CDT CODES 1

Diagnostic/ Adjunctive Services

1

D0999

Unspecified diagnostic procedure, by report

2

D0708

Intraoral – bitewing radiographic image – image capture only Image axis may be horizontal or vertical.

3

D0702

2-D cephalometric radiographic image – image capture only

4

Occlusal analysis

D0473

5

D0478

Immunohistochemical stains

Preventive

1

 D1206

Topical application of fluoride varnish

2

Prophylaxis Adult

D1110

3

Sealant – per tooth

 D1351

4

D1353

Sealant repair – per toot

5

Distal shoe space maintainer- fixed, unilateral

D1575

Restorative

1

D2140

Amalgam – one surface, permanent or primary

2

Prefabricated resin crown

D2932

3

Inlay – metallic, one surface

D2510

4

D2712

Crown - ¾ resin-based composite (indirect) does not include facial veneers

5

D2910

Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration

Endodontics

1

Codes under Endodontics Procedure

D3000-3999

2

It includes exams, pulp tests, pulpotomy, pulpectomy, extirpation of pulp, and pre-operative, operative, and post-operative radiographs/diagnostic images, filling of canals, bacteriologic cultures, and local anesthesia.

ENDODONTIC PROCEDURES

3

Pulp cap- Direct (excluding restoration)

D3110

4

D3110

Pulp cap- Direct (excluding restoration)

5

Submission requirements for participating providers for D3100

TOOTH IDENTIFICATION

Periodontics

1

 D4255

 Full mouth debridement

2

CDT Code for Periodontal Maintenance

D4910

3

 D4264

 Bone replacement graft-retained natural tooth- each additional site in quadrant

4

True of False: Local anesthesia is usually considered to be part of Periodontal procedures

TRUE

5

Guidelines/ Frequency limitation for D4245 under Group Choice Copayment PPO

NOT A COVERED BENEFIT