The Provider Benefit Resource Tool provides information on Medicaid-covered dental services and the applicable regulations and policies in effect as of October 1, 2026. Any updates made after this date will be documented in the tool’s version history under the applicable ADA CDT code.
For information prior to October 1, 2026, please contact CTDHP Provider Services at 855-CT-DENTAL, or Gainwell Provider Services at 1-800-842-8440.
This tool is designed to help providers quickly locate information on Medicaid-covered services in one convenient place. It does not replace the Connecticut Department of Social Services Medical Assistance Program (CT DSS MAP) Dental Fee Schedule or Provider Manual, which can be found at:
https://www.ctdssmap.com/CTPortal/
How to use the tool:
Search by American Dental Association (ADA) CDT code or by keyword. Keywords may include common dental terminology, categories of service (e.g., Diagnostic), or specific dental procedures.
If you identify an error, discrepancy, or have suggestions for improvement, please contact CTDHP at info@ctdhp.com.
Prior Authorization Tag Color Legend
Not all providers have the same Prior Authorization Rules. To help clarify what type of Prior Authorization is needed for each provider, we have applied colored tags next to the provider type.
PA RequiredPrior Authorization required for all ages
PA 0-20Prior Authorization required for patients ages 0–20
PA 21+Prior Authorization required for patients 21 and older
PR RequiredPost Review required
No tagNo authorization required for that provider specialty
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Current Dental Terminology (including procedure codes, nomenclature, descriptors and the data contained therein) is copyright 2026 American Dental Association.
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| Primary Column | Category of Service | Procedure Code | Procedure Description | Adult Fee | Children Fee | HUSKY B Copay | Coverage Effective Date | Coverage End Date | Authorization Required by Provider Type? | If Yes, PA Provider Type | If Yes, Provider Type and Age UNDER 21 | If Yes, Provider Type and Age OVER 21 | If Yes, PR by Provider Type | Providers ELIGIBLE to Perform Service | Providers INELIGIBLE to Perform Service | Age Limitation (Specific To Only Certain Age) | Authorization Rules? | Frequency Limit Adult (21 Years and Older) | Frequency Limit Children (Member Ages 0-20) | Coverage Guidelines | Authorization Submission Guidelines | Edit/Update/Change Made? | Summary of Change | Date Change Published |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Diagnostic | D0120 | PERIODIC ORAL EVALUATION - ESTABLISHED P | $22.75 | $34.30 | NA | 07/01/2022 | 12/31/2299 | No | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | No | No | One (1) Per Calendar Year | One (1) Every Six (6) Months per Calendar Year | In the circumstance when an adult (over the age of twenty-one (21)) has received frequency limited services within the current calendar year AND has a chronic medical or dental condition that warrants a dental service more frequently than the defined limitations, an additional service may be requested through the established post or prior authorization review process. Adults (over the age of twenty-one (21)) with predetermined medical conditions, evidenced by HUSKY medical claims, qualify for a second annual periodic exam and prophylaxis without the need for requesting authorization:
Once a member turns the age of twenty-one (21), the member is now considered an adult member and is eligible for a periodic oral exam and cleaning regardless of the member receiving the services during the same year as a “child”. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0140 | LIMITED ORAL EVALUATION - PROBLEM FOCUSE | $31.20 | $47.04 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Four (4) Problem Focused Exams Per Calendar Year | Four (4) Problem Focused Exams Per Calendar Year | A problem-focused oral examination will not be reimbursed in conjunction with other examination codes, routine or previously scheduled dental care, or palliative treatment. Once a member turns the age of twenty-one (21), the member is now considered an adult member and is eligible for four (4) problem focused exams regardless of the member receiving the services during the same year as a “child”. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Diagnostic | D0150 | COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT | $42.45 | $63.70 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) Per Lifetime. When a client changes providers, an additional comprehensive examination service can be requested through the established prior authorization process. | One (1) Per Thirty-Six (36) Months | The examination shall include the taking of the medical history, vital signs, the thorough evaluation and recording of the state of both intra-oral and extra-oral hard and soft tissue findings resulting in a new treatment plan for the member. A second comprehensive oral examination can be authorized only when the member has experienced a lapse in treatment of one and a half (1.5) years or more and such lapse is documented in the member's treatment record. Once a member turns the age of twenty-one (21), the member is eligible for a comprehensive oral evaluation, as an adult, even if the member received a comprehensive oral evaluation prior to their twenty-first (21st) birthday. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Diagnostic | D0160 | DETAILED AND EXTENSIVE ORAL EVALUATION - | $32.50 | $49.00 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per Provider per Calendar Year | One (1) per Provider per Calendar Year | One (1) detailed and extensive examination performed by an anesthesiologist, endodontist, oral medicine specialist, orofacial pain specialist, oral and maxillofacial surgeon, orthodontist, pathologist, periodontist, or radiologist per provider per year. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Diagnostic | D0180 | COMPREHENSIVE PERIODONTAL EVALUATION-NEW OR ESTAB PATIENT | $97.00 | $97.00 | NA | 01/01/2024 | 12/31/2299 | No | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | No | No | One (1) per Lifetime | One (1) per Lifetime | One (1) Comprehensive Periodontal Examination per lifetime for patients who are showing signs and symptoms of periodontal disease and includes an evaluation of the periodontal conditions, probing depths and complete charting, evaluation for oral cancer, evaluation of the salivary system, the member's medical and dental history, and general health assessment. Caries and restorations must be noted, and the condition of the restorations provided Children (ages zero through twenty (0-20)) may qualify for additional evaluations under Early, Periodic, Screening, Diagnosis, and Treatment (EPSDT) Guidelines. Prior Authorization submission is necessary. The service may be billed independently; however, D4355 or D0150 cannot be billed on the same date of service. D0180 should only be used when the office or clinic will be providing the periodontal services (scaling and root planing, debridement). If the member must go to another office or clinic to receive the periodontal treatment, the D0180 will be recouped. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0191 | ASSESSMENT OF A PATIENT | $35.00 | $35.00 | NA | 08/01/2023 | 12/31/2299 | No | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Children Only (0-20) | No | Not Applicable | Per Need | This service code is exclusively used for billing for a Multi-Disciplinary Exam (MDE) provided for children covered by the HUSKY Health plan who are in the custody of the State of Connecticut- Department of Children and Families (DCF). The MDE is a comprehensive examination with three (3) components:
The MDE must result in a written report with recommendations for appropriate treatment and follow-up care. MDE services are provided by DCF-contracted MDE service providers or their subcontractors. In some cases, a single agency is licensed to provide all three (3) components of the MDE while being entitled to reimbursement for each component. In other cases, multiple agencies or providers are involved in performing one (1) of the components of an MDE, each within its scope of licensure. Any provider who wishes to be reimbursed for any individual component of an MDE must be:
Encounters for MDE services rendered in an FQHC setting should be coded using the procedure code T1015 (Clinic visit/Encounter, All-Inclusive) in conjunction with the appropriate procedure code(s) listed above. The FQHC is eligible to receive its full medical, dental, or behavioral health encounter reimbursement for each of the components that is provided and for which the FQHC is separately enrolled and licensed. However, each component must be submitted on a separate claim. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0210 | INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) | $65.65 | $98.98 | NA | 12/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per Three (3) Years | One (1) per Three (3) Years | Either one (1) complete mouth or tomosynthesis imaging series or a panoramic film plus bitewing or tomosynthesis diagnostic imaging one (1) time per three-year (3-year) period for members over the age of nine (9). An intraoral, complete series (full mouth series) consists of at least ten periapical films plus bitewings. Under the HUSKY and COVERED CT dental plan, a panoramic or a full mouth series is covered under the plan one (1) time per thirty-six (36) months. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Diagnostic | D0220 | INTRAORAL-PERIAPICAL-FIRST FILM | $12.35 | $18.62 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Up to Four (4) per calendar year | Up to Four (4) per calendar year | One (1) initial periapical or tomosynthesis image and up to three (3) additional tomosynthesis or images annually per member or four (4) periapical or tomosynthesis images in total per member. Subject to the following limitations:
Periapical are not covered on the same date of service as a full moth series, a panoramic film, or lateral jaw films. If the number of films billed will exceed the fee of a full mouth series, a full mouth series should be billed. If a member has a documented need that warrants more than four (4) periapical radiographs in a three hundred sixty-five (365) day period, an additional service may be request through the prior authorization process. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0230 | INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM | $11.05 | $16.66 | NA | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Up to Four (4) per Three Hundred Sixty-Five (365) day Period | Up to Four (4) per Three Hundred Sixty-Five (365) day Period | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Diagnostic | D0240 | INTRAORAL-OCCLUSAL FILM | $12.35 | $18.62 | NA | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | One (1) per Arch every Two (2) Calendar Years | One (1) per Arch every Two (2) Calendar Years | Occlusal imaging one (1) time per arch every two years. Will not be reimbursed for routine screening purposes. Additional occlusal images may be prior authorized for members who have experienced trauma or have dento-facial anomalies. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0270 | BITEWING-SINGLE FILM | $9.10 | $13.72 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) Set per Calendar Year | One (1) Set per Calendar Year | One (1) set of horizontal or vertical, intraoral or extraoral bitewing images per member in a calendar year. Bitewing images are included in the complete mouth series and shall not be reimbursed separately from a complete mouth series or where a panoramic radiograph is substituted for a complete mouth series:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0272 | BITEWINGS-TWO FILMS | $20.80 | $31.36 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) Set per Calendar Year | One (1) Set per Calendar Year | One (1) set of horizontal or vertical, intraoral or extraoral bitewing images per member in a calendar year. Bitewing images are included in the complete mouth series and shall not be reimbursed separately from a complete mouth series or where a panoramic radiograph is substituted for a complete mouth series:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0274 | BITEWINGS-FOUR FILMS | $31.20 | $47.04 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) Set per Calendar Year | One (1) Set per Calendar Year | One (1) set of horizontal or vertical, intraoral or extraoral bitewing images per member in a calendar year. Bitewing images are included in the complete mouth series and shall not be reimbursed separately from a complete mouth series or where a panoramic radiograph is substituted for a complete mouth series:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0321 | OTHER TEMPOROMANDIBULAR JOINT FILMS BY | $227.50 | $343.00 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Temporomandibular imaging for each joint with prior authorization. Frequency determined by member's documentation supporting medical necessity. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Diagnostic | D0330 | PANORAMIC FILM | $56.55 | $85.26 | NA | 07/01/2022 | 12/31/2299 | Yes | Orthodontist | Dental Anesthesiologist Endodontist General Dentist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per Three (3) Year Period | One (1) per Three (3) Year Period. Auth not required under the age of 21 | A panoramic image one (1) time per three-year (3-year) period for members over the age of nine (9). Prior Authorization required except for oral and maxillofacial surgeons and orthodontists. The panoramic radiograph may be taken with tomosynthesis bitewing diagnostic imaging in lieu of the complete series and shall have the right and left sides clearly identified. Under the HUSKY and COVERED CT dental plan, a full mouth series or a panoramic is covered under the plan one (1) time per thirty-six (36) months. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||
| Diagnostic | D0340 | CEPHALOMETRIC RADIOGRAPHIC IMAGE | $83.20 | $125.44 | NA | 07/01/2022 | 12/31/2299 | Yes | General Dentist Oral Surgeon Orthodontist Pediatric Dentist Public Health Dentist | General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Oral & Maxillofacial Pathologist Periodontist Prosthodontist | No | Yes | One (1) per Pre-Operative Surgery Event | One (1) per Pre-Operative Surgery Event | One (1) pre-operative cephalometric image per member per orthodontic and oral surgical providers for orthodontic cases and for cases requiring orthognathic surgery. Additional cephalometric images may be prior authorized for members who have dento-facial anomalies and for adults (over the age of twenty-one (21)) (over the age of twenty-one (21)) in the event of facial trauma or need for reconstruction. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Diagnostic | D0364 | CONE BEAM CT CAPTURE AND INTERPRETATION WITH LIMIT | $90.00 | $90.00 | NA | 07/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) every Three (3) Years | One (1) every Three (3) Years | One (1) cone beam image when medically necessary to determine the extent of disease states such as cysts, tumors or when major traumatic events have occurred within the upper or lower jaw or oro-facial structures. Additional cone beam imaging may be prior authorized for members who have dento-facial anomalies for any reason or have undergone repair and require monitoring. One (1) cone beam maxillae or mandible image for multi-rooted premolar and molar teeth undergoing endodontic therapy limited to one (1) time every three (3) years with prior authorization if the tooth to be treated is eligible for endodontic therapy (includes root canal therapy, retreatment of previously endodontically treated teeth and apicoectomies) and can be restored with an exception being made if a root fracture is discovered. Note: Use of Cone Beam may be indicated when deciding between retreatment and apicoectomy or extraction if 2D imaging (conventional radiography) does not clearly indicate which path has a more favorable prognosis. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0365 | CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF ONE FULL DENTAL ARCH - MANDIBLE | $125.00 | $125.00 | NA | 07/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) every Three (3) Years | One (1) every Three (3) Years | One (1) cone beam image when medically necessary to determine the extent of disease states such as cysts, tumors or when major traumatic events have occurred within the upper or lower jaw or oro-facial structures. Additional cone beam imaging may be prior authorized for members who have dento-facial anomalies for any reason or have undergone repair and require monitoring. One (1) cone beam maxillae or mandible image for multi-rooted premolar and molar teeth undergoing endodontic therapy limited to one (1) time every three (3) years with prior authorization if the tooth to be treated is eligible for endodontic therapy (includes root canal therapy, retreatment of previously endodontically treated teeth and apicoectomies) and can be restored with an exception being made if a root fracture is discovered. Note: Use of Cone Beam may be indicated when deciding between retreatment and apicoectomy or extraction if 2D imaging (conventional radiography) does not clearly indicate which path has a more favorable prognosis. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0366 | CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF ONE FULL DENTAL ARCH - MAXILLA, WITH OR WITHOUT CRANIUM | $125.00 | $125.00 | NA | 07/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) every Three (3) Years | One (1) every Three (3) Years | One (1) cone beam image when medically necessary to determine the extent of disease states such as cysts, tumors or when major traumatic events have occurred within the upper or lower jaw or oro-facial structures. Additional cone beam imaging may be prior authorized for members who have dento-facial anomalies for any reason or have undergone repair and require monitoring. One (1) cone beam maxillae or mandible image for multi-rooted premolar and molar teeth undergoing endodontic therapy limited to one (1) time every three (3) years with prior authorization if the tooth to be treated is eligible for endodontic therapy (includes root canal therapy, retreatment of previously endodontically treated teeth and apicoectomies) and can be restored with an exception being made if a root fracture is discovered. Note: Use of Cone Beam may be indicated when deciding between retreatment and apicoectomy or extraction if 2D imaging (conventional radiography) does not clearly indicate which path has a more favorable prognosis. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0367 | CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF BOTH JAWS; WITH OR WITHOUT CRANIUM | $170.00 | $170.00 | NA | 07/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) every Three (3) Years | One (1) every Three (3) Years | One (1) cone beam image when medically necessary to determine the extent of disease states such as cysts, tumors or when major traumatic events have occurred within the upper or lower jaw or oro-facial structures. Additional cone beam imaging may be prior authorized for members who have dento-facial anomalies for any reason or have undergone repair and require monitoring. One (1) cone beam maxillae or mandible image for multi-rooted premolar and molar teeth undergoing endodontic therapy limited to one (1) time every three (3) years with prior authorization if the tooth to be treated is eligible for endodontic therapy (includes root canal therapy, retreatment of previously endodontically treated teeth and apicoectomies) and can be restored with an exception being made if a root fracture is discovered. Note: Use of Cone Beam may be indicated when deciding between retreatment and apicoectomy or extraction if 2D imaging (conventional radiography) does not clearly indicate which path has a more favorable prognosis. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0368 | CONE BEAM CT CAPTURE ANDINTERPRETATION FOR TMJ SERIES INCLUDING TWO OR MORE EXPOSURES $ | $200.00 | $200.00 | NA | 07/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) every Three (3) Years | One (1) every Three (3) Years | One (1) cone beam image when medically necessary to determine the extent of disease states such as cysts, tumors or when major traumatic events have occurred within the upper or lower jaw or oro-facial structures. Additional cone beam imaging may be prior authorized for members who have dento-facial anomalies for any reason or have undergone repair and require monitoring. One (1) cone beam maxillae or mandible image for multi-rooted premolar and molar teeth undergoing endodontic therapy limited to one (1) time every three (3) years with prior authorization if the tooth to be treated is eligible for endodontic therapy (includes root canal therapy, retreatment of previously endodontically treated teeth and apicoectomies) and can be restored with an exception being made if a root fracture is discovered. Note: Use of Cone Beam may be indicated when deciding between retreatment and apicoectomy or extraction if 2D imaging (conventional radiography) does not clearly indicate which path has a more favorable prognosis. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0372 | TOMO COMP SERIES IMAGES | $65.65 | $98.98 | NA | 01/01/2023 | 12/31/2299 | No | Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist FQHC | No | No | One (1) Set per Calendar Year | One (1) Set per Calendar Year | One (1) set of horizontal or vertical, intraoral or extraoral tomosynthesis images per member in a calendar year. Tomosynthesis images are included in the complete mouth series and shall not be reimbursed separately from a complete tomosynthesis series or where a panoramic radiograph is substituted for a complete tomosynthesis series:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0373 | TOMO BITEWING IMAGE | $9.10 | $13.72 | NA | 01/01/2023 | 12/31/2299 | No | Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist FQHC | No | No | One (1) Set per Calendar Year | One (1) Set per Calendar Year | One (1) set of horizontal or vertical, intraoral or extraoral tomosynthesis images per member in calendar year. Tomosynthesis images are included in the complete mouth series and shall not be reimbursed separately from a complete tomosynthesis series or where a panoramic radiograph is substituted for a complete tomosynthesis series:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0374 | TOMO PERIAPICAL IMAGE | $12.35 | $18.62 | NA | 01/01/2023 | 12/31/2299 | No | Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist FQHC | No | No | One (1) Set per Calendar Year | One (1) Set per Calendar Year | One (1) set of horizontal or vertical, intraoral or extraoral tomosynthesis images per member in calendar year. Tomosynthesis images are included in the complete mouth series and shall not be reimbursed separately from a complete tomosynthesis series or where a panoramic radiograph is substituted for a complete tomosynthesis series:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0412 | BLOOD GLUCOSE LEVEL TEST | $4.38 | $4.54 | NA | 07/01/2022 | 12/31/2299 | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist FQHC Hospital and Free Standing Clinics | No | No | One (1) per Visit | One (1) per Visit | Service is an in-office use of a glucose meter to determine the member's glucose level at the time of collection. Intention is to determine how a member's glucose level may affect dental treatment planned during and after the visit. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Diagnostic | D0425 | CARIES SUSCEPTIBILITY TESTS | $29.25 | $44.10 | NA | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Pediatric Dentist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist | No | Yes | Determined by PA | Determined by PA | Diagnostic testing to determine susceptibility to caries and other dental diseases. Caries susceptibility test includes the collection of saliva, plaque, or carious dentin for the evaluation and determination of the relative risk rate of future caries development for children (ages zero through twenty (0-20)) Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, involving Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children (ages zero through twenty (0-20)) | When submitting a prior authorization, providers should include:
AAuthorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Diagnostic | D0470 | DIAGNOSTIC CASTS | $63.70 | $96.04 | NA | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | One (1) per provider | One (1) per provider | Diagnostic casts or digital models are covered at one (1) set per member per provider. Oral surgeons and orthodontists are allowed two (2) sets of diagnostic casts or digital models per member. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0601 | CARIES RISK ASSESS LOW RISK | $14.95 | $22.54 | NA | 07/01/2022 | 12/31/2299 | No | Dental Hygienist FQHC Hospital and Free Standing Clinics | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | One (1) per Six (6) Months | One (1) per Six (6) Months | A screening examination performed ONLY by a Public Health Registered Dental Hygienist who has practiced in public health settings for at least two (2) years, successfully completed calibration training, and performs the screening examination in public health settings. Note: Public health settings are in locations that are NOT dental homes where an ongoing relationship between a dentist and a patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and person or family-centered way. The screening examination results are to be documented in compliance with the "Screening for Oral Health" form content and placed in the Members health record. A screening examination will not be covered as a separate billable procedure when performed within a dental home. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0602 | CARIES RISK ASSESS MOD RISK | $14.95 | $22.54 | NA | 07/01/2022 | 12/31/2299 | No | Dental Hygienist FQHC Hospital and Free Standing Clinics | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | One (1) per Six (6) Months | One (1) per Six (6) Months | A screening examination performed ONLY by a Public Health Registered Dental Hygienist who has practiced in public health settings for at least two (2) years, successfully completed calibration training, and performs the screening examination in public health settings. Note: Public health settings are in locations that are NOT dental homes where an ongoing relationship between a dentist and a patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and person or family-centered way. The screening examination results are to be documented in compliance with the "Screening for Oral Health" form content and placed in the Members health record. A screening examination will not be covered as a separate billable procedure when performed within a dental home. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0603 | CARIES RISK ASSESS HIGH RISK | $14.95 | $22.54 | NA | 07/01/2022 | 12/31/2299 | No | Dental Hygienist FQHC Hospital and Free Standing Clinics | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | One (1) per Six (6) Months | One (1) per Six (6) Months | A screening examination performed ONLY by a Public Health Registered Dental Hygienist who has practiced in a public health settings for at least two (2) years, successfully completed calibration training, and performs the screening examination in public health settings. Note: Public health settings are in locations that are NOT dental homes where an ongoing relationship between a dentist and a patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and person or family-centered way. The screening examination results are to be documented in compliance with the "Screening for Oral Health" form content and placed in the Members health record. A screening examination will not be covered as a separate billable procedure when performed within a dental home. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Diagnostic | D0999 | UNSPECIFIED DIAGNOSTIC PROCEDURE BY REP | MP | MP | NA | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| |||||||||
| Preventive | D1110 | PROPHYLAXIS-ADULT | $41.60 | $62.72 | NA | 05/01/2026 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Yes: Adults Only (Over Age 21) | No | One (1) per Calendar Year | Not Applicable | Removal of plaque, calculus, and stains from the tooth structures in the permanent and transitional dentition. Prophylaxis includes cleaning, supra and sub gingival scaling and polishing. Limited to one (1) time per calendar year for a healthy adult (over the age of twenty-one (21)) or where there are no dental or medical conditions that warrant additional prophylaxis procedures. An additional service may be requested in the circumstance when an adult (over the age of twenty-one (21)):
Adults (over the age of twenty-one (21)) with predetermined medical conditions, evidenced by HUSKY medical claims, qualify for a second annual periodic exam and prophylaxis without the need for requesting authorization:
Limited to one (1) time per six (6) months per calendar year. When a child (ages zero through twenty (0-20)) has a chronic medical condition (examples include but are not limited to uncontrolled diabetes, organ transplant or is taking an anti-seizure medication) that warrants a dental prophylaxis more than one (1) time per six-month (6-month) period for a child up to the age of twenty-one (21), an additional service may be requested. Once a member turns twenty-one (21), the member is now considered an adult and is eligible for an adult prophylaxis regardless of if the member received the services during the same year as a “child.” | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1120 | PROPHYLAXIS-CHILD | NA | $45.08 | NA | 09/01/2016 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Yes: Children Only (0-20) | No | Not Applicable | One (1) per Six (6) Months | Removal of plaque, calculus, and stains from the tooth structures in the primary and transitional dentition. Prophylaxis includes cleaning, supra and sub gingival scaling and polishing. When a member has a chronic medical condition (examples include but are not limited to uncontrolled diabetes, organ transplant or is taking an anti-seizure medication) that warrants a dental prophylaxis more than one (1) time per six-month (6-month) period for a child up to the age of twenty-one (21), an additional service may be requested. Once a member turns twenty-one (21), the member is now considered an adult and is eligible for an adult prophylaxis regardless of if the member received the services during the same year as a “child.” | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1206 | TOPICAL FLUORIDE VARNISH; THERAPEUTIC AP | $18.85 | $28.42 | NA | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | One (1) per Six (6) Months | One (1) per Six (6) Months | Topical application of fluoride or a professional anti-cariogenic agent for members, one (1) time per every six-month (6-month) period, or in conjunction with dental prophylaxis. Dental codes D1206 and D1208 are applied to frequency limit interchangeably. Additional fluoride treatments with prior authorization are authorized when the member:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1208 | TOPICAL APP OF FLUORIDE | $18.85 | $28.42 | NA | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | One (1) per Six (6) Months | One (1) per Six (6) Months | Topical application of fluoride or a professional anti-cariogenic agent for members, one (1) time per every six (6) month period, or in conjunction with dental prophylaxis. Dental codes D1206 and D1208 are applied to frequency limit interchangeably. Additional fluoride treatments with prior authorization are authorized when the Member:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1320 | TOBACCO COUNSELING FOR THE CONTROL AND PREVENTION | $4.23 | $6.37 | NA | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | One (1) per Dental Visit | One (1) per Dental Visit | Counseling members to cease use of tobacco products in any form. The member's chart must:
| Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1351 | SEALANT-PER TOOTH | NA | $39.20 | NA | 09/01/2016 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Yes: See Coverage Guidelines | No | Not Applicable | One (1) time per Three (3) Years | Sealants are covered for one (1) time per three-year (3-year) period per member for non-carious teeth for pits and fissures in the permanent dentition for Members ages five (5) through twenty (20) Teeth Numbers 2, 3, 14, 15, 18, 19, 30 & 31 are candidates for sealant placement. The teeth shall be free from decay or determined by the provider that the sealant will arrest decay and shall have erupted sufficiently so proper isolation can be achieved for sealant placement. Sealant placement will be reimbursed on a per tooth basis and includes the following:
Sealant placement shall be subject to the following age limitations:
In the event there are sealants that fail within three (3) years from the date of placement, the reimbursement fee will be recouped from the office that placed the original sealant or the provider who placed the original sealant may be replaced at no cost. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1354 | INTERIM CARIES ARRESTING MEDICAMENT | $28.42 1st tooth in the arch, $1.00 for each tooth after | 28.42 1st tooth in the arch, $1.00 for each tooth after. | NA | 11/01/2022 | 12/31/2299 | No | FQHC General Dentist Pediatric Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Prosthodontist Public Health Dentist | Yes: See Coverage Guidelines | No | One (1) Time Per Tooth every four (4) months. Maximum of six (6) times per lifetime of tooth/teeth. | Patient Dependent- See Coverage Guidelines | Silver Diamine Fluoride (SDF) used as a caries arresting medicament, in a “sandwich technique” or as a topical fluoride treatment for children and adults as recommended by the American Academy of Pediatric Dentistry and American Dental Association respectively as the prevailing standard of care. Intended for members who are at risk for advancing caries and is for use by dentists only. The application of SDF is approved based on the arch and tooth number(s). All teeth requiring SDF application shall be treated in one visit and not over multiple appointments regardless of the type of provider, facility, clinic, or Federally Qualified Health Center (FQHC) delivering the service. For Primary Teeth (Teeth A through T): SDF may be applied one (1) time every four (4) months regardless of the tooth surface until the tooth nears exfoliation. For Permanent Teeth (Teeth 1 through 32): SDF may be applied one (1) time per tooth regardless of the tooth surface every four (4) months for a maximum of six (6) times per lifetime of the tooth/teeth. SDF is known to cause dark stains on tooth surfaces where the decay is located and treated. Removal of the arrested caries and the restoration placement with a composite resin restoration will restore the aesthetics of the tooth. It is recommended that the aesthetic results of the use of SDF on decayed tooth surfaces be fully explained to the patient before treatment with the SDF application. SDF also temporarily stains the oral mucosa for a period of about three (3) months. Caution should be taken when applying the SDF to carious lesions. Additional applications may be prior authorized if medically necessary. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Preventive | D1510 | SPACE MAINTAINER-FIXED UNILATERAL | $139.75 | $210.70 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Periodontist Prosthodontist | Oral Surgeon | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Four (4) per Lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Four (4) per Lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||
| Preventive | D1515 | SPACE MAINTAINER-FIXED BILATERAL | $170.56 | $321.44 | 33% | 09/01/2016 | 12/31/2018 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Four (4) per Lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Four (4) per Lifetime for HUSKY A, C, D. One space maintainer per area per Member. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Preventive | D1516 | FIXED BILA SPACE MAINT, MAX | $213.20 | $321.44 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B Members. | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Preventive | D1517 | FIXED BILA SPACE MAINT, MAN | $213.20 | $321.56 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Preventive | D1525 | SPACE MAINTAINER-REMOVABLE BILATERAL | $182.00 | $343.00 | 33% | 09/01/2016 | 12/31/2018 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Four (4) covered per lifetime for HUSKY A, C, D. No frequency limits for HUSKY B members. | Four (4) covered per lifetime for HUSKY A, C, D. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Preventive | D1526 | REMOVE BILAT SPACE MAIN, MAX | $227.50 | $343.00 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Preventive | D1527 | REMOVE BILAT SPACE MAIN, MAN | $227.50 | $343.00 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist FQHC | No | Yes | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Two (2) covered per lifetime for HUSKY A, C, D. One (1) space maintainer per area per Member. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Preventive | D1551 | RECEMENT RE-BOND OF SPACE MAINTAINER - MAX | $39.65 | $59.78 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist | Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Re-cementing or re-bonding the space maintainer per quadrant. | Prior Authorization required for the following providers when the member is a child age zero through twenty (0-20):
Prior Authorization required for the following providers for members of any age:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Preventive | D1552 | RECEMENTATION OF SPACE MAINTAINER - MAN | $39.65 | $59.78 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist | Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Re-cementing or re-bonding the space maintainer. | Prior Authorization required for the following providers when the member is a child age zero through twenty (0-20):
Prior Authorization required for the following providers for members of any age:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Preventive | D1553 | RECEMENTATION OF UNILATER SPACE MAINTAINER PER QUADRANT | $39.65 | $59.78 | 20% | 07/01/2022 | 12/31/2019 | Yes | Dental Anesthesiologist | Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist | Dental Anesthesiologist Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist FQHC | No | Yes | Re-cementing or re-bonding the space maintainer. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Preventive | D1556 | REMOVAL OF FIXED UNIL SPACE MAINTAINER PER QUADRANT | $48.75 | $73.50 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist | Dental Anesthesiologist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist Hospital and Free Standing Clinics | No | Yes | Removal per quadrant of appliance designed to prevent tooth movement. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1557 | REMOVAL OF FIXED BILATER SPACE MAINTAINER - MAXILLARY | $48.75 | $73.50 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist | Dental Anesthesiologist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist Hospital and Free Standing Clinics | No | Yes | Removal of appliance designed to prevent tooth movement. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1558 | REMOVAL OF FIXED BILATER SPACE MAINTAINER - MANDIBULAR | $48.75 | $73.50 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist | Dental Anesthesiologist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist Hospital and Free Standing Clinics | No | Yes | Removal of appliance designed to prevent tooth movement. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Preventive | D1575 | DIST SPACE MAINT, FIXED UNIL- PER QUAD | NA | $210.70 | 33% | 01/01/2017 | 12/31/2299 | Yes | Endodontist General Dentist Hospital and Free-Standing Clinic Oral Surgeon Orthodontist Periodontist Prosthodontist | Endodontist General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist | Dental Anesthesiologist Dental Hygienist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Public Health Dentist | No | Yes | Two (2) covered per lifetime for HUSKY A, C, D. No frequency limits for HUSKY B members. | Two (2) covered per lifetime for HUSKY A, C, D. No frequency limits for HUSKY B members. | Space maintainers are covered when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. This includes the replacement of lost space maintainers. | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Restorative | D2140 | AMALGAM-ONE SURFACE PRIMARY OR PERMANENT | $61.75 | $93.10 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface. No frequency limits for HUSKY B members. | One (1) per two (2) years for same surface. No frequency limits for HUSKY B members. | Amalgam, composite, and glass ionomer restorations performed by the same provider are limited to one (1) restoration per tooth every two (2) years, regardless of the number of surfaces treated. No primary teeth are to be restored which are about to exfoliate. These services are subject to the following guidelines:
Included services:
| Providers required to submit for authorization must provide necessary documentation justifying service. Documentation is required to be submitted for authorization by the following provider types:
| |||||||
| Restorative | D2150 | AMALGAM-TWO SURFACES PRIMARY OR PERMANENT | $74.10 | $111.72 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface. | One (1) per two (2) years for same surface. | Amalgam, composite, and glass ionomer restorations performed by the same provider are limited to one (1) restoration per tooth every two (2) years, regardless of the number of surfaces treated. These services are subject to the following guidelines:
Included services:
| Providers required to submit for authorization must provide necessary documentation justifying service. Documentation is required to be submitted for authorization by the following provider types:
| |||||||
| Restorative | D2160 | AMALGAM-THREE SURFACES PRIMARY OR PERMANENT | $94.25 | $142.10 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface. | One (1) per two (2) years for same surface. | Amalgam, composite, and glass ionomer restorations performed by the same provider are limited to one (1) restoration per tooth every two (2) years, regardless of the number of surfaces treated. These services are subject to the following guidelines:
Included services:
| Providers required to submit for authorization must provide necessary documentation justifying service. Documentation is required to be submitted for authorization by the following provider types:
| |||||||
| Restorative | D2161 | AMALGAM-FOUR OR MORE SURFACES PRIMARY OR PERMANENT | $130.00 | $196.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface. | One (1) per two (2) years for same surface. | Amalgam, composite, and glass ionomer restorations performed by the same provider are limited to one (1) restoration per tooth every two (2) years, regardless of the number of surfaces treated. These services are subject to the following guidelines:
Included services:
| Providers required to submit for authorization must provide necessary documentation justifying service. Documentation is required to be submitted for authorization by the following provider types:
| |||||||
| Restorative | D2330 | RESIN-ONE SURFACE ANTERIOR | $65.00 | $98.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2331 | RESIN-TWO SURFACES ANTERIOR | $88.40 | $133.28 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2332 | RESIN-THREE SURFACES ANTERIOR | $110.50 | $166.60 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2335 | RESIN-FOUR OR MORE SURFACES OR INVOLVING | $136.50 | $205.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2390 | COMPOSITE CROWN ANTERIOR | N/A | $205.80 | 20% | 01/01/2018 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist FQHC | Yes: Children Only (0-20) | Yes | Primary anterior teeth are only eligible. | Authorization request considered with appropriate documentation outlining medical necessity. | |||||||||
| Restorative | D2391 | RESIN-BASED COMPOSITE - ONE SURFACE POS | $61.75 | $93.10 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Molar teeth numbers 2,3,14,15,18,19,30,31 are eligible to have posterior resin restorations for adult and children. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2392 | RESIN-BASED COMPOSITE - TWO SURFACES PO | $74.10 | $111.72 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Molar teeth numbers 2,3,14,15,18,19,30,31 are eligible to have posterior resin restorations for adult and children. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2393 | RESIN-BASED COMPOSITE - THREE SURFACES | $94.25 | $142.10 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Molar teeth numbers 2,3,14,15,18,19,30,31 are eligible to have posterior resin restorations for adult and children. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2394 | RESIN-BASED COMPOSITE-FOUR OR MORE SURF | $130.00 | $196.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per two (2) years for same surface by same provider. | One (1) per two (2) years for same surface by same provider. | Primary teeth that are about to exfoliate are ineligible. Tooth surface B (buccal) and F (facial) cannot be billed in conjunction with each other for the same procedure code and tooth number. Molar teeth numbers 2,3,14,15,18,19,30,31 are eligible to have posterior resin restorations for adult and children. Dental providers will be reimbursed for the total number of surfaces restored on a single (1) tooth per one-year (1-year) period regardless of the provider performing the restorations. The same surface even billed in conjunction with a different surface will not be covered in that same one-year (1-year). | Any restoration that is defective or has recurrent decay and requires replacement within two (2) years of the original placement date will require prior authorization, regardless of the provider performing the replacement. Replacement of the restoration may also result in recoupment of the fee paid for the original restoration from the provider who performed the initial procedure. | |||||||
| Restorative | D2542 | ONLAY - MET - TWO SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2543 | ONLAY - MET - THREE SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2544 | ONLAY - MET - FOUR OR MORE SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2642 | ONLAY- PORC/CER -TWO SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2643 | ONLAY- PORC/CER -THREE SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2644 | ONLAY- PORC/CER -FOUR OR MORE SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2662 | ONLAY- RES -TWO SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2663 | ONLAY- RES -THREE SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2664 | ONLAY- RES -FOUR OR MORE SURFACES | MP | MP | 20% | 10/01/2026 | 12/31/2305 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members over the age of sixteen (16) when root formation is complete. Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2740 | CROWN-PORCELAIN/CERA | $523.25 | $788.90 | 33% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years per tooth | One (1) per ten (10) years per tooth | For members under the age of twenty-one (21) and at least sixteen (16) years of age where root formation is complete. Not covered on primary teeth. For adults (over the age of twenty-one (21)) (over the age of twenty-one (21)) where the crown is used to restore a tooth where there is excessive loss of tooth structure due to caries or trauma, or root canal therapy has been performed and the prognosis is favorable. The tooth to be treated must be in occlusion with a natural tooth or the opposing tooth will be immediately restored or replaced with an artificial tooth. For adults (over the age of twenty-one (21)) (over the age of twenty-one (21)) with bilaterally missing teeth in the same arch are not eligible for multiple, single (1) crowns to restore deteriorated dentition unless the crowns will form the last remaining abutment tooth/teeth in an arch for partial denture placement. Tooth must have good prognosis and be restorable. Replacement of an existing artificial crown shall be covered only when the crown becomes defective in the permanent teeth after a ten-year (10-year) period has lapsed. Replacement of a lost crown on a permanent tooth will be reimbursed after a three-year (3-year) period has lapsed by the same provider. | Documentation submitted must include:
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| Restorative | D2751 | CROWN-PORCELAIN FUSED TO PREDOMINANTLY B | $523.25 | $788.90 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Public Health Dentist | Prosthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members under the age of twenty-one (21) and at least sixteen (16) years of age where root formation is complete. Not covered on primary teeth. For adults (over the age of twenty-one (21)) where the crown is used to restore a tooth where there is excessive loss of tooth structure due to caries or trauma, or root canal therapy has been performed and the prognosis is favorable. The tooth to be treated must be in occlusion with a natural tooth or the opposing tooth will be immediately restored or replaced with an artificial tooth. For adults (over the age of twenty-one (21)) with bilaterally missing teeth in the same arch are not eligible for multiple, single (1) crowns to restore deteriorated dentition unless the crowns will form the last remaining abutment tooth/teeth in an arch for partial denture placement. Tooth must have good prognosis and be restorable. Replacement of an existing artificial crown shall be covered only when the crown becomes defective in the permanent teeth after a ten-year (10-year) period has lapsed. Replacement of a lost crown on a permanent tooth will be reimbursed after a three-year (3-year) period has lapsed by the same provider. | Documentation submitted must include:
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| Restorative | D2791 | CROWN-FULL CAST PREDOMINANTLY BASE METAL | $455.00 | $686.00 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Public Health Dentist | Prosthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | One (1) per ten (10) years | One (1) per ten (10) years | For members under the age of twenty-one (21) and at least sixteen (16) years of age where root formation is complete. Not covered on primary teeth. For adults (over the age of twenty-one (21)) where the crown is used to restore a tooth where there is excessive loss of tooth structure due to caries or trauma, or root canal therapy has been performed and the prognosis is favorable. The tooth to be treated must be in occlusion with a natural tooth or the opposing tooth will be immediately restored or replaced with an artificial tooth. For adults (over the age of twenty-one (21)) with bilaterally missing teeth in the same arch are not eligible for multiple, single (1) crowns to restore deteriorated dentition unless the crowns will form the last remaining abutment tooth/teeth in an arch for partial denture placement. Tooth must have good prognosis and be restorable. Replacement of an existing artificial crown shall be covered only when the crown becomes defective in the permanent teeth after a ten-year (10-year) period has lapsed. Replacement of a lost crown on a permanent tooth will be reimbursed after a three-year (3-year) period has lapsed by the same provider. | Documentation submitted must include:
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| Restorative | D2910 | RECEMENT INLAY ONLAY OR PARTIAL COVERAGE | $18.20 | $27.44 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Tooth must have good prognosis | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation submitted must include:
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| Restorative | D2920 | RECEMENT CROWN | $27.30 | $41.16 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per calendar year | One (1) per calendar year | Tooth must have good prognosis | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation submitted must include:
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| Restorative | D2930 | PREFABRICATED STAINLESS STEEL CROWN-PRIM | $149.50 | $200.00 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Covered only when breakdown of tooth is determined to be excessive. Crowns will not be covered if the primary teeth are exfoliating. | Documentation submitted must include:
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| Restorative | D2931 | PREFABRICATED STAINLESS STEEL CROWN-PERM | $149.50 | $200.00 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | FQHC General Dentist Hospital and Free-Standing Clinic Pediatric Dentist Public Health Dentist | Prosthodontist | Dental Hygienist | No | Yes | Covered only when breakdown of tooth is determined to be excessive. Crowns will not be covered if the primary teeth are exfoliating. | Documentation submitted must include:
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| Restorative | D2934 | PREFABRICATED ESTHETIC COATED STAINLESS STEEL CROWN | $220.35 | $300.00 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Public Health Dentist | Pediatric Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Covered only when breakdown of tooth is determined to be excessive. Crowns will not be covered if the primary teeth are exfoliating. | Documentation submitted must include:
Submission of post-procedure radiograph required. | ||||||||
| Restorative | D2940 | INTERIM PROTECTIVE RESTORATION | $32.50 | $49.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage approved when used to treat dental pain requiring emergency treatment or treatment plan is for tooth to heal for a short time before completing treatment Not separately billable on same day as other restorative services or endodontic therapy on the same tooth. | Authorization request considered with appropriate documentation outlining medical necessity. | |||||||||
| Restorative | D2950 | CORE BUILD-UP INCLUDING ANY PINS | $80.60 | $121.52 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) every five (5) years | Once (1) every five (5) years | The core buildup replaces part or the entire anatomical crown when there is insufficient crown structure remaining to provide mechanical retention for an artificial crown provided said teeth can support the suitable placement of intra- dental pins, without causing damage to the existing pulp and therefore, serves as a base for the artificial crown. This procedure may be used with non-endodontically treated teeth that require an artificial crown when longevity is essential for the tooth in treatment and can demonstrate at least a supportable five (5) year positive prognosis. A core buildup is covered when more than 50% of the tooth structure is missing, and subject to the following:
Submission for fillers to smooth out irregularities in the tooth preparation are not covered. They are considered an integral part of the crown procedure and do not constitute a separate billable service. | Documentation submitted must include:
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| Restorative | D2951 | PIN RETENTION-PER TOOTH IN ADDITION TO | $22.75 | $34.30 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | This is covered when 3/4 or more of the coronal tooth structure is missing/carious. Tooth must have a good prognosis. | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation submitted must include:
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| Restorative | D2954 | PREFABRICATED POST AND CORE IN ADDITION TO CROWN | $149.50 | $225.40 | 33% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | The post/core replaces part or the entire anatomical crown when there is insufficient crown structure remaining to provide mechanical retention for an artificial crown and serves as a base for the artificial crown. This procedure may be used only on endodontically treated teeth that require an artificial crown when longevity is essential for the tooth in treatment and can demonstrate at least a supportable five (5) year positive prognosis. A post/core is covered when endodontic treatment has been successfully completed and subject to the following:
| Documentation submitted must include:
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| Restorative | D2982 | ONLAY REPAIR -MATERIAL FAILURE | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per seven (7) years per tooth | One (1) per seven (7) years per tooth | Posterior teeth eligible only. Tooth must have good prognosis and be restorable. Must have an opposing natural tooth or artificial natural tooth in occlusion. Any restorations that are faulty or have recurrent decay and require replacement within five (5) years from the initial date of placement will require prior authorization regardless of the provider and the replacement may result in recoupment of the initial restoration fee paid to the provider who performed the original restoration or must be replaced for no fee. For restorations that are faulty which require replacement after five (5) years, repair is covered at the direct placement restoration fee rate based on number of surfaces. | Documentation submitted must include:
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| Restorative | D2990 | RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS | $40.00 | $40.00 | 33% | 11/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Cannot be used not be used inconjunction with a stainless‑steel crown on a primary tooth. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Restorative | D2991 | APPLICATION OF HYDROXAPATITE REGENERATION MEDICA PER TOOTH | $70.00 | $70.00 | NA | 01/01/2024 | 12/31/2299 | No | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | No | No | One (1) application per tooth surface per year. | One (1) application per tooth surface per year. | The service is limited to one (1) time per tooth every year and additional applications per year must be prior authorized and follow the same restrictions as restorative fillings. Reimbursement will not be authorized for the restoration of separate surfaces when treatment is performed on a single (1) tooth by the same provider (on the same tooth, for the same member). | Authorization request may be considered with appropriate documentation demonstrating medical necessity. Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Restorative | D2999 | UNSPECIFIED RESTORATIVE PROCEDURE BY REPORT | MP | 33% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist Endodontist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
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| Endodontics | D3110 | PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION) | $67,60 | $101.92 | 20% | 07/01/2022 | 12/31/2299 | Yes | FQHC Hospital and Free-Standing Clinic Periodontist | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | Yes: Children Only (0-20) | Yes | Direct pulp cap covered for children (ages zero through twenty (0-20)) including all bases and liners. | Documentation submitted must include:
Prior authorization is required for certain specialties. Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Endodontics | D3120 | PULP CAP- INDIRECT (EXLCUD FINAL RESTORATION) | $41.00 | $41.00 | 20% | 10/01/2026 | 12/31/2299 | Yes | FQHC Hospital and Free Standing Clinics Periodontist | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Public Health Dentist | No | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Indirect pulp caps, including all bases and liners are covered. Covered when the following conditions are met:
| Documentation submitted must include:
Prior authorization is required for certain specialties. Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | Yes | ||||||
| Endodontics | D3220 | THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION) | $86.45 | $130.34 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Covered for children (ages zero through twenty (0-20)) when it’s performed on a primary tooth and the dentist restores the tooth with a crown. In the instance an adult (over the age of twenty-one (21)) is experiencing severe pain, the dentist can submit a request for emergency approval. Those requests are reviewed case‑by‑case to determine if the service is medically necessary. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3310 | ENDO THERAPY ANTERIOR (EXCLUDING FINAL RESTORATION) | $577.22 | $577.22 | 20% | 07/01/2022 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | No | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Endodontic therapy (root canal treatment) is covered once (1) per tooth per lifetime when:
For adults (over the age of twenty-one (21), the tooth must be restored immediately after treatment. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3320 | ENDO THERAPY PREMOLAR (EXCLUDING FINAL RESTORATION) | $742.84 | $742.84 | 20% | 07/01/2022 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | No | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Endodontic therapy (root canal treatment) is covered once (1) per tooth per lifetime when:
For adults (over the age of twenty-one (21), the tooth must be restored immediately after treatment. Prior Authorization is required when the Member is an adult over age twenty-one (21) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. Post Procedure Review is required when the Member is a child under the age of twenty-one (21) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). Prior Authorization is required when the Member is an adult over the age of twenty-one (21) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. Post Procedure Review is required when the Member is a child (ages zero through twenty (0-20)) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. | |||||||
| Endodontics | D3330 | ENDO THERAPY MOLAR (EXCLUDING FINAL RESTORATION) | $857.50 | $857.50 | 20% | 07/01/2022 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | No | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Endodontic therapy (root canal treatment) is covered once (1) per tooth per lifetime when:
For adults (over the age of twenty-one (21), the tooth must be restored immediately after treatment. Prior Authorization is required when the Member is an adult over age twenty-one (21) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. Post Procedure Review is required when the Member is a child under the age of twenty-one (21) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). Prior Authorization is required when the Member is an adult over the age of twenty-one (21) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. Post Procedure Review is required when the Member is a child (ages zero through twenty (0-20)) for Prosthodontist, Pediatric Dentists, General Dentists, Public Health Dentists, Hospital and Fee-Standing Clinics, and FQHCs. | |||||||
| Endodontics | D3346 | RETREATMENT OF PREVIOUS RCT ANTERIOR | $577.22 | $577.22 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Covered for both children and adult members. Limited to one (1) retreatment per tooth per lifetime when:
| Prior Authorization Submission must include completed charting/documentation confirmation of the following:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3347 | RETREATMENT OF PREVIOUS RCT BICUSPID | $742.84 | $742.84 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Covered for both children and adult members. Limited to one (1) retreatment per tooth per lifetime when:
| Prior authorization must include completed charting/documentation confirmation of the following:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20).. | |||||||
| Endodontics | D3348 | RETREATMENT OF PREVIOUS RCT MOLAR | $857.50 | $857.50 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Covered for both children and adult members. Limited to one (1) retreatment per tooth per lifetime when:
| Prior authorization must include completed charting/documentation confirmation of the following:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3351 | APEXIFICATION/RECALCIFICATION-INITIAL VI | NA | $247.94 | 20% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Apexification is covered once (1) per tooth per lifetime for members up to the age of eighteen (18). This includes all interim visits to complete the service excluding the final root canal therapy. Does NOT include the final root canal therapy. PA is required for all specialties except endodontists. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3352 | APEXIFICATION/RECALCIFICATION - INTERIM MEDICATION REP | NA | $247.94 | 20% | 09/01/2016 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist | Yes: See Coverage Guidelines | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Apexification is covered once (1) per tooth per lifetime for members up to the age of eighteen (18). This includes all interim visits to complete the service excluding the final root canal therapy. Does NOT include the final root canal therapy. PA is required for all specialties except endodontists. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3353 | APEXIFICATION/RECALCIFICATION-FINAL VISIT (INCLUDES CO | NA | $247.94 | 20% | 09/01/2016 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist | Yes: See Coverage Guidelines | Yes | Once (1) Per Tooth Per Lifetime | Once (1) Per Tooth Per Lifetime | Apexification is covered once (1) per tooth per lifetime for members up to the age of eighteen (18). This includes all interim visits to complete the service excluding the final root canal therapy. Does NOT include the final root canal therapy. PA is required for all specialties except endodontists. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3410 | APICOECTOMY/PERIRADICULAR SURGERY-ANTERI | $260.00 | $392.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist | FQHC General Dentist Hospital and Free-Standing Clinic Oral Surgeon Pediatric Dentist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Adults Only (Over Age 21) | Yes | Once (1) per tooth per lifetime | Not Applicable | Covered for adults (over the age of twenty-one (21)) once (1) time per tooth per lifetime when:
| Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||
| Endodontics | D3421 | APICOECTOMY/PERIRADICULAR SURGERY-BICUSP | $292.50 | $441.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist | FQHC General Dentist Hospital and Free-Standing Clinic Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Adults Only (Over Age 21) | Yes | Once (1) per tooth per lifetime | Not Applicable | Covered for adults (over the age of twenty-one (21)) once (1) time per tooth when:
| Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||
| Endodontics | D3425 | APICOECTOMY/PERIRADICULAR SURGERY-MOLAR | $325.00 | $490.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist | FQHC General Dentist Hospital and Free-Standing Clinic Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Adults Only (Over Age 21) | Yes | Once (1) per tooth per lifetime | Not Applicable | Covered for adults (over the age of twenty-one (21)) once (1) time per tooth when:
| Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||
| Endodontics | D3950 | CANAL PREPARATION AND FITTING OF PREFORM | $88.40 | $133.28 | 20% | 07/01/2022 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | No | Yes | Once (1) per tooth per lifetime | Once (1) per tooth per lifetime | Covered for both children and adult members when a tooth needs a retreatment of a previous root canal. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Endodontics | D3999 | UNSPECIFIED ENDODONTIC PROCEDURE BY REP | MP | MP | 20% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| |||||||||
| Periodontics | D4210 | GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONT TEETH | $260.65 | $392.98 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | FQHC General Dentist Hospital and Free-Standing Clinic Oral Surgeon Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) time per quadrant during a one-year (1) period | One (1) time per quadrant during a one-year (1) period | Prior Authorization required for adults (over the age of twenty-one (21)) and limited to patients with severe effects caused by medication. | Documentation submitted must include:
| ||||||
| Periodontics | D4211 | GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONT TEETH | $68.25 | $102.90 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | FQHC General Dentist Hospital and Free-Standing Clinic Oral Surgeon Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) time per quadrant during a one-year (1) period | One (1) time per quadrant during a one-year (1) period | Prior Authorization required for adults (over the age of twenty-one (21)) and limited to patients with severe effects caused by medication. | Documentation submitted must include:
| ||||||
| Periodontics | D4240 | GINGIVAL FLAP INCLD. ROOT PLANING - FOUR OR MORE CONTIG. TEETH OR TOOTH BONDED PER QUAD. | $366.00 | $366.00 | 50% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per quadrant/site per three (3) years | One (1) per quadrant/site per three (3) years | Must have had either D4341 or D4342 (Scaling and Root Planing) in the quadrant being considered within the past twelve (12) months without sufficient clinical success necessitating surgical intervention to improve access. | Documentation submitted must include:
| |||||||
| Periodontics | D4241 | GINGIVAL FLAP INCLD. ROOT PLANING - ONE TO THREE CONTIG. TEETH OR TOOTH BONDED PER QUAD. | $309.00 | $309.00 | 50% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per qudrant/site per three (3) years | One (1) per qudrant/site per three (3) years | Must have had either D4341 or D4342 (Scaling and Root Planing) in the quadrant being considered within the past twelve (12) months without sufficient clinical success necessitating surgical intervention to improve access. | Documentation submitted must include:
| |||||||
| Periodontics | D4341 | PERIODONTAL SCALING AND ROOT PLANING 4 OR MORE TEETH PER QUAD | $223.00 | $223.00 | 50% | 01/01/2024 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | Yes: See Coverage Guidelines | Yes | Four (4) quadrants per thiry-six (36) months | Four (4) quadrants per thiry-six (36) months | Covered for children (ages zero through twenty (0-20)) regardless of medical condition. Covered for adults (over the age of twenty-one (21)) who have treatable periodontal disease and a diagnosis of at least one (1) of the following medical conditions evidenced by medical claim history: Requires Prior Authorization.
Note: No more than two (2) combinations per quadrant per visit. All FQHCs are required to submit the same documentation for HUSKY and Covered CT members. One (1) unit of each periodontal services will be authorized for each encounter.
Procedures for debridement and scaling and root planning should be performed as one (1) debridement encounter and one (1) encounter for each periodontal scaling and root planning treatment. | Providers need to submit the following documentation:
| |||||||
| Periodontics | D4342 | PERIODONTAL SCRP; PER 1 TO 3 TEETH | $129.00 | $129.00 | 50% | 01/01/2024 | 12/31/2299 | Yes | Dental Hygienist FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | Yes: See Coverage Guidelines | Yes | Four (4) quadrants per thiry-six (36) months | Four (4) quadrants per thiry-six (36) months | Covered for children (ages zero through twenty (0-20)) regardless of medical condition. Covered for adults (over the age of twenty-one (21)) who have treatable periodontal disease and a diagnosis of at least one (1) of the following medical conditions evidenced by medical claim history:
Note: For CDT code D4342 (Scaling and Root Planing 1-3 teeth) a tooth number must be submitted in addition to the quadrant indicating the central tooth in the site.
Note: No more than two combinations per quadrant per visit. All FQHCs are required to submit the same documentation for HUSKY and Covered CT members. One (1) unit of each periodontal services will be authorized for each encounter.
Procedures for debridement and scaling and root planning should be performed as one (1) debridement encounter and one (1) encounter for each periodontal scaling and root planning treatment. | Providers need to submit the following documentation:
| |||||||
| Periodontics | D4355 | FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE PERIODONTAL EVALUATION | $153.00 | $153.00 | NA | 01/01/2024 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | Yes: See Coverage Guidelines | Yes | Limited to one (1) per lifetime per HUSKY member | Limited to one (1) per lifetime per HUSKY member | Covered for children (ages zero through twenty (0-20)) regardless of medical condition. Additional debridement services may be requested for reasons of medical necessity for adults (over the age of twenty-one (21)) who have special healthcare needs and children (ages zero through twenty (0-20)) may qualify for additional debridement under EPSDT guidelines. Note: D4355 cannot be billed on the same date of service as D0180 or D4341/D4342. All FQHCs are required to submit the same documentation for HUSKY and Covered CT members. One (1) unit of each periodontal services will be authorized for each encounter.
Procedures for debridement and scaling and root planning should be performed as one (1) debridement encounter and one (1) encounter for each periodontal scaling and root planning treatment. | As part of Periodontal services, providers should to submit the following documentation:
| |||||||
| Periodontics | D4910 | PERIODONTAL MAINTENANCE | $138.00 | $138.00 | N/A | 01/01/2024 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist | No | Yes | Two (2) per calendar year | Two (2) per calendar year | Covered for children (ages zero through twenty (0-20)) regardless of medical condition. Covered for adults (over the age of twenty-one (21)) who have treatable periodontal disease and a diagnosis of at least one (1) of the following medical conditions evidenced by medical claim history: Requires Prior Authorization
All FQHCs are required to submit the same documentation for HUSKY and Covered CT members. One (1) unit of each periodontal services will be authorized for each encounter.
Procedures for debridement and scaling and root planning should be performed as one (1) debridement encounter and one (1) encounter for each periodontal scaling and root planning treatment. Note: Cannot be performed in conjunction with D0180, D4341 or D4342. | As part of Periodontal services, providers need to submit the following documentation:
| |||||||
| Periodontics | D4999 | UNSPECIFIED PERIODONTAL PROCEDURE; BY REPORT | MP | MP | 50% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| |||||||||
| Prosthodontics, removable | D5110 | COMPLETE DENTURE - MAXILLARY | $692.90 | $1,044.68 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per seven (7) years | Once (1) per seven (7) years | Complete dentures are covered when the following conditions are met:
Covered once (1) every seven (7) years. Members must sign an acceptance form acknowledging the seven (7) year replacement policy and confirming that the prosthesis is acceptable. CTDHP supplies these forms at no cost at ctdhp.org. Denture labeling is required for patients residing in long term care facilities. If a patient requires a replacement denture within the seven-year (7-year) period, a prior authorization request is required. The PA must include documentation supporting medical necessity. If the denture was stolen or destroyed due to an accident or natural disaster, an official report—such as a police or fire marshal report—must be included. Cosmetic replacements are not covered. Note: Fixed prosthetics (bridges) are not covered under HUSKY. Denture adjustments may be billed six (6) months after initial placement. | Complete charting and documentation of the dentition and any planed extractions. Mounted pre operative periapical X-rays, panoramic, or FMX (no bitewings). Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5120 | COMPLETE DENTURE - MANDIBULAR | $692.90 | $1,044.68 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per seven (7) years | Once (1) per seven (7) years | Complete dentures are covered when the following conditions are met:
Covered once every seven (7) years. Members must sign an acceptance form acknowledging the seven-year (7-year) replacement policy and confirming that the prosthesis is acceptable. CTDHP supplies these forms at no cost at ctdhp.org. Denture labeling is required for patients residing in long term care facilities. If a patient requires a replacement denture within the seven (7) year period, a prior authorization request is required. The PA must include documentation supporting medical necessity. If the denture was stolen or destroyed due to an accident or natural disaster, an official report—such as a police or fire marshal report—must be included. Cosmetic replacements are not covered. Note: Fixed prosthetics (bridges) are not covered under HUSKY. Denture adjustments may be billed six (6) months after initial placement. | Complete charting and documentation of the dentition and any planed extractions. Mounted pre-operative periapical X-rays, panoramic, or FMX (no bitewings). Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5211 | UPPER PARTIAL-RESIN BASE (INCLUDING ANY | $649.35 | $979.02 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per seven (7) years | Once (1) per seven (7) years | Removable Partial Dentures are covered when the following conditions are met:
Covered once every seven (7) years. Adjacent teeth are defined as teeth with no spacing between them (e.g., two (2) bicuspids occluding with two (2) bicuspids; a second bicuspid and first molar occluding with the same; first and second molars occluding with the same). If a member requires a complete denture within the first two (2) years of placement of partial denture(s) by the same provider, the money for the partial denture shall be recouped and all preventive, restorative, endodontic, and extraction procedures shall be completed prior to requesting prior authorization and before constructing the partial denture(s). Denture labeling is covered for patients in long term care facilities only. Fixed prosthetics-bridges are not covered. | Complete charting and documentation of the dentition and any planned extractions. Mounted pre-operative periapical X-rays, panoramic, or FMX (bitewings alone are not acceptable). Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5212 | LOWER PARTIAL-RESIN BASE (INCLUDING ANY | $630.50 | $950.60 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per seven (7) years | Once (1) per seven (7) years | Removable Partial Dentures are covered when the following conditions are met:
Covered once every seven (7) years. Adjacent teeth are defined as teeth with no spacing between them (e.g., two (2) bicuspids occluding with two (2) bicuspids; a second bicuspid and first molar occluding with the same; first and second molars occluding with the same). If a member requires a complete denture within the first two (2) years of placement of partial denture(s) by the same provider, the money for the partial denture shall be recouped and all preventive, restorative, endodontic, and extraction procedures shall be completed prior to requesting prior authorization and before constructing the partial denture(s). Denture labeling is covered for patients in long term care facilities only. Fixed prosthetics-bridges are not covered. | Complete charting and documentation of the dentition and any planned extractions. Mounted pre-operative periapical X-rays, panoramic, or FMX (bitewings alone are not acceptable). Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5213 | MAXILLARY PARTIAL DENTURE - CAST METAL F | $778.05 | $1,173.06 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per seven (7) years | Once (1) per seven (7) years | Removable Partial Dentures are covered when the following conditions are met:
Covered once every seven (7) years. Adjacent teeth are defined as teeth with no spacing between them.
If a member requires a complete denture within the first two (2) years of placement of partial denture(s) by the same provider, the money for the partial denture shall be recouped and all preventive, restorative, endodontic, and extraction procedures shall be completed prior to requesting prior authorization and before constructing the partial denture(s). Denture labeling is covered for patients in long term care facilities only. Fixed prosthetics-bridges are not covered. | Complete charting and documentation of the dentition and any planned extractions. Mounted pre-operative periapical X-rays, panoramic, or FMX (bitewings alone are not acceptable). Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5214 | MANDIBULAR PARTIAL DENTURE - CAST METAL | $764.40 | $1,152.48 | 50% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per seven (7) years | Once (1) per seven (7) years | Removable Partial Dentures are covered when the following conditions are met:
Covered once every seven (7) years. Adjacent teeth are defined as teeth with no spacing between them.
If a member requires a complete denture within the first two (2) years of placement of partial denture(s) by the same provider, the money for the partial denture shall be recouped and all preventive, restorative, endodontic, and extraction procedures shall be completed prior to requesting prior authorization and before constructing the partial denture(s). Denture labeling is covered for patients in long term care facilities only. Fixed prosthetics-bridges are not covered. | Complete charting and documentation of the dentition and any planned extractions. Mounted pre-operative periapical X-rays, panoramic, or FMX (bitewings alone are not acceptable). Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5511 | REP BROKE COMP DENT BASE MANDIBULAR | $125.45 | $189.14 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5512 | REP BROKE COMP DENT BASE MAXILLARY | $125.45 | $189.14 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5520 | REPLACE MISSING OR BROKEN TEETH-COMPLETE | $42.90 | $64.68 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5611 | REPAIR RESIN DENTURE BASE MANDIBULAR | $97.50 | $147.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5612 | REPAIR RESIN DENTURE BASE MAXILLARY | $97.50 | $147.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5621 | REPAIR CAST PARTIAL FRAME MANDIBULAR | $39.00 | $58.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5622 | REPAIR CAST PARTIAL FRAME MAXILLARY | $39.00 | $58.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5630 | REPAIR OR REPLACE BROKEN CLASP | $92.95 | $140.14 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5640 | REPLACE BROKEN TEETH-PER TOOTH | $80.60 | $121.52 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5650 | ADD TOOTH TO EXISTING PARTIAL DENTURE | $62.40 | $94.08 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5660 | ADD CLASP TO EXISTING PARTIAL DENTURE | $82.55 | $124.46 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5710 | REBASE - COMP. MAX. DENTURE | $158.55 | $241.60 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5711 | REBASE-COMP. MAND. DENTURE | $158.55 | $241.60 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5720 | REBASE- PARTIAL MAX. DENTURE | $149.52 | $227.84 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5721 | REBASE - PARTIAL MAND. DENTURE | $149.52 | $227.84 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5725 | REBASE OF HYBRID PROSTHESIS | $129.35 | $195.02 | 20% | 07/01/2022 | 12/31/2299 | No | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Prosthodontics, removable | D5730 | RELINE COMPLETE MAXILLARY DENTURE (DIRECT-CHAIRSIDE) | $71.50 | $107.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5731 | RELINE LOWER COMPLETE MANDIBULAR DENTURE (DIRECT-CHAIRSIDE) | $71.50 | $107.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5740 | RELINE MAXILLARY PARTIAL DENTURE (DIRECT-CHAIRSIDE) | $71.50 | $107.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5741 | RELINE MANDIBULAR PARTIAL DENTURE (DIRECT-CHAIRSIDE) | $71.50 | $107.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5750 | RELINE COMPLETE MAXILLARY DENTURE (INDIRECT - LAB) | $129.35 | $195.02 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5751 | RELINE COMPLETE MANDIBULAR DENTURE (INDIRECT - LAB) | $129.35 | $195.02 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5760 | RELINE MAXILLARY PARTIAL DENTURE ((INDIRECT - LAB) | $124.15 | $187.18 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5761 | RELINE MANDIBULAR PARTIAL DENTURE (INDIRECT - LAB) | $124.15 | $187.18 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Prosthodontics, removable | D5765 | SOFT LINER FOR COMPLETE OR PARTIAL DENTURE (INDIRECT - LAB) | $129.35 | $195.02 | 20% | 07/01/2022 | 12/31/2299 | FQHC General Dentist Hospital and Free Standing Clinics Pediatric Dentist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist | No | No | Once (1) per two (2) years | Once (1) per two (2) years | Covered once (1) every two (2) years and may be performed no sooner than six (6) months after the initial denture placement. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Prosthodontics, removable | D5899 | UNSPECIFIED REMOVABLE PROSTHODONTIC PROC | MP | MP | 50% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist | Dental Hygienist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| |||||||||
| Maxillofacial Prosthetics | D5931 | OBTURATOR PROSTHESIS SURGICAL | $741.00 | $1,117.20 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime | Once (1) in a lifetime | Used for congenital or acquired defect prosthesis placed immediately after surgery. | Documentation submitted must include:
| |||||||
| Maxillofacial Prosthetics | D5932 | OBTURATOR PROSTHESIS DEFINITIVE | $1,422.85 | $2,145.22 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) per seven (7) years | Once (1) per seven (7) years | Used for congenital or acquired defect prosthesis. | Documentation submitted must include:
| |||||||
| Maxillofacial Prosthetics | D5986 | FLUORIDE GEL CARRIER | $87.75 | $132.30 | NA | 07/01/2022 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Periodontist Prosthodontist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist | Yes: See Coverage Guidelines | Yes | See Coverage Guidelines | See Coverage Guidelines | Covered for children (ages zero through twenty (0-20)) one (1) time every two (2) years. Covered for adults (over the age of twenty-one (21)) with severe xerostomia and/or patients with a diagnosis of and undergoing treatment for head and neck cancer (radiation treatment). Covered once (1) per lifetime. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Maxillofacial Prosthetics | D5999 | USPECIFIED MAXILLOFACIAL PROSTHESIS BY REPORT | MP | MP | 50% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| |||||||||
| Implant Services | D6049 | SCALING AND DEBRIDEMENT SINGLE IMP | $86.00 | $86.00 | NA | 01/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist General Dentist Oral Surgeon | Dental Anesthesiologist General Dentist Oral Surgeon | Dental Hygienist Endodontist FQHC Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) per implant per Thirty-Six (36) Months | One (1) per implant per Thirty-Six (36) Months | Single (1) implant must be affected by peri-implantitis, characterized by inflammation, bleeding, and deep pockets. D6049 requires prior authorization and must demonstrate the tooth qualifies via chart notes and radiographs. D6049 is not billable in conjunction with D4341/D4342. | Providers need to submit the following documentation:
| |||||||
| Implant Services | D6110 | IMPLANT/ABUT SUPPORTED REMOVABLE DENTURE ENDENTULOUS - MAXILLARY | MP | MP | NA | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every seven (7) years | One (1) every seven (7) years | Coverage for implant supported overdentures occur when the following conditions are met:
| Documentation submitted must include:
| |||||||
| Implant Services | D6111 | IMPLANT/ABUT SUPPORTED REMOVABLE DENTURE ENDENTULOUS- MANDIBULAR | MP | MP | NA | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every seven (7) years | One (1) every seven (7) years | Coverage for implant supported overdentures occur when the following conditions are met:
| Documentation submitted must include:
| |||||||
| Implant Services | D6112 | IMPLANT/ABUT SUPPORTED REMOVABLE DENTURE PARTIALLY ENDENTULOUS- MAXILLARY | MP | MP | NA | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every seven (7) years | One (1) every seven (7) years | Coverage for implant supported overdentures occur when the following conditions are met:
| Documentation submitted must include:
| |||||||
| Implant Services | D6113 | IMPLANT/ABUT SUPPORTED REMOVABLE DENTURE PARTIALLY ENDENTULOUS- MANDIBULAR | MP | MP | NA | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every seven (7) years | One (1) every seven (7) years | Coverage for implant supported overdentures occur when the following conditions are met:
| Documentation submitted must include:
| |||||||
| Implant Services | D6191 | SEMI-PRE ABUTMENT-PLAC | MP | MP | NA | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every seven (7) years | One (1) every seven (7) years | Coverage for implant supported overdentures occur when the following conditions are met:
| Documentation submitted must include:
| |||||||
| Implant Services | D6192 | SEMI-PRE ATTACH-PLAC | MP | MP | NA | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every seven (7) years | One (1) every seven (7) years | Coverage for implant supported overdentures occur when the following conditions are met:
| Documentation submitted must include:
| |||||||
| Prosthodontics, fixed | D6241 | PONTIC- PORCELAIN FUSED N. METAL | NA | $788.90 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Children Only (0-20) | Yes | Not Applicable | One (1) every ten (10) years | Fixed Acid Etched Partial Dentures are covered when the following conditions are met:
Note: Acid etch or “Maryland” bridgework | Documentation to be submitted:
| |||||||
| Prosthodontics, fixed | D6245 | PONTIC- PORCELAIN/CER. | NA | $500.00 | 20% | 07/01/2020 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Children Only (0-20) | Yes | Not Applicable | One (1) every ten (10) years | Fixed Acid Etched Partial Dentures are covered when the following conditions are met:
Note: Acid etch or “Maryland” bridgework | Documentation to be submitted:
Members must be provided the “Caring for Your Dentures” brochure and initial/sign the “Member Acknowledgement of Receipt of Denture(s) and Description of the Policies for Replacement form downloadable from https://ctdhp.org/resources/. The original signed copy must be entered in the Member’s chart. | |||||||
| Implant Services | D6280 | IMPLANT MAINTENANCE - PER ARCH | MP | MP | NA | 01/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist General Dentist Oral Surgeon | Dental Anesthesiologist General Dentist Oral Surgeon | Dental Hygienist Endodontist FQHC Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Two (2) times in a calendar year | Two (2) times in a calendar year | Conducted when a full arch removable implant/abutment supported denture is removed and reinserted, including cleansing of prosthesis and abutments - per arch | Documentation submitted must include:
| |||||||
| Prosthodontics, fixed | D6545 | RETAINER - CAST METAL/RES. | NA | $500.00 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Children Only (0-20) | Yes | Not Applicable | One (1) every ten (10) years | Fixed Acid Etched Partial Dentures are covered when the following conditions are met:
Note: Acid etch or “Maryland” bridgework | Documentation to be submitted:
| |||||||
| Prosthodontics, fixed | D6930 | RECEMENT BRIDGE | $18.20 | $27.44 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per calendar year | One (1) per calendar year | Prognosis must be favorable | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Complete charting and recent (less than one (1) year) radiographs consisting of one (1) periapical and minimum one (1) bitewing of tooth in question are required for submission. | |||||||
| Prosthodontics, fixed | D6999 | UNSPECIFIED FIXED PROSTHODONTIC PROCEDU | MP | MP | 50% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| |||||||||
| Oral & Maxillofacial Surgery | D7111 | EXTRACTION; CORONAL REMANTS - DECIDUOUS | $58.50 | $88.20 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Covered for primary teeth only. | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include a pre-operative periapical x-ray. | |||||||
| Oral & Maxillofacial Surgery | D7140 | EXTRACTION ERUPTED TOOTH OR EXPOSED ROO | $74.75 | $112.70 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Covered for all permanent, primary and supernumerary teeth | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include a pre-operative periapical x-ray. | |||||||
| Oral & Maxillofacial Surgery | D7210 | SURGICAL REMOVAL OF ERUPTED TOOTH REQUIR | $130.00 | $196.00 | 33% | 07/01/2022 | 12/31/2299 | Yes | Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Radiologist Pediatric Dentist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Covered for all permanent, primary and supernumerary teeth Note: Oral Surgeons are not required to submit prior authorization for surgical extractions | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include pre-operative panoramic, complete series or periapical x-ray. | ||||||
| Oral & Maxillofacial Surgery | D7220 | REMOVAL OF IMPACTED TOOTH-SOFT TISSUE | $148.20 | $223.44 | 33% | 07/01/2022 | 12/31/2299 | Yes | Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Radiologist Pediatric Dentist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Elective impactions require special consideration & x-rays supporting the need for service. | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include pre-operative panoramic, complete series or periapical x-ray. | ||||||
| Oral & Maxillofacial Surgery | D7230 | REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY | $187.20 | $282.24 | 33% | 07/01/2022 | 12/31/2299 | Yes | Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Radiologist Pediatric Dentist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Elective impactions require special consideration & x-rays supporting the need for service. | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include pre-operative panoramic, complete series or periapical x-ray. | ||||||
| Oral & Maxillofacial Surgery | D7240 | REMOVAL OF AN IMPACTED TOOTH-COMPLETE B | $243.75 | $367.50 | 33% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Radiologist Orthodontist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Elective impactions require special consideration & x-rays supporting the need for service. Requires x-ray. | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include preoperative panoramic, complete series or periapical x-ray | |||||||
| Oral & Maxillofacial Surgery | D7241 | REMOVAL OF IMPACTED TOOTH-COMPLETE BONY | $272.35 | $410.62 | 33% | 07/01/2022 | 12/31/2299 | Yes | Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist General Dentist Hospital and Free-Standing Clinic Oral Surgeon Oral and Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Elective impactions require special consideration & x-rays supporting the need for service. | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include preoperative panoramic, complete series or periapical x-ray | ||||||
| Oral & Maxillofacial Surgery | D7250 | SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS | $185.90 | $280.28 | 33% | 07/01/2022 | 12/31/2299 | Yes | Endodontist Oral & Maxillofacial Pathologist Orthodontist | Dental Anesthesiologist General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per tooth | Once (1) in a lifetime per tooth | Post Procedure Review is required to be obtained after service is performed by the following provider types:
Documentation should include pre-operative panoramic, complete series or periapical x-ray. | |||||||
| Oral & Maxillofacial Surgery | D7251 | CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVAL | $185.25 | $279.30 | 20% | 07/01/2022 | 12/31/2299 | No | Hospital and Free Standing Clinics Oral Surgeon | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Requires documented medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7260 | OROANTRAL FISTULA CLOSURE | $412.75 | $622.30 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Requires documented medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7261 | PRIMARY CLOSURE OF A SINUS PERFERATION | $416.00 | $627.20 | NA | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Pediatric Dentist Periodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | No | No | Requires documented medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7270 | TOOTH REIMPLANTATION AND/OR STABILIZATIO | $483.60 | $729.12 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist | Yes: See Coverage Guidelines | No | Once (1) in a lifetime per tooth | Service restricted to members ages zero through twenty (0-20). | Post Procedure Review (PR) is required for the following providers:
Note: PR means Authorization Review is required to be obtained from Connecticut Dental Health Partnership after the service has been performed. Narrative and x-ray are required. | ||||||||
| Oral & Maxillofacial Surgery | D7272 | TOOTH TRANSPLANTATION (INCLUDES REIMPLAN | $103.35 | $155.82 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | Once (1) in a lifetime per tooth | Service restricted to members under the age of eighteen (18). | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7280 | SURGICAL ACCESS OF AN UNERUPTED TOOTH | NA | $344.96 | 20% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Children Only (0-20) | Yes | Once (1) in a lifetime per tooth | Member must be in active, approved orthodontic care. Service is intended to create a path for eruption that will not leave the coronal of the tooth exposed post operatively. | Prior Authorization Submission must include documentation to demonstrate the impacted tooth needs traction guidance to erupt into place factoring in tooth position, angle, and patient age. | ||||||||
| Oral & Maxillofacial Surgery | D7283 | PLACEMENT OF DEVICE TO FACILITATE ERUPTION OF IMPACTED | NA | $93.10 | NA | 09/01/2016 | 12/31/2299 | Yes | FQHC General Dentist Pediatric Dentist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Periodontist Prosthodontist | Yes: Children Only (0-20) | Yes | Once (1) in a lifetime per tooth | Member must be in active, approved orthodontic care. Service is intended to create a path for eruption that will not leave the coronal of the tooth exposed post operatively. | Prior Authorization Submission must include documentation to demonstrate the impacted tooth needs traction guidance to erupt into place factoring in tooth position, angle, and patient age. | ||||||||
| Oral & Maxillofacial Surgery | D7284 | EXCISIONAL BIOPSY OF MINOR SALIVARY GLANDS | $61.10 | $92.12 | NA | 01/01/2024 | 12/31/2299 | No | General Dentist Hospital and Free Standing Clinics Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | No | No | ||||||||||||
| Oral & Maxillofacial Surgery | D7285 | BIOPSY OF ORAL TISSUE - HARD | $194.00 | $194.00 | 20% | 10/01/2026 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Oral tissue - hard (bone, tooth) | Post Procedure review; Requires a copy of the biopsy report required. | |||||||||
| Oral & Maxillofacial Surgery | D7286 | BIOPSY OF ORAL TISSUE - SOFT | $85.15 | $128.38 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Oral tissue - soft | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7294 | SURGICAL PLACEMENT: TEMPORARY ANCHORAGE DEVICE | $117.00 | $176.40 | NA | 07/01/2022 | 12/31/2299 | Yes | General Dentist Pediatric Dentist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Periodontist Prosthodontist | No | Yes | Member must have an active, approved orthodontic case on file | Documentation submitted must include:
| |||||||||
| Oral & Maxillofacial Surgery | D7299 | REMOVAL OF TEMPORARY ANCHORAGE DEVICE REQUIRING FLAP | $390.00 | $588.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Hospital and Free Standing Clinics Oral Surgeon Orthodontist | Hospital and Free Standing Clinics Oral Surgeon Orthodontist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Member must have an active, approved orthodontic case on file | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7300 | REMOVAL OF TEMPORARY ANCHORAGE DEVICE(ANCHORAGE PLATE WITH SCREWS) WITH FLAP | $390.00 | $588.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Hospital and Free Standing Clinics Oral Surgeon Orthodontist | Hospital and Free Standing Clinics Oral Surgeon Orthodontist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Member must have an active, approved orthodontic case on file | Documentation submitted must include:
| |||||||||
| Oral & Maxillofacial Surgery | D7320 | ALVEOLOPLASTY NOT WITH EXT FOUR OR MORE TEETH | $130.00 | $196.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | No | Yes | Once (1) in a lifetime per site | Once (1) in a lifetime per site | Alveoloplasty when four (4) or more contiguous teeth are extracted. Service not performed in conjunction with a tooth extraction. | Cannot be billed in conjunction with extractions. Requires narrative detailing the need for treatment. Can only be approved when there is an edentulous area. Not covered to remove bony spicule or smoothing of bone. | |||||||
| Oral & Maxillofacial Surgery | D7321 | ALVEOLOPLASTY NOT WITH EXT ONE TO THREE TEETH | $78.00 | $118.00 | 20% | 10/01/2026 | 12/31/2299 | Yes | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | FQHC General Dentist Hospital and Free Standing Clinics Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | No | Yes | Once (1) in a lifetime per site | Once (1) in a lifetime per site | Service not performed in conjunction with tooth extractions or within six (6) months of surgical extractions. | Cannot be billed in conjunction with extractions. Requires narrative detailing the need for treatment. Can only be approved when there is an edentulous area. Not covered to remove bony spicule or smoothing of bone. | |||||||
| Oral & Maxillofacial Surgery | D7410 | EXCISION OF BENIGN LESION UP TO 1.25 CM | $61.10 | $92.12 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Benign lesion up to 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7411 | EXCISION OF BENIGN LESION GREATER THAN 1 | $146.25 | $220.50 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Benign lesion greater than 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7412 | EXCISION OF BENIGN LESION COMPLICATED | $187.20 | $282.24 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Benign lesion, complicated | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7413 | EXCISION OF MALIGNANT LESION UP TO 1.25 | $133.25 | $200.90 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Malignant lesion up to 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7414 | EXCISION OF MALIGNANT LESION GREATER THA | $176.80 | $266.56 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Malignant lesion greater than 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7415 | EXCISION OF MALIGNANT LESION COMPLICATE | $224.25 | $338.10 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Malignant lesion, complicated | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7440 | EXCISION OF MALIGNANT TUMOR-LESION DIAME | $142.48 | $268.52 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Malignant tumor-lesion diameter up to 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7441 | EXCISION OF MALIGNANT TUMOR-LESION DIAME | $178.88 | $337.12 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Malignant tumor-lesion diameter greater than 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7450 | REMOVAL OF BENIGN ODONTOGENIC CYST OR TU | $142.48 | $446.88 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Benign odontogenic cyst/tumor-lesion up to 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7451 | REMOVAL OF BENIGN ODONTOGENIC CYST OR TU | $178.88 | $429.24 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Benign odontogenic cyst/tumor-lesion greater than 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7460 | REMOVAL OF BENIGN NONODONTOGENIC CYST OR | $142.48 | $446.88 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Benign nonodontogenic cyst/tumor-lesion up to 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7461 | REMOVAL OF BENIGN NONODONTOGENIC CYST OR | $178.88 | $1,274.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Benign nonodontogenic cyst/tumor-lesion greater than 1.25 cm | Post Procedure review; Requires a copy of the pathology report | |||||||||
| Oral & Maxillofacial Surgery | D7465 | DESTRUCTION OF LESION(S) BY PHYSICAL OR | $86.45 | $130.34 | 20% | 07/01/2022 | 12/31/2299 | Yes | Oral Surgeon | Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Pathologist Oral and Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Detailed documentation, method of destruction | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7471 | REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR | $68.25 | $102.90 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Approved prosthetic treatment on file | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7472 | REMOVAL OF TORUS PALATINUS | $338.00 | $509.60 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Approved prosthetic claim on file | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7473 | REMOVAL OF TORUS MANDIBULARIS | $341.90 | $515.48 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Approved prosthetic claim on file | Documentation submitted must include:
| |||||||||
| Oral & Maxillofacial Surgery | D7485 | SURGICAL REDUCTION OF OSSEOUS TUBEROSITY | $116.35 | $175.42 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Approved prosthetic claim on file | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7509 | MARSUPIALIZATION ODON CYST | NA | $142.48 | 20% | 01/01/2023 | 12/31/2299 | No | Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist FQHC Oral & Maxillofacial Radiologist | Yes: Children Only (0-20) | No | Radiographs and supporting medical necessity documentation | Documentation submitted must include:
| ||||||||||
| Oral & Maxillofacial Surgery | D7510 | INCISION AND DRAINAGE OF ABSCESS-INTRAOR | $46.80 | $70.56 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist FQHC Oral & Maxillofacial Radiologist Orthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Radiographs and supporting documentation of medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7511 | INCISION AND DRAINAGE OF ABSCESS - INTRA | $64.35 | $97.02 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral and Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | Radiographs and supporting documentation of medical necessity | Documentation submitted must include:
| |||||||||
| Oral & Maxillofacial Surgery | D7520 | INCISION AND DRAINAGE OF ABSCESS-EXTRAOR | $64.35 | $97.02 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral and Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | Radiographs and supporting documentation of medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7521 | INCISION AND DRAINAGE OF ABSCESS - EXTRA | $65.00 | $98.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral and Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | Radiographs and supporting documentation of medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7530 | REMOVAL OF FOREIGN BODY FROM MUCOSA SKI | $27.95 | $42.14 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral and Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | Radiographs and supporting documentation of medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7540 | REMOVAL OF REACTION-PRODUCING FOREIGN BO | $42.90 | $64.68 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral and Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | Radiographs and supporting documentation of medical necessity | Documentation submitted must include:
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| Oral & Maxillofacial Surgery | D7550 | PARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REM | $68.25 | $102.90 | 20% | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Oral and Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of clinical circumstance and medical necessity can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7560 | MAXILLARY SINUSOTOMY FOR REMOVAL OF TOOT | $464.75 | $700.70 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of clinical circumstance and medical necessity can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7630 | MANDIBLE-OPEN REDUCTION (TEETH IMMOBILIZED) | $464.75 | $700.70 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of clinical circumstance and medical necessity can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7640 | MANDIBLE-CLOSED REDUCTION (TEETH IMMOBILIZED) | $572.00 | $862.40 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist | Pediatric Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of clinical circumstance and medical necessity can be submitted as Post Procedure Review (PR). | ||||||||
| Oral & Maxillofacial Surgery | D7660 | MALAR AND/OR ZYGOMATIC ARCH - CLOSED | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7670 | ALVEOLUS - CLOSED REDUCTION MAY INCLUDE | $273.00 | $411.60 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Periodontist | Endodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||
| Oral & Maxillofacial Surgery | D7671 | ALVEOLUS - OPEN REDUCTION MAY INCLUDE S | $286.00 | $431.20 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||
| Oral & Maxillofacial Surgery | D7710 | MAXILLA-OPEN REDUCTION | $305.50 | $460.60 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7720 | MAXILLA-CLOSED REDUCTION | $87.10 | $131.32 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7730 | MANDIBLE-OPEN REDUCTION | $670.80 | $1,011.36 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7740 | MANDIBLE-CLOSED REDUCTION | $464.10 | $699.72 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7750 | MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTI | $309.40 | $466.48 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7760 | MALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUC | $51.35 | $77.42 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7770 | ALVEOLUS - OPEN REDUCTION MAY INCLUDE S | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7771 | ALVEOLUS - CLOSED REDUCTION MAY INCLUDE | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7780 | FACIAL BONES-COMPLICATED REDUCTION WITH | $670.80 | $1,011.36 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7810 | OPEN REDUCTION OF DISLOCATION | $500.50 | $754.60 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7820 | CLOSED REDUCTION OF DISLOCATION | $51.35 | $77.42 | 20% | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | Covered for spontaneous medical dislocations, not if the dislocation occurs during routine dental treatment. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||||
| Oral & Maxillofacial Surgery | D7840 | CONDYLECTOMY | $773.50 | $1,166.20 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist FQHC General Dentist Hospital and Free-Standing Clinic | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||
| Oral & Maxillofacial Surgery | D7852 | DISC REPAIR | $1,625.00 | $2,450.00 | 20% | 07/01/2022 | 12/31/2299 | No | Hospital and Free Standing Clinics Oral Surgeon | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||||
| Oral & Maxillofacial Surgery | D7865 | ARTHROPLASTY | $1,625.00 | $2,450.00 | 20% | 07/01/2022 | 12/31/2299 | No | Hospital and Free Standing Clinics Oral Surgeon | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||||
| Oral & Maxillofacial Surgery | D7870 | ARTHORCENTISIS | $200.00 | $200.00 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage for patients with acute onset focal TMJ pain or lack of mobility such as S/P trauma. In chronic TMJ treatment after conservative therapy yields minimal improvement with existing focal pain and/or closed lock. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7871 | NON-ARTHROSCOPIC LYSIS AND LAVAGE | $520.00 | $784.00 | 20% | 07/01/2022 | 12/31/2299 | No | Hospital and Free Standing Clinics Oral Surgeon | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||||
| Oral & Maxillofacial Surgery | D7880 | OCCLUSAL ORTHOTIC APPLIANCE | $520.00 | $784.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Prosthodontist Public Health Dentist | General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Oral & Maxillofacial Pathologist Pediatric Dentist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7910 | SUTURE OF RECENT SMALL WOUNDS UP TO 5 CM | $89.70 | $135.24 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Pathologist Oral and Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7911 | COMPLICATED SUTURE-UP TO 5 CM | $267.15 | $402.78 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Pathologist Oral and Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7912 | COMPLICATED SUTURE-GREATER THAN 5 CM | $71.50 | $107.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral and Maxillofacial Pathologist Oral and Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7922 | PLACE INTRA-SOCKET BIO DRESS | MP | MP | 33% | 01/01/2020 | 12/31/2299 | Yes | Hospital and Free Standing Clinics Oral Surgeon | Hospital and Free Standing Clinics Oral Surgeon | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7940 | OSTEOPLASTY-FOR ORTHOGNATHIC DEFORMITIES | $914.55 | $1,378.86 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7941 | OSTEOTOMY - MANDIBULAR RAMI | $3,900.00 | $5,880.00 | 20% | 07/01/2022 | 12/31/2299 | No | Hospital and Free Standing Clinics Oral Surgeon | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | ||||||||||
| Oral & Maxillofacial Surgery | D7944 | OSTEOTOMY-SEGMENTED OR SUBAPICAL | $914.55 | $1,378.86 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7945 | OSTEOTOMY-BODY OF MANDIBLE | $825.50 | $1,244.60 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7946 | LEFORT I (MAXILLA-TOTAL) | $915.85 | $1,380.82 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7947 | LEFORT I (MAXILLA-SEGMENTED) | $915.85 | $1,380.82 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7948 | LEFORT II OR LEFORT III (OSTEOPLASTY OF | $915.85 | $1,380.82 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7949 | LEFORT II OR LEFORT III-WITH BONE GRAFT | $915.85 | $1,380.82 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||||
| Oral & Maxillofacial Surgery | D7950 | OSSEOUS, OSTEOPERIOSTEAL, OR CART GRAFT - MANDIBLE OR MAXILLA | MP | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) Per Lifetime | Once (1) Per Lifetime | Coverage when existing bone of the denture base is insufficient for function (full arch) and/or there is residual bony defect s/p infection, tumor or trauma surgery to create inability to adequately restore the patient to adequate function (can be partial or full arch) . | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||
| Oral & Maxillofacial Surgery | D7953 | BONE GRAFT REPLACEMENT - PER SITE | $280.00 | $280.00 | 20% | 10/01/2026 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) per extraction site | One (1) per extraction site | Coverage is available under the limited circumstance in which an oral surgeon is attending to and treating hospital-based cases. | Demonstration of medical necessity including clinical notes and radiographs can be submitted as Post Procedure Review (PR). | |||||||
| Oral & Maxillofacial Surgery | D7960 | FRENULECTOMY (FRENECTOMY OR FRENOTOMY)-S | $138.32 | $260.68 | 20% | 08/01/2019 | 12/31/2020 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Photographs and supporting documentation of medical necessity | Documentation submitted must include:
For members under the age of two (2), a letter of medical necessity from the child's pediatrician is required. | |||||||||
| Oral & Maxillofacial Surgery | D7961 | BUCCAL/ LABIAL FRENECTOMY | $172.90 | $260.68 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Documentation submitted must include:
For members under the age of two (2) a letter of medical necessity from the child's pediatrician is required. | ||||||||||
| Oral & Maxillofacial Surgery | D7962 | LINQUAL FRENECTOMY | $172.90 | $260.68 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Documentation submitted must include:
For members under the age of two (2) a letter of medical necessity from the child's pediatrician is required. | ||||||||||
| Oral & Maxillofacial Surgery | D7970 | EXCISION OF HYPERPLASTIC TISSUE-PER ARCH | $102.05 | $153.86 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per arch | Once (1) in a lifetime per arch | Requires a diagnosis of hyperplastic tissue | Documentation submitted must include:
| |||||||
| Oral & Maxillofacial Surgery | D7971 | EXCISION OF PERICORONAL GINGIVA | $184.60 | $278.32 | 20% | 07/01/2022 | 12/31/2299 | Yes | General Dentist | Endodontist FQHC Hospital and Free-Standing Clinic Oral Surgeon Oral and Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Orthodontist | No | Yes | Once (1) in a lifetime per site | Once (1) in a lifetime per site | Evidence of pericoronitis for a partially erupted or impacted tooth. Not to be used solely for cosmetic reasons. Exclusion – cannot be billed separately if it is done on the same day as a crown or other restoration on the same tooth. | Documentation submitted must include:
| ||||||
| Oral & Maxillofacial Surgery | D7972 | SURGICAL REDUCTION OF FIBROUS TUBEROSITY | $87.10 | $131.32 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Once (1) in a lifetime per quadrant | Once (1) in a lifetime per quadrant | Patient should qualify for maxillary removable prosthesis | Documentation submitted must include:
| |||||||
| Oral & Maxillofacial Surgery | D7980 | SIALOLITHOTOMY | $213.85 | $322.42 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Requires documented medical necessity | Documentation submitted must include:
| |||||||||
| Oral & Maxillofacial Surgery | D7983 | CLOSURE OF SALIVARY FISTULA | $412.75 | $622.30 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Requires documented medical necessity | Documentation submitted must include:
| |||||||||
| Oral & Maxillofacial Surgery | D7990 | EMERGENCY TRACHEOTOMY | $289.25 | $436.10 | 20% | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | No | ||||||||||||
| Oral & Maxillofacial Surgery | D7997 | APPLIANCE REMOVAL (NOT BY DENTIST WHO PLACED) | $390.00 | $588.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist | Endodontist Pediatric Dentist Periodontist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Covered for the removal for hardware placed by a different provider. | Documentation submitted must include:
| ||||||||
| Oral & Maxillofacial Surgery | D7999 | UNSPECIFIED ORAL SURGERY PROCEDURE BY R | MP | MP | 20% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| |||||||||
| Orthodontics | D8010 | LIMITED ORTHODONTIC TRANSITIONAL- PRIMARY | NA | MP | 20% | 10/01/2026 | 12/31/2299 | Yes | FQHC General Dentist Orthodontist Public Health Dentist | FQHC General Dentist Orthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist | Yes: Children Only (0-20) | Yes | Once (1) per lifetime for HUSKY A, C, D Unlimited HUSKY B | Interceptive orthodontic can be approved to correct dentofacial conditions using:
| Documentation submitted must include:
| ||||||||
| Orthodontics | D8020 | LIMITED ORTHODONTIC TREATMENT - TRANSITIONAL | NA | MP | 20% | 01/01/2022 | 12/31/2299 | Yes | FQHC General Dentist Orthodontist Public Health Dentist | FQHC General Dentist Orthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist | Yes: Children Only (0-20) | Yes | Once (1) per lifetime for HUSKY A, C, D Unlimited HUSKY B | Interceptive orthodontic can be approved to correct dentofacial conditions using:
| Documentation submitted must include:
| ||||||||
| Orthodontics | D8030 | LIMITED ORTHODONTIC TREATMENT- ADOLESCENT | NA | MP | 20% | 01/01/2022 | 12/31/2300 | Yes | FQHC General Dentist Orthodontist Public Health Dentist | FQHC General Dentist Orthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist | Yes: Children Only (0-20) | Yes | Once (1) per lifetime for HUSKY A, C, D Unlimited HUSKY B | Interceptive orthodontic can be approved to correct dentofacial conditions using:
| Documentation submitted must include:
| ||||||||
| Orthodontics | D8070 | COMPREHENSIVE ORTHO TREATMENT - TRANSITIONAL | NA | $584.31 | NA | 09/01/2016 | 12/31/2298 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | Once (1) per Lifetime | Once (1) per lifetime for HUSKY A, C, D Unlimited HUSKY B | To qualify for orthodontic therapy as a child member (ages zero through twenty (0-20)):
Therapy must be completed by age of twenty-one (21) For adults (over the age of twenty-one (21)) coverage is only when there are untreated congenital conditions, facial forms of cancer or trauma, or surgical facial reconstruction is required. | Documentation submitted must include:
| |||||||
| Orthodontics | D8080 | COMPREHENSIVE ORTHODONTIC TREATMENT OF T | NA | $584.31 | NA | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | Once (1) per Lifetime | Once (1) per lifetime for HUSKY A, C, D Unlimited HUSKY B | To qualify for orthodontic therapy as a child member (ages zero through twenty (0-20)):
Therapy must be completed by age of twenty-one (21) For adults (over the age of twenty-one (21)) coverage is only when there are untreated congenital conditions, facial forms of cancer or trauma, or surgical facial reconstruction is required. | Documentation submitted must include:
| |||||||
| Orthodontics | D8210 | REMOVABLE APPLIANCE THERAPY | NA | 20% | 10/01/2026 | 12/31/2298 | Yes | FQHC General Dentist Orthodontist Public Health Dentist | FQHC General Dentist Orthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist | Yes: Children Only (0-20) | Yes | Once (1) per lifetime for HUSKY A, C, D Unlimited HUSKY B | The following devices can be used to correct dentofacial conditions:
| Documentation submitted must include:
| |||||||||
| Orthodontics | D8220 | FIXED APPLIANCE THERAPY | NA | $784.00 | 20% | 09/01/2016 | 12/31/2299 | Yes | General Dentist Orthodontist Public Health Dentist | General Dentist Orthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist | Yes: Children Only (0-20) | Yes | Once (1) per lifetime for HUSKY A, C, D Unlimited HUSKY B | The following devices can be used to correct dentofacial conditions:
| Documentation submitted must include:
| ||||||||
| Orthodontics | D8660 | PRE-ORTHODONTIC VISIT | NA | $33.63 | NA | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Children Only (0-20) | Yes | Twice (2) Times per Lifetime | For members ages zero through twenty (0-20). Must demonstrate sufficient growth and development for exam. | Documentation submitted must include:
| ||||||||
| Orthodontics | D8670 | PERIODIC ORTHODONTIC TREATMENT VISIT | NA | $87.13 | 100% | 08/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines for Comprehensive Orthodontic Treatment (D8080) | Yes | Once (1) per Lifetime | Must be approved for D8080. Approved orthodontic cases (case processing) will be entitled to reimbursement for diagnostic and records procedures including this code for thirty (30) monthly payments, if those services are submitted in conjunction with the original pre-approval submission or the claim detailing the insertion of orthodontic appliance(s). For members turning twenty-one (21) years old, the last payment will be made the month prior to their twenty-first (21st) birthday. | Documentation submitted must include:
| ||||||||
| Orthodontics | D8692 | REPLACEMENT OF LOST OR BROKEN RETAINER | $104.00 | $196.00 | 100% | 09/01/2018 | 12/31/2019 | Yes | General Dentist Hospital and Free Standing Clinics Orthodontist Pediatric Dentist Public Health Dentist | General Dentist Hospital and Free Standing Clinics Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist Prosthodontist Public Health Dentist | Yes: See Coverage Guidelines for Comprehensive Orthodontic Treatment (D8080) | Yes | Once (1) per Lifetime | Must be approved for D8080. Retainers for each arch limited to replacement one (1) time per lifetime per member regardless of the reason. | Documentation submitted must include:
| ||||||||
| Orthodontics | D8696 | REP OF ORTHO APPLIANCE MAX | NA | MP | 20% | 01/01/2020 | 12/31/2299 | Yes | General Dentist Hospital and Free-Standing Clinic Oral Surgeon Orthodontist | General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Yes: See Coverage Guidelines for Comprehensive Orthodontic Treatment (D8080) | Yes | Once (1) per Lifetime | Must be approved for D8080. The orthodontic case fee includes the first set of maxillary and mandibular retainers. | Documentation submitted must include:
| ||||||||
| Orthodontics | D8697 | REP OF ORTHO APPLIANCE MAN | NA | MP | 20% | 01/01/2020 | 12/31/2299 | Yes | General Dentist Hospital and Free-Standing Clinic Oral Surgeon Orthodontist | General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Yes: See Coverage Guidelines for Comprehensive Orthodontic Treatment (D8080) | Yes | Once (1) per Lifetime | Must be approved for D8080. The orthodontic case fee includes the first set of maxillary and mandibular retainers. | Documentation submitted must include:
| ||||||||
| Orthodontics | D8703 | REPLACE BROKEN RETAINER MAX | $130.00 | $196.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | General Dentist Hospital and Free Standing Clinics Orthodontist Pediatric Dentist Public Health Dentist | General Dentist Hospital and Free Standing Clinics Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist Prosthodontist | Yes: See Coverage Guidelines for Comprehensive Orthodontic Treatment (D8080) | Yes | Once (1) per Lifetime | Must be approved for D8080. Retainers for each arch limited to replacement one (1) time per lifetime per member regardless of the reason. | Documentation submitted must include:
| ||||||||
| Orthodontics | D8704 | REPLACE BROKEN RETAINER MAN | $130.00 | $196.00 | 20% | 07/01/2022 | 12/31/2299 | Yes | General Dentist Hospital and Free Standing Clinics Orthodontist Pediatric Dentist Public Health Dentist | General Dentist Hospital and Free Standing Clinics Orthodontist Pediatric Dentist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Periodontist Prosthodontist | Yes: See Coverage Guidelines for Comprehensive Orthodontic Treatment (D8080) | Yes | Once (1) per Lifetime | Must be approved for D8080. Retainers for each arch limited to replacement one (1) time per lifetime per member regardless of the reason. | Documentation submitted must include:
| ||||||||
| Orthodontics | D8999 | UNSPECIFIED ORTHODONTIC PROCEDURE BY RE | MP | 100% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines for Comprehensive Orthodontic Treatment (D8080) | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
| ||||||||||
| Adjunctive General Services | D9110 | PALLIATIVE (EMERGENCY) TREATMENT OF DENT | $58.50 | $88.20 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral Surgeon Oral and Maxillofacial Pathologist Oral and Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Emergency treatment of dental pain-minor procedure. Service requires submission of a post review and cannot be billed with any other procedure codes. | Requires a detailed narrative noting the patient's symptoms and what treatment was rendered to alleviate pain. Note: Writing a prescription is not emergency treatment. | |||||||||
| Adjunctive General Services | D9222 | DEEP SEDATION/GENERAL ANESTHESIA-EACH 15 | $82.55 | $124.46 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Limited to eight (8) units per visit in agreement with sedation logs. | Limited to eight (8) units per visit in agreement with sedation logs. | For any members ages zero through twenty (0-20) or members who have a behavioral or cognitive condition which prevents them from receiving care safely. For use with all members undergoing in office oral surgical procedure(s) where sedation:
| The following must be documented in the member's chart and authorization submission:
| |||||||
| Adjunctive General Services | D9223 | DEEP SEDATION/GENERAL ANESTHESIA-EACH 15 | $82.55 | $124.46 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Limited to eight (8) units per visit in agreement with sedation logs. | Limited to eight (8) units per visit in agreement with sedation logs. | For any members ages zero through twenty (0-20) or members who have a behavioral or cognitive condition which prevents them from receiving care safely. For use with all members undergoing in office oral surgical procedure(s) where sedation:
| The following must be documented in the member's chart and authorization submission:
| |||||||
| Adjunctive General Services | D9224 | ADMIN OF GA W/ ADVANCE AIR, 1ST 15 MIN | $82.55 | $124.46 | 20% | 01/01/2026 | 12/31/2299 | No | Dental Anesthesiologist Oral Surgeon | Dental Hygienist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | Limited to eight (8) units per visit in agreement with sedation logs. | Limited to eight (8) units per visit in agreement with sedation logs. | Administration of general anesthesia with advanced airway first fifteen-minute (15) increment is conducted with or without co administration of nitrous oxide. The service can only be performed by an Oral and Maxillofacial Surgeon or Dental Anesthesiologist who has an active permit to administer dental anesthesia/deep sedation issued by the Connecticut Department of Public Health (DPH) and in accordance with DPH’s regulations on the administration and use of anesthesia and sedation in dentistry. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Services are considered complete when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. | If exceeds eight (8) units per visit, sedation logs and appropriate documentation demonstrating medical necessity need to be submitted. | ||||||||
| Adjunctive General Services | D9225 | ADMIN OF GA W/ ADVANCE AIR, ADDL 15 MIN | $82.55 | $124.46 | 20% | 01/01/2026 | 12/31/2299 | No | Dental Anesthesiologist Oral Surgeon | Dental Hygienist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | Limited to eight (8) units per visit in agreement with sedation logs. | Limited to eight (8) units per visit in agreement with sedation logs. | Administration of general anesthesia with advanced airway additional first fifteen-minute (15) increment is conducted with or without co administration of nitrous oxide. The service can only be performed by an Oral and Maxillofacial Surgeon or Dental Anesthesiologist who has an active permit to administer dental anesthesia/deep sedation issued by the Connecticut Department of Public Health (DPH) and in accordance with DPH’s regulations on the administration and use of anesthesia and sedation in dentistry. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Services are considered complete when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. | If exceeds eight (8) units per visit, sedation logs and appropriate documentation demonstrating medical necessity need to be submitted. | ||||||||
| Adjunctive General Services | D9230 | ANALGESIA; ANXIOLYSIS; INHALA | $39.00 | $58.80 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Inhalation of nitrous oxide for members of any age who have a diagnosis of a documented anxiety, behavioral health, cognitive disorder or medical condition(s) which supports the need for behavior management related to the dental procedures to be delivered, provided that techniques are employed in conjunction with the delivery of dental services to individuals to help to facilitate a safe environment and reduce dental anxiety. | The member's chart and submission of authorization contains the following documentation:
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| Adjunctive General Services | D9239 | IV MOD SEDATION, 1ST 15 MIN | $82.55 | $124.46 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | For any members ages zero through twenty (0-20) or members who have a behavioral or cognitive condition which prevents them from receiving care safely. For use with all members undergoing in office oral surgical procedure(s) where sedation:
| The following must be documented in the member's chart and authorization submission:
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| Adjunctive General Services | D9243 | INTRAVENOUS MODERATE(CONSCIOUS) SEDATION/ANALGESIA | $82.55 | $124.46 | 20% | 07/01/2022 | 12/31/2299 | Yes | Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: See Coverage Guidelines | Yes | For any members ages zero through twenty (0-20) or members who have a behavioral or cognitive condition which prevents them from receiving care safely. For use with all members undergoing in office oral surgical procedure(s) where sedation:
| The following must be documented in the member's chart and authorization submission:
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| Adjunctive General Services | D9246 | ADMIN OF MOD SEDATION - NON-IV - PARENTERAL 1ST 15 MIN | $61.91 | $93.34 | 20% | 01/01/2026 | 12/31/2299 | FQHC | Dental Anesthesiologist Oral Surgeon | Dental Hygienist Endodontist FQHC General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | When moderate sedation is achieved by administration of drug(s) by the parenteral route, not including intravenous. The service can only be performed by an Oral and Maxillofacial Surgeon or Dental Anesthesiologist who has an active permit to administer dental anesthesia/deep sedation issued by the Connecticut Department of Public Health (DPH) and in accordance with DPH’s regulations on the administration and use of anesthesia and sedation in dentistry. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Services are considered complete when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. | Sedation logs and appropriate documentation demonstrating medical necessity may need to be submitted. | ||||||||||
| Adjunctive General Services | D9247 | ADMIN OF MOD SEDATION - NON-IV - PARENTERAL ADDL 15 MIN | $61.91 | $93.34 | 20% | 01/01/2026 | 12/31/2299 | FQHC | Dental Anesthesiologist Oral Surgeon | Dental Hygienist Endodontist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | Administration of moderate sedation by administration of drug(s) subsequent first fifteen-minute (15) increment. The service can only be performed by an Oral and Maxillofacial Surgeon or Dental Anesthesiologist who has an active permit to administer dental anesthesia/deep sedation issued by the Connecticut Department of Public Health (DPH) and in accordance with DPH’s regulations on the administration and use of anesthesia and sedation in dentistry. Anesthesia time begins when the doctor administering the anesthetic agent initiates the appropriate anesthesia and non-invasive monitoring protocol and remains in continuous attendance of the patient. Services are considered complete when the patient may be safely left under the observation of trained personnel and the doctor may safely leave the room. | Sedation logs and appropriate documentation demonstrating medical necessity may need to be submitted. | ||||||||||
| Adjunctive General Services | D9310 | CONSULTATION - DIAGNOSTIC SERVICE PROVID | $22.10 | $33.32 | NA | 07/01/2022 | 12/31/2299 | Yes | FQHC | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Only for cases where a general dentist or physician refers a patient for an evaluation or second opinion. It can not be used for routine exams, self-referred patients, case presentations or cosmetic consultants. Not to be billed with routine or problem-focused exams code D0140, D0150. | Documentation must include a copy of the referral from general dentist or physician. | |||||||||
| Adjunctive General Services | D9410 | HOUSE/EXTENDED CARE FACILITY CALL | $16.25 | $24.50 | NA | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | Yes | One (1) visit per member per home or facility per day. | One (1) visit per member per home or facility per day. | Limited to one (1) visit per member, per home or facility, per day. Private‑practice dentists and public‑health hygienists providing care outside a traditional office or clinic setting. Requires Place of Service Codes other than "11" or "50". | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Adjunctive General Services | D9420 | HOSPITAL OR ASC CALL | $61.75 | $93.10 | NA | 07/01/2022 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | No | No | One (1) visit per member per home or facility per day. | One (1) visit per member per home or facility per day. | Limited to one (1) visit per member, per home or facility, per day. Private‑practice dentists and public‑health hygienists providing care outside a traditional office or clinic setting. Requires Place of Service Codes other than "11" or "50". | Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Adjunctive General Services | D9610 | INFUSION OF THERAPEUTIC DRUG SINGLE DOSE | MP | MP | NA | 01/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist FQHC Hospital and Free Standing Clinics | No | Yes | Currently considered for six (6) medications:
| Documentation submitted must include:
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| Adjunctive General Services | D9613 | INFILTRATION OF SUSTAIN RELEASE THERAP ANALGESIC MULTI SITES | $210.00 | $210.00 | NA | 01/01/2019 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist General Dentist Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist FQHC Hospital and Free Standing Clinics | No | Yes | This code is used to bill for Exparel when administered the same day as extractions. | Documentation must be submitted on the same date of service as extractions. | |||||||||
| Adjunctive General Services | D9920 | BEHAVIOR MANAGEMENT BY REPORT (Prior Authorization) | MP | MP | 20% | 09/01/2016 | 12/31/2299 | No | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Dental Hygienist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | Coverage is limited to members with cognitive disabilities that significantly impair their ability to understand directions and who therefore require additional time and support from the dentist to safely receive care. Providers must:
| Please bill directly to Gainwell Technologies Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||||
| Adjunctive General Services | D9941 | FABRICATION OF ATHLETIC MOUTHGUARD | $222.30 | $335.16 | 20% | 07/01/2022 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | Yes: Children Only (0-20) | Yes | One (1) per lifetime | Custom laboratory made athletic guards for children (ages zero through twenty (0-20)) who are engaged in a contact sport and who have no other means for the provision of the guard for the members. | Letter from school or CYO organization on letterhead where the child is enrolled in a contact sport. Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | ||||||||
| Adjunctive General Services | D9944 | OCCLUSAL GUARD, HARD, FULL ARCH | $335.16 | $335.16 | NA | 02/01/2023 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every two (2) years | One (1) every two (2) years | Coverage includes one (1) custom‑fitted, laboratory‑processed occlusal guard every two (2) years for members when it is clearly documented in the clinical record that the appliance is needed to minimize the effects of occlusal‑related pathology. All follow‑up care associated with the occlusal guard is included in the original payment for the service. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Adjunctive General Services | D9945 | OCCLUSAL GUARD, SOFT, FULL ARCH | $150.00 | $150.00 | NA | 02/01/2023 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free-Standing Clinic Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | One (1) every two (2) years | One (1) every two (2) years | Coverage includes one (1) custom‑fitted, laboratory‑processed occlusal guard every two (2) years for members when it is clearly documented in the clinical record that the appliance is needed to minimize the effects of occlusal‑related pathology. All follow‑up care associated with the occlusal guard is included in the original payment for the service. | Documentation submitted must include:
Authorization requests that exceed standard frequency and coverage limits may be considered with documentation supporting medical necessity, including Early Periodic Screen Diagnostic and Treatment (EPSDT) covered dental services for children ages zero through twenty (0-20). | |||||||
| Adjunctive General Services | D9992 | CASE MNGMT/CARE COORD | MP | MP | 33% | 01/01/2017 | 12/31/2299 | Yes | Endodontist General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Periodontist Prosthodontist | Endodontist General Dentist Hospital and Free Standing Clinics Oral Surgeon Orthodontist Periodontist Prosthodontist | Dental Anesthesiologist Dental Hygienist FQHC Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Pediatric Dentist Public Health Dentist | No | Yes | Determined by authorization | Covered for children (ages zero through twenty (0-20) requiring coordination and monitoring of treatment rendered to a patient by multiple medical and dental practitioners and healthcare settings. | Documentation submitted must include:
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| Adjunctive General Services | D9997 | DENT CASE MGMT SPECIAL NEEDS | $60.00 | $60.00 | 20% | 01/01/2020 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist FQHC Pediatric Dentist | No | Yes | Determined by authorization | Covered for children (ages zero through twenty (0-20)) with physical, medical, developmental, or cognitive conditions that create substantial functional limitations and require modified, customized, or comprehensive treatment approaches. | Documentation submitted must include:
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| Adjunctive General Services | D9999 | UNSPECIFIED ADJUNCTIVE PROCEDURE BY REP | MP | MP | 33% | 09/01/2016 | 12/31/2299 | Yes | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Anesthesiologist Endodontist FQHC General Dentist Hospital and Free Standing Clinics Oral & Maxillofacial Pathologist Oral & Maxillofacial Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist | Dental Hygienist | No | Yes | By report. Codes are to be used when no standard, covered CDT code describes the proposed service to be performed. | Documentation submitted must include:
|