CoverKids Dental Covered Codes

re-cement or re-bond bilateral space maintainer - mandibular apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D7880 D4249 D5214 tissue conditioning, maxillary D6545 D5213 D5212 D5211 precision attachment, by report D9930 D7510 pre-orthodontic treatment examination to monitor growth and development D5110 D4263 D4260 D4381 D4261 D5228 apexification/recalcification - interim medication replacement D5227 D5226 D5225 D7520 D9945 D9944 retainer crown - porcelain fused to high noble metal pontic - porcelain fused to noble metal bone replacement graft - retained natural tooth - each additional site in quadrant D4341 D4342 crown repair necessitated by restorative material failure D9910 periodic orthodontic treatment visit D9911 space maintainer - fixed - bilateral, mandibular reline complete maxillary denture (indirect) cone beam CT capture and interpretation with limited field of view of one full dental arch - mandible full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit reline complete mandibular denture (direct) treatment of complications (post surgical) - unusual circumstances, by report pulp cap - indirect (excluding final resoration) D4355 limited orthodontic treatment of the adolescent dentition immediate maxillary partial denture - flexible base (including any clasps, rests and teeth) reline mandibular partial denture (direct) maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) replace missing or broken teeth - partial denture - per tooth D2391 D5660 D2390 D3240 D2393 D2150 D2392 D4323 D3353 D4322 D3230 D3351 D3472 D6740 D3110 D3352 D3473 D5650 intraoral - periapical first radiographic image therapeutic parenteral drug, single administration D7953 reline complete mandibular denture (indirect) D2160 D2161 retreatment of previous root canal therapy - anterior prefabricated abutment - includes modification and placement cone beam CT capture and interpretation with limited field of view of one full dental arch - maxilla, with or without cranium space maintainer - removable - bilateral, mandibular D4211 D2394 D6752 D3120 D6751 D4210 interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary D6750 cone beam CT capture and interpretation with field of view of both jaws; with or without cranium D7961 D7962 mandibular partial denture - resin base (including retentive/clasping materials, rests, and teeth) retreatment of previous root canal therapy - premolar D5512 D5511 excisional biopsy of minor salivary glands D3332 apicoectomy (each additional root) D5630 D5751 D5750 D3330 pulp cap - direct (excluding final restoration) add clasp to existing partial denture - per tooth repair cast partial framework, maxillary removable appliance therapy occlusal adjustment - limited adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures abutment supported porcelain fused to metal crown (high noble metal) D3471 D2140 tissue conditioning, mandibular D3346 D3347 D5765 D3221 D3222 D5520 D5640 D5761 amalgam - three surfaces, primary or permanent D3220 D5760 removal of impacted tooth - soft tissue excision of benign lesion up to 1.25 cm pontic - porcelain/ceramic D3348 precision attachment prefabricated stainless steel crown - primary tooth apicoectomy - premolar (first root) extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated complete denture - maxillary D0170 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant crown - full cast predominantly base metal D5612 osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant D5611 D5731 D3430 D5730 D5851 orthodontic retention (removal of appliances, construction and placement of retainer(s)) D3310 D5850 semi-precision attachment - placement re-cement or re-bond fixed partial denture D0180 crown - porcelain fused to noble metal D5622 retrograde filling - per root D5621 D3320 D5741 D5862 D5740 D6950 immediate denture - mandibular D0270 D1354 administration of moderate sedation - enteral re-cement or re-bond bilateral space maintainer - maxillary D3410 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant D0140 D1110 resin-based composite - one surface, anterior D1351 biologic materials to aid in soft and osseous tissue regeneration, per site add tooth to existing partial denture - per tooth partial extraction for immediate implant placement amalgam - one surface, primary or permanent exposure of an unerupted tooth mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) resin-based composite - one surface, posterior 2D oral/facial photographic image obtained intra-orally or extra-orally comprehensive oral evaluation - new or established patient bitewings - two radiographic images D0160 cone beam CT capture and interpretation for TMJ series including two or more exposures D2332 D0277 topical application of fluoride varnish D2335 D3421 D6930 D0150 D0272 D2331 D0274 D1120 D2330 intraoral - periapical each additional radiographic image retainer crown - porcelain fused to predominantly base metal D3425 D5725 D3426 resin-based composite - two surfaces, posterior pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) panoramic radiographic image nerve dissection space maintainer - fixed - bilateral, maxillary D0364 D0365 D0366 topical application of fluoride - excluding varnish retainer crown - porcelain fused to noble metal D0240 D0120 autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in graft endodontic therapy, molar tooth (excluding final restoration) D0367 crown - full cast noble metal D0368 sealant - per tooth re-evaluation - limited, problem focused (established patient; not post-operative visit) resin-based composite - three surfaces, posterior pontic - porcelain fused to high noble metal D5821 occlusal guard - soft appliance, full arch D5820 D2791 D2790 comprehensive periodontal evaluation - new or established patient D2792 limited oral evaluation - problem focused D2799 periodic oral evaluation - established patient administration of moderate sedation - intravenous - each subsequent 15 minute increment, or any portion thereof soft liner for complete or partial removable denture - indirect intraoral - comprehensive series of radiographic images therapeutic parenteral drug, two or more administrations, different medications administration of moderate sedation - non-intravenous parenteral – each subsequent 15 minute increment, or any portion thereof administration of moderate sedation - non-intravenous parenteral – first 15 minute increment, or any portion thereof space maintainer - fixed, unilateral - per quadrant D0220 D1552 D1551 limited orthodontic treatment of the transitional dentition administration of deep sedation/general anesthesia - each subsequent 15 minute increment, or any portion thereof D1553 guided tissue regeneration, natural teeth - resorbable barrier, per site D0460 D0340 D0461 office visit - after regularly scheduled hours crown - full cast high noble metal administration of moderate sedation - intravenous - first 15 minute increment, or any portion thereof alveoloplasty in conjuction with extractions - four or more teeth or tooth spaces, per quadrant drugs or medicaments dispensed in the office for home use office visit for observation (during regularly scheduled hours) - no other services performed apicoectomy - anterior periodontal scaling and root planing - one to three teeth per quadrant D8080 maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) application of desensitizing medicament D0470 D0350 D0230 D1208 D1206 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) immediate mandibular partial denture - flexible base (including any clasps, rests and teeth) pulp vitality tests D2740 D0321 D2980 incision and drainage of abscess - intraoral soft tissue custom fabricated abutment - includes placement D0330 D2751 D0210 D2750 comprehensive orthodontic treatment of the adolescent dentition D2752 mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) D2991 alveoloplasty in conjuction with extractions - one to three teeth or tooth spaces, per quadrant interim crown - further treatment or completion of diagnosis necessary prior to final impression D8030 D9243 D9244 D9245 D9246 removal of impacted tooth - partially bony splint - intra-coronal; natural teeth or prosthetic crowns D1510 retainer - cast metal for resin bonded fixed prosthesis lingual frenectomy (frenulectomy) fixed appliance therapy D0426 D1516 D1517 D9239 abutment supported retainer for porcelain fused to metal FPD (high noble metal) retainer crown - porcelain/ceramic incomplete endodontic therapy; inoperable, unrestorable or fractured tooth administration of general anesthesia with advanced airway - each subsequent 15 minute increment, or any portion thereof endodontic therapy, premolar tooth (excluding final restoration) bitewing - single radiographic image D0431 other temporomandibular joint radiographic images, by report immediate denture - maxillary D1527 D9247 D1526 partial pulpotomy for apexogenesis - permanent tooth with incomplete root development D4910 D6191 diagnostic casts D7283 D7284 D7285 D7286 palliative treatment of dental pain - per visit D9222 D9223 D9224 resin-based composite - three surfaces, anterior D6192 D7280 space maintainer - removable - bilateral, maxillary in-office administration of minimal sedation - single drug - enteral D2940 apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary D6069 core buildup, including any pins when required resin-based composite - two surfaces, anterior apicoectomy - molar (first root) reline maxillary partial denture (indirect) D8020 D9230 repair resin partial denture base, maxillary D9110 cone beam CT capture and interpretation with limited field of view - less than one whole jaw D2951 D2950 prefabricated post and core in addition to crown repair broken complete denture base, mandibular hospital or ambulatory surgical center call D0415 D9225 D2952 D2954 surgical repair of root resorption - premolar collection of microorganisms for culture and sensitivity D9440 D2928 splint - extra-coronal; natural teeth or prosthetic crowns D6056 D7140 bone replacement graft for ridge preservation - per site therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament endodontic therapy, anterior tooth (excluding final restoration) incisional biopsy of oral tissue - hard (bone, tooth) D7259 D2920 application of hydroxyapatite regeneration medicament - per tooth D7270 D6066 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth D6065 incisional biopsy of oral tissue - soft implant supported crown - porcelain fused to high noble alloys D6059 placement of interim direct restoration D6057 administration of nitrous oxide resin-based composite - four or more surfaces, posterior D2931 D2930 D2933 D2932 crown - porcelain/ceramic D7240 D7241 D8210 D9420 application of desensitizing resin for cervical and/or root surface, per tooth crown - porcelain fused predominantly base metal re-cement or re-bond unilateral space maintainer - per quadrant pin retention - per tooth, in addition to restoration D7250 D7252 D8220 D9430 detailed & extensive oral evaluation- problem focused, by report repair broken complete denture base, maxillary replace missing or broken teeth - complete denture - per tooth removal of residual tooth roots (cutting procedure) amalgam - two surfaces, primary or permanent gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant 2D cephalometric radiographic image - acquisition, measurement, and analysis clinical crown lengthening - hard tissue bone replacement graft - retained natural tooth - first site in quadrant implant supported porcelain/ceramic crown repair resin partial denture base, mandibular prefabricated resin crown rebase hybrid prosthesis D2910 D8670 D7220 repair or replace broken retentive/clasping materials - per tooth D6010 D5283 D5282 removal of impacted tooth - completely bony tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth surgical repair of root resorption - anterior crown - porcelain fused to high noble metal occlusal orthotic device, by report D6245 prophylaxis - child vertical bitewings - 7 to 8 radiographic images odontoplasty - per tooth removable unilateral partial denture - one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular surgical repair of root resorption - molar D8680 D7230 bitewings - four radiographic images collection, preparation, and analysis of saliva sample – point-of-care reline maxillary partial denture (direct) prefabricated stainless steel crown with resin window pulpal debridement, primary and permanent teeth administration of deep sedation/general anesthesia - first 15 minute increment, or any portion thereof post and core in addition to crown, indirectly fabricated D7320 periodontal scaling and root planing - four or more teeth per quadrant D5140 intraoral - occlusal radiographic image interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular placement of device to facilitate eruption of impacted tooth prophylaxis - adult D7311 D9610 reline complete maxillary denture (direct) D9612 re-cement or re-bond crown removal of impacted tooth - completely bony, with unusual surgical complications repair cast partial framework, mandibular D8660 D7210 D9630 D6242 D6241 D6240 prefabricated porcelain/ceramic crown - permanent tooth testing for cracked tooth resin-based composite - four or more surfaces, anterior periodontal maintenance buccal/labial frenectomy (frenulectomy) osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant administration of general anesthesia with advanced airway - first 15 minute increment, or any portion thereof occlusal guard - hard appliance, full arch D4273 pontic - porcelain fused to predominantly base metal D5120 complete denture - mandibular extraction, erupted tooth or exposed root (elevation and/or forceps removal) application of caries arresting medication - per tooth incision and drainage of acscess - extraoral soft tissue D4266 D4264 D4265 D7410 D9951 maxillary partial denture - resin base (including retentive/clasping materials, rests, and teeth) surgical placement of implant body: endosteal implant semi-precision abutment - placement D7310 D9971 D5130 prefabricated stainless steel crown - permanent tooth reline mandibular partial denture (indirect) resin-based composite crown, anterior amalgam - four or more surfaces, primary or permanent retreatment of previous root canal therapy - molar re-cement or re-bond inlay, onlay, veneer or partial coverage restoration