Prior authorization codes
Clear Spring Health
Active CPT codes that appear on the extracted prior authorization list for this health plan.
| Code | Procedure / Service | Effective | Revised | Confidence | Source |
|---|---|---|---|---|---|
| 02226 | publication is available at: www.medicare.gov/Pubs/pdf/ -Medicare-and-Clinical-Research | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 10820 | WRITE Guilford Road, Suite 202 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 11435 | https://www.medicare.gov/sites/default/files/2021-10/ | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 11534 | www.medicare.gov/Pubs/pdf/ -Medicare-Rights-and-Protections.pdf.) | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 14718 | P.O. Box | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 20701 | Annapolis Junction, MD | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 21244 | Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland -1850 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 23219 | Building, 109 Governor Street Richmond, VA | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 23229 | Number/TTY | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 33027 | Miramar, FL | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 33313 | Plantation, FL | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 40512 | Lexington, KY -4718 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 63166 | St. Louis, MO -6588 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 66097 | P.O. Box | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 66588 | P.O. Box | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| 75266 | Dallas, TX -0907 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0120 | Periodic oral evaluation Two ( , , ) every Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0140 | Limited oral evaluation 3 per 12 months not allowed with Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0150 | Comprehensive oral exam One of ( , ) every 36 Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0160 | Periodic oral evaluation Two ( , , ) every Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0170 | Periodic oral evaluation Two ( , , ) every Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0180 | Comprehensive oral exam One of ( , ) every 36 Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0210 | Intraoral-complete series One of ( , , ) Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0220 | Intraoral periapical-1st One of , per date of service. Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0230 | Intraoral periapical-each additional Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0240 | Intraoral occlusal radiographic Two per 24 months Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0270 | Bitewing-single radiographic One of ( , , , Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0272 | Bitewing-single radiographic One of ( , , , Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0273 | Bitewing-single radiographic One of ( , , , Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0274 | image ) every 12 months, per patient | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0277 | Intraoral-complete series One of ( , , ) Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D0330 | Intraoral-complete series One of ( , , ) Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D1110 | Phrophylaxis-adult Two of ( , , ) Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D1206 | Topical application of fluoride 2 of ( , , ) per 12 Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D1208 | Topical application of fluoride 2 of ( , , ) per 12 Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2140 | Amalgam - one surface, primary or One of ( , , , Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2150 | Amalgam - one surface, primary or One of ( , , , Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2160 | Amalgam - one surface, primary or One of ( , , , Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2161 | permanent | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2330 | permanent | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2331 | permanent | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2332 | permanent | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2335 | D2393, D2394, D2990), one | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2390 | D2393, D2394, D2990), one | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2391 | D2393, D2394, D2990), one | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2392 | D2393, D2394, D2990), one | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2393 | ), one | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2394 | ), one | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2510 | Inlay-metallic-one surface One of ( , , , Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2520 | Inlay-metallic-one surface One of ( , , , Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2530 | Inlay-metallic-one surface One of ( , , , Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2542 | D2620, D2630, D2642, D2643, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2543 | D2620, D2630, D2642, D2643, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2544 | D2620, D2630, D2642, D2643, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2610 | D2620, D2630, D2642, D2643, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2620 | D2644, D2650, D2651, D2652, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2630 | D2644, D2650, D2651, D2652, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2642 | D2644, D2650, D2651, D2652, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2643 | D2644, D2650, D2651, D2652, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2644 | D2662, D2663, D2664, D2710, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2650 | D2662, D2663, D2664, D2710, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2651 | D2662, D2663, D2664, D2710, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2652 | D2662, D2663, D2664, D2710, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2662 | D2712, D2720, D2721, D2722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2663 | D2712, D2720, D2721, D2722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2664 | D2712, D2720, D2721, D2722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2710 | D2712, D2720, D2721, D2722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2712 | D2740, D2750, D2751, D2752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2720 | D2740, D2750, D2751, D2752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2721 | D2740, D2750, D2751, D2752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2722 | D2740, D2750, D2751, D2752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2740 | D2753, D2780, D2781, D2782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2750 | D2753, D2780, D2781, D2782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2751 | D2753, D2780, D2781, D2782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2752 | D2753, D2780, D2781, D2782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2753 | D2783, D2790, D2791, D2792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2780 | D2783, D2790, D2791, D2792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2781 | D2783, D2790, D2791, D2792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2782 | D2783, D2790, D2791, D2792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2783 | D2794), once per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2790 | D2794), once per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2791 | D2794), once per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2792 | D2794), once per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2794 | ), once per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2799 | Provisional crown Disallow - included in the crown Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2910 | Recement or re-bond inlay, onlay, Once per tooth per 24 months only Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2915 | Recement or re-bond indirectly Once per tooth per 24 months only Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2920 | Recement or re-bond crown Once per tooth per 24 months only Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2940 | Protective restoration-direct Once per tooth per lifetime Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2950 | Core build-up, including any pins One of ( , , ) Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2951 | Pin retention-per tooth, in addition One of once per tooth per 60 Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2952 | Core build-up, including any pins One of ( , , ) Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2953 | Each additional post, same tooth, One per 60 months per tooth when Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2954 | Core build-up, including any pins One of ( , , ) Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2980 | Crown repair necessitated by Once per tooth per 24 months only Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2990 | ), one | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D2999 | Unspecified restorative procedure, Restorative | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3220 | Therapeutic Pulpotomy One of ( or ) once per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3221 | Therapeutic Pulpotomy One of ( or ) once per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3310 | Endodontic therapy, (root canal), Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3320 | Endodontic therapy (root canal), Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3330 | Endodontic therapy (root canal), Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3331 | Treatment of root canal Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3346 | Retreatment of previous root canal Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3347 | Retreatment of previous root canal Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3348 | Retreatment of previous root canal Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3410 | Apicoectomy-anterior Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3421 | Apicoectomy/periradicular Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3425 | Apicoectomy/periradicular Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3426 | Apicoectomy/periradicular surgery Once per permanent tooth per Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3430 | Retrograde filling Once per tooth per lifetime Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D3999 | Unspecified endontonic procedure Endodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4210 | Gingivectomy-gingivoplasty-four One of ( , ) once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4211 | Gingivectomy-gingivoplasty-four One of ( , ) once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4240 | Gingival flap procedure, including One of ( , ) once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4241 | Gingival flap procedure, including One of ( , ) once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4249 | Clinical crown lengthening-hard Once per permanent tooth per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4260 | Osseous surgery - four or more One of ( or ), once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4261 | Osseous surgery - four or more One of ( or ), once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4341 | Periodontal scaling and root One of ( or ), once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4342 | Periodontal scaling and root One of ( or ), once per Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4346 | Phrophylaxis-adult Two of ( , , ) Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4355 | Full mouth debridement to enable One per 36 months, per patient Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4910 | Phrophylaxis-adult Two of ( , , ) Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D4999 | Unspecified periodontal procedure Periodontics | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5110 | Complete denture - maxillary One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5120 | Complete denture - mandibular One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5130 | Complete denture - maxillary One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5140 | Complete denture - mandibular One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5211 | Complete denture - maxillary One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5212 | Complete denture - mandibular One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5213 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5214 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5221 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5222 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5223 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5224 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5225 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5226 | Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5227 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5228 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5410 | Adjust complete denture- Two adjustments per arch per 12 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5411 | Adjust complete denture - Two adjustments per arch per 12 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5421 | Adjust partial denture - maxillary Two adjustments per arch per 12 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5422 | Adjust partial denture - mandibular Two adjustments per arch per 12 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5511 | Repair broken complete denture Once per arch per 12 months (after 6 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5512 | Repair broken complete denture Once per arch per 12 months (after 6 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5520 | Replace missing or broken teeth - Once per tooth per 12 months (after Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5611 | Repair resin denture base, Once per arch per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5612 | Repair resin denture base, Once per arch per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5621 | Repair cast framework, Once per arch per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5622 | Repair cast framework, maxillary Once per arch per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5630 | Repair or replace broken clasp-per Once per tooth per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5640 | Replace broken teeth - per tooth Once per tooth per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5650 | Add tooth to existing partial Once per tooth per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5660 | Add clasp to existing partial Once per tooth per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5710 | Rebase complete maxillary denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5711 | Rebase complete mandibular One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5720 | Rebase maxillary partial denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5721 | Rebase mandibular partial denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5725 | Rebase of hybrid prosthesis One of per arch per 36 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5730 | Rebase complete maxillary denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5731 | Rebase complete mandibular One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5740 | Rebase maxillary partial denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5741 | Rebase mandibular partial denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5750 | Rebase complete maxillary denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5751 | Rebase complete mandibular One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5760 | Rebase maxillary partial denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5761 | Rebase mandibular partial denture One of ( , , ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5765 | Soft liner for complete or partial One of per arch per 36 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5850 | Tissue conditioning maxillary Only allowed in conjunction with Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5851 | Tissue conditioning mandibular Only allowed in conjunction with Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5863 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5864 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5865 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5866 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5876 | Add metal substructure to acrylic Only allowed on the same date of Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5899 | Unspecified removable Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D5999 | Unspecified maxillofacial Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6110 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6111 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6112 | ), once per 60 months, per | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6113 | ), once per 60 months, per | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6205 | Pontic-indirect resin-based One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6210 | Pontic-indirect resin-based One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6211 | Pontic-indirect resin-based One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6212 | composite , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6214 | composite , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6240 | composite , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6241 | composite , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6242 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6243 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6245 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6250 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6251 | ) per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6252 | ) per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6545 | Retainer - cast metal for resin One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6548 | Retainer - cast metal for resin One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6549 | Retainer - cast metal for resin One of ( , , , Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6602 | bonded fixed prosthesis , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6603 | bonded fixed prosthesis , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6604 | bonded fixed prosthesis , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6605 | bonded fixed prosthesis , , , , Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6606 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6607 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6608 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6609 | Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6610 | D6614, D6615, D6624, D6634, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6611 | D6614, D6615, D6624, D6634, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6612 | D6614, D6615, D6624, D6634, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6613 | D6614, D6615, D6624, D6634, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6614 | D6710, D6720, D6721, D6722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6615 | D6710, D6720, D6721, D6722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6624 | D6710, D6720, D6721, D6722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6634 | D6710, D6720, D6721, D6722, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6710 | D6740, D6750, D6751, D6752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6720 | D6740, D6750, D6751, D6752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6721 | D6740, D6750, D6751, D6752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6722 | D6740, D6750, D6751, D6752, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6740 | D6753, D6780, D6781, D6782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6750 | D6753, D6780, D6781, D6782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6751 | D6753, D6780, D6781, D6782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6752 | D6753, D6780, D6781, D6782, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6753 | D6784, D6790, D6791, D6792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6780 | D6784, D6790, D6791, D6792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6781 | D6784, D6790, D6791, D6792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6782 | D6784, D6790, D6791, D6792, | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6784 | D6793, D6794), per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6790 | D6793, D6794), per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6791 | D6793, D6794), per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6792 | D6793, D6794), per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6793 | ), per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6794 | ), per tooth per 60 | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6930 | Re-cement fixed partial denture Once per 24 months only after 6 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6980 | Fixed partial denture repair, Once per 24 months only after 6 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D6999 | Unspecified fixed prosthodontics Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7140 | Extraction - erupted tooth or Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7210 | Surgical removal of erupted tooth Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7220 | Removal impacted tooth-soft Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7230 | Removal of impacted tooth - Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7240 | Removal of impact tooth- Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7241 | Removal of impacted tooth - Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7250 | Surgical remove of residual roots Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7251 | Coronectomy Once per tooth per lifetime Extractions | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7260 | Oralantral fistula closure 2 per Arch per lifetime Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7261 | Primary closure of a sinus 2 per Arch per lifetime Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7285 | Incisional biopsy of oral tissue- Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7286 | Incisional biopsy of oral tissue-soft Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7310 | Alveoloplasty with extractions- One of ( or ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7311 | Alveoloplasty with extractions- One of ( or ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7320 | Alveoloplasty not in conjunction One of ( or ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7321 | Alveoloplasty not in conjunction One of ( or ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7340 | Vestibuloplasty - ridge extension One per arch per lifetime Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7350 | Vestibuloplasty-ridge extensions One per arch per lifetime Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7410 | Excision of benign lesion of up Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7411 | Excision of benign lesion greater Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7440 | Excision of malignant tumor - Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7441 | Excision of malignant tumor - Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7450 | Removal of benign odontogenic Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7451 | Removal of benign odontogenic Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7460 | Removal of benign Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7461 | Removal of benign Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7471 | Removal of lateral exostosis 2 per arch per lifetime per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7472 | Removal of Torus Palatinus Once per lifetime per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7473 | Removal of torus mandibularis 2 per lifetime per patient/member, Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7485 | Reduction of osseous tuberosity 2 per lifetime per patient/member, Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7510 | Incision and drainage of abscess - not allowed in conjunction with Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7520 | Incision and drainage of abscess - Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7521 | Incision and drainage of abscess Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7961 | Buccal / labial frenectomy One ( , ) once per arch Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7962 | Lingual frenectomy One ( ) once per arch per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7963 | Buccal / labial frenectomy One ( , ) once per arch Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7970 | Excision of hyperplastic tissue - Once per arch per lifetime Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7971 | Excision of pericoronal gingiva Once per tooth per lifetime Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D7999 | Unspecified oral surgery Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9110 | Palliative (emergency) treatment Not allowed with anything other Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9222 | Deep Sedation/general anesthesia- One per member per date of service. Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9223 | Deep Sedation/general anesthesia- 3 per member per date of service. Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9230 | Inhalation of nitrous oxide/ One per member per date of service. Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9239 | first 15 minutes Not allowed with ( , ) Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9243 | first 15 minutes Not allowed with ( , ) Oral/Maxillofacial | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9248 | ) on the same Surgery, Other Services | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9310 | Consultation - diagnostic service One per provider or location per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9410 | House/ Extended care facility call One per date of service. 6 per year. Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9420 | Hospital or ambulatory surgical One per date of service. 6 per year. Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9910 | Topical application of fluoride 2 of ( , , ) per 12 Preventive | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9930 | Treatment of complications (post- Once per year per patient. Not to be Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9950 | Occlusal analysis- mounted case One of ( , ) per 60 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9951 | Occlusal adjustment - limited Once per 12 months Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9952 | Occlusal analysis- mounted case One of ( , ) per 60 Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9995 | Teledentistry – synchronous; real- One of ( or ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9996 | Teledentistry – synchronous; real- One of ( or ) per Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |
| D9999 | Unspecified adjunctive procedure, Prosthodontics,Other | 2026-07-06 | Not listed | 97% | [PDF] Evidence of Coverage: - Clear Spring Health |