EPSDT PROCEDURE CODES
|
|
|
- Franklin Morgan
- 5 years ago
- Views:
Transcription
1 EPSDT PROCEDURE CODES Provided in the tables on the following pages are the procedure codes for EPSDT Dental Services. All procedure codes designated as non-specific are meant to cover procedures not specifically assigned an individual procedure code. The provider must furnish detailed information as to the nature of the procedure, justification for the provision of the procedure, and the provider's usual and customary fee. All services marked with an asterisk (*) require prior authorization. All services marked with a number sign (#) require a tooth number or letter, a quadrant designator, or an arch designator in the tooth # or letter column of the ADA Dental Claim Form in order for the claim to be processed. Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright 2015 American Dental Association. The CDT Code and Nomenclature used throughout this document have been obtained from Current Dental Terminology (including procedure codes, nomenclatures, descriptors and other data contained therein) ( CDT ). CDT is copyright 2015 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Page 1 of 6
2 DIAGNOSTIC AND PREVENTIVE DENTAL PROCEDURE CODES Periodic Oral Examination Patient of Record Emergency or Referral Exam No Treatment. Do not bill with any other procedure (except x-ray radiographs) on the same day (Consult, Prescription Rx) *00210 Full Mouth x-ray radiograph #00220 First P.A. x-ray radiograph 5.00 #00230 Each added P.A. x-ray radiograph - Limit *00240 Occlusal x-ray radiograph Bitewing x-rays radiographs Limit 1 set/yr/same provider *00330 Panographic-Type Radiograph *00470 Diagnostic Casts *00501 Biopsy/Report Adult Prophy 12 to 21 years Child Prophy - Toothbrush or Rubber Cup Topical Fluoride (Excluding Prophy) 16 Yrs. Maximum Age Limit - Limit One per Year with Same Provider #01351 Sealant/Tooth - 6 yr. and 12 yr. Molars Only Limit 1/Lifetime/Same Provider *01510 Fixed Unilateral Spacer *01515 Fixed Bilateral Spacer Page 2 of 6
3 RESTORATIVE DENTAL PROCEDURE CODES #02110 Amalgam 1 Surface Deciduous #02120 Amalgam 2 Surface Deciduous #02130 Amalgam 3 Surface Deciduous #02140 Amalgam 1 Surface Permanent #02150 Amalgam 2 Surface Permanent #02160 Amalgam 3 Surface Permanent #02330 Resin 1 Surface #02331 Resin 2 Surfaces #02332 Resin 3 Surfaces #*02930 Stainless Steel Crown, Primary Tooth #*02931 Stainless Steel Crown, Permanent Tooth #*02932 Polycarbonate Crown #*02950 Crown Buildup (Amalgam or Resin) #02951 Pin Limit 1 Per Tooth #*02954 Post and Core #*02999 Non-Specific Restoration (With Report) ***** ENDODONTIA DENTAL PROCEDURE CODES #03110 Pulp Cap Direct Only #03220 Pulpotomy #*03310 Root Canal 1 Canal #*03320 Root Canal 2 Canals #*03330 Root Canal 3 Canals Page 3 of 6
4 ENDODONTIA DENTAL PROCEDURE CODES #*03351 Apexification Initial Visit #*03352 Apexification 2 nd Visit #*03353 Apexification Final Visit #*03410 Apicoectomy #*03999 Unspecified Endodontic Procedure, By Report ***** PERIODONTIA DENTAL PROCEDURE CODES #*04210 Gingivectomy Per Quadrant List Quadrant #*04341 Periodontal Scaling Per Quadrant List Quadrant *04910 Periodontal Prophy *04999 Non-Specific Periodontal (With Report) ***** PROSTHETICS DENTAL PROCEDURE CODES *05110 Full Upper Denture *05120 Full Lower Denture *05130 Immediate Full Upper Denture *05140 Immediate Full Lower Denture *05211 Upper Acrylic Partial/Clasp *05212 Lower Acrylic Partial/Clasp *05213 Upper Cast Partial/Acrylic *05214 Lower Cast Partial/Acrylic #05510 Repair Full Denture Base Page 4 of 6
5 PROSTHETICS DENTAL PROCEDURE CODES #05520 Replace 1 Tooth On Denture or Partial #05521 Replace 2 Teeth On Denture or Partial #05522 Replace 3 Teeth On Denture or Partial #05523 Replace 4 Teeth On Denture or Partial #05610 Repair Partial Base #05630 Repair/Add Clasp (Cast) #05635 Repair/Add Clasp (Wire) *05750 Reline Full Upper Denture - Laboratory Reline *05751 Reline Full Lower Denture Laboratory Reline *05760 Reline Upper Partial Laboratory Reline *05761 Reline Lower Partial Laboratory Reline *05820 Upper Flipper *05821 Lower Flipper #*05999 Non-Specific Prosthetics (With Report) ***** CROWN AND BRIDGE DENTAL PROCEDURE CODES *06242 Porcelain/Metal Pontic #*06752 Porcelain/Metal Crown #*06792 Cast Metal Crown *06330 Maryland Bridge *06999 Non-Specific Crown and Bridge (With Report) ***** Page 5 of 6
6 ORAL SURGERY PROCEDURE CODES #07110 Simple Extraction #*07210 Surgical Extraction #*07220 Soft Tissue Impaction #*07230 Partial Bony Impaction #*07240 Full Bony Impaction #*07310 Alveoloplasty Per Quadrant Incision and Drainage *07960 Frenulectomy #*07971 Pericoronal Excision *07999 Non-Specific Oral Surgery (With Report) ***** MISCELLANEOUS SERVICES PROCEDURE CODES *08999 Non-Specific Ortho. (With Report) ***** Palliative Treatment Do not bill with other treatment on the same date of service Nitrous Oxide 7.00 *09240 I.V. Sedation *09410 Emergency Hospital/Home/After Hours Office Visit *09420 Hospitalization *09630 Conscious Sedation *09920 Pain Management #*09951 Occlusal Adjustment Per Quadrant Page 6 of 6
LOUISIANA 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.
LOUISIANA 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.
APPENDIX 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
APPENDIX 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
APPENDIX 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
Employee 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
General 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
General 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
SECURE 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
Delta 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
SECTION 8 DENTAL BENEFITS SCHEDULE OF DENTAL BENEFITS
SECTION 8 DENTAL BENEFITS The Fund pays up to a maximum of $2,000 per year for Dental expenses incurred by Participants and/or Dependents age 19 or over in accordance with the Schedule of Dental benefits;
For a Correction Captains Association Dental Claim Form please follow this link CCA Dental Claim form.pdf
Correction Captains Association Retiree Security Benefit Fund Group #132 Summary of Benefit for Retired members: Annual maximum $3,500.00 individual Individual Ortho Lifetime max $3,500 Appliance $600,
Delta 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
RETIREE 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
CHOICES Patients Covered dental services
CHOICES Patients Covered dental services Important points: There is a $7 co-pay for each covered service visit at the UF College of Dentistry except for some denture therapy services which may require
Managed 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
Schedule 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
Schedule 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:
Newport 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
DIAGNOSTIC/PREVENTIVE SERVICES
DIAGNOSTIC/PREVENTIVE SERVICES Diagnostic Services D0120 Periodic oral evaluation 100% 100% D0140 Limited oral evaluation problem focused 100% 100% D0150 Comprehensive oral evaluation 100% 100% D0160 Detailed
ADA Code Restorative Procedures (Fillings) Member Fee Usual Fee You Save D2951 Pin retention per tooth $ 35.00
Northeast General Dentistry Fee Schedule I District of Columbia, Maryland, New Jersey, New York, Pennsylvania, Virginia Please note: This fee schedule applies to procedures performed by a General Dentists
Schedule 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
Delta 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
SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS
SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under age 19 Two (2) or more Members
Staywell 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
DELTA 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.
Aetna 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
Aetna 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
Exclusive 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
ATTACHMENT AA DentaQuest of Illinois, LLC
DentaQuest of Illinois, LLC 112 ATTACHMENT AA DentaQuest of Illinois, LLC HFS Dental Program Fee Schedule for and Adult Beneficiaries Rates Effective July 1, 2009 Please note: have limited dental coverage.
Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits
Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual
GUARANTY 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
GUARANTY 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
SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits
COST-SHARING SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx Member Services:
DENTAL RATE FEE SCHEDULE rates effective 5/1/15 through 6/30/15
Procedure Code D0120 Description April 2014 Fee Rate cute 16.75% Amount of Reduction May/June 2015 Fee $28.00 $28.00 Periodic Oral Exam Ages 0 thru 18 D0120 Periodic Oral Exam Ages 19 thru 20 and Pregnant
Scheduled 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
Concordia 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,
Code Description Cap Freq D5660 ADD CLASP TO EXISTING PARTIAL DENTURE - PER TOOTH 4 1
Code Description Cap Freq D5660 ADD CLASP TO EXISTING PARTIAL DENTURE - PER TOOTH D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE D5411 ADJUST COMPLETE DENTURE - MANDIBULAR D5410 ADJUST COMPLETE DENTURE -
CIGNA Dental Care (*DHMO) Patient Charge Schedule
A2O07 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
Summary 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
Delta 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
ADA Code Cosmetic Procedures Member Fee Usual Fee You Save Bonding (per tooth): D2960 Full face buildup chairside $
New England General Dentistry Fee Schedule Connecticut, Massachusetts, New Hampshire & Rhode Island Please note: This fee schedule applies to procedures performed by a General Dentists only. Rates are
LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule
LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule Members must select, and be assigned to, a LIBERTY Dental Plan contracted dental office to utilize covered benefits. LIBERTY Dental Plan
Texas Essential Health Benefit PLUS Family Plan with EHB PLUS (for Children)
This summary of benefits, along with the exclusions and limitations describe the benefits of the Essential Health Benefit PLUS Family Plan with EHB PLUS (for Children). Please review closely to understand
MDG 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
Please note a few important reminders to help expedite the process of dental claims/estimates:
To: Valued Members and Providers From: Member Services Date: January 2019 RE: Attached is the for all members. Note: The Plan Pays amount on the fee schedule already has the percentages factored in. The
Delta 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
MDG-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
ASSISTANT 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
LIST 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
cigna dental care (*DHMO) patient charge schedule
C15V9 Subject to regulatory approval cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights
Dental Rate Increases
Dental Fee Reimbursement Increases, New EPSDT Dental Procedure Codes and Policy Revisions Effective for Dates of Service On and After December 24, 2008 Dental Rate Increases Effective retroactively for
California Children s Dental PPO
This Schedule of Benefits, along with the Exclusions and describe the benefits of the Children s Dental PPO Plan. Please review closely to understand all benefits, exclusions and limitations. Member Cost
AmeriPlan 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
(315) (315) $1,500 & PREVENTIVE
SERVICE EMPLOYEES BENEFIT FUND Phone (315) 218-6513 Fax (315) 701-0686 Dental Schedule of Benefits Calendar year maximum $1,500 per person/no deductible Procedure Code Description Reimbursement DIAGNOSITC
Managed 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
Access 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
DINA 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
SCHEDULE A Description of Benefits and Copayments DHMO-901
866.650.3660 WWW.PREMIERLIFE.COM SCHEDULE A Description of Benefits and Copayments DHMO-901 The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to
Dental 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
ADA 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
HUDSON VALLEY COMMUNITY COLLEGE DENTAL BENEFITS PLAN SCHEDULE OF ALLOWANCES
HUDSON VALLEY COMMUNITY COLLEGE DENTAL BENEFITS PLAN SCHEDULE OF ALLOWANCES 1 PLAN ADMINISTERED BY DELTA DENTAL Effective January 1, 2015 Annual Maximum for all services - $1200 DIAGNOSTIC Clinical Oral
State of Tennessee. Prepaid Plan. Dental Benefit Option. Sponsored by the. State of Tennessee
State of Tennessee Prepaid Plan Dental Benefit Option Sponsored by the State of Tennessee 2011 Products and services marketed by Assurant Employee Benefits are underwritten and/or provided by Union Security
Massachusetts Family High Dental Plan with Enhanced Child Orthodontia
SCHEDULE OF BENEFITS Massachusetts Family High Dental Plan with Enhanced Child Orthodontia This Schedule of Benefits lists the services available under the MetLife plan, as well as the co-insurance payments
ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS
PRESTIGE 25 Schedule of Benefits and Subscriber Copayments ADA CODE PROCEDURE PATIENT PAYS ADA CODE PROCEDURE PATIENT PAYS APPOINTMENTS 5130 Immediate maxillary (upper)...$300.00 9430 Office visit (normal
Fee 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
Concordia Plus Schedule of Benefits
Concordia Plus Schedule of Benefits Plan TX IMPORTANT INFORMATION ABOUT YOUR PLAN The pays a $ office visit Copayment per visit in addition to the Copayments listed on this Schedule of Benefits. This schedule
TX Prepaid DHMO Dental
TX Prepaid DHMO Dental Good news about dental benefits for employees of Pearland Independent School District A Dental Plan Means Healthy Smiles Because you are a valued employee, we are pleased to offer
LIST OF COVERED DENTAL SERVICES PREVENTIVE SERVICES
The Guardian Life Insurance Company of America A Mutual Company Incorporated 1860 by the State of New York 7 Hanover Square, New York, New York 10004 (212)598-8000 DENTAL POLICY OUTLINE OF COVERAGE This
Concordia 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
Careington 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
SHL Dental PPO Plan 29 - SB Adult Only Coverage
SHL Dental PPO Plan 29 - SB Adult Only Coverage Attachment A Benefit Schedule Please read the definition of Eligible Dental Expenses ( EDE ) and SHL Reimbursement Schedule in the Certificate. When accessing
Covered 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
WASHINGTON STATE COUNCIL OF COUNTY AND CITY EMPLOYEES AFSCME AFL-CIO DENTAL PLAN VIII
WASHINGTON STATE COUNCIL OF COUNTY AND CITY EMPLOYEES AFSCME AFL-CIO DENTAL PLAN VIII HOW TO OBTAIN PLAN BENEFITS To obtain benefits see the Payment of Claims provision. Forward Your completed claim form
The. Dental Plan. Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation
The Dental Plan Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation Now you can have comprehensive DENTAL coverage at a cost you can afford! Since 1981, Denta-Chek has been providing
HumanaDental PPO 09 (High Option)
HumanaDental PPO 09 (High Option) FLORIDA ICUBA If you use IN-NETWORK provider If you use OUT-OF-NETWORK provider Plan-year deductible Annual maximum Preventive services Oral examinations X-rays Cleanings
CIGNA 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
2018 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
Out-of- In-Network Essential Health Benefit. Network** N/A Class IV/Orthodontia N/A Deductible. $0 $50 Out of Pocket Maximum
Utah Essential Health Benefit PPO Family Plan with EHB (for Children) This summary of benefits, along with the exclusions and limitations describe the benefits of the Essential Health Benefit PPO Family
DMO Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS $0 CODE DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic
This Patient Charge Schedule lists the benefits of the Dental Plan including covered procedures and patient charges.
A3O09 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
D0120 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
CIGNA 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
Active. Comparison of Dental Benefits
Carpenters Southwest Administrative Corporation ADMINISTRATIVE OFFICE: 533 S. Fremont Ave. Los Angeles, CA 90071-1706 Tel: (213) 386-8590 Toll Free: (800) 293-1370 www.carpenterssw.org Active Comparison
DID YOU KNOW? Every in preventive oral care can save in restorative and emergency treatments. 1
DID YOU KNOW? Every in preventive oral care can save in restorative and emergency treatments. 1 Research shows that oral health and overall health are closely related. So when you keep your teeth healthy,
SCHEDULE OF BENEFITS POLICY BENEFITS
The Guardian Life Insurance Company of America A Mutual Company Incorporated 1860 by the State of New York 7 Hanover Square, New York, New York 10004 SCHEDULE OF BENEFITS The Schedule of Benefits provides
INDIANA 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
State of Tennessee Prepaid Plan
State of Tennessee Prepaid Plan Dental Benefit Option Sponsored by the State of Tennessee 2009 Products and services marketed by Assurant Employee Benefits are underwritten and/or provided by Union Security
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
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
State of TN Cigna Dental Care (*DHMO) Patient Charge Schedule Plan effective 1/1/2016
State of TN Cigna Dental Care (*DHMO) Schedule Plan effective 1/1/2016 This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule
EssentialSmile 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
PLEASE 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
Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS CODE $5 DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 FMS (inc. BWX) D0330 Panoramic X-Ray
Senior 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
EssentialSmile 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
Dental Benefits Summary
CODE PROCEDURE Office Visit Copay PATIENT PAYS CODE $0 DIAGNOSTIC PROCEDURE PATIENT PAYS D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series X-rays D0330 Panoramic
Kaiser Permanente and Delta Dental
Kaiser Permanente and Delta Dental Dental Program for Kaiser Permanente FEHBP Enrollees You must be a Kaiser Permanente FEHBP enrollee to participate in the dental plan. Kaiser Permanente and Delta Dental
EXHIBIT 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