D9110

A = NA

D9120

A = 13 years of age or older, prior authorization

D9210

A = NA, refer to additional limitations

D9211

A = NA, refer to additional limitations

D9212

A = NA, refer to additional limitations

D9215

A = NA, refer to additional limitations

D9220

A = NA, prior authorization, DOC

D9221

A = NA, prior authorization, must be billed with D9220

D9230

A = NA, refer to additional limitations

D9241

A = NA, refer to additional limitations

D9242

A = NA, must be billed with D9241

D9248

A = NA, more than 2 services/12 months requires prior authorization, refer to Section 14.2.5.13, "Adjunctive General Services"

D9310

A = NA, prior authorization

D9420

A = NA, prior authorization, refer to Section 14.2.6.2

D9430

A = NA

D9440

A = NA

D9610

A = NA, prior authorization, limited to once per client per day, DOC

D9612

A = NA, prior authorization, limited to once per client per day, DOC

D9630

A = NA, prior authorization, DOC

D9910

A = NA, limited to once per year, not to be used for bases, liners, or adhesives

D9920

A = 1 year of age or older, prior authorization, denied when billed on the same day as procedure code D9220, D9221, D9230, D9241, or D9248; claim must include diagnosis of MR, refer to additional limitations

D9930

A = NA

D9940

A = NA, prior authorization

D9950

A = 13 years of age or older, prior authorization

D9951

A = 13 years of age or older, prior authorization, may be reimbursed once per year per client, considered full-mouth procedure

D9952

A = 13 years of age or older, prior authorization, may be reimbursed once per lifetime per provider, considered full-mouth procedure

D9974

A = 13 years of age or older, DOC

D9999

A = NA, prior authorization, DOC