UCR MEANS 75% OF THE PROVIDERS UCR ALL CHARGES INCLUDE LAB FEES,NC MEANS NO CHARGE
|
|
- Alan Armstrong
- 5 years ago
- Views:
Transcription
1 NOTE: UCR MEANS 75% OF THE PROVIDERS UCR ALL CHARGES INCLUDE LAB FEES,NC MEANS NO CHARGE LP1 Procedure Category: Diagnostics LP1 Proc code Procedure Description 17 Cancelled Appt (less than 24hr notice) $ Periodic Oral Evaluation NC 140 Limited Oral Evaluation- Problem Focused NC 150 Comprehensive Oral Evaluation NC 160 Detailed and Extensive Oral Evaluation- Problem focused $ Re-Evaluation- Limited, Problem focused NC 180 Comprehensive Periodontal Evaluation NC 210 Intraoral- Complete Series (Including Bitewings) $ Intraoral- Periapical- One Film NC 230 Intraoral- Periapical- Each Additional Film NC 240 Intraoral- Occlusal Film NC 250 Extraoral- First Film NC 260 Extraoral- Each Additional Film NC 270 Bitewing- Single Film NC 272 Bitewing- Two Films NC 273 Bitewing- Three Films NC 274 Bitewing- Four Films NC 277 Vertical Bitewings- Seven to Eight Films $ Posterior, Anterior, Lateral Skull or Facial Bone Surgery UCR 310 Sialography UCR 320 Temporomandiblar Joint Arthrogram UCR 321 Other Temporomandiblar Joint Films UCR 322 Tomographic Survey UCR 330 Panoramic Film $ Cephalometric Film UCR 350 Oral or Facial Images (Including Intraoral and Extraoral) UCR 415 Bacteriologic Studies for Determination of Pathology UCR 425 Caries Susceptibility UCR 460 Pulp Vitality Tests NC 470 Diagnostic Casts (Per Cast) NC 472 Accession of Tissue, Gross Exam, Prep NC 473 Accession of Tissue, Gross and Microscopic Exam UCR 474 Accession of Tissue, Gross or Micro Exam; Surgical NC 480 Processing or Interpretation of Cytologic Smears NC 502 Other Oral Pathology Procedures, by Report UCR 999 Unspecified Diagnostic Procedures, by Report UCR
2 Procedure Category: Preventative 1110 Prophylaxis, Adult NC 1120 Prophylaxis, Children NC 1203 Topical Application of Fluoride w/out Prophylaxis NC 1204 Topical Application of Fluoride w/out Prophylaxis NC 1310 Nutritional Counseling for Control of Dental Disease UCR 1320 Tobacco Counseling for Control and Prevention UCR 1330 Oral Hygiene Instruction UCR 1351 Sealant- Per Tooth $ Space Maintainer- Fixed- Unilateral $ Space Maintainer- Fixed- Bilateral $ Space Maintainer- Removeable- Unilateral $ Space Maintainer- Removeable- Bilateral $ Recementation of Space Maintainer NC 1555 Removal of Fixed Space Maintainer NC Procedure Category: Restorative 2140 Amalgam- One Surface, Permanent or Deciduous $ Amalgam- Two Surfaces, Permanent or Deciduous $ Amalgam- Three Surfaces, Permanent or Deciduous $ Amalgam- Four or More Surfaces, Permanent or Deciduous UCR 2330 Resin-Based Composite- One Surface, Anterior $ Resin-Based Composite- Two Surfaces, Anterior $ Resin-Based Composite- Three Surfaces, Anterior $ Resin-Based Composite- Four or More Surfaces, Anterior $ Resin-Based Composite Crown, Anterior NC 2391 Resin-Based Composite- One Surface, Posterior $ Resin-Based Composite- Two Surfaces, Posterior $ Resin-Based Composite- Three Surfaces, Posterior $ Resin-Based Composite- Four or More Surfaces, Posterior $ Gold Foil- One Surface UCR 2420 Gold Foil- Two Surfaces UCR 2430 Gold Foil- Three Surfaces UCR 2510 Inlay- Metallic- One Surface $ Inlay- Metallic- Two Surfaces $ Inlay- Metallic- Three Surfaces $ Onlay- Metallic- Two Surfaces $ Onlay- Metallic- Three Surfaces $ Onlay- Metallic- Four or More Surfaces $ Inlay- Porcelain or Ceramic- One Surface $ Inlay- Porcelain or Ceramic- Two Surfaces $ Inlay- Porcelain or Ceramic- Three Surfaces $ Onlay- Porcelain or Ceramic- Two Surfaces $ Onlay- Porcelain or Ceramic- Three Surfaces $ Onlay- Porcelain or Ceramic- Four or More Surfaces $ Inlay- Resin-Based Composite-One Surface $ Inlay- Resin-Based Composite-Two Surfaces $ Inlay- Resin-Based Composite-Three Surfaces $ Onlay- Resin Based Composite-Two Surfaces $400.00
3 2663 Onlay- Resin Based Composite-Three Surfaces $ Onlay- Resin Based Composite-Four or More Surfaces $ Procedure Category: Crowns Prod Code Procedure Description 2710 Crown- Resin (laboratory) $ Crown- 3/4 Resin- Based Composite(laboratory) $ Crown- Resin with High Noble Metal $ Crown-Resin with Predominantly Base Metal $ Crown- Resin with Noble Metal $ Crown- Porcelain or Ceramic Substrate $ Crown-Porcelain Fused to High Noble Metal $ Crown-Porcelain Fused to Predominantly Base Metal $ Crown- Porcelain Fused to Noble Metal $ Crown- 3/4 Cast High Noble Metal $ Crown- 3/4 Cast Predominantly Base Metal $ Crown- 3/4 Cast Noble Metal $ Crown- 3/4 Porcelain or Ceramic $ Crown- Full Cast High Noble Metal $ Crown- Full Cast Predominately Base Metal $ Crown- Full Cast Noble Metal $ Crown- Titanium $ Provisional Crown- Used for a Minimum of Six Months $ Recement Inlays NC 2915 Recement Cast or Prefabricated Post and Core NC 2920 Recement Crowns NC 2930 Prefabricated Stainless Steel Crown- Primary $ Prefabricated Stainless Steel Crown- Permanent U&C 2932 Prefabricated Resin Crown U&C 2933 Prefabricated Stainless Steel Crown with Resin U&C 2940 Sedative Filing U&C 2950 Crown Buildup, Including any Pins $ Pin Retention in Adition ot Restoration- per Tooth NC 2952 Cast Post and Core in Addition to Crown $ Each Additional Cast Post- Same Tooth $ Prefabricated Post and Core in Addition to Crown $ Post Removal (not in conjunction with Endodontic) NC 2957 Each Additional Prefabricated Post- Same Tooth NC 2960 Labial Veneer (Resin Laminate)- Chair side $ Labial Veneer (Resin Laminate)- Laboratory $ Labial Veneer (Procelain Laminate)- Laboratory $ Temporary Crown (Fractured Tooth) NC 2980 Crown Repair, by Report $ Continued Treatment- Crowns NC 2999 Unspecified Restorative Precedure, by Report NC Procedure Category: Endodontics 3110 Pulpal Cap- Direct (Excluding Final Restoration) $ Pulpal Cap- Indirect (Excluding Final Restoration) $ Theraputic Pulpotomy (Excluding Restoration) $ Pulpal Debridement, Primay and Permanent Teeth $100.00
4 3230 Pulpal Therapy(Resorbable Filling)- Anterior, Primary $ Pulpal Therapy(Resorbable Filling)- Posterior, Primary $ One Canal(Excluding Final Restoration) $ Two Canals (Excluding Final Restoration) $ Three Canals(Excluding Final Restoration) $ Treatment of Root Canal Obstruction, Non- Surgical $ Incomplete Endodonitc Therapy; Inoperable $ Internal Root Repair or Perforation Defects $ Four or More Canals(Excluding Final Restoration) $ Retreatment-Anterior (Excluding Specialists) $ Retreatment- Bicuspid(Excluding Specialists) $ Retreatment- Molar(Excluding Specialists) $ Apexification/Recalcification- Initial visit $ Apexification/Recalcification- Interim Meds Replacement $ Apexification/Recalcification- Final Visit $ Apicoectomy/Periradicular Surgery- Anterior $ Apicoectomy/Periradicular Surgery- Bicuspid $ Apicoectomy/Periradicular Surgery- Molar $ Apicoectomy/Periradicular Surgery- (Each Additional) $ Retrograde Filling- Per Root $ Root Amputation- Per Root $ Endodontic Endosseous Implant UCR 3470 Intentional Re-Implantation(Including Necessary) UCR 3910 Tooth Isolation- Surgical $ Hemisection Including Root Removal not Root Canal $ Canal Preparation and Fitting- Dowel or Post NC 3970 Continued Treatment- Endodontics NC 3999 Unspecified Endodontic Procedure, by Report NC Procedure Category: Periodontics 4210 Gingivectomy or Gingivoplasty(4+ Contiguous Teeth) $ Gingivectomy or Gingivoplasty(1-3 Contiguous Teeth) $ Anatomical Grown Exposure(Four or More Teeth) $ Anatomical Grown Exposure(Three Teeth) $ Gingival Flap Procedure w/ Root Plan(4+ Contiguous) $ Gingival Flap Procedure w/ Root Plan(1-3 contiguous) $ Apically Positioning Flap $ Clinical Crown Lengthening- Hard tissue $ Osseous Surgery(Per Quadrant) $ Osseous Surgery- With Flap (1-3 teeth per quadrant) $ Bone Replacement Graft- Single Site(per quadrant) UCR 4264 Bone Replacement Graft- Multiple Sites (per quadrant) UCR 4265 Biologic Materials to Aid in Soft and Osseous Regeneration UCR 4266 Guided Tissue Reganeration- Resorbable Barrier UCR 4267 Guided Tissue Regenertation- Nonresorbable Barrier UCR 4268 Surgical Revision Procedure- Per Tooth UCR 4270 Pedicle Soft Tissue Graft Procedure UCR 4271 Free Soft Tissure Graft Procedure UCR 4273 Subephitelial Connective Tissue Graft Procedures UCR 4274 Distal or Proximal Wedge Procedure w/out same UCR 4275 Soft Tissue Allograft UCR
5 4276 Combined Connective Tissue and Double Pedicle UCR 4320 Provisional Splinting- Intracoronal(Per Tooth) $ Provisional Splinting- Extracoronal(Per Tooth) $ Root Planning(4+ Contiguous Teeth per Quadrant) $ Periodontal Scaling or Root Planning(1-3 contiguous) $ Full mouth Debriedment to Enable a full evalutation NC 4381 Localized Delivery of Chemotherapeutic Agents $ Periodontal Maintenance- Active Therapy NC 4920 Unscheduled Dressing Change (not the treating) $ Unspecified Periodontal Procedure, by report NC Procedure Category: Prosthodontics 5110 Complete Upper Denture $ Complete Lower Denture $ Immediate Upper Denture $ Immediate Lower Denture $ Upper Partial Denture- Resin Base $ Lower Partial Denture- Resin Base $ Upper Partial Denture- Cast Chrome $ Lower Partial Denture- Cast Chrome $ Maxillary with Flexible Base $ Mandidula with Flexible Base $ Unilateral Partial Denture- Chrome $ Adjust complete denture- Upper NC 5411 Adjust complete denture- Lower NC 5421 Adjust partial denture- Upper NC 5422 Adjust partial denture- Lower NC 5510 Repair Broken complete Denture Base $ Replace Missing or Broken Teeth (complete denture) $ Repair Resin Denture Base $ Repair Cast Framework $ Repair or Replace Broken Clasp $ Replace Broken Teeth- per tooth $ Add tooth to Existing Partial Denture $ Add Clasp to Existing Partial Denture $ Replace All Teeth- Acrylic on Cast Metal Framework $ Replace All Teeth- Acrylic on Cast Metal Framework $ Rebase Complete Upper Denture $ Rebase Complete Lower Denture $ Rebase Upper partial Denture $ Rebase Lower Partial Denture $ Reline complete Upper Denture(office) $ Reline complete Lower Denture(office) $ Reline Upper Partial Denture(office) $ Reline Lower Partial Denture(Office) $ Reline Complete Upper Denture (lab) $ Reline Complete Lower Denture (lab) $ Reline Upper Partial Denture (lab) $ Reline Lower Partial Denture (lab) $ Interim Complete Denture (Upper) $ Interim Complete Denture (Lower) $400.00
6 5820 Interim Partial Denture (Upper) $ Interim Partial Denture (Lower) $ Tissue Conditioning- Upper NC 5851 Tissue Conditioning- Lower NC 5860 Overdenture- Complete, by Report $ Overdenture- Partial, by report $ Precision Attachment, by report $ Replacement of Replaceable Part(Semi or Full) $ Modification of Removable Prothesis after Implant $ Unspecified Removable Prosthodontic Procedure NC 5980 Continued Treatment- Prosthodontics NC 5999 Unspecified Maxillofacial Prothesis, by Report NC Procedure Category: Bridge Pont. And Crown Abut Pontic- Indirect Resin.. $ Pontic- Cast High Noble Medal $ Pontic- Cast Predominately Base Metal $ Pontic- Cast Noble Medal $ Pontic- Titanium $ Pontic- Porcelain Fused to High Noble Metal $ Pontic- Porcelain Fused to Base Metal $ Pontic- Porcelain Fused to Noble Metal $ Pontic- Porcelain/ Ceramic $ Pontic- Resin with High Noble Metal $ Pontic- Resin with Base Metal $ Pontic- Resin with Noble Metal $ Provisional Pontic NC 6545 Cast Medal Retainer with Acid Etched Arm $ Porcelain/Ceramic Retainer with Acid Etched Arm $ Inlay- Porcelain/Ceramic- Two surfaces $ Inlay- Porcelain/Ceramic- Three or more surfaces $ Inlay- Cast High Noble Metal- Two surfaces $ Inlay- Cast High Noble Metal- Three or more surfaces $ Inlay- Cast Predominately Base Metal- Two surfaces $ Inlay-Cast Predominately Base Metal-Three or more surfaces $ Inlay- Cast Noble Metal- Two surfaces $ Inlay- Cast Noble Metal- Three or more surfaces $ Onlay- Porcelain/Ceramic- two surfaces $ Onlay- Porcelain/Ceramic- three or more surfaces $ Onlay- Cast High Noble Metal- Two Surfaces $ Onlay- Cast High Noble Metal- Three or more surfaces $ Onlay-Cast Predominately Base Metal- Two surfaces $ Onlay- Cast Predominately Base Metal- Three or more surfaces $ Onlay- Cast Noble Metal- two surfaces $ Onlay- Cast Noble Metal- three or more surfaces $ Inlay- Titanium $ Onlay- Titanium $ Crown- Resin based composite $ Crown- Resin with High Noble metal $ Crown- Resin with Base metal $ Crown- Resin with Noble metal $300.00
7 6740 Crown- Porcelain/ Ceramic $ Crown- Porcelain fused to high noble metal $ Crown- Porcelain fused to base metal $ Crown- Porcelain fused to noble metal $ Crown- Three Quarter Cast to High Noble Metal $ Crown- Three Quarter Cast to Predominately Base Metal $ Crown- Three Quarter Cast Noble Metal $ Crown- Three Quarter Porcelain/ Ceramic $ Crown- Full cast High Noble Metal $ Crown- Full Cast Base Metal $ Crown- Full Cast Noble Metal $ Provisional Retainer Crown NC 6794 Crown- Titanium $ Connector Bar $ Recement Bridge NC 6940 Stress Breaker $ Precision Attachment $ Cast Post and Core in addition ot Fixed Partial denture $ Prefabricated Post and core- Add to Bridge NC 6973 Core Build up for Retainer, Including any Pins $ Coping- Metal NC 6976 Each additional Cast Post- Same tooth $ Each Additional Prefabricated Post- Same tooth NC 6980 Bridge Repair, Per crown $ Pediatric Partial Denture, Fixed UCR 6990 Continued Treatment- Bridges NC 6999 Unspecified Fixed Prosthodontic Procedure, by report NC Procedure Category: Oral Surgery 7111 Coronal Remnants- Deciduous Tooth $ Extraction, Erupted Tooth/ Exposed Root (elevation) $ Surgical Removal of Erupted tooth $ Surgical Removal of Impacted tooth- soft tissue $ Surgical Removal of Impacted tooth- Partially $ Surgical Removal of Impacted tooth- Completely $ Surgical Removal of Impacted tooth- Completely $ Root Recovery, Surgical Removal $ Oroantral Fistula closure UCR 7261 Primary Closure of a Sinus Perforation UCR 7270 Tooth Reimplantation UCR 7272 Tooth Transplatation UCR 7280 Surgical Exposure Impaction/ Unerupted tooth UCR 7281 Surgical Exposure Impaction/ Unerupted tooth UCR 7282 Mobilization of Erupted or Malpositioned Tooth UCR 7283 Deuce to Facilitate Eruption UCR 7285 Biopsy of Oral Tissue- Hard UCR 7286 Biopsy of Oral Tissue- Soft UCR 7287 Cytology Sample Collection $ Surgical repositioning Teeth UCR 7291 Transseptal Fiberotomy/ Supra Crestal Fiberotomy $ Alveoloplasty Per Quadrant in Conjunction $125.00
8 7311 Alveoloplasty in Conjunction with $ Alveoloplasty Per Quadrant Not in conjuction UCR 7321 Alveoloplasty in Conjunction with UCR 7340 Vestibuloplasty- Ridge Ext-Second UCR 7350 Vestibuloplasty- Complicated UCR 7410 Excision of Benign Lesion up to 1.25cm UCR 7411 Excision of Benign Lesion greater than 1.25cm UCR 7412 Excision of benign lesion, complicated UCR 7413 Excision of Malignant lesion up to 1.25cm UCR 7414 Excision of Malignant lesion greater than 1.25cm UCR 7415 Excision of Malignant lesion, complicated UCR 7440 Excision of Malignant tumor- lesion up to 1.25cm UCR 7441 Excision of Malignant tumor- lesion over 1.25cm UCR 7450 Remove Odontogen Cyst or Tumor up to 1.25cm UCR 7451 Remove Odontogen Cyst or Tumor over 1.25cm UCR 7460 Remove Benign Non-Odontogen Cyst or Tumor up to 1.25cm UCR 7461 Remove Benign Non-Odontogen Cyst or Tumor over 1.25cm UCR 7465 Destruction of Lesion(s) by Physical/ Chemical UCR 7471 Remove lateral Exostosis (Maxilla or Mandible) UCR 7472 Remove Torus Palatinus UCR 7473 Remove Torus Mandibularis UCR 7485 Surgical Reduction of Osseous Tuberosity UCR 7490 Radical Resection of Mandible with Bone Graft UCR 7510 Incision and Drainage of Abscess- Intraoral Soft $ Incision and Drainage of Abscess- Intraoral Soft $ Incision and Drainage of Abscess- Extraoral Soft $ Incision and Drainage of Abscess- Extraoral Soft $ Remove Foreign Body from Mucosa/skin/Alveola UCR 7540 Remove Reaction Producing Foreign bodies UCR 7550 Partial Ostectomy/Sequestrectomy- Non-vital UCR 7560 Maxillary Sinusotomy to Remove tooth Fragment UCR 7610 Maxilla- Open Reduction (teeth immobilized) UCR 7620 Maxilla- Closed Reduction (teeth immobilized) UCR 7630 Mandible- Open Reduction (teeth Immobilized) UCR 7640 Mandible- closed reducation (teeth Immobilized) UCR 7650 Malar and/or Zygomatic Arch- Open Reduction UCR 7660 Malar and/or Zygomatic Arch- closed reduction UCR 7670 Alveolus- closed reduction, teeth stabilization UCR 7671 Alveolus- open reduction, teeth stabilization UCR 7680 Facial Bones- complicated Reduction w/ Fixatior UCR 7710 Maxilla- Open Reduction UCR 7720 Maxilla- Closed Reduction UCR 7730 Mandible- Open Reduction UCR 7740 Mandible- Closed Reduction UCR 7750 Malar and/or Zygomatic Arch- Open Reduction UCR 7760 Malar and/or Zygomatic Arch- closed reduction UCR 7770 Alveolus- Open Reduction Stabilization of Teeth UCR 7771 Alveolus- Closed Reduction Stabilization of Teeth UCR 7780 Facial Bones- complicated Reduction w/ Fixatior UCR 7960 Frenectomy $ Surgical Reduction of Fiberous Tuberosity $ Continued Treatment- Oral Surgery NC
9 7999 Unspecified Oral Surgery Procedure by Report NC Procedure Category: Orthodontia 8010 Limited Orthodontic Treatment- Primary UCR 8020 Limited Orthodontic Treatment- Transitional UCR 8030 Limited Orthodontic Treatment- Adolescent UCR 8040 Limited Orthodontic Treatment- Adult UCR 8050 Interceptive Orthodontic Treatment of Primary UCR 8060 Interceptive Orthodontic Treatment of Transitional UCR 8070 Comprehensive Orthodontic Treatment- Transitional $3, Comprehensive Orthodontic Treatment- Adolescent $3, Comprehensive Orthodontic Treatment- Adult $3, Removable Appliance Therapy/ Habit $ Fixed Appliance Therapy/ Habit $ Pre- Orthodontic Treatment Visit NC 8670 Periodic Orthodontic Treatment Visit NC 8680 Orthodontic Retention (Removal of Appliances) $ Orthodontic Treatment UCR 8691 Repair of Orthodontic Appliance $ Replacement of Lost or Broken Retainer UCR 8693 Rebonding or Recementing Fixed Retainers NC Procedure Category: Other Services 9110 Palliative Emergency Treatment $ Local Anesthesia w/out Operative/Surgical NC 9211 Regional Block Anethesia NC 9212 Trigeminal Division Block Anesthesia NC 9215 Local Anesthesia NC 9220 Anesthesia- General(Per Quadrant) $ Inhilation- Nitrous Oxide $ IV Sedation (Per Quadrant) $ Consultation- Per Session(Excluding Specialists) NC 9430 Office Visit for Observation- No other services NC 9440 Office Visit after Regularly Scheduled Hours $ Theraputic Drug Injection, by report UCR 9630 Other drugs and/or medicaments, by report UCR 9910 Application of Desensitizing Medicine NC 9930 Treatment of Complications (Post- Surgical) NC 9940 Occlusal Guards $ Fabrication of Athletic Mouth Guard $ Occlusion Analysis- Mounted Case $ Occlusal Adjustment- Limited $ Occlusal Adjustment- Completed UCR NOTE: ANY PROCEDURES NOT LISTED HERE SHALL BE CHARGED AT 75% OF THE PROVIDERS UCR
LP1 Procedure Category: Diagnostics
LP1 Procedure Category: Diagnostics Proc code Procedure Description Fee's 17 Cancelled Appt (less than 24hr notice) $20.00 120 Periodic Oral Evaluation $15.00 140 Limited Oral Evaluation- Problem Focused
More informationBOSTON TEACHERS UNION PARAPROFESSIONAL HEALTH AND WELFARE FUND Schedule of Covered Dental Procedures for the Dental Plan - Effective January 1, 2009
TYPE 1 D0120 Periodic oral evaluation 27.81 D0140 Limited oral evaluation - problem focused 43.15 D0145 Oral evaluation for a patient under three years of age and 22.20 counseling with primary caregiver
More informationMDG Dental Plan Comparison
D0999 Office visit during regular hours, general dentist only Evaluations D0120 Periodic oral examination - established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for
More informationADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or
ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or established patient(initial exam) 0 D0160 Detailed and
More informationD0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive
D0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive Oral Examination $43 D0160 Detailed And Extensive Oral
More informationRETIREE DENTAL PLAN. RETIREE DENTAL PLAN FEE SCHEDULE Page 1 of 8
D0120 periodic oral evaluation $ 30.50 D0140 limited oral evaluation problem focused $ 30.50 D0150 comprehensive oral evaluation - new or established patient $ 30.50 D0160 detailed and extensive oral evaluation
More informationGeneral Dentist Fee Schedule
General Dentist Fee Schedule ADA Diagnostic D0120 Periodic oral evaluation $0 $72 $72 D0140 Limited oral evaluation problem focused $77 $107 $30 D0150 Comprehensive oral evaluation new or established patient
More informationGeneral Dentist Fee Schedule
General Dentist Fee Schedule Diagnostic D0120 Periodic oral evaluation $0 $59 $59 D0140 Limited oral evaluation problem focused $71 $88 $17 D0150 Comprehensive oral evaluation new or established patient
More informationManaged DentalGuard Texas
Page 1 of 5 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131
More informationThis schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General
More informationThis schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General
More informationTEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National
Effective: 01/01/ - Delta Dental PPO Plus Premier National D0120 PERIODIC ORAL EXAMINATION $21.00 D0140 LIMITED EVAL PROBLEM FOCUS $38.00 D0145 ORAL EVALUATION FOR PATIENTS UNDER THREE YEARS OF AGE $21.00
More informationMY SMILE DENTAL PLAN FEE SCHEDULE
D0120 periodic oral evaluation D0140 limited oral evaluation problem focused D0145 exam under 3 years D0150 comprehensive oral evaluation - new or established patient D0160 detailed and extensive oral
More informationCCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List
CCPOA PRIMARY DENTAL CCPOA s Fee-for-Service Procedure Code List Effective December 2017 We have provided these payment allowances for informational purposes only and not as a guarantee of payment. All
More information2018 fee schedule. Georgia. Diagnostic Services (Performed by a General Dentist)
Diagnostic Services (Performed by a General Dentist) page 1 of 12 IS NOT A REGISTERED INSURANCE PLAN. It is a savings plan offered exclusively by Coast Dental practices to patients who do not have dental
More informationGUARANTY ASSURANCE COMPANY - DINA Dental Plan SCHEDULED BENEFITS RIDER
OSHA Charge for disposables for patients protection, per person, per visit* $5.00 120 Periodic oral exam $5.00 140 Limited oral exam $30.00 150 Comprehensive oral evaluation $20.00 180 Comprehensive Perio
More informationConcordia Plus Schedule of Benefits
Concordia Plus Schedule of Benefits Plan MD/DC 6 IMPORTANT INFORMATION ABOUT YOUR PLAN This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment,
More informationAmeriPlan Lime Fee Zip: 78411
AmeriPlan Lime Fee Zip: 78411 SPECIALIST FEE SCHEDULE Any AmeriPlan /Dental Plans of America member receiving treatment from a participating specialist provider (advanced degree), shall receive a 15% discount
More informationCareington Corporation Care PPO Schedule CI-10
Careington Corporation Care PPO Schedule Page 1 of 5 This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this
More informationDelta Dental of Colorado EXCLUSIVE PANEL OPTION (EPO) Schedule EPO 1B List of Patient Co-Payments. * See Special Provisions on Last Page
List of Co-Payments Code edure Code Definition Co-Pay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
More informationSECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE
DentiCare of Alabama, Inc. 3595 Grandview Parkway, Suite 650 Birmingham, AL 35243 SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE SECTION I: PLAN DENTIST SERVICES (Subject to Exclusions and Limitations Listed
More informationIRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation
D0120 IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation established patient* $ 66.50 D0140 limited oral evaluation
More informationBelk Dental Plan Options
Belk Dental Plan Options Belk Low Plan Deductibles No Deductible for Preventive & Diagnostic Services $ 50 Calendar Year Deductible per person applies to Basic and Major Services Fee Schedule Special Fee
More informationGUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual
Effective: January 1, 2016 Eligibility: (866) 436-3093 GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual Diagnostic D0999 Office Visit Copay - Per Person, Per Visit $9.00
More informationLIST OF COVERED DENTAL SERVICES
LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental Services which will be considered for payment by Constitution Life Insurance Company after the expiration of any applicable
More informationManaged DentalGuard - Plan Schedule
D0999 Office visit during regular hours, general dentist only * $5 Evaluations D0120 Periodic oral examination established patient 0 D0140 Limited oral evaluation problem focused 0 D0145 Oral evaluation
More informationDental Fee Schedule Dental Advantage Essentials. What is the out-of-pocket limit? Primary care dentist
Dental Fee Schedule Dental Advantage Essentials This plan covers dental services for enrolled individuals age 18 and younger, as required under the Affordable Care Act. Out-of-Pocket Limit $350 per person
More informationD Pulp vitality tests $52.30 D Diagnostic casts $75.69 D Prophylaxis adult $ Page # 1
Boston Teachers Union Health and Welfare Group No: 006318 Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D0120 1 Periodic oral evaluation
More informationEmployee Benefit Fund July 2018 ADA Codes and Plan Fees
CSEA Employee Benefit Fund July 2018 ADA Codes and Plan Fees DIAGNOSTIC D0120 periodic oral examination 40 34 42 45 48 38 30 32 31 D0140 limited oral examination (Does not look at 9110) 40 34 42 45 48
More informationPLEASE READ IMPORTANT PLAN INFORMATION AT THE END OF THIS SCHEDULE
Careington Corporation Care POS Schedule CI-4 Please Call 800-290-0523 for Customer Service ***Discount plans are not insurance*** This schedule applies to services provided by a participating General
More informationDELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008
DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO TABLE OF ALLOWANCE The Delta Dental PPO table plan
More informationDINA Dental. Prepaid Plan Highlights. Prepaid Plan Bi-weekly Premiums $ 7.00 $10.76 $ Employee Only Employee + One Employee + Family
DINA Dental Prepaid Plan Highlights NO Claim Forms NO Maximums NO Deductibles NO Waiting Period - Some Preventive and Diagnostic Services Provided at NO CHARGE - Over 180 procedures covered by co-payments
More informationAflac Dental Insurance Premier Plus Coverage
Aflac Dental Insurance Premier Plus Coverage Policy Series A81400 Aflac will pay the following benefits when a charge is incurred for covered dental treatment that occurs while coverage is in force. If
More informationNewport News Public Schools Summary Schedule of Services Delta Dental PPO EPO Plan
Newport News Public Schools Summary of Services Delta Dental PPO EPO Plan Services In-Network Out-of-Network PPO Premier All Other Diagnostic & Preventive Oral Exams & Teeth Cleanings Fluoride Applications
More informationDelta Dental of Colorado DENVER HEALTH AND HOSPITAL AUTHORITY GROUP #587. EXCLUSIVE PANEL OPTION (EPO) List of Patient Copayments
List of Copayments Code edure Code Definition Copay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation
More informationSenior Dental Insurance Scheduled Allowance
Senior Dental Insurance Scheduled Allowance LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental services which will be considered for payment by The American Progressive Life
More informationMDG-FP-U10NYI04-SCH-NY-OFF-17
SECTION XVI MANAGED DENTALGUARD SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under Age 19 Two (2) or More Members under Age 19 Participating
More informationDELTA DENTAL PPO EPO PLAN DESIGN CP070
DELTA DENTAL PPO EPO PLAN DESIGN CP070 SCHEDULE OF BENEFITS AND The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations and exclusions of the program.
More informationAccess Dental Family DHMO
866-569-9900 HTTPS://MYDENTAL.GUARDIANLIFE.COM SCHEDULE OF BENEFITS Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Access Dental Individual & Family
More information08/03/2017 Procedure Code Procedure Name Procedure Type Value Plan Allowance Gold Plan Allowance Platinum Plan Allowance D0120 Periodic oral
D0120 Periodic oral evaluation - established patient. 1 *Full Coverage *Full Coverage *Full Coverage D0145 Oral evaluation for a patient under three years of age and counseling 1 *Full Coverage *Full Coverage
More informationExclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #
Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #6694 7.2011 MAXIMUM BENEFIT Calendar Year Orthodontic Lifetime CALENDAR YEAR DEDUCTIBLE WHO CAN BE COVERED
More informationTABLE OF DENTAL PROCEDURES PLATINUM PLAN PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.
TABLE OF DENTAL PROCEDURES PLATINUM PLAN PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are
More information2018 Dental Code Set For dates of service from 1/1/ /31/2018
D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED D0150 COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT D0160 DETAILED AND EXTENSIVE ORAL EVALUATION
More information2018 Dental Code Set
D0120 D0140 D0150 D0160 D0180 D0210 D0220 D0230 D0240 D0250 D0251 D0270 D0272 D0273 D0274 D0277 D0290 D0310 D0330 D0340 D0350 D0393 D0470 D0502 PERIODIC ORAL EVALUATION ESTABLISHED PATIENT LIMITED ORAL
More informationEXHIBIT A PROCEDURE DESCRIPTION MSP50809 CDT CODE
D0120 Periodic Exam 28.00 D0140 Limited Oral Evaluation Problem Focused 42.00 D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver 38.00 D0150 Comprehensive
More informationNDB Nevada Kids Silver In-Network Schedule of Benefits
NDB Nevada Kids Silver Diagnostic D0120 Periodic Oral Evaluation Established Patient (1 per 6 months)... No Charge D0140 Limited Oral Evaluation Problem Focused (3 per 6 months)... No Charge D0145 Oral
More informationScheduled Dental Benefit Plan Schedule of Dental Allowances
Diagnostic Scheduled Dental Benefit Plan Schedule of Dental Allowances 0120 Periodic Oral Evaluation (once in 5 months after comprehensive) 20.00 0140 Limited Oral Evaluation 20.00 0150 Comprehensive Oral
More informationConcordia Plus ScheduleofofBenefits
Concordia Plus ScheduleofofBenefits Benefits Concordia Plus Schedule Plan 931 Plan CACA 1131 IMPORTANT INFORMATION ABOUT YOUR PLAN ÂÂ This Schedule of Benefits provides a listing of procedures covered
More informationKaiser Permanente Insurance Company Dental Insurance Plan 2015 Table of Allowances
Kaiser Permanente Insurance Company Dental Insurance Plan 2015 Table of Allowances This plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan,
More informationour promise to State of Florida 2008
our promise to State of Florida 2008 TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures
More informationSchedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2016 Effective Date: January 1, 2016 Schedule: 1A Cert Base: 1 For: DMO - All
More information2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees
2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees Schedule effective date for all Plans: January 1, 2018 Annual Deductibles For all Plans: $50 per person
More informationSafeGuard Scheduled Reimbursement Dental Plan
Summary of Benefi ts Schedule of Reimbursements, Exclusions & Limitations Please refer to your Certifi cate of Insurance for full benefi t information. SafeGuard Scheduled Reimbursement Dental Plan Dental
More informationSouthern California Pipe Trades Administration Corporation ABREVIATED SCHEDULE OF DENTAL BENEFITS TABLE OF ALLOWANCES REVISED SEPTEMBER 30, 2016
The following is an abbreviated Schedule of Dental Benefits. All benefit payments are subject to Plan limits including the Calendar Year Deductible and any applicable coinsurance. D0120 Periodic Oral Evaluation
More informationCIGNA DENTAL CARE (*DHMO)
B1-05 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies
More informationFee Schedule Detail Procedure Procedure Description Code Fee
Fee Schedule Detail Procedure Procedure Description Code Fee D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $ 32.29 D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ 53.02 D0150 COMPREHENSIVE ORAL
More informationASSISTANT SECRETARY PRESIDENT
Charge Code TYPE I* Benefit Co-Insurance $21.00 0120* Periodic oral exam $21.00 Balance Billing $30.00 0140* Limited oral exam $30.00 Balance Billing $35.00 0150* Comprehensive oral evaluation $35.00 Balance
More informationSchedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: Roman Catholic Diocese Of Dallas GP-870560-WI Issue Date: February 9, 2015 Effective Date: January 1, 2015 Schedule: 7A Cert Base:
More informationSchedule of Benefits Access Dental Family DHMO
Schedule of Benefits Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Premier Access Individual & Family Plan, as well as the Copayments associated with
More informationDelta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM
Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM SCHEDULE OF BENEFITS AND COPAYMENTS/ The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations
More informationDelta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
More information2016 Dental Code Set For dates of service from 1/1/16-12/31/16
HCPCS DESCRIPTIONS D0120 D0140 D0150 D0160 D0180 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0290 D0310 D0330 D0340 D0350 D0470 D0502 D1110 D1206 D1208 D1352 D2140 D2150 D2160 D2161
More informationStaywell FL Child Medicaid Plan Benefits
The following is a complete list of dental procedures for which benefits are payable under this Plan. For beneficiaries under age 21, additional coverage may be available with documentation of medical
More informationDelta Dental EPO City & County of Denver Group #6791 EPO
MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule
More informationdeltadentalins.com/usc
Plan Benefit Highlights for: UNIVERSITY OF SOUTHERN CALIFORNIA STUDENT PLAN Group No: 05008 The Delta Dental PPO table plan provides you great dental benefits at a reasonable cost. With a table of allowance
More informationSchedule of Benefits (GR-9N S )
Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 1A Cert Base: 1 For: DMO - All
More informationTYPE 1 PROCEDURES PAYMENT BASIS - Maximum Covered Expense BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations
TYPE 1 PROCEDURES PAYMENT BASIS - BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations ROUTINE ORAL EVALUATION D0120 Periodic oral evaluation - established patient. $14.00 D0145
More informationSCHEDULE A Description of Benefits and Copayments DHMO-PA3
SCHEDULE A Description of Benefits and s DHMO-PA3 855.280.2882 WWW.PREMIERLIFE.COM The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to the limitations
More informationCovered Dental Services and Patient Charges U10TXI04
The services covered by this Plan are named in this list. If a service, treatment or procedure is not on this list, it is not a covered service. All services must be provided by the assigned PCD. The Member
More informationSECTION XVII. EssentialSmile 111, NS, INN, Family Dental, Dep 29 SCHEDULE OF BENEFITS
SECTION XVII. EssentialSmile 111, NS, INN, Family Dental, Dep 29 SCHEDULE OF BENEFITS COST- Participating Provider Member Responsibility for Cost-Sharing Non-Participating Provider Member Responsibility
More informationDENTAL GRID - SCMEBF Page 1 of 8 Vol. 1 #7 as of 1/16/18
0120 Periodic oral evaluation - established patient $25 0140 Limited oral evaluation - problem focused $30 0150 Comprehensive oral eval.-new or established patient $35 0160 0180 Detailed & extensive oral
More informationAetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: BNSF Railway Company GROUP AGREEMENT: 727796 PLAN EFFECTIVE: January 1, 2016 The benefits
More informationCDT updates on this schedule are subject to approval by regulatory agencies in the following states: CA, FL, MD, MO, NY, OK, TX, VA and WA
CDT updates on this schedule are subject to approval by regulatory agencies in the following states: CA, FL, MD, MO, NY, OK, TX, VA and WA SCHEDULE A Description of Benefits and Copayments The Benefits
More informationFEE SCHEDULE. Complete Dental Plan is a discount plan offered and administered by our organization at:
FEE SCHEDULE Complete Dental Plan is a discount plan offered and administered by our organization at: 7801 CORAL WAY SUITE # 106, MIAMI, FL 33144 (786) 326-6873 F (305) 6979785 COMPLETE DENTAL PLAN HIGHLIGHTS
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
More informationSummary of Benefits - Dental HMO Deluxe Plan
Office visit Office visit $5 per visit Diagnostic (exams and x-rays) D0120 Periodic oral evaluation You pay nothing D0140 Limited oral evaluation - problem focused You pay nothing D0145 Oral evaluation
More informationLOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16
APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.
More informationAetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE
Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: Clear Creek ISD GROUP AGREEMENT: 620318 PLAN EFFECTIVE: September 1, 2014 The benefits shown
More informationEssentialSmile Ped 221 Schedule of Benefits
EssentialSmile Ped 221 Schedule of Benefits P.O. Box 19199 Plantation, FL 33318 Telephone: 877-760-2247 Fax: 954-370-1701 www.mysolstice.net Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx
More informationEssentialSmile Ped 221 Schedule of Benefits
EssentialSmile Ped 221 Schedule of Benefits P.O. Box 9 Plantation, FL 33318 Telephone: 877 760 2247 Fax: 954 370 1701 www.mysolstice.net Members can search for a Network Provider atwww.solsticecare.com/provider
More informationNDB Nevada Kids Silver In-Network Schedule of Benefits
Diagnostic D0120 Periodic Oral Evaluation - Established Patient (1 Per 6 No Charge D0140 Limited Oral Evaluation - Problem Focused (As Necessary) (3 Per 6 No Charge D0145 Oral Evaluation for a Patient
More informationPlan CA15B DeltaCare USA Description of Benefits and Copayments
SCHEDULE A Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program.
More informationNC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2017
NC Dental Reimbursement s Refer to the NC and Health Choice Clinical Coverage Policies on the DMA website. D0120 Periodic oral evaluation 24.51 D0140 Limited oral evaluation - problem focused 34.94 D0145
More informationAPPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
More informationHSCSN Table Top Reference Guide
Age Limitation Covered One per 6 months per dentist or dental group. Only one exam (D0120) every 6 months per dentist or dental D0120 iodic oral evaluation 0-20 No group. D0140 Limited oral evaluation
More informationCalifornia Family Dental HMO
California Family Dental HMO This Schedule of Benefits lists the services available to you under your Access Dental Individual Plan, as well as the Copayments associated with each procedure. Please review
More informationCIGNA Dental Care (*DHMO) Patient Charge Schedule
G1-07 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered
More informationSupplemental Dental Codes List
Supplemental Dental Codes List The following list of preventive and comprehensive dental codes is effective as of 01/01/2019. Covered codes may change throughout the year. Covered codes vary by plan. The
More informationImprove your smile and overall well-being with. Dental Health Services. Dental Health Services. Difference today!
Improve your smile and overall well-being with Dental Health Services Great oral health is essential for your overall well-being. With a Dental Health Services plan, you can achieve a healthy smile while
More informationSCHEDULE OF DENTAL PROCEDURES. This schedule accompanies Plan 2 Brochure A82275.
SCHEDULE OF DENTAL PROCEDURES This schedule accompanies Plan 2 Brochure A82275. TERMS YOU NEED TO KNOW COVERED PERSON: Any person insured under the coverage type you applied for: individual (named insured
More informationMassachusetts State Health Care Professionals' Dental Fund Group Number: Schedule of Dental Benefits (Maximum Payments) Effective
D0120 I Periodic oral evaluation (maximum of two per calendar year)* 100% 100% D0140 I Limited oral evaluation - problem focused (maximum of two per calendar year) 100% 100% D0145 I Oral Evaluation under
More informationSOLSTICE S700PB. CODE DESCRIPTION MEMBER'S COPAY periodontal evaluation - new or established patient CODE DESCRIPTION MEMBER'S COPAY APPOINTMENTS
SOLSTICE S700PB SCHEDULE OF BENEFITS Members of the Solstice S700 dental plan are eligible to receive benefits immediately upon the effective date of coverage with: No Waiting Periods No Deductibles No
More informationARGUS DENTAL & VISION, INC.
Schedule of Benefits: The below co-payments contained in this fee schedule are valid when treatment is provided by a Participating Dentist. If the services of a Non-Participating Dentist are recommended
More informationSupplemental Dental Codes List
Supplemental Dental Codes List The following list of preventive and comprehensive dental codes is effective as of 01/01/2019. Covered codes may change throughout the year. Covered codes vary by plan. The
More informationSCHEDULE OF BENEFITS
SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN* HN Plus DHMO 185 This Schedule of Benefits lists the services available to you under your Health Net plan, as well as the co- payments associated with
More informationINDIANA HEALTH COVERAGE PROGRAMS
INDIANA HEALTH COVERAGE PROGRAMS PROVIDER CODE TABLES Note: Due to possible changes in Indiana Health Coverage Programs (IHCP) policy or national coding updates, inclusion of a code on the code tables
More informationAPPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE
: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures
More information