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2019 Dental Code SetFor dates of service from D0160D0180PERIODIC ORAL EVALUATION - ESTABLISHED PATIENTLIMITED ORAL EVALUATION - PROBLEM FOCUSEDCOMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENTDETAILED AND EXTENSIVE ORAL EVALUATION - PROBLEM FOCUSED, BY REPORTCOMPREHENSIVE PERIODONTAL EVALUATION - NEW OR ESTABLISHED PATIENTD0210INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC IMAGESD0220INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGED0230INTRAORAL - PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC IMAGED0240INTRAORAL - 0CCLUSAL RADIOGRAPHIC IMAGEPage 1 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from 1/1/2019-12/31/2019HCPCSDescriptionD0250EXTRAORAL - FIRST RADIOGRAPHIC IMAGED0251Extra-oral posterior dental radiographic imageD0270BITEWING - SINGLE RADIOGRAPHIC IMAGED0272BITEWINGS - TWO RADIOGRAPHIC IMAGESPage 2 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from 1/1/2019-12/31/2019HCPCSDescriptionD0273BITEWINGS - THREE RADIOGRAPHIC IMAGESD0274BITEWINGS - FOUR RADIOGRAPHIC IMAGESD0277VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGESD0290POSTERIOR-ANTERIOR OR LATERAL SKULL AND FACIAL BONE SURVEY RADIOGRAPHIC IMAGED0310SIALOGRAPHYPage 3 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from 1/1/2019-12/31/2019HCPCSDescriptionD0330PANORAMIC RADIOGRAPHIC IMAGED0340CEPHALOMETRIC RADIOGRAPHIC IMAGED0350ORAL/FACIAL PHOTOGRAPHIC IMAGESD0393D0470D0502D1110D1206D1208Treatment simulation using 3D image volumeDIAGNOSTIC CASTSOTHER ORAL PATHOLOGY PROCEDURES, BY REPORTPROPHYLAXIS-ADULTTOPICAL APPLICATION OF FLUORIDE VARNISHTopical application of fluoridePage 4 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from Preventive resin restoration in a moderate to high caries risk patient - permaneAMALGAM-ONE SURFACE, PRIMARY OR PERMANENTAMALGAM-TWO SURFACES, PRIMARY OR PERMANENTAMALGAM-THREE SURFACES, PRIMARY OR PERMANENTAMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENTRESIN-ONE SURFACE, ANTERIORRESIN-TWO SURFACES, ANTERIORRESIN-THREE SURFACES, ANTERIORRESIN-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR)RESIN-BASED COMPOSITE CROWN, ANTERIORRESIN-BASED COMPOSITE - ONE SURFACE, POSTERIORRESIN-BASED COMPOSITE - TWO SURFACES, POSTERIORRESIN-BASED COMPOSITE - THREE SURFACES, POSTERIORRESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIORCROWN-PORCELAIN/CERAMIC SUBSTRATECROWN-PROCELAIN FUSED TO PREDOMINANTLY BASE METALCROWN-FULL CAST HIGH NOBLE METALRECEMENT CROWNPREFABRICATED STAINLESS STEEL CROWN-PERMANENT TOOTHPROTECTIVE RESTORATIONCORE BUILD-UP, INCLUDING ANY PINSPREFABRICATED POST AND CORE IN ADDITION TO CROWNPULP CAP-DIRECT (EXCLUDING FINAL RESTORATION)Page 5 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from PULPAL DEBRIDEMENT, PRIMARY AND PERMANENT TEETHENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION)ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATION)ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION)TREATMENT OF ROOT CANAL OBSTRUCTION; NON-SURGICAL ACCESSRETREATMENT OF PREVIOUS ROOT CANAL THERAPY-ANTERIORRETREATMENT OF PREVIOUS ROOT CANAL THERAPY-BICUSPIDRETREATMENT OF PREVIOUS ROOT CANAL THERAPY-MOLARGINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED SGINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED SGINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETHGINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - ONE TO THREE CONTIGUOUS TEETHOSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - FOUR OR MORE CONTIGUOUS TEEOSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - ONE TO THREE CONTIGUOUS TEEBONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANTBONE REPLACEMENT GRAFT - EACH ADDITIONAL SITE IN QUADRANTGUIDED TISSUE REGENERATION - RESORBABLE BARRIER, PER SITEGUIDED TISSUE REGENERATION - NONRESORBABLE BARRIER, PER SITE, (INCLUDESPEDICLE SOFT TISSUE GRAFT PROCEDURESUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER TOOTHDISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN NOT PERFORMED IN CONJUCTION WITHSOFT TISSUE ALLOGRAFTCOMBINED CONNECTIVE TISSUE AND DOUBLE PEDICLE GRAFT, PER TOOTHPage 6 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from PERIODONTAL SCALING AND ROOT PLANING - FOUR OR MORE TEETH PER QUADRANTPERIODONTAL SCALING AND ROOT PLANING - ONE TO THREE TEETH, PER QUADRANTFULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSISPERIODONTAL MAINTENANCEUNSCHEDULED DRESSING CHANGE (BY SOMEONE OTHER THAN TREATING DENTIST)UNSPECIFIED PERIODONTAL PROCEDURE, BY REPORTEXTRACTION, CORONAL REMNANTS - DECIDUOUS TOOTHEXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL)SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OFREMOVAL OF IMPACTED TOOTH-SOFT TISSUEREMOVAL OF IMPACTED TOOTH-PARTIALLY BONYREMOVAL OF IMPACTED TOOTH-COMPLETELY BONYREMOVAL OF IMPACTED TOOTH-COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONSSURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)ORAL ANTRAL FISTULA CLOSUREPRIMARY CLOSURE OF A SINUS PERFORATIONBIOPSY OF ORAL TISSUE - HARD (BONE, TOOTH)BIOPSY OF ORAL TISSUE - SOFTEXCISION OF BENIGN LESION UP TO 1.25 CMEXCISION OF BENIGN LESION GREATER THAN 1.25 CMEXCISION OF BENIGN LESION, COMPLICATEDEXCISION OF MALIGNANT LESION UP TO 1.25 CMEXCISION OF MALIGNANT LESION GREATER THAN 1.25 CMPage 7 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from EXCISION OF MALIGNANT LESION, COMPLICATEDEXCISION OF MALIGNANT TUMOR-LESION DIAMETER UP TO 1.25 CMEXCISION OF MALIGNANT TUMOR-LESION DIAMETER GREATER THAN 1.25 CMREMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP T0 1.25 CMREMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THAN 1.25 CMREMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER UP TO 1.25 CMREMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR-LESION DIAMETER GREATER THANREMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE)RADICAL RESECTION OF MAXILLA OR MANDIBLEINCISION AND DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUEINCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE - COMPLICATEDINCISION AND DRAINAGE OF ABSCESS-EXTRAORAL SOFT TISSUEINCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE - COMPLICATEDREMOVAL OF FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUEREMOVAL OF REACTION-PRODUCING FOREIGN BODIES-MUSCULOSKELETAL SYSTEMPARTIAL OSTECTOMY/SEQUESTRECTOMY FOR REMOVAL OF NON-VITAL BONEMAXILLARY SINUSOTOMY FOR REMOVAL OF TOOTH FRAGMENT OR FOREIGN BODYMAXILLA-OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)MAXILLA-CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)MANDIBLE-OPEN REDUCTION (TEETH IMMOBILIZED IF PRESENT)MANDIBLE-CLOSED REDUCTION (TEETH IMMOBILIZED IF PRESENT)MALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTIONMALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUCTIONPage 8 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from ALVEOLUS - CLOSED REDUCTION, MAY INCLUDE STABILIZATION OF TEETHALVEOLUS - OPEN REDUCTION, MAY INCLUDE STABILIZATION OF TEETHFACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICALMAXILLA-OPEN REDUCTIONMAXILLA-CLOSED REDUCTIONMANDIBLE-OPEN REDUCTIONMANDIBLE-CLOSED REDUCTIONMALAR AND/OR ZYGOMATIC ARCH-OPEN REDUCTIONMALAR AND/OR ZYGOMATIC ARCH-CLOSED REDUCTIONALVEOLUS - OPEN REDUCTION STABILIZATION OF TEETHALVEOLUS, CLOSED REDUCTION STABILIZATION OF TEETHFACIAL BONES-COMPLICATED REDUCTION WITH FIXATION AND MULTIPLE SURGICALOPEN REDUCTION OF DISLOCATIONCLOSED REDUCTION OF DISLOCATIONMANIPULATION UNDER ANESTHESIACONDYLECTOMYSURGICAL DISCECTOMY; WITH/WITHOUT IMPLANTSYNOVECTOMYMYOTOMYJOINT Page 9 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from NON-ARTHROSCOPIC LYSIS AND LAVAGEARTHROSCOPY-DIAGNOSIS, WITH OR WITHOUT BIOPSYARTHROSCOPY-SURGICAL: LAVAGE AND LYSIS OF ADHESIONSARTHROSCOPY-SURGICAL: DISC REPOSITIONING AND STABILIZATIONARTHROSCOPY-SURGICAL: SYNOVECTOMYARTHROSCOPY-SURGICAL: DISCECTOMYARTHROSCOPY-SURGICAL: DEBRIDEMENTSUTURE OF RECENT SMALL WOUNDS UP TO 5 CMCOMPLICATED SUTURE-UP TO 5 CMCOMPLICATED SUTURE-GREATER THAN 5 CMOSTEOPLASTY-FOR ORTHOGNATHIC DEFORMITIESOSTEOTOMY - MANDIBULAR RAMIOSTEOTOMY - MANDIBULAR RAMI WITH BONE GRAFT; INCLUDES OBTAINING THE GRAFTOSTEOTOMY-SEGMENTED OR SUBAPICALOSTEOTOMY-BODY OF MANDIBLELEFORT I (MAXILLA-TOTAL)LEFORT I (MAXILLA-SEGMENTED)LEFORT II OR LEFORT III (OSTEOPLASTY OF FACIAL BONES FOR MIDFACE HYPOPLASIA ORLEFORT II OR LEFORT III-WITH BONE GRAFTOSSEOUS, OSTEOPERIOSTEAL, OR CARTILAGE GRAFT OF THE MANDIBLE OR MAXILLA - AUTOGEREPAIR OF MAXILLOFACIAL SOFT AND/OR HARD TISSUE DEFECTEXCISION OF HYPERPLASTIC TISSUE-PER ARCHEXCISION OF PERICORONAL GINGIVAPage 10 of 11Date will stop beingcovered
2019 Dental Code SetFor dates of service from 9430D9440D9610D9612D9930DescriptionSURGICAL REDUCTION OF FIBROUS TUBEROSITYSIALOLITHOTOMYEXCISION OF SALIVARY GLAND, BY REPORTSIALODOCHOPLASTYCLOSURE OF SALIVARY FISTULAEMERGENCY TRACHEOTOMYCORONOIDECTOMYPALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN-MINOR PROCEDURESLOCAL ANESTHESIA N0T IN CONJUNCTION WITH OPERATIVE OR SURGICAL PROCEDURESIntravenous moderate (conscious) sedation/analgesia - each 15 minute incrementIntravenous moderate (conscious) sedation/analgesia - each 15 minute incrementNON-INTRAVENOUS CONSCIOUS SEDATIONCONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN REHOUSE/EXTENDED CARE FACILITY CALLHOSPITAL OR AMBULATORY SURGICAL CENTER CALLOFFICE VISIT FOR OBSERVATION (DURING REGULARLY SCHEDULED HOURS) NO OTHEROFFICE VISIT-AFTER REGULARLY SCHEDULED HOURSTHERAPEUTIC PARENTERAL DRUG, SINGLE ADMINISTRATIONTHERAPEUTIC PARENTERAL DRUGS, TWO OR MORE ADMINISTRATIONS, DIFFERENT MEDICATIONSTREATMENT OF COMPLICATIONS (POSTSURGICAL) - UNUSUAL CIRCUMSTANCES, BY REPORTPage 11 of 11Date will stop beingcovered
D2140 AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT D2150 AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT D2160 AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT . TREATMENT OF DENTAL PAIN-MINOR PROCEDURES D9210 LOCAL ANESTHESIA N0T IN CONJUNCTION WITH OPER
