practicing under PHS, IPDHs practicing under PHS may use this code for all ages. IPDHs may use this code only for members up to age 21. Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D1120 Prophylaxis – Child YES NO NO Twice per calendar year, but no more than once every 150 days. Prior Authorization necessary for greater frequency. Includes oral hygiene instruction. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code. $30.00 TOPICAL FLUORIDE TREATMENTS (Office Procedure) D1206 Topical Application of Fluoride Varnish YES NO NO Members age 3: twice per calendar year, and a third treatment per calendar year is permitted for Members who either have a high caries rate or the Member has had new restorations placed in the previous eighteen (18) months. $12.00
D2950 Core Buildup, Including Any Pins when required YES YES NO NO $150.00 D2951 Pin Retention - Per in Addition to Restoration YES YES NO NO $19.00 D2952 Post & Core in Addition to Crown, Indirectly Fabricated NO NO Not Covered D2953 Each Additional Indirectly Fabricated Post - Same Tooth NO NO Not Covered D2954 Prefabricated Post & Core in Addition to YES YES NO NO Permanent tooth only $95.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D2955 Post Removal NO NO Not Covered Each Additional Prefabricated Post-Same Tooth, Use with D2954 YES YES NO NO Permanent tooth only $47.50 Labial Veneer (resin laminate)-Chairside NO NO Not Covered D2961 Labial Veneer (resin laminate)-Laboratory NO NO Not Covered Labial Veneer (porcelain laminate)-Laboratory NO NO Not Covered Temporary Crown (Fractured Tooth) YES YES NO NO $40.00 D2971 Additional Procedures to Construct New under Existing Partial Denture Framework NO NO Not Covered Coping NO NO Not Covered D2980 Crown Repair Necessitated By Restorative Material Failure YES Yes NO NO $34.00 D2981 Inlay Repair Necessitated By Restorative Material Failure NO NO Not Covered D2982 Repair Necessitated By Restorative Material Failure NO NO Not Covered Veneer Repair Necessitated By Restorative Material Failure NO NO Not Covered D2990 Resin Infiltration of Incipient Smooth Surface Lesions NO NO Not Covered
D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in the same graft site YES NO YES Must be reported in conjunction with D4277 $125.00 NON-SURGICAL PERIODONTAL SERVICES Provisional Splinting - Intracoronal NO NO Not Covered Provisional Splinting – Extracoronal No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D4341 Periodontal Scaling and Root Planing – Four or More Per Quadrant Yes Yes Yes Yes No PA required for diagnosis code 101 and the Department may authorize payment for Diagnosis Code 101 retroactively. $40.00 D4342 Periodontal Scaling and Root Planing – One to Three Teeth, Per Quadrant No no Not Covered Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis Yes Yes YES YES Once per year per provider. Dental Hygienists practicing under PHS and IPDHs practicing under PHS may use this code. $100.00 D4381 Localized Delivery of Antimicrobial Agents Via a Controlled Release Vehicle into Diseased Crevicular Tissue, Per Tooth No NO Not Covered
OTHER PERIODONTAL SERVICES Periodontal Maintenance Yes NO YES $39.00 Unscheduled Dressing Change (by someone than treating dentist or their staff) Yes No No $27.00 D4999 Unspecified Periodontal Procedure, by Report Yes Yes Yes Yes By Report VI. PROSTHODONTICS, REMOVABLE COMPLETE DENTURES (INCLUDING ROUTINE POST DELIVERY CARE) Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D5110 Complete Denture - Maxillary Yes Yes Yes Yes Every 5 years, Denturists may also use this code $393.00 D5120 Complete Denture - Mandibular Yes Yes Yes Yes Every 5 years, Denturists may also use this code $393.00 D5130 Immediate Denture - Maxillary Yes Yes Yes Yes Every 5 years, Denturists may also use code $423.00 D5140 Immediate Denture - Mandibular Yes Yes Yes Yes Every 5 years, Denturists may also use this code $423.00 PARTIAL DENTURES (INCLUDING ROUTINE POST-DELIVERY CARE)
D5211 Maxillary Partial Denture-Resin Base (including any conventional clasps, rests and teeth) Yes YES Yes YES Every 5 years. Denturists may also use this code. $280.00 D5212 Mandibular Partial Denture-Resin Base (including any conventional clasps, rests and teeth) Yes YES Yes YES Every 5 years. Denturists may also use this code. $280.00 D5213 Maxillary Partial Denture-Cast Framework with Resin Denture Bases (including any conventional clasps, rests and teeth) Yes YES Yes YES Every 5 years. Denturists may also use this code. $423.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D5214 Mandibular Partial Denture-Cast Metal Framework with Resin Denture Bases (including any conventional clasps, and teeth) Yes YES Yes YES 5 years. Denturists may also use this code. $423.00 D5225 Maxillary Partial Denture-Flexible Base (including any clasps, rests and teeth) NO NO Not Covered D5226 Mandibular Partial Denture-Flexible Base (including any clasps, rests and teeth) NO NO Not Covered D5281 Removable Unilateral Partial Denture - One Piece Case Metal (including clasps and teeth) No No Not Covered ADJUSTMENTS TO DENTURES D5410 Adjust Complete Denture - Maxillary Yes Yes No No Denturists may also use this code $26.00
D5730 Reline Complete Maxillary Denture (chairside) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $78.00 D5731 Reline Complete Mandibular Denture (chairside) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $78.00 D5740 Reline Maxillary Partial Denture (chairside) No No Not Covered D5741 Reline Mandibular Partial Denture (chairside) No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D5750 Reline Complete Maxillary Denture (laboratory) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $150.00 D5751 Reline Complete Mandibular Denture (laboratory) Yes Yes No No Refer to Chapter II, 25.03. Denturists may also use this code. $150.00 D5760 Reline Maxillary Partial Denture (laboratory) No No Not Covered D5761 Reline Mandibular Partial Denture (laboratory) No No Not Covered INTERIM PROSTHESIS D5810 Interim Complete Denture (maxillary) No No Not Covered D5811 Interim Complete Denture (mandibular) No No Not Covered D5820 Interim Partial Denture (maxillary) No No Not Covered Interim Partial Denture (mandibular) No No Not Covered OTHER REMOVABLE PROSTHETIC SERVICES
D6067 Implant Supported Metal Crown (titanium, titanium alloy, high noble metal) No No Not Covered D6068 Abutment Supported Retainer for Porcelain/Ceramic FPD No No Not Covered D6069 Abutment Supported Retainer for Porcelain Fused to Metal FPD (high noble mental) No No Not Covered Abutment Supported Retainer for Porcelain Fused to Metal FPD (predominantly base metal) No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D6071 Abutment Supported Retainer for Porcelain Fused to Metal FPD (noble metal) No No Not Covered D6072 Abutment Supported Retainer for Cast Metal FPD (high noble metal) No No Not Covered D6073 Abutment Supported Retainer for Cast Metal FPD (predominantly base metal) No No Not Covered Abutment Supported Retainer for Cast Metal FPD (noble metal) No No Not Covered D6075 Implant Supported Retainer for Ceramic FPD No No Not Covered D6076 Implant Supported Retainer for Porcelain to Metal FPD (titanium, titanium alloy, or high noble metal) No No Not Covered D6077 Implant Supported Retainer for Cast Metal FPD (titanium, titanium alloy, or high noble metal) No No Not Covered D6078 Implant/Abutment Supported Fixed Denture for Completely Edentulous Arch No No Not Covered
Implant/Abutment Supported Fixture Denture for Partially Edentulous Arch NO NO Not Covered OTHER IMPLANT SERVICES Implant Maintenance Procedures, when Prostheses are Removed and Reinserted, Including Cleansing of Prostheses and Abutments No No Not Covered D6090 Repair Implant Supported Prosthesis, by Report No No Not Covered Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all residents age 21 & over when allowed under 25.04 D6091 Replacement of Semi-precision or Precision Attachment (male or female component) of Implant/Abutment Supported Prosthesis, per Attachment NO NO Not Covered D6092 Recement Implant/Abutment Supported Crown NO NO Not Covered D6093 Recement Implant/Abutment Supported Fixed Partial Denture NO NO Not Covered D6094 Abutment Supported - (titanium) NO NO Not Covered D6095 Repair Implant Abutment, by Report No No Not Covered D6100 Implant Removal, by Report No No Not Covered D6101 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure NO NO Not Covered
X. ORAL and Maxillofacial SURGERY EXTRACTIONS - INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED & ROUTINE POSTOPERATIVE CARE D7111 Extraction, Coronal Remnants – Deciduous YES YES NO NO $55.00 D7140 Extraction, Erupted Tooth or exposed Root (elevation and/or forceps removal) YES YES NO NO $91.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed 25.04 age 21 & all residents age 21 & over when allowed under 25.04 SURGICAL EXTRACTIONS – (INCLUDES LOCAL ANESTHESIA, SUTURING, IF NEEDED, & ROUTINE POSTOPERATIVE CARE) D7210 Surgical Removal of Erupted Tooth Requiring Removal of Bone and/or Sectioning Yes Yes No No Documented need demonstrated by X-rays $110.00 D7220 Removal of Impacted - Soft Tissue Yes Yes No No Documented need demonstrated by X-rays $95.00 D7230 Removal of Impacted Tooth - Partially Bony Yes Yes No No Documented need demonstrated by X-rays $155.00 D7240 Removal of Impacted Tooth – Completely Bony Yes Yes No No Documented need demonstrated by X-rays $185.00 D7241 Removal of Impacted Tooth – Completely Bony, with Unusual Surgical Complications Yes Yes No No Documented need demonstrated by X - rays $215.00
Surgical Placement: Temporary Anchorage Device Requiring Surgical Flap NO NO Not Covered D7294 Surgical Placement: Temporary Anchorage Device Without Surgical Flap NO NO Not Covered Harvest of Bone for use in Autogenous Grafing Procedure YES YES NO YES Only reimbursable when necessary for bone graft for reconstruction of alveolar defect. $225.00 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 ALVEOLOPLASTY - SURGICAL PREPARATION OF FOR DENTURES D7310 Alveoloplasty in Conjunction with Extractions - Four or More or Tooth Spaces, Per Quadrant Yes Yes NO NO $64.00 D7311 Alveoloplasty in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per Quadrant NO NO Not Covered D7320 Alveoloplasty not in Conjunction with Extractions - Four or More or Tooth Spaces, Per Quadrant Yes Yes NO NO Only reimbursable for members who have alveolar segment irregularity preventing denture placement. $94.00 D7321 Alveoloplasty not in Conjunction with Extractions - One to Three Teeth or Tooth Spaces, Per Quadrant YES YES NO NO Only reimbursable for members who have alveolar segment irregularity preventing denture placement. $47.00
D7877 Arthroscopy – Surgical; Debridement NO NO Not Covered D7880 Occlusal Orthotic Device Yes Yes Yes Yes $250.00 Unspecified TMD Therapy, by Report NO NO Not Covered REPAIR OF TRAUMATIC WOUNDS D7910 Suture of Recent Wounds Up to 5 cm YES Yes No No $84.75 COMPLICATED SUTURING (RECONSTRUCTION REQUIRING DELICATE HANDLING OF TISSUES AND WIDE UNDERMINING FOR METICULOUS CLOSURE) D7911 Complicated Suture - Up to 5 cm Yes Yes No No $193.00 D7912 Complicated Suture – Greater Than 5 cm Yes Yes No No $263.50 Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all ICF-IID residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 OTHER REPAIR PROCEDURES D7920 Skin Grafts (identify defect covered, location, and type of graft) NO NO Not Covered D7921 Collection and Application of Autologous Blood Concentrate Product NO NO Not Covered D7940 Osteoplasty for Orthognathic Deformities YES YES YES YES By Report D7941 Osteotomy – Mandibular Rami YES YES YES YES By Report
Osteotomy – Mandibular Rami with Bone Graft; Includes Obtaining The Graft Yes Yes Yes Yes $2,529.00 Osteotomy - Segmented or Subapical Yes Yes Yes Yes $2,213.00 Osteotomy - Body of The Mandible Yes Yes Yes Yes $2,213.00 LeFort I (maxilla - total) Yes Yes Yes Yes $2,213.00 LeFort I (maxilla - segmented) Yes Yes Yes Yes $2,213.00 LeFort II or LeFort III (Osteoplasty of Facial Bones for Midface Hypoplasia or Retrusion) - without Bone Graft Yes Yes Yes Yes $2,213.00 LeFort II or LeFort III – with Bone Graft Yes Yes Yes YES $2,529.00 D7950 Osseous, Osteoperiosteal, or Cartilage of The Mandible or Maxilla - Autogenous or Nonautogenous, by Report Yes Yes Yes Yes By Report D7951 Sinus Augmentation with Bone or Bone Substitutes via a Lateral Open Approach NO NO Not Covered D7952 Sinus Augmentation via a Vertical Approach NO NO Not Covered Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D7953 Bone Replacement Graft for Ridge Preservation - Per Site YES YES NO NO Only reimbursable when necessary for bone graft for reconstruction of alveolar defect. $325.00 D7955 Repair of Maxillofacial Soft and/or Hard Tissue Defect Yes Yes No No $412.00 D7960 Frenulectomy (Frenectomy or Frenotomy) - Separate Procedure Not Incidental to Another Yes Yes No NO $97.00 Frenuloplasty YES YES NO NO $125.00
D8080 and D8090 - all inclusive fee includes D8080 Comprehensive Orthodontic Treatment of The Adolescent Dentition Yes No Yes appliances, brackets, treatment visits, one appliance repair or $2,725.00 Comprehensive Orthodontic Treatment of The Adult Dentition Yes No YES replacement, and one retainer repair or replacement. Covered to age 21 $2,725.00 TREATMENT TO CONTROL HARMFUL HABITS D8210 Removable Appliance Therapy Yes No Yes $375.00 D8220 Appliance Therapy Yes No Yes $375.00 ORTHODONTIC SERVICES D8660 Pre-Orthodontic Treatment Visit Yes No No $22.50 Proc. Code Description Covered Service Age/ICF-IID Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed 25.04 Periodic Orthodontic Treatment Visit (as part of contract) YES No YES Cannot be billed in conjunction with D8070, D8080, D8090 $66.00 D8680 Orthodontic Retention (removal of appliances, construction and placement of retainer(s)) No No Not Covered D8690 Orthodontic Treatment (alternative billing to a contract fee) No No Not Covered D8691 Repair of Orthodontic Appliance YES NO YES $75.00 D8692 Replacement of Lost or Broken Retainer YES NO NO $125.00
Occlusal Adjustment - Limited No No Not Covered D9952 Occlusal Adjustment - Complete No No Not Covered D9970 Enamel Microabrasion No No Not Covered D9971 Odontoplasty 1-2 Teeth; Includes Removal of Enamel Projections No No Not Covered D9972 External Bleaching – Per Arch Performed In Office No NO Not Covered External Bleaching – Per Tooth No No Not Covered D9974 Internal Bleaching – Per Tooth No No Not Covered D9975 External Bleaching For Home Application, Per Arch; Includes Materials And Fabrication Of Custom Trays NO NO Not Covered D9999 Unspecified Adjunctive Procedure, by Report YES YES YES YES By Report