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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

Scheduled Dental Benefit Plan Schedule of Dental Allowances

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Fee Schedule Detail Procedure Procedure Description Code Fee

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Employee Benefit Fund July 2018 ADA Codes and Plan Fees

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EssentialSmile Ped 221 Schedule of Benefits

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General Dentist Fee Schedule

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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

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

Newport News Public Schools Summary Schedule of Services Delta Dental PPO EPO Plan

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GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual

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2018 fee schedule. Georgia. Diagnostic Services (Performed by a General Dentist)

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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

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

DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008

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deltadentalins.com/usc

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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

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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

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ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or

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IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation

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MY 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

BOSTON 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

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Please note a few important reminders to help expedite the process of dental claims/estimates:

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TEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National

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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

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

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

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This 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

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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

For a Correction Captains Association Dental Claim Form please follow this link CCA Dental Claim form.pdf

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08/03/2017 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

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

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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

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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

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CODE PROCEDURE Office Visit Copay PATIENT PAYS $0 D2510 Inlay - Metallic 1 Surf D6073 Abutment Supported Retainer for Cast Metal FPD (Predominantly Base Metal) D2520 Inlay - Metallic 2 Surf D6074 Abutment

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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

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PATIENT PAYS PATIENT PAYS CODE PROCEDURE CODE PROCEDURE Office Visit Copay $0 DIAGNOSTIC D0120-D0180 Oral Evaluations D0277 Vertical Bitewings - 7 to 8 Films D0210 Full mouth series Images D0330 Panoramic

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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

our promise to State of Florida 2008

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Frequently Used Dental Codes Intermediate/Major Category Description GOLD FOIL - TWO SURFACES

Code D2410 D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782

EFFECTIVE DATE: 04/24/14 REVISED DATE: 04/23/15, 04/28/16, 06/22/17, 06/28/18 POLICY NUMBER: CATEGORY: Dental

MEDICAL POLICY SUBJECT: DENTAL IMPLANTS PAGE: 1 OF: 5 If a product excludes coverage for a service, it is not covered, and medical policy criteria do not apply. If a commercial product (including an Essential

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