Clinical Criteria (By Procedure)

Preventive Services

(D1510-D1575): Clinical criteria for space maintenance

Restorative Services

(D2950, D2952-D2957): Clinical criteria for restorative substructures 

(D2928-D2934): Clinical criteria for prefabricated crowns 

(D2710-D2794): Clinical criteria for single crowns 

(D2140-D2394): Clinical criteria for direct restorations 

(D2991): Clinical criteria for hydroxyapatite regeneration 

Endodontic Services

(D3310-D3333): Clinical criteria for endodontic Therapy 

Periodontal Services

(D4341-D4342): Clinical criteria for periodontal scaling and root planing 

(D4910): Clinical criteria for periodontal maintenance 

(D4210-D4212): Clinical criteria for gingivectomy 

(D4240-D4241): Clinical criteria for the gingival flap procedure 

(D4260-D4261): Clinical criteria for periodontal osseous surgery 

(D4263-D4267): Clinical criteria for periodontal regenerative treatment 

Removable Prosthodontic Services

(D5211-D5286): Clinical criteria for removable partial dentures 

Fixed Prosthodontic Services

(D6205-D6999): Clinical criteria for fixed partial dentures 

Oral and Maxillofacial Services

(D7111-D7250): Clinical criteria for extraction of teeth 

(D7310-D7321): Clinical criteria for alveoloplasty 

(D7961-D7963): Clinical criteria for frenectomy 

(D7251): Clinical criteria for coronectomy 

Orthodontic Services

(D8010-D8090, D8210-D8670, D8680): Clinical criteria for orthodontic treatment 

Adjunctive General Services

(D9222-D9223, D9239-D9243): Clinical criteria for anesthesia and intravenous sedation 

Other Criteria

(D0120-D9999)*: Clinical criteria for appropriateness of care 

*These criteria apply to any dental procedure deemed to have been provided in a clinically inappropriate manner