is covered prior to impressions for reline or
denture prosthesis. The patient is responsible for
D5851 Tissue conditioning, mandibular
the charges related to additional treatments, if any.
Service covered twice per arch per calendar year.
D5862 Precision attachment, by report Not a covered benefit None
D5863 Overdenture – complete maxillary One (1) in five (5) years Alternate Benefit to D5110
D5864 Overdenture – partial maxillary Not a covered benefit None
D5865 Overdenture – complete mandibular One (1) in five (5) years Alternate Benefit to D5120
D5866 Overdenture – partial mandibular Not a covered benefit None
Submission
Providers
D5867 Replacement of replaceable part or semi- Not a covered benefit None None
precision or precision attachment (male
or female component)
D5875 Modification of removable prosthesis

following implant surgery
D5876 add metal substructure to acrylic full Not a covered benefit None None
denture (per arch)
D5899 Unspecified removable prosthodontic By report Individual consideration Tooth

procedure, by report identification
Arch identification
MAXILLOFACIAL PROSTHETICS
D5911 Facial moulage (sectional) Not a covered benefit None None
D5912 Facial moulage (complete)
D5913 Nasal prosthesis
D5914 Auricular prosthesis
D5915 Orbital prosthesis Not a covered benefit None None
Submission
Providers
D5916 Ocular prosthesis Not a covered benefit None None
D5919 Facial prosthesis
D5922 Nasal septal prosthesis
D5923 Ocular prosthesis, interim
D5924 Cranial prosthesis
D5925 Facial augmentation implant prosthesis
D5926 Nasal prosthesis, replacement
D5927 Auricular prosthesis, replacement
D5928 Orbital prosthesis, replacement
D5929 Facial prosthesis, replacement
D5931 Obturator prosthesis, surgical
Submission
Providers
D5932 Obturator prosthesis, definitive Not a covered benefit None None
D5933 Obturator prosthesis, modification
D5934 Mandibular resection prosthesis with

guide flange
D5935 Mandibular resection prosthesis without

guide flange
D5936 Obturator prosthesis, interim
D5937 Trismus appliance (not for TMD

treatment)
D5951 Feeding aid
D5952 Speech aid prosthesis, pediatric
D5953 Speech aid prosthesis, adult
Submission
Providers
D5954 Palatal augmentation prosthesis Not a covered benefit None None
D5955 Palatal lift prosthesis, definitive
D5958 Palatal lift prosthesis, interim
D5959 Palatal lift prosthesis, modification
D5960 Speech aid prosthesis, modification
D5982 Surgical stent
D5983 Radiation carrier
D5984 Radiation shield
D5985 Radiation cone locator
D5986 Fluoride gel carrier
D5987 Commissure splint
Submission
Providers
D5988 Surgical splint Not a covered benefit None None
D5991 Vesiculobullous disease medicament

carrier
D5992 Adjust maxillofacial prosthetic appliance,

by report
D5993 Maintenance and cleaning of a

maxillofacial prosthesis (extra or
intraoral) other than required
adjustments, by report
D5994 Periodontal medicament carrier with

peripheral seal – laboratory processed
Individual Consideration. Detailed narrative Detailed narrative

D5999 Unspecified maxillofacial prosthesis, by By report
report required.
CDT: IMPLANT SERVICES
IMPLANT SERVICES
Coverage
General Information
 Verify member coverage code and eligibility prior to providing implant services as some plans recognize implant services and some do not. Additionally,
some implant services may be covered as an alternate benefit. When services are available as an alternate benefit, the Member is responsible for the
difference between The Plan’s payment and the providers charge.
Implant Services
Benefits for dental implants, abutments, and implant/abutment supported crowns are covered up to the member’s annual maximum. Coverage may be provided as
an alternate benefit.
Coverage for implant services has a maximum lifetime dollar amount and covers the surgical placement of endosteal implants with a minimum age qualification of
fifteen (15) for the replacement of teeth numbers 2-15 and teeth numbers 18-31.
The implant benefit does not cover the following services:
 Special preparatory radiographic or imaging studies (i.e., tomographic, CT, or MRI)
 Adjunctive periodontal (D4000 series) or surgical (D7000 series) procedures in preparation for implant placement, in association with implant placement,
or in association with salvage attempts of a failing implant; (covers implants only)
 Maxillofacial prosthetic procedure D5982, surgical stent (implant positioning type); (covers implants only)
Please also note:

 Routine radiographs/diagnostic imaging (i.e., periapical and panoramic) may be covered under the member’s general dental insurance policy to the same
extent and under the same conditions and guidelines as those applied to a natural tooth.
 The frequency limitation for dental implants is once per tooth (replacement) per lifetime.
Submission
Providers
D6010 Surgical placement of implant body: Not all plans cover this benefit. Once per tooth per lifetime. Patient must be age Tooth area
endosteal implant Please check with the Plan for fifteen (15) or older. identification
member’s eligibility for this service.
D6011 Second stage implant surgery Not all plans cover this benefit. Covers second stage surgery and placement of Tooth area
Please check with the Plan for healing cap. identification
D6012 Surgical placement of interim implant Not a covered benefit None None
body for transitional prosthesis,
endosteal implant
D6013 Surgical placement of mini implant Not all plans cover this benefit. Once per tooth per lifetime. Patient must be age Tooth area
Please check with the Plan for fifteen (15) or older . Limited to 2 per arch in order identification
member’s eligibility for this service. to stabilize a denture.
D6040 Surgical placement, eposteal implant Not a covered benefit None None
D6050 Surgical placement, transosteal implant
D6051 Interim abutment
D6052 Semi-precision attachment abutment
Submission
Providers
D6055 Connecting bar – implant supported or Not a covered benefit None None
abutment supported
D6056 Prefabricated abutment, includes Not all plans cover this benefit. Once per tooth per 5 years. Age fifteen (15) or Tooth
modification and placement Please check with the Plan for older. All new members subject to twelve (12) identification
member’s eligibility for this service. month waiting period. Five (5) year service
D6057 Custom fabricated abutment, includes Coverage may be provided as an limitation between services.
placement alternate Benefit: One (1) per tooth
in a five (5) year period; age fifteen
D6058 Abutment-supported porcelain/ceramic (15) and older
crown
D6059 Abutment-supported porcelain fused to

metal crown (high noble metal)

metal crown (predominantly base metal)

metal crown (noble metal)
D6062 Abutment-supported cast metal crown

(high noble metal)
D6063 Abutment-supported cast metal crown

(predominantly base metal)
Submission
Providers
D6064 Abutment-supported cast metal crown Not all plans cover this benefit. Once per tooth per 5 years. Age fifteen (15) or Tooth
(noble metal) Coverage may be provided as an older. All new members subject to twelve (12) identification
alternate Benefit: Please check with month waiting period. Five (5) year service
D6065 Implant-supported porcelain/ceramic the Plan for member’s eligibility for limitation between services.
crown this service. One (1) per tooth in a
five (5) year period; age fifteen (15)
D6066 Implant-supported porcelain fused to and older
metal crown (titanium, titanium alloy, high
noble metal)
D6067 Implant supported metal crown (titanium,

titanium alloy, high noble metal)
D6068 Abutment supported retainer for

porcelain/ceramic FPD
D6069 Abutment-supported retainer for

porcelain fused to metal FPD (high noble
metal)

porcelain fused to metal FPD
(predominately base metal)

porcelain fused to metal FPD (noble
metal)
Submission
Providers
D6072 Abutment-supported retainer for cast Not all plans cover this benefit. Once per tooth per 5 years. Age fifteen (15) or Tooth
metal FPD (high noble metal) Coverage may be provided as an older. All new members subject to twelve (12) identification
alternate Benefit: Please check with month waiting period. Five (5) year service
D6073 Abutment-supported retainer for cast the Plan for member’s eligibility for limitation between services.
metal FPD (predominately base metal) this service. One (1) per tooth in a
five (5) year period; age fifteen (15)
D6074 Abutment-supported retainer for cast and older
metal FPD (noble metal)
D6075 Implant-supported retainer for ceramic

FPD
D6076 Implant-supported retainer for porcelain

fused to metal FPD (titanium, titanium
alloy, or high noble metal)
D6077 Implant-supported retainer for cast metal

FPD (titanium, titanium alloy, or high
noble metal)
OTHER IMPLANT SERVICES
D6080 Implant maintenance procedures when Not all plans cover this benefit. Service is for the entire mouth. Once per six (6) None
prostheses are removed and reinserted, Please check with the Plan for months. Age fifteen (15) or older. All new members
including cleansing of prosthesis, and member’s eligibility for this service. subject to twelve (12) month waiting period.
abutments. Coverage may be provided as an
alternate Benefit. Age fifteen (15)
and older
Submission
Providers
D6081 Scaling and debridement in the presence Not a covered benefit None None
of inflammation or mucositis of a single
implant, including cleaning of the implant
surfaces, without flap entry and closure
D6085 Provisional implant crown
D6090 Repair implant supported prosthesis, by Not all plans cover this benefit. Once per arch per six (6) months. Age fifteen (15) Tooth
report Please check with the Plan for or older. All new members subject to twelve (12) identification
member’s eligibility for this service. month waiting period.
Age fifteen (15) and older
D6091 Replacement of semi-precision or Not a covered benefit None None

precision attachment (male or female
component) of implant/abutment-
supported prosthesis, per attachment
D6092 Re-cement or re-bond implant/abutment- Not all plans cover this benefit. Considered a basic service. Once per tooth/bridge Tooth
supported crown Please check with the Plan for per twelve (12) months. Age fifteen (15) or older. identification
member’s eligibility for this service. No twelve (12) month waiting period for new
D6093 Re-cement or re-bond implant/abutment- Age fifteen (15) and older members.
supported fixed partial denture
D6094 Abutment supported crown, titanium Not all plans cover this benefit. Once per tooth per 5 years. Age fifteen (15) or
Please check with the Plan for older. All new members subject to twelve (12)
One (1) in a five (5) year period. limitation between services.
Submission
Providers
D6095 Repair implant abutment, by report Not all plans cover this benefit. Once per tooth per six (6) months. Age fifteen (15) Tooth
Please check with the Plan for or older. All new members subject to twelve (12) identification
member’s eligibility for this service. month waiting period.
D6096 Remove broken implant retaining screw
Once per tooth per six (6) months.
D6100 Implant removal, by report
D6101 Debridement of a peri-implant defect or Not a covered benefit None None

defects surrounding a single implant, and
surface cleaning of the exposed implant
surfaces, including flap entry and closure.
D6102 Debridement and osseous contouring of a

peri-implant defect or defects surrounding a
single implant and includes surface
cleaning of the exposed implant surfaces
including flap entry and closure.
D6103 Bone graft for repair of peri-implant defect –

does not include flap entry and closure.
Placement of a barrier membrane or
biologic materials to aid in osseous
regeneration are reported separately.
D6104 Bone graft a time of implant placement
Submission
Providers
D6110 Implant /abutment supported removable Not all plans cover this benefit. Alternate Benefit Use code 5110 None
denture for edentulous arch – maxillary
Please check with the Plan for
Once per implant/tooth per lifetime.
D6111 Implant /abutment supported removable Not all plans cover this benefit. Alternate Benefit Use code 5120
denture for edentulous arch – mandibular
denture for partially edentulous arch –
maxillary
mandibular
Submission
Providers
D6114 Implant /abutment supported fixed Not all plans cover this benefit. Alternate Benefit Use code 5110 None
denture for edentulous arch – maxillary
D6115 Implant /abutment supported fixed Not all plans cover this benefit. Alternate Benefit Use code 5120
denture for edentulous arch – mandibular
maxillary
mandibular
Submission
Providers
D6118 implant/abutment supported interim fixed Not a covered benefit None None
denture for edentulous arch –
mandibular. Used when a period of
healing is necessary prior to fabrication
and placement of a permanent prosthetic
D6119 implant/abutment supported interim fixed

denture for edentulous arch – maxillary.
Used when a period of healing is
necessary prior to fabrication and
placement of a permanent prosthetic
D6190 Radiographic/surgical implant index, by

report
D6194 Abutment supported retainer crown for Not all plans cover this benefit. Once per tooth per 5 years. Age fifteen (15) or Tooth
FPD, titanium Please check with the Plan for older. All new members subject to twelve (12) identification
limitation between services.
One (1) in a five (5) year period.
D6199 Unspecified implant procedure, by report Individual Consideration. Detailed narrative Tooth
By report
required. identification,
Detailed narrative
CDT: PROSTHODONTICS, FIXED
PROSTHODONTICS, FIXED
 Coverage to restore the normal compliment of teeth.
 Edentulous space must have adequate mesial-distal and vertical dimension to accommodate a functional pontic.
 Abutment teeth must be endodontically and periodontally sound.
 Correction of congenital or developmental abnormalities.
 Service includes preparation of teeth, indirect pulp cap, bases, liners, laboratory costs, temporary crowns/bridges, cementation and local anesthesia.
 Gingivectomy performed in conjunction with an inlay/onlay is considered a part of the procedure and cannot be billed separately.
FIXED PARTIAL DENTURE PONTICS
D6205 Pontic – indirect resin-based composite Once per tooth per five (5) years, Alternate D6240 for anterior and bicuspids. Tooth
age fifteen (15) and older Alternate D6210 for molars. identification
D6210 Pontic - cast high noble Once per tooth, in a five (5) year Cantilever fixed partial dentures with one (1) pontic
period are covered. One (1) in five (5) years. The patient
must be age fifteen (15) or older. Service or
Submission
Providers
D6211 Pontic – cast predominantly base metal Once per tooth, in a five (5) year Cantilever fixed partial dentures with one (1) pontic Tooth
period are covered. One (1) in five (5) years. The patient identification
must be age fifteen (15) or older. Service or
D6212 Pontic – cast noble metal completion date is the cementation date.
D6214 Pontic – titanium
D6240 Pontic – porcelain fused to high noble Alternate benefit: D6210 for molars,
metal Once per tooth, in a five (5) year
period
D6241 Pontic – porcelain fused to predominantly Alternate benefit: D6211 for

base metal molars, Once per tooth, in a five (5)
year period
D6242 Pontic – porcelain fused to noble metal Alternate benefit: D6212 for
molars, Once per tooth, in a five (5)
year period
D6245 Pontic – porcelain/ceramic Alternate benefit: D6210 for molars,

D6240 for anterior and bicuspids.
Once per tooth, in a five (5) year
period
Submission
Providers
D6250 Pontic – resin with high noble metal Alternate benefit: D6210 for molars, Cantilever fixed partial dentures with one (1) pontic Tooth
Once per tooth, in a five (5) year are covered. One (1) in five (5) years. The patient identification
period must be age fifteen (15) or older. Service or
D6251 Pontic – resin with predominantly base Alternate benefit: D6211 for molars,
metal Once per tooth, in a five (5) year
period
D6252 Pontic – resin with noble metal Alternate benefit: D6212, Once per
tooth, in a five (5) year period
D6253 Provisional pontic Not a covered benefit None
FIXED PARTIAL DENTURE RETAINERS – INLAYS/ONLAYS
D6545 Retainer – cast metal for resin-bonded One (1) in a five (5) year period Metal retainers are covered. Coverage is for Tooth
fixed prosthesis permanent teeth only. Five (5) year waiting period identification
between services. The patient must be age fifteen
(15) or older. Service or completion date is the
cementation date.
Submission
Providers
D6548 Retainer – porcelain/ ceramic for resin- Alternate benefit: D6545 Porcelain/ceramic retainers are paid at the metallic Tooth
bonded fixed prosthesis One (1) in a five (5) year period. rate as an alternate benefit with the member identification
responsible for the difference between The Plan
payment and the provider’s actual charge.
Coverage includes laboratory charges, liners, bases
and local anesthesia. Five (5) year waiting period
between services. The patient must be age fifteen
(15) or older. Service or completion date is the
cementation date.
D6549 Resin retainer – for resin bonded fixed Alternate benefit: D6545 Resin retainers are paid at the metallic rate as an Tooth
prosthesis One (1) in a five (5) year period. alternate benefit with the member responsible for identification
the difference between The Plan payment and the
provider’s actual charge. Coverage includes
laboratory charges, liners, bases and local
anesthesia. Five (5) year waiting period between
services. The patient must be age fifteen (15) or
older. Service or completion date is the cementation
date.
D6600 Inlay - porcelain/ceramic, 2 surfaces Alternate benefit: D2520 Once per Coverage is for permanent teeth only. Tooth
tooth per five (5) years Porcelain/ceramic inlay/onlays are paid at the identification,
metallic rate as an alternate benefit with the Surface
member responsible for the difference between The identification
D6601 Inlay - porcelain/ceramic, 3 or more Alternate benefit: D2530 Once per Plan’s payment and the provider's actual charge.
surfaces tooth per five (5) years Five (5)-year waiting period between services.
Submission
Providers
D6602 Inlay – high-noble metal, 2 surfaces Once per tooth per five (5) years Metal inlay/onlay retainers are covered. Coverage is Tooth
for permanent teeth only. Five (5) year waiting identification,
Inlay – cast high-noble metal, 3 or more period between services. The patient must be age Surface
D6603 fifteen (15) or older. Service or completion date is identification
surfaces
the cementation date.
D6604 Inlay - cast, predominately base metal, 2
surfaces.
D6605 Inlay – cast, predominately base metal, 3

or more surfaces
D6606 Inlay - cast noble metal, 2 surfaces
D6607 Inlay - cast noble metal, 3 or more

surfaces
D6624 Inlay – titanium
D6608 Onlay - porcelain ceramic, 2 surface Alternate benefit: D2542 One (1) in Coverage is for permanent teeth needing buccal/lingual Tooth
a five (5) year period cusp coverage only. Porcelain/ceramic inlay/onlays identification
are paid at the metallic rate as an alternate benefit with Surface
the member responsible for the difference between identification, must
D6609 Onlay - porcelain ceramic, 3 or more Alternate benefit: D2543 One (1) in The Plan’s payment and the provider's actual charge. include B or L
surfaces (2543) a five (5) year period Five (5) year waiting period between services. The surface
patient must be age fifteen (15) or older. Service or
Submission
Providers
D6610 Onlay - cast high noble metal, 2 surface One (1) in a five (5) year period Metal inlay/onlay retainers are covered. Coverage Tooth
is for permanent teeth needing buccal/lingual cusp identification
coverage only. Five (5) year waiting period between Surface
D6611 Onlay - cast high noble, 3 or more services. The patient must be age fifteen (15) or identification, must
surfaces older. Service or completion date is the include B or L
cementation date. surface
D6612 Onlay - cast predominately base metal,

2 surfaces
D6613 Onlay - cast predominately base metal,

3 or more surfaces
D6614 Onlay - cast noble metal, 2 surfaces
D6615 Onlay - cast noble metal, 3 or more

surfaces
D6634 Onlay – titanium
Submission
Providers
FIXED PARTIAL DENTURE RETAINERS – CROWNS
D6710 Crown – indirect resin-based composite Alternate benefit: D6750 for anterior Five (5) year waiting period between services. Tooth
and bicuspids, D6790 for molars. Patient must be age fifteen (15) or older. Service identification
One (1) in a five (5) year period or completion date is the cementation date
D6720 Crown – resin with high noble metal Alternate benefit: D6790 for molars.
One (1) in a five (5) year period
D6721 Crown – resin with predominantly base Alternate benefit: D6791 for molars.
metal One (1) in a five (5) year period
D6722 Crown – resin with noble metal Alternate benefit: D6792 for molars.
One (1) in a five (5) year period
D6740 Crown – porcelain/ceramic Alternate benefit: D6790 for molars.

Alternate benefit: D6750 for anterior
and bicuspids. One (1) in a five (5)
year period
D6750 Crown – porcelain fused to high noble Alternate benefit: D6790 for molars.
metal One (1) in a five (5) year period
D6751 Crown – porcelain fused to Alternate benefit: D6791 for molars.

predominantly base metal One (1) in a five (5) year period
Submission
Providers
D6752 Crown – porcelain fused to noble metal Alternate benefit: D6792 for molars. Crowns are covered when as a result of extensive Tooth
One (1) in a five (5) year period caries or fracture the tooth cannot be restored with a identification
direct restoration. Porcelain/ceramic, porcelain
fused to metal, resin, and resin with metal and metal
meeting policy guidelines. Resin/porcelain crowns
or resin/porcelain on metal crowns placed on molars
are covered as an alternate benefit at the full metal
crown rate. Five (5) year waiting period between
services. Patient must be age fifteen (15) or older.
For Permanent teeth only. Service or completion
date is the cementation date
D6780 Crown – ¾ cast high noble metal One (1) in a five 5) year period Crowns are covered when as a result of extensive
caries or fracture the tooth cannot be restored with a
direct restoration. Five (5) year waiting period
D6781 Crown – ¾ cast predominately base between services. Patient must be age fifteen (15)
metal or older. For permanent teeth only. Service or
completion date is the cementation date
D6782 Crown – ¾ cast noble metal
D6783 Crown – ¾ porcelain/ceramic Alternate benefit: D6780. One (1) in Five (5) year waiting period between services.
a five (5) year period Patient must be age fifteen (15) or older. For
permanent teeth only. Service or completion date
is the cementation date
Submission
Providers
D6790 Crown – full cast high noble metal One (1) in a five (5) year period Crowns are covered when as a result of extensive Tooth
caries or fracture the tooth cannot be restored with a identification
D6791 Crown – full cast predominantly base between services. Patient must be age fifteen (15)
metal or older. For permanent teeth only. Service or
completion date is the cementation date
D6792 Crown – full cast noble metal
D6793 Provisional retainer crown Not a covered benefit None None
D6794 Crown – titanium One (1) in a five (5) year period Crowns are covered when as a result of extensive Tooth
caries or fracture the tooth cannot be restored with a identification
between services. Patient must be age fifteen (15)
or older. For permanent teeth only. Service or
Submission
Providers
OTHER FIXED PARTIAL DENTURE SERVICES
D6920 Connector bar Not a covered benefit None None
D6930 Re-cement or re-bond fixed partial Two (2) in a five (5) year period Plan covers two (2) recementations per fixed partial Tooth
denture denture in 5 years and Recementation of a fixed identification
partial denture if more than 6 months have passed
from the date of cementation. There is a twelve (12)
month waiting period between recementations.
Patient must be age fifteen (15) or older. For
permanent teeth only.
D6940 Stress breaker Not a covered benefit None None
D6950 Precision attachments
D6980 Fixed partial denture repair necessitated Once per five (5) year period. Coverage is for permanent teeth only. There is a Tooth
by restorative material failure. five (5) year waiting period between services. Must identification
be age fifteen (15) or older.
D6985 Pediatric partial denture, fixed Not a covered benefit None None
Individual Consideration. Detailed narrative Detailed narrative

D6999 Unspecified fixed prosthodontic By report
procedure, by report required.
CDT: ORAL AND MAXILLOFACIAL SURGERY
ORAL AND MAXILLOFACIAL SURGERY
Submission
Providers
EXTRACTIONS: 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).
Palliative (emergency treatment of dental pain – minor procedures (D9110) is a covered procedure and paid separately unless submitted in conjunction with a definitive
procedure on the same date of service.
General and Intravenous sedations: D9221 and D9242 are not covered codes and should not be billed separately as they are included in the allowance of codes D9220
and D9241.
D7111 Extraction - coronal remnants, deciduous One (1) per tooth per lifetime The Plan coverage includes local anesthetic, Tooth
tooth suturing, if needed, and routine postoperative care. identification
Once per tooth.
D7140 Extraction - erupted tooth or exposed
root (elevation and/or forceps removal)
SURGICAL EXTRACTIONS (Includes local anesthesia, suturing, if needed, and routine postoperative care)
D7210 Surgical removal of an erupted tooth One (1) per tooth per lifetime Surgical removal of an erupted tooth requiring Tooth
requiring removal of bone and/or removal of bone and/or sectioning of tooth and identification
sectioning of tooth and including including elevation of mucoperiosteal flap if
elevation of mucoperiosteal flap if indicated. Once per tooth
indicated
Submission
Providers
D7220 Removal of impacted tooth – soft tissue One (1) per tooth per lifetime Procedures include local anesthesia, suturing if Tooth
needed and routine postoperative care. D7241 is a identification
D7230 Removal of impacted tooth – partially “by report” procedure and will be reviewed by the
bony Dental Consultant or Dental Director. Once per
tooth
D7240 Removal of impacted tooth – completely
bony
D7241 Removal of impacted tooth – completely

bony, with unusual surgical complications
D7250 Surgical removal of residual tooth roots Coverage includes local anesthesia, suturing if
(cutting procedure) needed, and routine post-operative care. Extraction
of a tooth and surgical removal of a residual root of
the same tooth, on the same service date are not
paid separately.
D7251 Coronectomy: intentional partial tooth Procedure includes local anesthesia, suturing if
removal needed and routine post operative care. Once per
tooth per lifetime.
Submission
Providers
OTHER SURGICAL PROCEDURES
D7260 Oroantral fistula closure Not a covered benefit None Submit to

medical carrier
for payment
determination.
D7261 Primary closure of a sinus perforation A covered benefit Once per maxillofacial posterior tooth. None
D7270 Tooth reimplantation and/or stabilization Once per tooth per lifetime Reimplantation is limited to permanent teeth. The Tooth
of accidentally evulsed or displaced tooth procedure code is not used for intentional identification
reimplantation (D3470) and surgical repositioning of
teeth (D7290). Once per tooth per lifetime
D7272 Tooth transplantation (includes Not a covered benefit None None

reimplantation from one (1) site to
another and splinting and/or stabilization)
D7280 Surgical access of unerupted tooth One (1) per tooth per lifetime A narrative and tooth numbers must accompany the Tooth
claim. identification
D7282 Mobilization of erupted or mal-positioned Not a covered benefit None None

tooth to aid eruption
D7283 Placement of device to facilitate eruption

of impacted tooth
Submission
Providers
D7285 Incisional biopsy of oral tissue – hard Not a covered benefit None Submit to
(bone, tooth) medical carrier
for payment
determination.
D7286 Incisional biopsy of oral tissue – soft Submit to

medical carrier
for payment
determination.
D7287 Exfoliative cytology sample collection None
D7288 Brush biopsy – transepithelial sample

collection
D7290 Surgical repositioning of teeth – grafting
procedures are additional
Submission
Providers
D7291 Transseptal fiberotomy/supra crestal

fiberotomy, by report
D7292 Surgical placement of temporary anchorage

device (screw retained plate) requiring flap;
includes device removal

devise requiring flap; includes device removal

device without flap; includes device removal
D7295 Harvest of bone for use in autogenous grafting

procedures
D7296 corticotomy – one to three teeth or tooth

spaces, per quadrant. This procedure
involves creating multiple cuts, perforations, or
removal of cortical, alveolar or basal bone of
the jaw for the purpose of facilitating
orthodontic repositioning of the dentition. This
procedure includes flap entry and closure.
Graft material and membrane, if used, should
be reported separately.
D7297 corticotomy – four or more teeth or tooth

spaces, per quadrant. This procedure
involves creating multiple cuts, perforations, or
removal of cortical, alveolar or basal bone of
the jaw for the purpose of facilitating
orthodontic repositioning of the dentition. This
procedure includes flap entry and closure.
Graft material and membrane, if used, should
be reported separately.
Submission
Providers
ALVEOPLASTY: SURGICAL PREPARATION OF RIDGE FOR DENTURES
D7310 Alveoloplasty in conjunction with No limitations. The Plan coverage includes suturing, local Tooth
extractions – per quadrant anesthetic and routine postoperative care. For identification
reporting purposes, a quadrant is defined as four (4) Quadrant
or more contiguous teeth and/or tooth spaces distal identification
to the midline.
D7311 Alveoloplasty in conjunction with Tooth
extractions – one (1) to three (3) teeth or identification
tooth spaces, per quadrant
D7320 Alveoloplasty, not in conjunction with Tooth

extractions – per quadrant identification
Quadrant
identification
D7321 Alveoloplasty, not in conjunction with Tooth

extractions – one (1) to three (3) teeth or identification
tooth spaces, per quadrant
D7340 Vestibuloplasty – ridge extension Not a covered benefit None None

(secondary epithelialization)
D7350 Vestibuloplasty – ridge extension (incl.

soft tissue grafts, muscle re-attachment,
revision of soft tissue attachment and
management of hypertrophied and
hyperplastic tissue)
Submission
Providers
SURGICAL EXCISION OF REACTIVE SOFT TISSUE LESIONS
D7410 Excision of benign lesion, up to 1.25 cm Not a covered benefit None Submit to medical
carrier for payment
determination.
D7411 Excision of benign lesion > 1.25 cm
D7412 Excision of benign lesion; complicated Submit to medical

carrier for payment
determination.
D7413 Excision of malignant lesion, up to 1.25 Submit to medical

cm carrier for payment
determination.
D7414 Excision of malignant lesion > 1.25 cm
Submission
Providers
D7415 Excision of malignant lesion, complicated Not a covered benefit None Submit to
medical carrier
for payment
determination.
SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS
D7440 Excision of malignant tumor-lesion, Not a covered benefit None Submit to

diameter up to 1.25 cm medical carrier
for payment
D7441 Excision of malignant tumor-lesion, determination.
diameter > 1.25 cm
D7450 Removal of benign odontogenic cyst or No limitations The Plan covers the removal of odontogenic cysts None
tumor lesion, diameter up to 1.25 cm or tumors.
D7451 Removal of benign odontogenic cyst or

tumor, lesion diameter > 1.25 cm
Submission
Providers
D7460 Removal of benign non-odontogenic cyst Not a covered benefit None Submit to
or tumor, lesion, diameter up to 1.25 cm medical carrier
for payment
D7461 Removal of benign nonodontogenic cyst determination.
or tumor – lesion diameter greater than
1.25 cm
D7465 Destruction of lesion(s) by physical or

None
chemical methods, by report
EXCISION OF BONE TISSUE
D7471 Removal of lateral exostosis (maxilla or Once per site per lifetime None Detailed narrative
mandible)
D7472 Removal of torus palatinus
D7473 Removal of torus mandibularis Once per quadrant per lifetime
D7485 Surgical reduction of osseous tuberosity Not a covered benefit None
D7490 Radical resection of maxilla or mandible
Submission
Providers
SURGICAL INCISION
D7510 Incision and drainage of abscess – Covered when reported in Procedure is not to be used for endodontic access Tooth and Arch
intraoral soft tissue conjunction with extractions and drainage through a tooth or for open and identification; A
broach. brief narrative
describing
treatment, location
and/or tooth
number must
accompany claim.
D7511 Incision and drainage of By report Procedure is not to be used for endodontic access A brief narrative
abscess - intraoral soft and drainage through a tooth or for open and describing
tissue - complicated (includes drainage of broach. treatment, location
multiple fascial spaces) and/or tooth
number must
accompany claim.
Submit to medical
D7520 Incision and drainage of abscess – Not a covered benefit None
carrier for payment
extraoral soft tissue determination.
Submission
Providers
D7521 Incision and drainage of Not a covered benefit None Submit to

abscess - extraoral soft medical carrier
tissue - complicated (includes drainage of for payment
multiple fascial spaces) determination.
D7530 Removal of foreign body, mucosa, skin, None

or subcutaneous alveolar tissue
D7540 Removal of reaction-producing foreign

bodies - musculoskeletal system
D7550 Partial ostectomy, sequestrectomy for

removal of non-vital bone
D7560 Maxillary sinusotomy for removal of tooth

fragment or foreign body
Submission
Providers
TREATMENT OF FRACTURES – SIMPLE
D7610 Maxilla – open reduction (teeth Not a covered benefit None None
immobilized, if present)
D7620 Maxilla – closed reduction (teeth

D7630 Mandible – open reduction (teeth

D7640 Mandible – closed reduction (teeth

D7650 Malar and/or zygomatic arch – open

reduction
D7660 Malar and/or zygomatic arch – closed

reduction
D7670 Alveolus - closed reduction, may include Not a covered benefit None None
stabilization of teeth
D7671 Alveolus - open reduction, may include

stabilization of teeth
D7680 Facial bones – complicated reduction

with fixation and multiple surgical
approaches
Submission
Providers
TREATMENT OF FRACTURES – COMPOUND
D7710 Maxilla – open reduction Not a covered benefit None None
D7720 Maxilla – closed reduction
D7730 Mandible – open reduction
D7740 Mandible – closed reduction
D7750 Malar and/or zygomatic arch – open

reduction
D7760 Malar and/or zygomatic arch – closed

reduction
D7770 Alveolus – open reduction stabilization of Not a covered benefit None None
teeth
D7771 Alveolus - closed reduction, stabilization

of teeth
D7780 Facial bones – complicated reduction

with fixation and multiple surgical
approaches
Submission
Providers
REDUCTION OF DISLOCATION AND MANAGEMENT OF OTHER TEMPOROMANDIBULAR JOINT DYSFUNCTIONS:

Procedures that are an integral part of the primary procedure should not be reported separately.
D7810 Open reduction of dislocation Not a covered benefit None None
D7820 Closed reduction of dislocation
D7830 Manipulation under anesthesia
D7840 Condylectomy
D7850 Surgical disectomy; with or without

implant
D7852 Disc repair
D7854 Synovectomy
D7856 Myotomy
D7858 Joint reconstruction
D7860 Arthrotomy
D7865 Arthroplasty
Procedure Guidelines or Limitations, Exclusions and Integral Submission Requirements:

Frequency Limitation Considerations Participating Providers
D7870 Arthrocentesis Not a covered benefit None None
D7871 Non-anthroscopic lysis and lavage
D7872 Arthroscopy – diagnosis, with or

without biopsy
D7873 Arthroscopy – surgical: lavage and

lysis of adhesions
D7874 Arthroscopy – surgical: disc

repositioning and stabilization
D7875 Arthroscopy – surgical: synovectomy
D7876 Arthroscopy – surgical: discectomy
D7877 Arthroscopy – surgical: debridement
D7880 Occlusal orthotic device, by report Benefit for Federal plan only. When covered by Federal plan, coverage of Detailed narrative
Please check with the Plan for occlusal splint therapy is subject to the following
member’s eligibility for this service. limitations;
Benefit is limited to one treatment  A removable acrylic appliance is used in
evert 24 months. conjunction with the therapy
 The disorder is present at least one
month prior to the start of the therapy
and the therapy does not exceed ten
weeks
 The therapy does not result in any
irreversible alteration in the occlusion
 It is not intended to be for the treatment
of bruxism
 It is not for the prevention of injuries of
the teeth or occlusion
 The benefit is limited to once treatment
every 24 months
 The member is responsible for the
difference between the Plan's allowance
and the provider's billed charge.
Submission
Providers
D7881 Occlusal orthotic device adjustment Not a covered benefit None None
D7899 Unspecified TMD therapy, by report
REPAIR OF TRAUMATIC WOUNDS
D7910 Suture of recent small wounds up to 5 cm Not a covered benefit None Submit to
medical carrier
for payment
determination.
COMPLICATED SUTURING - Reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure
D7911 Complicated suture up to 5 cm Not a covered benefit None None
D7912 Complicated suture > 5 cm
Submission
Providers
OTHER REPAIR PROCEDURES
D7920 Skin grafts (identify defect covered, Not a covered benefit None None
location, and type of graft)
D7921 Collection and application of autologous

blood concentrate product.
D7940 Osteoplasty – for orthognathic

deformities
D7941 Osteotomy – mandibular rami
D7943 Osteotomy – mandibular rami with bone

graft; includes obtaining the graft
D7944 Osteotomy – segmented or sub-apical
D7945 Osteotomy – body of mandible
D7946 LeFort I (maxilla – total)
D7947 LeFort I (maxilla – segmented)
Submission
Providers
D7948 LeFort II or LeFort III (osteoplasty of facial Not a covered benefit None None
bones for midface hypoplasia or retrusion) –
without bone graft
D7949 LeFort II or LeFort II – with bone graft
D7950 Osseous, osteoperiosteal, or cartilage graft

of the mandible or maxilla - autogenous or
nonautogenous, by report
D7951 Sinus augmentation with bone or bone

substitutes via a lateral open approach
D7952 Sinus augmentation via a vertical approach
D7953 Bone replacement graft for ridge

preservation – per site
D7955 Repair of maxillofacial soft and/or hard

tissue defect
Submission
Providers
D7960 Frenulectomy – also known as (frenectomy No limitations None Arch identification;

or frenotomy) – separate procedure not Detailed narrative
incidental to another procedure
D7963 Frenuloplasty
D7970 Excision of hyperplastic tissue – per arch Once per arch per benefit period Not payable if filed in conjunction with D4210 or Arch identification;
D4211 Operative report
D7971 Excision of pericoronal gingiva No limitations. None None
D7972 Surgical reduction of fibrous tuberosity Not a covered benefit
D7979 Non-surgical sialolithotomy. A sialolith is

removed from the gland or ductal portion of
the gland without surgical incision into the
gland or the duct of the gland; for example
via manual manipulation, ductal dilation, or
any other non-surgical method.
D7980 Sialolithotomy
D7981 Excision of salivary gland, by report
D7982 Sialodochoplasty
D7983 Closure of salivary fistula
D7990 Emergency tracheotomy
Submission
Providers
D7991 Coronoidectomy Not a covered benefit None None
D7995 Synthetic graft, mandible or facial bones,

by report
D7996 Implant – mandible for augmentation

purposes (excluding alveolar ridge), by
report
D7997 Appliance removal (not by dentist who

placed appliance), includes removal of
archbar
D7998 Intraoral placement of a fixation device

not in conjunction with a fracture
D7999 Unspecified oral surgery procedure, by By report Individual Consideration. Detailed narrative Tooth
Detailed narrative
CDT: ORTHODONTIC SERVICES
ORTHODONTIC SERVICES
Orthodontic Benefit Administration
Limited Orthodontic Treatment

Orthodontic treatment with a limited objective, not necessarily involving the entire dentition. It may be directed at the only existing problem, or at only one aspect
of a larger problem in which a decision is made to defer or forego more comprehensive therapy.
Interceptive Orthodontic Treatment

Interceptive orthodontics is an extension of preventive orthodontics that may include localized tooth movement. Such treatment may occur in the primary or
transitional dentition and may include such procedures as the redirection of ectopically erupting teeth, correction of dental crossbite or recovery of space loss
where overall space is inadequate. When initiated during the incipient stages of a developing problem, interceptive orthodontics may reduce the severity of the
malformation and mitigate its cause. Complicating factors such as skeletal disharmonies, overall space deficiency, or other conditions may require subsequent
comprehensive therapy.
Comprehensive Orthodontic Treatment

Comprehensive orthodontic care includes a coordinated diagnosis and treatment leading to the improvement of a patient’s craniofacial dysfunction and/or
dentofacial deformity which may include anatomical, functional and/or esthetic relationships. Treatment may utilize fixed and/or removable orthodontic appliances
and may also include functional and/or orthopedic appliances in growing and non-growing patients. Adjunctive procedures to facilitate care may be required.
Comprehensive orthodontics may incorporate treatment phases focusing on specific objectives at various stages of dentofacial development.
How to Submit Claims - Please follow these guidelines when submitting claims for orthodontic treatment:
Limited, Interceptive and Minor Treatment. Submit a claim with the appropriate CDT procedure code, including the total treatment fee and the placement date of
the appliance. We will make payment after receipt of initial claim for treatment.
Comprehensive Treatment. One (1) installment equal to 25% of the lifetime maximum; pro-rated payments continue monthly until the treatment has ended or a
new treatment plan including complete treatment plan information is submitted. For patients whose comprehensive treatment started after their orthodontic benefits
became effective, submit the claim with the appropriate CDT procedure code, including the treatment charge and the date treatment began. Payment will be
prorated by comparing the banding date to the effective date of coverage and remaining length of treatment. (Accumulation transfers will be considered if provided
by prior carrier.) If comprehensive treatment began before the patient’s orthodontic benefits became effective, submit the monthly visits and your monthly fee using
the appropriate CDT procedure code. When submitting claims for the services included in orthodontic records, itemize the appropriate CDT procedure code for
each service (e.g., radiographs, evaluation, study models) with your usual fee. If you have questions regarding a patient’s coverage, effective dates, or benefits,
call our Dental Call Center at 808-948-6440 on Oahu or 800-792-4672 from Neighbor Islands.
Submission
Providers
ORTHODONTICS
D8010 Limited orthodontic treatment of primary A limited number of dental plans For those plans that do include benefits for Diagnosis,
dentition have orthodontic benefits orthodontics see the Dental Manual, Orthodontia banding date and
section for details on claim submission. estimated length
D8020 Limited orthodontic treatment of of treatment must
transitional dentition be submitted with
the claim
D8030 Limited orthodontic treatment of
adolescent dentition
D8040 Limited orthodontic treatment of adult

dentition
D8050 Interceptive orthodontic treatment of

primary dentition
D8060 Interceptive orthodontic treatment of

transitional dentition
D8070 Comprehensive orthodontic treatment of

transitional dentition
D8080 Comprehensive orthodontic treatment of

adolescent dentition
Submission
Providers
D8090 Comprehensive orthodontic treatment of A limited number of dental plans For those plans that do include benefits for Diagnosis,
adult dentition have orthodontic benefits orthodontics see the Dental Manual, Orthodontia banding date and
D8210 Removable appliance therapy of treatment must
be submitted with
the claim
D8220 Fixed appliance therapy
OTHER ORTHODONTIC SERVICES
D8660 Pre-orthodontic treatment examination to A limited number of dental plans For those plans that do include benefits for Diagnosis,
monitor growth and development have orthodontic benefits orthodontics see the Dental Manual, Orthodontia banding date and
D8670 Periodic orthodontic treatment visit of treatment must
be submitted
D8680 Orthodontic retention (removal of

appliances, construction and placement
of retainer(s)
D8681 Removable orthodontic retainer

adjustment
D8690 Orthodontic treatment (alternative billing

to a contract fee)
Submission
Providers
D8691 Repair of orthodontic appliance A limited number of dental plans For those plans that do include benefits for Diagnosis,
have orthodontic benefits orthodontics see the Dental Manual, Orthodontia banding date and
D8692 Replacement of lost or broken retainer
of treatment must
be submitted
D8693 Re-cement or re-bond fixed retainer
D8694 Repair of fixed retainers, includes

reattachment
D8695 Removal of fixed orthodontic appliances Not a covered benefit None None
for reasons other than completion of
treatment
D8999 Unspecified orthodontic procedure, by By report Individual Consideration. Detailed narrative Detailed narrative
report; Used for procedures not required.
adequately described by a code
CDT: ADJUNCTIVE GENERAL SERVICES
ADJUNCTIVE GENERAL SERVICES
Submission
/Providers
ADJUNCTIVE GENERAL SERVICES
D9110 Palliative (emergency) treatment of By report Palliative treatment is covered when a painful Tooth Quadrant or
dental pain – minor procedure emergency condition requires immediate treatment Arch identification
for relief. To be considered palliative, the procedure
A narrative
should alleviate but not cure. Coverage is for the
description of
emergency treatment (per visit) providing no other
procedure must
eligible services, except diagnostic radiographs, and
accompany the
exam, are performed. One (1) palliative service per
claim
visit. If submitted in conjunction with definitive
procedures palliative treatment will be denied. Tooth
identification
D9120 Fixed partial denture sectioning Routine removal of a fixed partial denture prior to A narrative
remake of the prosthesis is not covered separately. describing the
The procedure is by report. The patient must be age procedure and
fifteen (15) and older tooth numbers are
required with the
claim
D9130 Temporomandibular joint dysfunction – Not a covered benefit None None

non-invasive physical therapies
Submission
Providers
ANESTHESIA
D9210 Local anesthesia not in conjunction with Not a covered benefit Considered part of total fee for non-surgical or None
operative or surgical procedures surgical services.
D9211 Regional block anesthesia
D9212 Trigeminal division block anesthesia
D9215 Local anesthesia in conjunction with

operative or surgical procedures
D9219 Evaluation for deep sedation or general Denied as integral if in conjunction with same day
anesthesia D9223 or D9243. Or if submitted as a stand alone
code, it will deny as patient liability.
D9222 Deep sedation/general anesthesia – first 15 General anesthesia will be paid only when
minutes Anesthesia time begins when the Deep sedation, general anesthesia
performed in conjunction with a covered oral
doctor administering the anesthetic agent is a covered benefit when medically
surgical procedure code.
initiates the appropriate anesthesia and necessary and claimed in
non-invasive monitoring protocol and conjunction with a covered oral
remains in continuous attendance of the surgical procedure code.
patient. Anesthesia services are considered
completed when the patient may be safely
left under the observation of trained
personnel and the doctor may safely leave
the room to attend to other patients or
duties. The level of anesthesia is
determined by the anesthesia provider’s
documentation of the anesthetic effects
upon the central nervous system and not
dependent upon the route of administration.
Submission
Providers
D9223 Deep sedation/general anesthesia – Deep sedation, general anesthesia General anesthesia will be paid only when None
each 15 minute increment is a covered benefit when medically performed in conjunction with a covered oral
and claimed in conjunction with a surgical procedure code. Limited to 2 times per
covered oral surgical procedure session.
code. Limited to 2 times per
session.
D9230 Inhalation of nitrous oxide/analgesia, Not a covered benefit None

anxiolysis
D9239 Intravenous moderate (conscious) Intravenous moderate (conscious) Intravenous moderate (conscious)
sedation/analgesia- first 15 minutes sedation/analgesia is a covered sedation/analgesia will be paid only when performed
Anesthesia time begins when the doctor benefit when medically necessary in conjunction with a covered oral surgical
administering the anesthetic agent and claimed in conjunction with a procedure code.
initiates the appropriate anesthesia and covered oral surgical procedure
non-invasive monitoring protocol and code.
remains in continuous attendance of the
patient. Anesthesia services are
considered completed when the patient
may be safely left under the observation
of trained personnel and the doctor may
safely leave the room to attend to other
patients or duties. The level of
anesthesia is determined by the
anesthesia provider’s documentation of
the anesthetic effects upon the central
nervous system and not dependent upon
the route of administration.
Submission
Providers
D9243 Intravenous moderate (conscious) Intravenous moderate (conscious) Intravenous moderate (conscious) None
sedation/analgesia – each 15 minute sedation/analgesia is a covered sedation/analgesia will be paid only when performed
increment. benefit when medically necessary in conjunction with a covered oral surgical
and claimed in conjunction with a procedure code. Limited to 2 times per session.
covered oral surgical procedure
code. Limited to 2 times per
session.
D9248 Non-intravenous moderate (conscious) Not a covered benefit None

sedation
PROFESSIONAL CONSULTATION
D9310 Consultation (diagnostic service by Not a covered benefit None None

dentist or physician other than the
practitioner providing treatment)
D9311 Consultation with a medical health care

professional
Submission
Providers
PROFESSIONAL VISITS
D9410 House / extended care facility call Not a covered benefit None None
D9420 Hospital or ambulatory surgical center

call
D9430 Office visit for observation during regular

scheduled hours – no other services
performed
D9440 Office visit – after regularly scheduled By report, no frequency limitations This procedure may be paid in addition to other Detailed narrative
hours dental procedures
D9450 Case presentation, detailed and Not a covered benefit None None
extensive treatment planning
Submission
Providers
DRUGS
D9610 Therapeutic parenteral drug, single Not a covered benefit None None
administration
D9612 Therapeutic parenteral drugs, two (2) or

more administrations, different
medications
D9613 Infiltration of sustained release

therapeutic drug – single or multiple site
D9630 Other drugs and/or medicaments, by

report
MISCELLANEOUS SERVICES
D9910 Application of desensitizing medicament Not a covered benefit None None
D9911 Application of desensitizing resin for

cervical and/or root surface, per tooth
D9920 Behavior management, by report
D9930 Treatment of complications (post-

surgical) - unusual circumstances, by
report
Submission
Providers
D9932 Cleaning and inspection of removable Not a covered benefit Always integral None
complete denture, maxillary
D9933 Cleaning and inspection of removable

complete denture, mandibular
D9934 Cleaning and inspection of removable Not a covered benefit

partial denture, maxillary
D9935 Cleaning and inspection of removable

partial denture, mandibular
D9941 Fabrication of athletic mouthguard None
D9942 Repair and/ or reline of occlusal guard Not a covered benefit None
D9943 Occlusal guard adjustment
D9944 Occlusal guard Hard Appliance , full arch Not a covered benefit None
D9945 occlusal guard – soft appliance, full arch
D9946 occlusal guard – hard appliance, partial Not a covered benefit None
arch
D9950 Occlusion analysis - mounted case
D9951 Occlusal adjustment - limited None

D9952 Occlusal adjustment - complete
D9961 Duplicate/copy patient’s records

Submission
Providers
D9970 Enamel microabrasion Not a covered benefit None None
D9971 Odontoplasty one (1) to two (2) teeth;

includes removal of enamel projections
D9972 External bleaching – per arch –

performed in office
D9973 External bleaching – per tooth
D9974 Internal bleaching – per tooth
D9975 External bleaching for home application,

per arch; includes materials and
fabrication of custom trays
D9985 Sales tax Covered benefit on Federal plan Tax is a reimbursable benefit for federal plan
only members based on the HMSA eligible charge for
covered services.
D9986 Missed appointment Not a covered benefit None
D9987 Cancelled appointment
D9990 Certified translation or sign - language

services - per visit
D9991 Dental case management – addressing

appointment compliance barriers
Submission
Providers
D9992 Dental case management – care Not a covered benefit None None
coordination
D9993 Dental case management – motivational

interviewing
D9994 Dental case management – patient

education to improve oral health literacy
D9995 Teledentistry – synchronous; real-time

encounter. Reported in addition to other
procedures (e.g., diagnostic) delivered to
the patient on the date of service.
D9996 Teledentistry – asynchronous;

information stored and forwarded to
dentist for subsequent review. Reported
in addition to other procedures (e.g.,
diagnostic) delivered to the patient on the
date of service.
D9999 Unspecified adjunctive procedure by By report Individual Consideration. Detailed narrative Tooth Quadrant or
report required. Arch identification
and a detailed
narrative.

Dental Codes

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Dental Codes

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CDT 2020

Dental Procedure codes and

If you need additional information on how to submit a claim, you can:

 Refer to the Dental Administrative Manual

 Refer to the Dental Administrative Manual/How to submit a Medical claim

What is “Necessary and Appropriate Treatment?”

 Furnished in accordance with standards of good dental practice.

Services That Are Non-covered Due to Contractual Limitations

When Documentation Is Requested

When we do request documentation, please remember that radiographs must be:

 Preoperative radiographic images that are current and dated

 The Member’s name and ID

D0170 Re-evaluation: limited, problem focused Not a covered benefit None

D0171 Re-evaluation - post-operative office visit

D0191 Assessment of a patient A limited clinical inspection that is performed to

IMAGE CAPTURE WITH INTERPRETATION

D0250 Extraoral – 2D projection radiographic Not a covered benefit None None

D0251 Extraoral posterior dental radiographic

Vertical bitewings constitute a set of bitewings.

D0310 Sialography Not a covered benefit None

D0320 Temporomandibular joint arthrogram,

D0321 Other temporomandibular joint films, by

D0322 Tomographic survey

D0340 Cephalometric radiographic images Not a covered benefit None None

D0350 2D oral/facial photographic image

D0351 3D photographic image

D0364 Cone beam CT capture and

D0365 Cone beam CT capture and

D0366 Cone beam CT capture and

D0367 Cone beam CT capture and

D0369 Maxillofacial MRI capture and

D0370 Maxillofacial ultrasound capture and

D0371 Sialoendoscopy capture and

D0381 Cone beam CT capture and

D0383 Cone beam CT capture and

D0384 Cone beam CT capture and

D0385 Maxillofacial MRI capture and

D0386 Maxillofacial ultrasound capture and

POST PROCESSING OF IMAGE OR IMAGE SETS

D0394 Digital subtraction of two or more images

D0395 Fusion of two or more 3D image volumes

TESTS AND EXAMINATIONS

D0414 Laboratory processing of microbial Not a covered benefit None None

D0415 Collection of microorganisms for culture

D0416 Viral Culture

D0417 Collection and preparation of saliva

D0418 Analysis of saliva sample Not a covered benefit None None

D0422 Collection and preparation of genetic

D0423 Genetic test for susceptibility to diseases None

D0425 Caries susceptibility tests

Not a covered benefit Not a covered benefit

D0473 Accession of tissue, gross and

D0474 Accession of tissue, gross and None

D0475 Decalcification procedure

D0476 Special stains for microorganisms

D0477 Special stains, not for microorganisms

D0478 Immunohistochemical stains

Not a covered benefit None None

D0480 Processing and interpretation of

D0481 Electron microscopy

D0482 Direct immunofluorescence

D0483 Indirect immunofluorescence

D0484 Consultation on slides prepared