Covered and Non-Covered Dental Services, 1-1-2019 · If dental services are billed as medical...

Copyright Notice: Current Dental Terminology © 2015 American Dental Association.

All rights reserved. Applicable FARS/DFARS apply.

n

n

n

n

n

Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant

adults

D0120periodic oral eval-established

patientYes Yes Yes Line 53-Preventive dental svcs.GLN 17

D0140 limited oral eval-problem focus Yes Yes YesLine 54-Dental conditions (e.g. infection,

pain trauma)

D0145 oral evaluation, pt < 3yrs Yes No No Line 53-Preventive dental svcs..GLN 17

D0150comprehensive oral eval-new or

establishedYes Yes Yes Line 53-Preventive dental svcs..GLN 17

D0160extensive oral eval-problem

focusYes Yes Yes

Line 54-Dental conditions (e.g. infection,

pain trauma)

D0170 re-eval limited, problem focus Yes Yes YesLine 54-Dental conditions (e.g. infection,

pain trauma)

D0171 re-eval post operative office visit No No No Excluded File (travel vaccines etc.)

D0180comp periodic eval-new or

establishedYes Yes Yes Line 53-Preventive dental svcs..GLN 17

D0190 screening of a patient No No No Excluded File (travel vaccines etc.)

D0191 assessment of a patient Yes Yes Yes

Line 53-Preventive dental svcs.Line 3

Prevention services with evidence of

effectiveness .GLN 17-bundledD0210 intraoral-complete series Yes Yes Yes Diagnositic procedure

Covered and Non-Covered Dental Services

1/1/2018 Covered through 469-Status

This document pertains to services provided on or after January 1, 2019

Codes listed with a "No" are non-covered services for the specific benefit package(s) listed or are services that are "incidental" to another service

and are not reimbursed separately.If dental services are billed as medical pursuant to rule, they are billed on a CMS-1500 claim for using CPT or HCPCS codes and ICD-10-CM

diagnosis codes. (The procedures listed as "L" meaning "medical" on the table may not be all inclusive of every dental code that has a

corresponding medical code.)

The OHA Fee-for-Service Fee Schedule can be found at: (http://www.oregon.gov/OHA/HSD/Pages/Fee-Schedule.aspx). This schedule is

representative of a given point in time and may not include fees added to MMIS after the posted fee schedule date and are still payable..

BR (By report) indicates clinical documentation is required prior to payment determination.

Codes listed with a "Yes" in this table are covered services for the specific benefit package(s) listed. (Refer to the Dental Services rulebook for

futher details regarding coverage and limitations.)

OHP PLUS BENEFIT PACKAGEL=Medical, has CPT code

or usually billed on

medical claim/BR = BY

REPORTDESCRIPTIONCODE

Revised: 01-01-2019 1



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant

adults 1/1/2018 Covered through 469-Status





D0220intraoral-periapical first

radiographic imageYes Yes Yes Diagnostic procedure

D0230 introral-periapical each addtl Yes Yes Yes Diagnostic procedure

D0240 intraoral-occlusal Yes Yes Yes Diagnostic procedure

D0250

extraoral-2D projection

radiographic image created using

a stationary radiatin source, and

detector

Yes Yes Yes Diagnostic procedure

D0251extra-oral posterior dental


D0260 extraoral-each addtl No No No Diagnostic procedure

D0270 bitewing-single Yes Yes Yes Diagnostic procedure

D0272 bitewing-two radiographic images Yes Yes Yes Diagnostic procedure

D0273bitewing-three radiographic

imagesYes Yes Yes Diagnostic procedure

D0274bitewing-four radiographic

imagesYes Yes Yes Diagnostic procedure

D0277 vertical bitewing 7-8 Yes Yes Yes Diagnostic procedure

D0290posterior-anterior or skull & facial


D0310 sialography No No No L Diagnostic procedure

D0320 TMJ arthrogram No No No Diagnostic procedure

D0321 other TMJ radiographic images Yes Yes Yes Diagnostic procedure

D0322 tomographic survey Yes Yes Yes BR Diagnostic procedure

D0330 panoramic radiographic image Yes Yes Yes Diagnostic procedure

D0340

2D cephalometric radiographic

image - acquisition,

measurement and analysis

No No No

Line 615: Dental conditions (e.g.,

malocclusion)

D03502D oral/facial photographic

imageNo No No


malocclusion)

D0351 3D photographic image No No No Excluded File (travel vaccines etc.)

D0364cone beam, less than one whole

jawNo No No

Line 257,Deformities of the head, GLN

169

Revised: 01-01-2019 2



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D0365 cone beam, mandible No No NoLine 257,Deformities of the head, GLN

169

D0366 cone beam, maxilla No No NoLine 257,Deformities of the head, GLN

169

D0367 cone beam, both jaws No No NoLine 257,Deformities of the head, GLN

169

D0368 cone beam for TMJ series No No No Excluded File (travel vaccines etc.)

D0369 maxillofacial MRI No No No Excluded File (travel vaccines etc.)

D0370 maxillofacial ultrasound No No No Excluded File (travel vaccines etc.)

D0371 sialoendoscopy No No No Excluded File (travel vaccines etc.)

D0380cone beam image only, less than

one whole jawNo No No Excluded File (travel vaccines etc.)

D0381 cone beam image only, mandible No No No Excluded File (travel vaccines etc.)

D0382 cone beam image only, maxilla No No No Excluded File (travel vaccines etc.)

D0383 cone beam image only,both jaws No No No Excluded File (travel vaccines etc.)

D0384cone beam image only, for TMJ

seriesNo No No Excluded File (travel vaccines etc.)

D0385 maxillofacial MRI image only No No No Excluded File (travel vaccines etc.)

D0386maxillofacial ultrasound image

onlyNo No No Excluded File (travel vaccines etc.)

D0391interpretation of image by other

practitionerNo No No Excluded File (travel vaccines etc.)

D0393treatment simulation using 3D

image volumeNo No No

Line 616-Dental conditions (e.g.missing

teeth)

D0394digital subtraction of two or more

images or image volumesNo No No


teeth)

D0395fusion of two or more 3D image

volumesNo No No


teeth)

D0411 HbA1c in office point of service No No NoDiagnostic-Not in scope dental

procedure

Revised: 01-01-2019 3



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D0412blood glucose level test - in office

u sing a glucose meterNo No No Diagnostic-Not in scope procedure

D0414

Laboratory processing of

microbial specimen to include

culture and sensitivity studies,

preparation and transmission of

written report

No No No L Diagnositic procedure

D0415collection for culture and

sensitivityYes Yes Yes BR Diagnositic procedure

D0416 viral culture No No No Excluded File (travel vaccines etc.)

D0417collection and prep of saliva

sampleNo No No Excluded File (travel vaccines etc.)

D0418 analysis of saliva sample No No No Excluded File (travel vaccines etc.)

D0421Genetic test for susceptibility to

oral diseasesNo No No Excluded File (travel vaccines etc.)

D0422collection and preparation of

genetic sampleNo No No

Line 660: Conditions for which certain

interventions are unproven, have no

clinically important benefit or have

harms that outweigh benefits

D0423genetic test for susceptibility to

diseases – specimen analysisNo No No





D0425 caries susceptibility tests No No No Excluded File (travel vaccines etc.)

D0431 adjuntive pre-diagnostic test No No No Excluded File (travel vaccines etc.)

D0460 pulp vitality No No No Excluded File (travel vaccines etc.)

D0470 diagnostic casts No No No Excluded File (travel vaccines etc.)

D0472 accession of tissue No No NoDiagnostic procedure


Revised: 01-01-2019 4



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant







D0475 decalcification proc No No No Excluded File (travel vaccines etc.)

D0476 special stains for microorganism No No No Excluded File (travel vaccines etc.)

D0477special stains not for

microorganismNo No No Excluded File (travel vaccines etc.)

D0478 immunohistochemical stains No No No Excluded File (travel vaccines etc.)

D0479 tissue in-situ hybridization No No No Excluded File (travel vaccines etc.)

D0480accession of exfoliative cytologic

smearsNo No No Diagnostic procedure

D0481 electron microscopy No No No Excluded File (travel vaccines etc.)

D0482 direct immunofluorescence No No No Excluded File (travel vaccines etc.)

D0483 indirect immunofluorescence No No No Excluded File (travel vaccines etc.)

D0484consult on slides prepared

elsewhereNo No No Excluded File (travel vaccines etc.)

D0485 consultation No No No Excluded File (travel vaccines etc.)

D0486 accession of brush biopsy No No No Diagnostic procedure

D0502 other oral path proc No No No Diagnostic procedure

D0600Other oral pathology procedures,

by reportNo No No BR Excluded File (travel vaccines etc.)

D0601caries risk assessment and

documentation, low riskNo No No Line 53--dental svcs.,GLN 17, bundled


documentation, moderate riskNo No No Line 53--dental svcs..GLN 17, bundled


documentation, high riskNo No No Line 53--dental svcs.GLN 17, bundled

D0999 unspecified diagnostic proc No No No Excluded File (travel vaccines etc.)

D1110 prophylaxis-adult No Yes Yes Line 53-Preventive dental svcs..GLN 17

D1120 prophylaxis-child Yes No No Line 53-Preventive dental svcs..GLN 17

D1206 topical fluoride varnish Yes Yes Yes

Line 53 Preventive dental svcs. Line 3

Prevention services with evidence of

effectiveness - GLN 17

Revised: 01-01-2019 5



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D1208 topical application of fluoride Yes Yes Yes Line 53 Preventive dental svcs GLN 17

D1310 nutritional counseling No No NoLine 53-Preventive dental svcs..GLN 17,

bundled

D1320 tobacco counseling Yes Yes YesLine 5-Multisector intervention- tobacco

dependence,GLN 4

D1330 oral hygiene instructions No No NoLine 53-Preventive dental svcs. GLN17,

bundled

D1351 sealant Yes No No Line 53-Preventive dental svcs. GLN17

D1352preventive resin restoration, mod

to high risk - permanent toothNo No No Excluded File (travel vaccines etc.)

D1353 sealant repair - per tooth No No No Excluded File (travel vaccines etc.)

D1354

interim caries arresting

medicament application- per

tooth

Yes Yes YesLine 343 -Dental Conditions (e.g. caries,

fractured tooth), GLN 91, 123

D1510 space maintainer-fixed unilateral Yes No No Line 53-Preventive dental svcs. .GLN 17

D1516space maintainer - fixed-bilateral,

maxillaryYes No No Line 53-Preventive dental svcs.GLN 17.

D1517space maintainer - fixed-bilateral -

,mandibularYes No No Line 53-Preventive dental svcs.GLN 17.

D1520space maintainer-removable

unilateralYes No No Line 53-Preventive dental svcs.GLN 17.

D1526space maintainer - removalbel,

bilateral, maxillaryYes No No Line 53-Preventive dental svcs.GLN 17.

D1527space maintainer - removalbel,

bilateral, mandiblularYes No No Line 53-Preventive dental svcs.GLN 17.

D1550re-cement or re-bond space

maintainerYes No No Line 53-Preventive dental svcs..GLN 17

D1555 removal fixed space maintainer Yes No No Line 53-Preventive dental svcs..GLN 17

D1575Distal shoe space maintainer-

fixed unilateralYes No No Line 53-Preventive dental svcs..GLN 17

Revised: 01-01-2019 6



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D1999 unspecified preventive procedure No No No Excluded File (travel vaccines etc.)

D2140 amalgam-1 surface prim or perm Yes Yes YesLine 343-Dental conditions (e.g. caries,

fractured tooth), GLN 91,123





D2161amalgam-4 or more surface prim

or permYes Yes Yes

Line 343-Dental conditions (e.g. caries,


D2330resin based composite- 1

anteriorYes Yes Yes




anteriorYes Yes Yes




anteriorYes Yes Yes



D2335resin based composite- 4 or >

anteriorYes Yes Yes



D2390resin based composite-crown

anteriorYes No Yes




posteriorYes Yes Yes











D2394resin based composite- 4 or >




D2410 gold foil- 1 surface No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)


fractured tooth)


fractured tooth)

Revised: 01-01-2019 7



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D2510 inlay metallic- 1 surface No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2520 inlay metallic- 2 surface No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2530 inlay metallic- 3 or more surface No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2542 onlay metallic- 2 surface No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2543 onlay metallic- 3 surface No No NoLine 588Dental conditions (e.g. caries,

fractured tooth)

D2544 onlay metallic- 4 or more surface No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2610inlay porcelain/ceramic- 1

surfaceNo No No

Line 643- Dental conditions where

treatment is chosen primarily for

aesthetic considerations

D2620inlay porcelain/ceramic- 2

surfaceNo No No




D2630inlay porcelain/ceramic- 3 or

more surfaceNo No No




D2642onlay porcelain/ceramic- 2

surfaceNo No No




D2643onlay porcelain/ceramic-3

surfaceNo No No




Revised: 01-01-2019 8



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D2644onlay porcelain/ceramic- 4 or

more surfaceNo No No




D2650inlay resin-based composite- 1

surfaceNo No No




D2651inlay resin-based composite- 2

surfaceNo No No


fractured tooth)

D2652inlay resin-based composite- 3 or

> surfaceNo No No




D2662onlay resin-based composite- 2

surfaceNo No No





surfaceNo No No





or > surfaceNo No No

Line 643: Dental conditions where



D2710 crown resin based composite Yes No Yes

Line 466: Dental conditions (e.g., caries,

fractured tooth)

D2712 crown 3/4 resin based composite Yes No YesLine 466- Dental conditions (e.g., caries,

fractured tooth)

D2720 crown resin with high noble metal No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2721 crown resin with predominantly

base metalNo No No


fractured tooth)

Revised: 01-01-2019 9



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D2722 crown resin with noble metal No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2740 crown porcelain/ceramic No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2750crown porcelain fused to high

noble metalNo No No


fractured tooth)

D2751 crown porcelain fused to predom

base metalYes No Yes

Line 466- Dental conditions (e.g., caries,

fractured tooth)

D2752 crown porcelain fused to noble

metalYes No Yes

Line 466- Dental conditions (e.g., caries,

fractured tooth)

D2780 crown 3/4 cast high noble metal No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2781crown 3/4 cast predominantly

base metalNo No No


fractured tooth)

D2782 crown 3/4 cast noble metal No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2783 crown 3/4 porcelain/ceramic No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2790 crown full cast high noble metal No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2791crown full cast predominantly

base metalNo No No


fractured tooth)

D2792 crown full cast noble metal No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2794 crown titanium No No NoLine 588-Dental conditions (e.g. caries,

fractured tooth)

D2799 provisional crown No No No

644: Dental conditions where treatment

results in marginal improvement

D2910

re-cement or re-bond inlay,

onlay, veneer or part coverage

restoration

Yes Yes YesLine 267: Dental conditions (time

sensitive events)

Revised: 01-01-2019 10



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D2915

re-cement or re-bond indirectly

fabricated or prefabricated post

and core

Yes Yes YesLine 267: Dental conditions (time

sensitive events)

D2920 re-cement or re-bond crown Yes Yes YesLine 267: Dental conditions (time

sensitive events)

D2921 reattachment of tooth fragment Yes Yes YesLine 267: Dental conditions (time

sensitive events)

D2929prefab porcelain/ceramic crown,

primaryNo No No


fractured tooth)

D2930crown prefabricated stainless

steel primYes Yes Yes



D2931crown prefabricated stainless

steel permYes Yes Yes



D2932 crown prefabricated resin Yes No YesLine 343-Dental conditions (e.g. caries,


D2933crown prefab stainless steel w

resin windowYes No Yes



D2934crown prefab esthetic coated

stainless steel primNo No No

Line 643-Dental conditions where



D2940 protective restoration Yes Yes YesLine 267---Dental conditions (e.g. caries,

fractured tooth

D2941interim therapeutic restoration -

primary dentitionYes Yes Yes



D2949restorative foundation for indirect

restorationNo No No


fractured tooth)

D2950 core buildup Yes No Yes


fractured tooth),GLN 91,123

Line 267: Dental conditions (time

sensitive events)

D2951 pin retention Yes Yes YesLine 343-Dental conditions (e.g., caries,


D2952post & core in addt to crown,

indirectly fabricatedNo No No

Line 588-Dental conditions (e.g., caries,

fractured tooth)

Revised: 01-01-2019 11



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D2953post-each addtl indirectly

fabricatedNo No No


fractured tooth)

D2954 prefabricated post & core Yes No YesLine 343-Dental conditions (e.g., caries,

fractured tooth).GLN 91,123

D2955 post removal No No No


treatment results in marginal

improvement

D2957 prefabricated post -each addtl Yes No YesLine 343: Dental conditions (e.g., caries,

fractured tooth).GLN 91,123

D2960labial veneer, resin laminate -

chairsideNo No No




D2961labial veneer, resin laminate -

laboratoryNo No No




D2962labial veneer, porcelain laminate -

laboratoryNo No No




D2970Temporary crown (fractured

tooth)No No No


sensitive events)-CMS closed code in

2015

D2971construct new crown under

existing partial No No No


fractured tooth)

D2975 coping No No No Excluded File (travel vaccines etc.)

D2980 crown repair Yes Yes YesLine 343-Dental conditions (e.g., caries,


D2981 inlay repair No No NoLine 588-Dental conditions (e.g., caries,

fractured tooth)

D2982 onlay repair No No NoLine 588-Dental conditions (e.g., caries,

fractured tooth)

Revised: 01-01-2019 12



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D2983 veneer repair No No No




D2990resin infiltration of smooth

surface lesionsNo No No



improvementD2999 unspecified restorative proc No No No Ancillary procedure

D3110 pulp cap direct No No No


infection, pain, trauma)

D3120 pulp cap indirect No No NoLine 267 Dental conditions (time

sensitive events)

D3220 therapeutic pulpotomy Yes Yes YesLine 267 Dental conditions (time

sensitive events)

D3221 pulpal debridement Yes Yes YesLine 54 Dental conditions (e.g.,


D3222partial pulpotomy for

apexogenesisYes Yes Yes

Line 267:Dental conditions (time

sensitive events)

D3230 pulpal therapy - anterior, primary Yes No NoLine 267: Dental conditions (time

sensitive events)

D3240pulpal therapy - posterior,

primaryYes No No


sensitive events)

D3310 anterior Yes Yes YesLine 384 Dental conditions (e.g., pulpal

pathology, permanent anterior tooth)

D3320 bicuspid Yes Yes Yes

Line 410: Dental conditions (e.g., pulpal

pathology, permanent

bicuspid/premolar tooth)

D3330 molar Yes NoYes 1st

molar


pathology, permanent molar tooth)

Revised: 01-01-2019 13



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D3331 root canal obstruction, non

surgicalYes Yes Yes








D3332 incomplete endodontic therapy Yes Yes Yes BR








D3333internal root repair of perforation

defectsYes Yes Yes BR








D3346previous root canal therapy-

anteriorYes Yes Yes BR



Revised: 01-01-2019 14



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant







bicuspidNo No No





molarNo No No

Line 535 Dental conditions (e.g., pulpal


D3351 apexification/recalcification-initial

visitYes No Yes

Line 267 Dental conditions (time

sensitive events)

D3352apexification/recalcification-

interim medication replacementYes No Yes


sensitive events)

D3353apexification/recalcification-final

visitYes No Yes BR


sensitive events)

D3355 pulpal regneration-initial visit No No No



improvement

D3356pulpal regeneration-interim

medication replacementNo No No



improvement

D3357pulpal regeneration-completion of

treatmentNo No No



improvement

D3410 apicoectomy-anterior Yes Yes Yes



D3421 apicoectomy-bicuspid No No No




Revised: 01-01-2019 15



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D3425 apicoectomy-molar No No No



D3426apicoectomy/periradicular

surgery-each addtl rootNo No No






D3427periradicular surgery without

apicoectomyNo No No



improvement

D3428bone graft in conjunction with

periradicular surgeryNo No No



improvement

D3429 each additional contiguous tooth No No No



improvement

D3430 retrograde filling Yes Yes Yes BR








Revised: 01-01-2019 16



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D3431biologic materials to aid in soft

and osseous tissue regenerationNo No No



improvement

D3432 guided tissue regneration No No No



improvement

D3450 root amputation No No No






D3460 endodontic endosseous implant No No No




D3470 reimplantation No No No



improvement

D3910surgical proc for isolation of tooth

w rubber damNo No No Ancillary

D3920 hemisection No No No

Line 644:Dental conditions where


improvement

D3950 canal prep No No No

Line 644:Dental conditions where


improvementD3999 unspecified endodontic proc No No No Ancillary

D4210gingivectomy/gingivoplasty- 4 or

more teethYes Yes Yes


periodontal disease)-GLN 53

Revised: 01-01-2019 17



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D4211gingivectomy/gingivoplasty- 1 to

3 teethYes Yes Yes



D4212gingivectomy/gingivoplasty- per

toothNo No No


periodontal disease)-GLN 53, bundled

D4230anatomical crown exposure- 4 or

> teethNo No No




D4231anatomical crown exposure- 1 to

3 teethNo No No




D4240gingival flap proc- 4 or more

teethNo No No

Line 490:Dental conditions (e.g.,

periodontal disease)

D4241 gingival flap proc- 1 to 3 teeth No No NoLine 490:Dental conditions (e.g.,


D4245 apically positioned flap No No NoLine 490:Dental conditions (e.g.,


D4249 clinical crown lengthening No No No

588: Dental conditions (e.g., caries,

fractured tooth)

D4260 osseous surgery- 4 or more teeth No No NoLine 490:Dental conditions (e.g.,


D4261 osseous surgery- 1 to 3 teeth No No NoLine 490:Dental conditions (e.g.,


D4263 bone replacement graft- first site No No No



improvement

D4264bone replacement graft- each

addtl siteNo No No

Line 644 Dental conditions where


improvementD4265 biologic materials No No No Excluded File (travel vaccines etc.)

D4266tissue regeneration, resorbable

barrierNo No No Excluded File (travel vaccines etc.)

Revised: 01-01-2019 18



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D4267tissue regeneration,

nonresorbable barrierNo No No Excluded File (travel vaccines etc.)

D4268 surgical revision No No NoLine 490:Dental conditions (e.g.,


D4270 pedicle soft tissue graft No No NoLine 490:Dental conditions (e.g.,


D4273

autogenous connective tissue

graft procedure (including donor

and recipient surgical sites) - first

tooth, implant or edentulous tooth

position in the same graft site

No No NoLine 490:Dental conditions (e.g.,


D4274 distal or proximal wedge No No NoLine 490:Dental conditions (e.g.,


D4275

non-autogenous connective

issue graft procedure (including

recipient surgical site and donor

material) - first tooth, implant or

edentulous tooth position in

same graft site

No No No


periodontal disease, Excluded File

(travel vaccines etc.)

D4276combined connective tissue &

pedicle graftNo No No


periodontal disease,Excluded File

(travel vaccines etc.)

D4277

free soft tissue graft procedure

(including recipient and donor

surgical sites), first tooth,

implant, or edentulous tooth

position in graft



D4278

free soft tissue graft procedure

(including recipient and donor

surgical sites), each additional

contiguous tooth, implant, or


same graft site.



Revised: 01-01-2019 19



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D4283

autogenous connective tissue

graft procedure (including donor

and recipient surgical sites) -

each additional contiguous tooth,

implant or edentulous tooth

position in the same graft site



D4285

non-autogenous connective

issue graft procedure (including

recipient surgical site and donor

material) - each additional

contiguous tooth, implant or


same graft site



D4320 provisional splinting- intracoronal No No No

490: Dental conditions (e.g., periodontal

disease), bundled

D4321 provisional splinting- extracoronal No No No


disease), bundled

D4341

periodontal scaling- 4 or more

teeth- single implants may be

covered by counting the implant

as an add'l tooth.

Yes Yes Yes


periodontal disease), GLN 53

D4342

periodonal scaling- 1 to 3 teeth-

single implants may be covered

by counting the implant as an

add'l tooth.

Yes Yes YesLine 219:Dental conditions (e.g.,


D4346

scaling in presence of

generalized moderate to severe

inflamation -full mouth after oral

eval.

Yes Yes Yes

Line 53: Preventive dental services, GLN

17

D4355 full mouth debridement Yes Yes Yes


17

Revised: 01-01-2019 20



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D4381localized delivery of antimicrobial

agentsNo No No


disease)

D4910 periodontal maintenance Yes Yes Yes


disease)

D4920 unscheduled dressing change Yes Yes Yes BR267: Dental conditions (time sensitive

events)

D4921 gingival irrigation-per quadrant No No No Excluded File (travel vaccines etc.)

D4999 unspecified periodontal proc No No No Ancillary

D5110 complete denture-maxillary Yes Yes Yes


missing teeth, prosthesis failure), GLN

117

D5120 complete denture-mandibular Yes Yes Yes



117

D5130 immediate denture-maxillary Yes Yes Yes



117

D5140 immediate denture-mandibular Yes Yes Yes



117

D5211 partial denture-maxillary-resin Yes Yes Yes



117

D5212 partial denture-mandibular-resin Yes Yes Yes



117

D5213 partial denture-maxillary-cast

metalNo No No

588: Dental conditions (e.g., caries,

fractured tooth)

D5214 partial denture-mandibular-cast

metalNo No No

Line 588:Dental conditions (e.g., caries,

fractured tooth)

Revised: 01-01-2019 21



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5221

immediate maxillary partial

denture - resin base (including

any conventional clasps, rests

and teeth)

Yes Yes Yes451: Dental conditions (e.g., missing

teeth, prosthesis failure)

D5222

immediate mandibular partial

denture - resin base (including

any conventional clasps, rests

and teeth)

Yes Yes Yes



117

D5223

immediate maxillary partial

denture - cast metal framework

with resin denture bases

(including any conventional

clasps, rest and teeth)

No No NoLine 588:Dental conditions (e.g., caries,

fractured tooth)

D5224

immediate mandibular partial

denture - cast metal framework

with resin denture bases

(including any conventional

clasps, rests and teeth)


fractured tooth)

D5225partial denture-maxillary-flexible

baseNo No No


results in marginal improvement

D5226partial denture-mandibular-

flexible baseNo No No



improvement

D5282

removable unilateral partial

denture - one piece cast metal

(incl. clasp and teeth) maxillary-

replaces D5281


fractured tooth)

D5283

removable unilateral partial

denture - one piece cast metal

(incl. clasp and teeth) mandibular-

replaces D5281


fractured tooth)

Revised: 01-01-2019 22



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5410adjust complete denture-

maxillaryYes Yes Yes

267: Dental conditions (time sensitive

events)

D5411adjust complete denture-

mandibularYes Yes Yes


sensitive events)

D5421 adjust partial denture-maxillary Yes Yes YesLine 267: Dental conditions (time

sensitive events)

D5422 adjust partial denture-mandibular Yes Yes YesLine 267: Dental conditions (time

sensitive events)

D5511repair broken complete denture

base, mandibularYes Yes Yes


missing teeth, prosthesis failure))

D5512repair broken complete denture

base, maxillaryYes Yes Yes



117

D5520replace missing or brroken teeth-

complete denture(each tooth)Yes Yes Yes


missing teeth, prosthesis failure)

D5611repair resin partial denture base,




117

D5612repair resin partial denture base,

maxillary Yes Yes Yes



117

D5621repair cast partial framework,




117

D5622repair cast partial framework,

maxillary.Yes Yes Yes



117

D5630repair/replace broken clasp - per

toothYes Yes Yes



117

D5640 replace broken tooth Yes Yes Yes



117

Revised: 01-01-2019 23



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5650add tooth to existing partial

dentureYes Yes Yes



117

D5660add clasp to existing partial

denture - per toothYes Yes Yes



117

D5670 replace all teeth-maxillary Yes Yes Yes



117

D5671 replace all teeth-mandibular Yes Yes Yes



117

D5710 rebase complete denture-

maxillaryYes Yes Yes



117

D5711 rebase complete denture-




117

D5720 rebase partial denture-maxillary Yes Yes Yes



117

D5721 rebase partial denture-




117

D5730 reline complete denture-maxillary Yes Yes Yes



117

D5731reline complete denture-




117

D5740 reline partial denture-maxillary Yes Yes Yes



117

Revised: 01-01-2019 24



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5741 reline partial denture-mandibular Yes Yes Yes



117

D5750 reline complete denture-maxillary-

labYes Yes Yes



117

D5751 reline complete denture-

mandibular-labYes Yes Yes



117

D5760 reline partial denture-maxillary-

labYes Yes Yes



117

D5761 reline partial denture-mandibular-

labYes Yes Yes



117

D5810interim complete denture-

maxillaryNo No No


fractured tooth)

D5811interim complete denture-

mandibularNo No No


fractured tooth)

D5820 interim partial denture-maxillary Yes Yes Yes



117

D5821interim partial denture-




117

D5850 tissue conditioning-maxillary Yes Yes YesLine 267:Dental conditions (time

sensitive events)

D5851 tissue conditioning-mandibular Yes Yes YesLine 267:Dental conditions (time

sensitive events)

D5862 precision attachment No No No


fractured tooth)

D5863 overdenture-complete maxillary No No NoLine 588:Dental conditions (e.g., caries,

fractured tooth)

Revised: 01-01-2019 25



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5864 overdenture-partial maxillary No No No


missing teeth)

D5865overdenture-complete

mandibularNo No No


missing teeth)

D5866 overdenture-partial mandibular No No No


missing teeth)

D5867replace semi-precision or

precision attachmentNo No No


fractured tooth)

D5875modification of removable

prosthesis No No No


fractured tooth)

D5876add metal substructure to acrylic

full denture (per arch)Yes Yes Yes

Line 451: Dental Conditions (e.g.,

Missing teeth, Prosthesis failure)

D5899unspecified removable

prosthodontic procNo No No Ancillary

D5911 facial moulage-sectional No No No L Ancillary

D5912 facial moulage-complete No No No L Ancillary

D5913 nasal prosthesis No No No L Ancillary

D5914 auricular prosthesis No No No L

Line 599: Congenital anomalies of the

ear without impairment of hearing;

unilateral anomalies of the ear

D5915 orbital prosthesis No No No L

Line 257: Deformities of head

GLN 163,Line 482: Enophthalmos

D5916 ocular prosthesis No No No L Ancillary

D5919 facial prosthesis No No No Line 257: Deformities of head, GLN 169

D5922 nasal septal prosthesis No No No L Ancillary

D5923 ocular prosthesis-interim No No No L Ancillary

D5924 cranial prosthesis No No No L Line 257: Deformities of head, GLN 169

Revised: 01-01-2019 26



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5925 facial augmentation No No No LLine 257: Deformities of hea, GLN, 169

D5926 nasal prosthesis-replacement No No No L Ancillary

D5927 auricular prosthesis-replacement No No No L




D5928 orbital prosthesis-replacement No No No L

Line 257: Deformities of head, GLN 169

482: Enophthalmos

D5929 facial prosthesis-replacement No No No LLine 257: Deformities of head, 169

D5931 obturator prosthesis-surgical No No No LLine 257: Deformities of head, GLN 169

D5932 obturator prosthesis-definitive No No No LLine 300: Cleft palate and/or cleft lip

D5933 obturator prosthesis-modification No No No L

257: Deformities of head Line 300: Cleft

palate and/or cleft lip

D5934mandibular resection prosthesis

w guide flangeNo No No L

201: Cancer of bones

D5935mandibular resection prosthesis

w/o guide flangeNo No No L

Line 201: Cancer of bones

D5936 obturator prosthesis-interim No No No L Ancillary

D5937 trismus appliance No No No L

Line 71: Neurological dysfunction in

breathing, eating, swallowing, bowel, or

bladder control caused by chronic

conditions; attention to ostomies

Revised: 01-01-2019 27



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5951 feeding aid No No No LAncillary

D5952 speech aid prosthesis-pediatric No No No L Ancillary

D5953 speech aid prosthesis-adult No No No L Ancillary

D5954 palatal augmentation prosthesis No No No LLine 300: Cleft palate and/or cleft lip

D5955 palatal lift prosthesis-definitive No No No LLine 300: Cleft palate and/or cleft lip

D5958 palatal lift prosthesis-interim No No No LLine 300: Cleft palate and/or cleft lip

D5959 palatal lift prosthesis-modification No No No LLine 300: Cleft palate and/or cleft lip

D5960speech aid prosthesis-

modificationNo No No L

Line 300: Cleft palate and/or cleft lip

D5982 surgical stent No No No L


periodontal disease), bundled

D5983 radiation carrier No No No L

Line 287: Cancer of oral cavity, pharynx,

nose and larynx

D5984 radiation shield No No No L


Line 211: Cancer of thyroid


nose and larynx

D5985 radiation cone locator No No No L


nose and larynx

D5986 fluoride gel carrier No No No


17

D5987 comissure splint No No No LLine 300: Cleft palate and/or cleft lip

Revised: 01-01-2019 28



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5988 surgical splint No No No L

Line 229: Fracture of face bones; injury

to optic and other cranial nerves,

bundled

D5991 topical medicament carrier No No No LAncillary

D5992adjust maxillofacial prosthetic

applianceNo No No L

Line 71: Neurological dysfunction in



conditions; attention to ostomies




Line 482: Enophthalmos




D5993maintenance/cleaning of

maxillofacial prosthesisNo No No L

71: Neurological dysfunction in



conditions; attention to

ostomies

201: Cancer of bones

257: Deformities of head

300: Cleft palate and/or cleft lip

482: Enophthalmos

599: Congenital anomalies of the ear

without impairment of hearing;


Revised: 01-01-2019 29



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D5994 periodontal medicament carrier No No No



improvement

D5999unspecified maxillofacial

prosthesisNo No No L

Ancillary

D6010surgical placement of implant

body-endosteal No No No


missing teeth)

D6011 second stage implant surgery No No No


missing teeth)

D6012

surgical placement of interim

implant body for transitional

prosthesis-endosteal

No No No


missing teeth)

D6013surgical placement of mini

implantNo No No


missing teeth)

D6040surgical placement-eposteal

implantNo No No


missing teeth)

D6050surgical placement-transosteal

implantNo No No


missing teeth)

D6051 interim abutment No No No


missing teeth)

D6052smi-precision attachment

abutmentNo No No


missing teeth)

D6055dental implant supported

connecting barNo No No


missing teeth)

Revised: 01-01-2019 30



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6056 prefabricated abutment No No No


missing teeth)

D6057 custom fabricated abutment No No No


missing teeth)

D6058abutment supported

porcelain/ceramic crownNo No No


missing teeth)

D6059

abutment supported porcelain

fused to metal crown-high noble

metal

No No No


missing teeth)

D6060

abutment supported porcelain

fused to metal crown-

predominantly base metal

No No No


missing teeth)

D6061abutment supported porcelain

fused to metal crown-noble metalNo No No


missing teeth)

D6062abutment supported cast metal

crown-high noble metalNo No No


missing teeth)


crown-predominantly base metalNo No No


missing teeth)


crown-noble metalNo No No


missing teeth)

D6065implant supported

porcelain/ceramic crownNo No No


missing teeth)

D6066implant supported porcelain

fused to metal crownNo No No


missing teeth)

Revised: 01-01-2019 31



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6067 implant supported metal crown No No No


missing teeth)

D6068abutment supported retainer-

porcelain/ceramic FPDNo No No


missing teeth)

D6069

abutment supported retainer-

porcelain fused to metal FPD,

high noble metal

No No No


missing teeth)

D6070



predom base metal

No No No


missing teeth)

D6071



noble metal

No No No


missing teeth)

D6072abutment supported retainer-cast

metal FPD, high noble metalNo No No


missing teeth)


metal FPD, predom base metalNo No No


missing teeth)


metal FPD, noble metalNo No No


missing teeth)

D6075Implant supported retainer-

ceramic FPDNo No No


missing teeth)

D6076Implant supported retainer-

porcelain fused to metal FPDNo No No


missing teeth)

D6077Implant supported retainer-cast

metal FPDNo No No


missing teeth)

Revised: 01-01-2019 32



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6080 implant maintence No No No


missing teeth)

D6081

scaling and debridement in the

presence of inffflammation or

mucositis of a single implant,

including cleaning of the implant

surfaces, without flap entry and

closure.

No No No


missing teeth)

D6090 repair implant abutment No No No


missing teeth)

D6091replace semi/precision

attachmentNo No No


missing teeth)

D6092recement implant/abutment

supported crownNo No No


missing teeth)

D6093recement implant/abutment

supported fixed partialNo No No


missing teeth)

D6094 abutment supported crown No No No


missing teeth)

D6095 repair implant abutment No No No


missing teeth)

D6096

remove broken implant retainer

screw, with severe caries

infection

Yes Yes Yes

Line 344: Dental conditions (e.g., severe

caries, infection) GLN 34, 48

D6100 Implant removal No No No


missing teeth) Line 344: Dental

conditions (e.g., severe caries, infection)

GLN 34, 48

Revised: 01-01-2019 33



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6101debridement of periimplant

defectNo No No


missing teeth)

D6102debridement and osseous

contouring of periimplant defectNo No No


missing teeth)

D6103bone graft for repair of

periimplant defectNo No No


missing teeth)

D6104bone graft at time of implant

placementNo No No


missing teeth)

D6110

implant /abutment supported

removable denture for

edentulous arch – maxillary

No No No


missing teeth)

D6111


removable denture for

edentulous arch – mandibular

No No No


missing teeth)

D6112


removable denture for partially


No No No


missing teeth)

D6113


removable denture for partially


No No No


missing teeth)

D6114


fixed denture for edentulous arch

– maxillary

No No No


missing teeth)

D6115


fixed denture for edentulous arch

– mandibular

No No No


missing teeth)

D6116


fixed denture for partially


No No No


missing teeth)

Revised: 01-01-2019 34



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6117


fixed denture for partially


No No No


missing teeth)

D6118

Implant/abutment supported

interim fixed denture for

edentulous arch - mandibular

No No NoLine 616: Dental conditions (e.g.,

missing teeth)

D6119

Implant/abutment supported

interim fixed denture for

edentulous arch - maxillary

No No NoLine 616: Dental conditions (e.g.,

missing teeth)

D6190radiographic/surgical implant

indexNo No No


missing teeth)

D6194abutment supported retainer

crown for FPDNo No No


missing teeth)

D6199 unspecified implant proc No No No Ancillary

D6205 pontic-indirect resin based No No No588: Dental conditions (e.g., caries,

fractured tooth)

D6210 pontic-cast high noble metal No No No


missing teeth)

D6211 pontic-cast predom base metal No No No


missing teeth)

D6212 pontic-cast noble metal No No No


fractured tooth)

D6214 pontic-titanium No No No


fractured tooth)

D6240pontic-porcelain fused to high

noble metalNo No No


missing teeth)

Revised: 01-01-2019 35



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6241pontic-porcelain fused to predom

base metalNo No No


missing teeth)

D6242pontic-porcelain fused to noble

metalNo No No


missing teeth)

D6245 pontic-porcelain/ceramic No No No


missing teeth)

D6250 pontic-resin w/ high noble metal No No No


missing teeth)

D6251pontic-resin w/ predom base

metalNo No No


missing teeth)

D6252 pontic-resin w/ noble metal No No No


missing teeth)

D6253 provisional pontic No No No


fractured tooth)

D6545retainer-cast metal, resin bonded

fixed prosNo No No


missing teeth)

D6548retainer-porcelain/ceramic, resin

bonded fixed prosNo No No


is chosen primarily for aesthetic

considerations

D6549resin retainer - for resin bonded

fixed prosthesisNo No No


missing teeth)

D6600 inlay-porcelain/ceramic 2 surface No No No




Revised: 01-01-2019 36



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6601inlay-porcelain/ceramic 3 or >

surfaceNo No No




D6602 inlay-cast high noble 2 surface No No No


fractured tooth)

D6603inlay-cast high noble 3 or >

surfaceNo No No


fractured tooth)

D6604 inlay-cast predom base 2 surface No No No


fractured tooth)

D6605inlay-cast predom base 3 or >

surfaceNo No No


fractured tooth)

D6606 inlay-cast noble 2 surface No No No


fractured tooth)

D6607 inlay-cast noble 3 or > surface No No No


fractured tooth)

D6608onlay-porcelain/ceramic 2

surfaceNo No No




D6609onlay-porcelain/ceramic 3 or >

surfaceNo No No




D6610 onlay-cast high noble 2 surface No No No


fractured tooth)

Revised: 01-01-2019 37



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6611onlay-cast high noble 3 or >

surfaceNo No No


fractured tooth)

D6612onlay-cast predom base 2

surfaceNo No No


fractured tooth)

D6613onlay-cast predom base 3 or >

surfaceNo No No


fractured tooth)

D6614 onlay-cast noble 2 surface No No No


fractured tooth)

D6615 onlay-cast noble 3 or > surface No No No


fractured tooth)

D6624 inlay-titanium No No No


fractured tooth)

D6634 onlay-titanium No No No


fractured tooth)

D6710 crown-indirect resin based No No No


fractured tooth)

D6720 crown-resin w/ high noble metal No No No




D6721crown-resin w/ predom base

metalNo No No




Revised: 01-01-2019 38



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6722 crown-resin w/ noble metal No No No




D6740 crown-porcelain/ceramic No No No




D6750crown--porcelain fused to high

noble metalNo No No




D6751crown--porcelain fused to

predom base metalNo No No


missing teeth)

D6752crown-porcelain fused to noble

metalNo No No


missing teeth)

D6780 crown-3/4 cast high noble metal No No No


fractured tooth)

D6781crown-3/4 cast predom base

metalNo No No


fractured tooth)

D6782 crown-3/4 cast noble metal No No No


fractured tooth)

D6783 crown-3/4 porcelain/ceramic No No No


fractured tooth)

D6790 crown-full cast high noble metal No No No


fractured tooth)

Revised: 01-01-2019 39



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D6791crown-full cast predom base

metalNo No No


missing teeth)

D6792 crown-full cast noble metal No No No

Line598: Dental conditions (e.g.,

missing teeth)

D6793 provisional retainer crown No No No


fractured tooth)

D6794 crown-titanium No No No


fractured tooth)

D6920 connector bar No No No


fractured tooth)

D6930re-cement or re-bond fixed partial

dentureYes Yes Yes


sensitive events)

D6940 stress breaker No No No


fractured tooth)

D6950 precision attachment No No No


fractured tooth)

D6980 fixed partial denture repair Yes Yes Yes



D6985 pediatric partial denture, fixed No No No




D6999unspecified fixed prosthodontics

procNo No No Ancillary

Revised: 01-01-2019 40



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7111extraction-coronal remnants,

deciduous toothYes Yes Yes




sensitive events)

D7140extraction-erupted tooth or

exposed rootYes Yes Yes





D7210 surgical removal-erupted tooth Yes Yes Yes






caries, infection) gln 34, 48

D7220removal impacted tooth-soft

tissue- Yes Yes Yes




D7230 removal impacted tooth-partially

bonyYes Yes Yes

257: Deformities of head, GLN 169

344: Dental conditions (e.g., severe

caries, infection)GLN 34, 48

D7240 removal impacted tooth-

completely bonyYes Yes Yes

Line 257: Deformities of head, GLN

169Line 344: Dental conditions (e.g.,

severe caries, infection) GLN 34, 48

D7241

remove impacted tooth-

completely bony w/

complicationssee

Yes Yes Yes BR



Revised: 01-01-2019 41



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7250 surgical removal of residual roots Yes Yes Yes



caries, infection)

D7251coronectomy - intentional partial

tooth removalYes Yes Yes BR



D7260 oroantral fistula closure Yes Yes Yes


Line 573: Deviated nasal septum,

acquired deformity of nose, other

diseases of upper respiratory tract



D7261primary closure of sinus

perforationYes Yes Yes BR



D7270 tooth reimplantation Yes Yes YesLine 54: Dental conditions (e.g.,


D7272 tooth transplantation No No No



improvement

D7280 surgical access unerupted tooth No No No



malocclusion)

D7282mobilization

erupted/malpositioned toothNo No No


malocclusion)

D7283place device to facilitate eruption

of impacted toothNo No No



malocclusion)

D7285incisional biopsy of oral tissue-

hardYes Yes Yes L/BR Diagnostic procedures

D7286incisional biopsy of oral tissue-

softYes Yes Yes Diagnostic procedures

Revised: 01-01-2019 42



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7287exfoliative cytological sample

collectionYes Yes Yes L/BR Diagnostic procedures

D7288 brush biopsy Yes Yes Yes L/BR Diagnostic procedures

D7290 surgical repositioning of teeth No No NoLine 615: Dental conditions (e.g.,

malocclusion)

D7291transseptal fiberotomy/supra

crestal fiberotomyNo No No


malocclusion)

D7292 screw retained plate No No NoLine 615: Dental conditions (e.g.,

malocclusion)

D7293 temp anchorage device w flap No No NoLine 615: Dental conditions (e.g.,

malocclusion)

D7294 temp anchorage device w/o flap No No NoLine 615: Dental conditions (e.g.,

malocclusion)

D7295harvest of bone for use in

autogenous graft procNo No No Excluded File (travel vaccines etc.)

D7296 corticotomy-one to three teeth No No NoLine 615: Dental conditions (e.g.,

malocclusion)

D7297 corticotomy-four or more teeth No No NoLine 615: Dental conditions (e.g.,

malocclusion)

D7310alveoloplasty in conjunction with

extraction-4 or > teethNo No No


caries, infection) GLN 34, 48, bundled

D7311alveoloplasty in conjunction with

extraction-1 to 3 teethNo No No


caries, infection) GLN 34, 48, bundled

D7320alveoloplasty not in conjunction w

extraction-4 or > teethYes No Yes


caries, infection) GLN 34

D7321alveoloplasty not in conjunction w

extraction-1 to 3 teethYes No Yes


caries, infection )GLN 34, 48

Revised: 01-01-2019 43



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7340 vestibuloplasty ridge extension Yes Yes Yes L/BR


Line 582: Atrophy of edentulous alveolar

ridge

D7350vestibuloplasty ridge extension w/

graftYes Yes Yes L/BR


Line 582: Atrophy of edentulous alveolar

ridge

D7410excision of benign lesion-<=1.25

cmNo No No Ancillary

D7411excision of benign lesion->1.25

cmNo No No Excluded File (travel vaccines etc.)

D7412excision of benign lesion,

complicatedNo No No Excluded File (travel vaccines etc.)

D7413excision of malignant lesion-

<=1.25 cmNo No No Excluded File (travel vaccines etc.)

D7414excision of malignant lesion-

>1.25 cmNo No No Excluded File (travel vaccines etc.)

D7415excision of malignant lesion,

complicatedNo No No Excluded File (travel vaccines etc.)

D7440 excision malig tumor-<=1.25 cm No No No L



nose and larynx

D7441 excision malig tumor->1.25 cm No No No L



nose and larynx

D7450remove benign odontogenic cyst-

<=1.25cmYes Yes Yes L

Line 625: Benign neoplasms of skin and

other soft tissues


caries, infection), GLN 34, 48

Revised: 01-01-2019 44



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7451remove benign odontogenic cyst-

>1.25cmYes Yes Yes L


other soft tissues



D7460remove benign nonodontogenic

cyst-<=1.25cmNo No No

Line 594: Inconsequential cysts of oral

soft tissues


other soft tissues

D7461remove benign nonodontogen

cyst->1.25cmNo No No

Line 594: Inconsequential cysts of oral

soft tissues

D7465Destruction of lesion - physical or

chemical methodYes Yes Yes L/BR



D7471 remove lateral exostosis Yes Yes Yes LLine 344: Dental conditions (e.g., severe


D7472 remove torus palatinus Yes Yes Yes


missing teeth, prosthesis failure) GLN

117

D7473 remove torus mandibularis Yes Yes Yes


missing teeth, prosthesis failure) GLN

117

D7485surgical reduction osseous

tuberosityNo No No Excluded File (travel vaccines etc.)

D7490radical resection maxilla or

mandibleNo No No L Ancillary

D7510 incision/drain abscess intra Yes Yes Yes



D7511incision/drain abscess intra,

complicatedNo No No L Ancillary

D7520 incision/drain abscess extra Yes Yes Yes



Revised: 01-01-2019 45



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7521incision/drain abscess extra,

complicatedNo No No L Ancillary

D7530remove foreign body

skin/alveolar tissueYes Yes Yes L



D7540remove reaction producing

foreign bodyYes Yes Yes BR



D7550

partial

ostectomy/sequestrectomy non

vital bone

Yes Yes Yes L/BRLine 344: Dental conditions (e.g., severe


D7560 maxillary sinusotomy Yes Yes Yes L/BR



D7610simple fracture-maxilla open

reductionNo No No L Ancillary

D7620simple fracture-maxilla closed


D7630simple fracture-mandible open


D7640simple fracture-mandible closed


D7650simple fracture-malar/zygomatic

open reductionNo No No L Ancillary

D7660simple fracture-malar/zygomatic

closed reductionNo No No Ancillary

D7670simple fracture-alveolus closed

reductionYes Yes Yes L



D7671simple fracture-alveolus open

reductionNo No No L

Excluded File (travel vaccines etc.)

D7680simple fracture-facial bones-

complicated reductionNo No No L Ancillary

Revised: 01-01-2019 46



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7710compound fracture-maxilla open


D7720compound fracture-maxilla

closed reductionNo No No L Ancillary

D7730compound fracture-mandible

open reductionNo No No L Ancillary

D7740compound fracture-mandible

closed reductionNo No No L Ancillary

D7750compound fracture-

malar/zygomatic open reductionNo No No L Ancillary

D7760compound fracture-

malar/zygomatic closed reductionNo No No L Ancillary

D7770compound fracture-alveolus

closed reductionYes Yes Yes L/BR



D7771compound fracture-alveolus

open reductionNo No No L


D7780compound fracture-facial bones-

complicated reductionNo No No L Ancillary

D7810TMJ open reduction of

dislocationNo No No L

Line 359: Deformity/closed dislocation

of joint and recurrent joint dislocations

D7820TMJ closed reduction of

dislocationNo No No L



D7830TMJ manipulation under

anesthesiaNo No No L



D7840 condylectomy No No NoAncillary

Revised: 01-01-2019 47



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7850 surgical discectomy No No NoAncillary

D7852 disc repair No No NoLine 641: Tmj disorders

D7854 synovectomy No No NoLine 641: Tmj disorders

D7856 myotomy No No NoLine 641: Tmj disorders

D7858 joint reconstruction No No NoLine 641: Tmj disorders

D7860 arthrotomy No No NoLine 641: Tmj disorders

D7865 arthroplasty No No NoLine 641: Tmj disorders

D7870 arthrocentesis No No NoLine 641: Tmj disorders

D7871 non-artroscopic lysis and lavage No No NoLine 641: Tmj disorders

D7872 arthroscopy-diagnosis No No NoLine 641: Tmj disorders

D7873arthroscopy-surgical, lavage &

lysis of adhesionsNo No No

Line 641: Tmj disorders

D7874arthroscopy-surgical, disc

repositionNo No No


D7875arthroscopy-surgical,

synovectomyNo No No


D7876 arthroscopy-surgical,discetomy No No NoLine 641: Tmj disorders

D7877arthroscopy-surgical,

debridementNo No No


D7880 occlusal orthotic device No No NoLine 547: Tmj disorders

D7881occlusal orthotic device

adjustmentNo No No


Revised: 01-01-2019 48



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7899 unspecified TMD therapy No No NoLine 641: Tmj disorders

D7910 suture small wound <=5cm Yes Yes Yes



D7911 suture complicated <= 5cm Yes Yes Yes



D7912 suture complicated > 5 cm Yes Yes Yes L

Line 208: Deep open wound, with or

without tendon or nerve involvement


D7920 skin graft No No No L

Line 208: Deep open wound, with or

without tendon or nerve involvement


nose and larynx

379: Chronic ulcer of skin

D7921collection/application of

autologous blood concentrateNo No No L


D7940osteoplasty-orthognathic

deformitiesNo No No


Line 614: Anomalies of relationship of

jaw to cranial base, major anomalies of

jaw size, other specified and unspecified

dentofacial anomalies

Revised: 01-01-2019 49



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7941 osteotomy-mandibular rami No No No






D7943osteotomy-mandibular rami

w/bone graftNo No No






D7944osteotomy-segmented or

subapicalNo No No






D7945 osteotomy-body of mandible No No No






Revised: 01-01-2019 50



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7946 lefort I-maxilla total No No No






D7947 lefort I-maxilla segmented No No No






D7948 lefort II or III w/o bone graft No No No






D7949 lefort II or III w/bone graft No No No






D7950

osseous, osteoperiosteal, or

cartilage graft-autogenous or non-

autogenous

No No No L




improvement

Revised: 01-01-2019 51



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7951

sinus augmentation w bone/bone

substitutes via lateral open

approach

No No No



missing teeth)

D7952sinus augmentation via vertical

approachNo No No



missing teeth)

D7953 bone replacement graft No No No



D7955 repair maxillofacial tissue defect No No No



D7960 frenulectomy Yes No No


caries, infection), GLN 34, 48

Line 18: Feeding problems in newborns

D7963 frenuloplasty Yes No NoLine 344: Dental conditions (e.g., severe


D7970 excision hyperplastic tissue Yes Yes YesLine 451: Dental conditions (e.g.,

missing teeth, prosthesis failure)

D7971 excision pericoronal gingiva Yes No YesLine 344: Dental conditions (e.g., severe


D7972surgical reduction fibrous

tuberosityNo No No



improvement

Revised: 01-01-2019 52



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7979 Non-surgical sialolithotomy No No No

498: Sialolithiasis, mucocele,

disturbance of salivary secretion, other

and unspecified diseases of salivary

glands

D7980 sialolithotomy No No No

Line 498: Sialolithiasis, mucocele,



glands

D7981 excision of salivary gland Yes Yes Yes L/BR


nose and larynx

Line 323: Sialoadenitis, abscess, fistula

of salivary glands




glands


other soft tissues

D7982 sialodochoplasty Yes Yes Yes L/BR


of salivary glands




glands

D7983 closure of salivary fistula Yes Yes Yes L/BR


of salivary glands

D7990 emergency tracheotomy Yes Yes Yes BRAncillary procedures

D7991 coronoidectomy No No NoLine 641: Tmj disorders

Revised: 01-01-2019 53



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D7995 synthetic graft No No No




D7996implant-mandible for

augmentation No No No




D7997 appliance removal Yes Yes Yes



D7998intraoral placement of fixation

deviceNo No No



improvement

D7999 unspecified oral surgery proc No No No Ancillary

D8010 limited orthodontic primary

dentitionYes No No BR

Line 42: Cleft palate with airway

obstruction




malocclusion)

D8020 limited orthodontic transitional



obstruction




malocclusion)

Revised: 01-01-2019 54



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D8030 limited orthodontic adolescent



obstruction




malocclusion)

D8040 limited orthodontic adult dentition Yes No No BR


obstruction




malocclusion)

D8050interceptive orthodontic primary





malocclusion)

D8060interceptive orthodontic

transitional dentitionYes No No




malocclusion)

Revised: 01-01-2019 55



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D8070 comprehensive orthodontic

transitional dentitionYes No No


obstruction




malocclusion)

D8080comprehensive orthodontic

adolescent dentitionYes Yes Yes BR


obstruction




malocclusion)

D8090comprehensive orthodontic adult

dentitionYes Yes Yes BR


obstruction




malocclusion)

D8210 removable appliance therapy Yes No No BR


obstruction




malocclusion)

Revised: 01-01-2019 56



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D8220 fixed appliance therapy Yes No No BR

42: Cleft palate with airway obstruction



615: Dental conditions (e.g.,

malocclusion)

D8660 pre-orthodontic visit Yes No No BR


obstruction




malocclusion)

D8670 periodic orthodontic visit Yes No No BR


obstruction




malocclusion)

D8680 orthodontic retention Yes No No BR


obstruction




malocclusion)

Revised: 01-01-2019 57



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D8681removable orthodontic retainer

adjustmentYes No No BR


obstruction




malocclusion)

D8690 orthodontic treatment-alternative

billingYes No No BR


obstruction




malocclusion)

D8691 repair orthodontic appliance Yes No No


obstruction




malocclusion)

D8692 replacement lost/broken retainer Yes No No


obstruction




malocclusion)

Revised: 01-01-2019 58



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D8693rebond or recement of fixed

retainerNo No No


obstruction




malocclusion)

D8694repair of fixed retainer, includes

reattachmentNo No No


obstruction




malocclusion)

D8695

Removal of fixed orthodontic

appliances for reasons other than

completion of treatment

No No NoLine 267: Dental conditions (time

sensitive events)

D8999 unspecified orthodontics proc No No No Excluded File (travel vaccines etc.)

D9110 palliative treatment dental pain Yes Yes Yes BR



D9120 fix partial denture sectioning Yes Yes Yes BR


sensitive events)

D9130

temporomandibular joint

dysfunction -non- invasive

physical therapies

No No No Line 547: TMJ disorder

D9210 local anesthesia No No NoExcluded File (travel vaccines etc.),

bundled

D9211 regional block anesthesia Yes Yes Yes L/BR Ancillary

D9212 trigeminal block anesthesia Yes Yes Yes L Ancillary

D9215 local anesthesia No No NoExcluded File (travel vaccines etc.),

bundled

Revised: 01-01-2019 59



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D9219evaluation for deep sedation or

general anesthesiaNo No No Excluded File (travel vaccines etc.)

D9220Deep sedation/general

anesthesia-first 30 minutesYes Yes Yes Ancillary

D9221

Deep sedation/general

anesthesia-each additional 15

minutes

Yes Yes Yes Ancillary

D9222deep sedation/general

anesthesia- first 15 minutesYes Yes Yes Ancillary

D9223

deep sedation/general

anesthesia - each 15 minute

increment


D9230analgesia, anxiolysis, nitrous

oxideYes Yes Yes Ancillary

D9239

intravenous moderate (consious)

sedation/ analgesia-first fifteen

minutes


D9243

intravenous moderate

(conscious) sedation/analgesia -

each subsequent 15 minute

increment


D9248 non-IV conscious sedation Yes No No Ancillary

D9310 consultation Yes Yes Yes Ancillary

D9311Consultation with a medical

healthcare professionalNo No No Ancillary

D9410 house/LTC facility call Yes Yes Yes



D9420 hospital call Yes Yes Yes



D9430 office visit for observation No No No Ancillary

Revised: 01-01-2019 60



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D9440 office after reg hrs Yes Yes Yes



D9450 case presentation No No No Excluded File (travel vaccines etc.)

D9610therapeutic parenteral drug-

single adminYes Yes Yes



D9612therapeutic parenteral drug-2 or

> adminYes Yes Yes BR



D9613

inflitration of sustained release

therapeutic drug-singl or multiple

sites

No No No Excluded file

D9630 other drugs or meds Yes Yes Yes Ancillary

D9910 application of desensitizing med No No No



improvement

D9911 application of desensitizing resin No No No



improvement

D9920 behavior management Yes Yes Yes BR


17

D9930treatment of complications-

unusal circYes Yes Yes BR

344:Dental Conditions (e.g. severe

caries infection)

D9931Cleaning and inspection of a

removable applianceNo No No Excluded File (travel vaccines etc.)

Revised: 01-01-2019 61



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D9932

cleaning and inspection of

removable complete denture,

maxillary

No No No





D9933


removable complete denture,

mandibular

No No No





D9934


removable partial denture,

maxillary

No No No





D9935


removable partial denture,

mandibular

No No No





D9936 Missed Appointment No No No Excluded File (travel vaccines etc.)

D9941 fabrication of athletic mouthguard No No No



improvement

D9942 repair/reline occlusal guard No No No



improvement

Revised: 01-01-2019 62



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D9943 occulusal guard adjustment No No No



improvement

D9944occlusal guard - hard appliance,

full archNo No No



improvement

D9945occlusal guard - soft appliance,

full archNo No No



improvement

D9946occlusal guard - soft

appliance,partial archNo No No



improvement

D9950 occulsion analysis No No No


fractured tooth)

D9951 occulsal adjustment-limited No No No

267: Dental conditions (time sensitive

events)

D9952 occulsal adjustment-complete No No No



improvement

D9961 duplicate/copy patient's records No No NoExcluded File (travel vaccines etc.)

D9970 enamel microabrasion No No No




Revised: 01-01-2019 63



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D9971 odontoplasty No No No




D9972external bleaching-per arch-

performed in officeNo No No




D9973 external bleaching-per tooth No No No




D9974 internal bleaching-per tooth No No No




D9975external bleaching for home

application, per archNo No No




D9985 sales tax No No NoExcluded File (travel vaccines etc.)

D9987 Cancelled appointment No No NoExcluded File (travel vaccines etc.)

D9991

dental case management-

addressing appointment

compliance barriers

No No NoAncillary

D9992dental case management - care

coordinationNo No No

Ancillary

D9993dental case management -

motivational interviewingNo No No

Ancillary

D9994

dental case management -

patient education to improve oral

health literacy

No No NoAncillary

Revised: 01-01-2019 64



Under

age 21

Age 21 and

over, non-

pregnant

adults

Pregnant






D9995Teledentistry-synchronous-real

time encounterYes Yes Yes

Line 54-Dental conditions (e.g.,


D9996

Teledentistry-synchronous-r,

information stored and forwarded

to dentist for subsequent review

Yes Yes YesLine 54-Dental conditions (e.g.,

infection, pain, trauma

D9999 unspecified adjunctive proc No No No Ancillary

Revised: 01-01-2019 65

Covered and Non-Covered Dental Services, 1-1-2019 · If dental services are billed as medical...

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