S:\Rates\2014\F12-02-DentalProvider-FeeSchedule Rev
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1 120 PERIODIC ORAL EVALUATION ESTABLISHED PATIENT LIMITED ORAL EVALUATION - PROBLEM FOCUSED ORAL EVAL PT UND 3 YR AGE CNSL W/PRIM CAREGIVER COMP ORAL EVALUATION - NEW/ESTABLISHED PATIENT DTL&EXT ORAL EVALUATION - PROBLEM FOCUSED REPORT COMP PERIODONTAL EVALUATION - NEW/EST PATIENT INTRAORAL-COMPLETE SERIES INTRAORAL-PERIAPICAL-FIRST FILM INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM INTRAORAL - OCCLUSAL FILM BITEWING - SINGLE FILM BITEWINGS - TWO FILMS BITEWINGS - THREE FILMS BITEWINGS - FOUR FILMS VERTICAL BITEWINGS - 7 TO 8 FILMS PANORAMIC FILM CEPHALOMETRIC FILM PULP VITALITY TESTS DIAGNOSTIC CASTS ACCESS TISSUE GR&MIC EXAMINATION PREP/REPRT PROPHYLAXIS - ADULT PROPHYLAXIS - CHILD TOP FLUORIDE VARNISH; TX APPL MOD-HI CARIES RISK TOPICAL APPLICATION OF FLUORIDE SEALANT - PER TOOTH PREV RSN REST MOD HIGH CARIES RISK PT-PERM TOOTH SPACE MAINTAINER - FIXED-UNILATERAL SPACE MAINTAINER - FIXED-BILATERAL SPACE MAINTAINER - REMOVABLE-UNILATERAL SPACE MAINTAINER - REMOVABLE-BILATERAL RECEMENTATION OF SPACE MAINTAINER
2 2140 AMALGAM-ONE SURFACE PRIMARY OR PERMANENT AMALGAM-TWO SURFACES PRIMARY OR PERMANENT AMALGAM-THREE SURFACES PRIMARY OR PERMANENT AMALGAM-FOUR/MORE SURFACES PRIMARY/PERMANENT RESIN-BASED COMPOSITE ONE SURFACE ANTERIOR RESIN-BASED COMPOSITE TWO SURFACES ANTERIOR RESIN-BASED COMPOSITE THREE SURFACES ANTERIOR RESIN-BASED COMPOSITE 4/> SURFACES INCISAL ANGLE RESIN-BASED COMPOSITE CROWN ANTERIOR RESIN-BASED COMPOSITE - ONE SURFACE POSTERIOR RESIN-BASED COMPOSITE - TWO SURFACES POSTERIOR RESIN-BASED COMPOSITE - THREE SURFACES POSTERIOR RESIN COMPOS - FOUR OR MORE SURFACES POSTERIOR INLAY - METALLIC - ONE SURFACE INLAY - METALLIC - TWO SURFACES INLAY - METALLIC - THREE OR MORE SURFACES ONLAY - METALLIC - TWO SURFACES ONLAY METALLIC THREE SURFACES ONLAY METALLIC FOUR OR MORE SURFACES INLAY - PORCELAIN/CERAMIC - ONE SURFACE INLAY - PORCELAIN/CERAMIC - TWO SURFACES INLAY - PORCELAIN/CERAMIC - THREE/MORE SURFACES ONLAY - PORCELAIN/CERAMIC - TWO SURFACES ONLAY - PORCELAIN/CERAMIC - THREE SURFACES ONLAY - PORCELAIN/CERAMIC - 4 OR MORE SURFACES CROWN RESINBASED COMPOSITE INDIRECT CROWN - RESIN WITH HIGH NOBLE METAL CROWN - RESIN WITH PREDOMINANTLY BASE METAL CROWN - RESIN WITH NOBLE METAL CROWN - PORCELAIN/CERAMIC SUBSTRATE CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL
3 2751 CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL CROWN - PORCELAIN FUSED TO NOBLE METAL CROWN - 3/4 CAST HIGH NOBLE METAL CROWN - 3/4 CAST PREDOMINATELY BASE METAL CROWN - 3/4 CAST NOBLE METAL CROWN - 3/4 PORCELAIN/CERAMIC CROWN - FULL CAST HIGH NOBLE METAL CROWN - FULL CAST PREDOMINANTLY BASE METAL CROWN - FULL CAST NOBLE METAL RECEMENT INLAY ONLAY/PART COVERAGE RESTORATION RECEMENT CROWN PREFABR STAINLESS STEEL CROWN - PRIMARY TOOTH PREFABR STAINLESS STEEL CROWN - PERMANENT TOOTH PREFABRICATED RESIN CROWN PREFABR STAINLESS STEEL CROWN W/RESIN WINDOW PROTECTIVE RESTORATION CORE BUILDUP INCLUDING ANY PINS PIN RETENTION - PER TOOTH ADDITION RESTORATION POST AND CORE ADDITION TO CROWN INDIRECTLY FAB EACH ADDITIONAL INDIRECTLY FAB POST SAME TOOTH PREFABRICATED POST AND CORE IN ADDITION TO CROWN LABIAL VENEER - LABORATORY TEMPORARY CROWN FRACTURED TOOTH ADD PROC NEW CRWN UND XSTING PART DENTUR FRMEWRK PULP CAP - DIRECT PULP CAP - INDIRECT TX PULP-REMV PULP CORONAL DENTINOCEMENTL JUNC PULPAL DEBRIDEMENT PRIMARY AND PERMANENT TEETH PULPAL THERAPY - ANTERIOR PRIMARY TOOTH PULPAL THERAPY - POSTERIOR PRIMARY TOOTH ENDODONTIC THERAPY ANTERIOR TOOTH
4 3320 ENDODONTIC THERAPY BICUSPID TOOTH ENODODONTIC THERAPY MOLAR INTERNAL ROOT REPAIR OF PERFORATION DEFECTS RETREATMENT PREVIOUS RC THERAPY - ANTERIOR RETREATMENT PREVIOUS RC THERAPY - BICUSPID RETREATMENT PREVIOUS ROOT CANAL THERAPY - MOLAR APEXIFICATION/RECALCIFICAT/PUPAL REGEN INIT VST APEXIFICAT/RECALCIFICAT/PUPAL REGEN INT MED REPL APEXIFICATION/RECALCIFICATION - FINAL VISIT APICOECTOMY/PERIRADICULAR SURGERY - ANTERIOR APICOECTOMY/PERIRADICULAR SURGERY - MOLAR APICOECTOMY/PERIRADICULAR SURGERY RETROGRADE FILLING - PER ROOT ROOT AMPUTATION - PER ROOT CANAL PREPARATION&FITTING PREFORMED DOWEL/POST GINGIVECT/PLSTY 4/>CNTIG/TOOTH BOUND SPACES-QUAD GINGIVECT/PLSTY 1-3 CNTIG/TOOTH BOUND SPACE-QUAD GINGL FLP PROC 4/> CONTIG/TOOTH BOUND SPACE-QUAD GINGL FLP PROC 1-3 CONTIG/TOOTH BOUND SPACE-QUAD CLINICAL CROWN LENGTHENING - HARD TISSUE OSSEOUS SURG 4/> CONTIG/TOOTH BOUND SPACES-QUAD OSSEOUS SURG 1-3 CONTIG/TOOTH BOUND SPACES-QUAD BONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANT BONE REPLACEMENT GRAFT - EA ADD SITE QUADRANT GUID TISSUE REGEN - RESORBABLE BARRIER PER SITE GUID TISSUE REGEN - NONRESORB BARRIER PER SITE SUBEPITHEL CONECTIVE TISSUE GRAFT PROC PER TOOTH DISTAL OR PROXIMAL WEDGE PROCEDURE SOFT TISSUE ALLOGRAFT COMB CNCTIVE TISSUE&DBL PEDICLE GRAFT PER TOOTH SOFT TISSUE GRAFT PROCEDURE FIRST TOOTH
5 4278 SOFT TISSUE GRAFT PROCEDURE EACH ADD TOOTH PRDONTAL SCALING&ROOT PLANING 4/MORE TEETH-QUAD PRDONTAL SCALING&ROOT PLANING 1-3 TEETH-QUAD PERIODONTAL MAINTENANCE COMPLETE DENTURE - MAXILLARY COMPLETE DENTURE - MANDIBULAR IMMEDIATE DENTURE - MAXILLARY IMMEDIATE DENTURE - MANDIBULAR MAXILLARY PARTIAL DENTURE - RESIN BASE MANDIBULAR PARTIAL DENTURE - RESIN BASE MAX PART DENTUR-CAST METL FRMEWRK W/RSN BASE MAND PART DENTUR- CAST METL FRMEWRK W/RSN BASE MAXILLARY PARTIAL DENTRUE FLEXIBLE BASE MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE ADJUST COMPLETE DENTURE - MAXILLARY ADJUST COMPLETE DENTURE - MANDIBULAR ADJUST PARTIAL DENTURE - MAXILLARY ADJUST PARTIAL DENTURE - MANDIBULAR REPAIR BROKEN COMPLETE DENTURE BASE REPLACE MISSING/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 REBASE COMPLETE MAXILLARY DENTURE REBASE COMPLETE MANDIBULAR DENTURE REBASE MAXILLARY PARTIAL DENTURE REBASE MANDIBULAR PARTIAL DENTURE RELINE COMPLETE MAXILLARY DENTURE CHAIRSIDE
6 5731 RELINE COMPLETE MANDIBULAR DENTURE CHAIRSIDE RELINE MAXILLARY PARTIAL DENTURE CHAIRSIDE RELINE MANDIBULAR PARTIAL DENTURE CHAIRSIDE RELINE COMPLETE MAXILLARY DENTURE LABORATORY RELINE COMPLETE MANDIBULAR DENTRUE LABORATORY RELINE MAXILLARY PARTIAL DENTURE LABORATORY RELINE MANDIBULAR PARTIAL DENTURE LABORATORY INTERIM COMPLETE DENTURE MAXILLARY INTERIM COMPLETE DENTURE MANDIBULAR INTERIM PARTIAL DENTURE MAXILLARY INTERIM PARTIAL DENTURE MANDIBULAR TISSUE CONDITIONING MAXILLARY TISSUE CONDITIONING MANDIBULAR ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN ABUT SUPP PORCELAIN TO METL CROWN HI NOBLE METL IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWN IMPLANT SUPPORTED METAL CROWN PONTIC - CAST HIGH NOBLE METAL PONTIC - CAST PREDOMINANTLY BASE METAL PONTIC - CAST NOBLE METAL PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL PONTIC - PORCELN FUSED PREDOMINANTLY BASE METAL PONTIC - PORCELAIN FUSED TO NOBLE METAL PONTIC - RESIN WITH HIGH NOBLE METAL PONTIC - RESIN WITH PREDOMINANTLY BASE METAL PONTIC - RESIN WITH NOBLE METAL RETAINER - CAST METAL RESIN BONDED FIX PROSTH RETAINER - PORCELN/CERAMIC RSN BONDED FIX PROSTH CROWN - RESIN WITH HIGH NOBLE METAL CROWN RESIN W/PREDOMINANTLY BASE METAL-DENTURE
7 6722 CROWN - RESIN WITH NOBLE METAL CROWN PORCELAIN FUSED TO HI NOBLE METAL-DENTURE CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL CROWN - PORCELAIN FUSED TO NOBLE METAL CROWN - 3/4 CAST HIGH NOBLE METAL CROWN FULL CAST HIGH NOBLE METAL-DENTURE CROWN FULL CAST PREDOMINANTLY BASE METAL-DENTURE CROWN FULL CAST NOBLE METAL-DENTURE RECEMENT FIXED PARTIAL DENTURE STRESS BREAKER PRECISION ATTACHMENT EXTRACTION CORONAL REMNANTS DECIDUOUS TOOTH EXTRACTION ERUPTED TOOTH OR EXPOSED ROOT SURG REMOVAL ERUPTED TOOTH REMV BONE ELEV FLAP REMOVAL OF IMPACTED TOOTH - SOFT TISSUE REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY REMV IMP TOOTH - CMPL BONY W/UNUSUAL SURG COMPS SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS OROANTRAL FISTULA CLOSURE PRIMARY CLOSURE OF A SINUS PERFORATION TOOTH REIMPL &OR STBL ACC EVULSED/DISPLCD TOOTH TOOTH TRANSPLANTATION SURGICAL ACCESS OF AN UNERUPTED TOOTH BIOPSY OF ORAL TISSUE HARD BIOPSY OF ORAL TISSUE SOFT ALVEOLOPLASTY W/EXTRACTION 4/> TEETH/SPACE QUAD ALVEOLOPLASTY NOT W/EXTRACTIONS 4/> TEETH/SPACE VESTIBULOPLASTY RIDGE EXT SEC EPITHELIALIZATION VESTIBULOPLASTY RIDGE EXT W/SOFT TISS GRAFTS EXCISION OF BENIGN LESION UP TO 1.25 CM
8 7440 EXC MALIG TUMOR-LESION DIAMETER UP TO 1.25 CM EXC MALIG TUMOR-LESION DIAM GREATER THAN 1.25 CM REMOVAL BEN ODONTOGENIC CYST/TUMR- UP T CM REMOVAL BENIGN ODONTOGENIC CYST/TUMOR- > 1.25 CM REMOVAL BEN NONODONTOGENIC CYST/TUMR- UP 1.25 CM REMOVAL OF TORUS MANDIBULARIS INCISION & DRAINAGE ABSCESS-INTRAORAL SOFT TISS I & D ABSCESS INTRAORAL SOFT TISSUE COMPLICATED INCISION & DRAINAGE ABSCESS-EXTRAORAL SOFT TISS I & D ABSCESS EXTRAORAL SOFT TISSUE COMPLICATED REMV REACT-PRODUC FOREIGN BODIES-MUSCULOSKEL SYS PART OSTEC/SEQUESTRECTOMY REMOVAL NON-VITAL BONE BONE REPLCMT GRAFT RIDGE PRESERVATION PER SITE FRENULECTOMY SEP PROC NOT INCIDENTL ANOTHER PROC EXCISION OF HYPERPLASTIC TISSUE-PER ARCH EXCISION OF PERICORONAL GINGIVA PALLIATIVE EMERGENCY TX DENTAL PAIN MINOR PROC DEEP SEDATION/GENERAL ANESTHESIA-1ST 30 MINUTES NON-INTRAVENOUS CONSCIOUS SEDATION OFFICE VISIT-AFTER REGULARLY SCHEDULED HOURS OCCLUSAL GUARD BY REPORT REPAIR AND/OR RELINE OF OCCLUSAL GUARD
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
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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
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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Code 01/01/13 Schedule Detail Listing Description D0120 PERIODIC ORAL EVALUATION ESTABLISHED PATIE $14.00 D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED $23.00 D0145 ORAL EVAL PT UND 3 YR AGE CNSL W/PRIM
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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
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
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
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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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
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
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
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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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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
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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
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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
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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
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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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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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
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D Pulp vitality tests $52.30 D Diagnostic casts $75.69 D Prophylaxis adult $ Page # 1
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Code Description Cap Freq D5660 ADD CLASP TO EXISTING PARTIAL DENTURE - PER TOOTH 4 1
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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
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Access Dental Family DHMO
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deltadentalins.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
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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
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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
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
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FEE SCHEDULE. Complete Dental Plan is a discount plan offered and administered by our organization at:
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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
TABLE OF DENTAL PROCEDURES PLATINUM PLAN PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS.
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2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees
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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
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2018 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
2018 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
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.
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: 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
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.
Massachusetts 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
TYPE 1 PROCEDURES PAYMENT BASIS - Maximum Covered Expense BENEFIT PERIOD - Calendar Year For Additional Limitations - See Limitations
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SCHEDULE OF BENEFITS. Tests and Examinations D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0
SCHEDULE OF BENEFITS DENTAL PLAN This sample Schedule of Benefits lists the services available to you under your SafeGuard plan as well as the copayments associated with each procedure. There are other
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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.
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