Gingivectomy, excision gingival, each quadrant Gingivoplasty, each quadrant
|
|
- Jayson Little
- 5 years ago
- Views:
Transcription
1 Dental in Nature Oral Surgery Effective CDT D3410 surgery - anterior D3421 surgery bicuspid (first root) D3425 surgery molar (first root) D3426 D3427 surgery (each additional root) Periradicular surgery without apicoectomy D3428 Bone graft in conjunction with periradicular surgery per tooth, single si te D3429 Bone graft in conjunction with periradicular surgery each additional contiguous tooth in the same surgical si te D3430 retrograde filling per tooth D3431 D3432 D3450 D3460 D3470 D3920 Biologic materials to aid in soft and osseous ti ssue regeneration in conjunction with periradicular surgery Guided ti ssue regeneration, resorbable barrier, per site, in periradicular surgery root amputation - per root endodontic endosseous implant intentional reimplantation (including necessary splinting) hemisection (including any root removal), not including root canal therapy D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per D4211 gingivectomy or gingivoplasty - one to three teeth, per Gingivectomy, excision gingival, each Gingivoplasty, each Gingivectomy, excision gingival, each Gingivoplasty, each
2 D4212 D4220 D4240 D4241 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth gingival curettage, surgical per, by report (Deleted 1/01/03) gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per gingival flap procedure, including root planing - one to three teeth, per Gingivectomy, excision gingival, each Gingivoplasty, each D4245 apically positioned flap D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per Alveoloplasty, each (specify) D4261 osseous surgery (including flap entry and closure) - one to three teeth, per D4263 bone replacement graft - fi rst in D4264 bone replacement graft - each additional si te in D4265 D4266 D4267 D4268 D4270 D4271 D4273 D4274 biologic materials to aid in soft and osseous ti ssue regeneration guided tissue regeneration - resorbable barrier, per si te guided tissue regeneration - nonresorbable barrier, per si te (includes membrane removal) surgical revision procedure, per tooth pedicle soft ti ssue graft procedure free soft ti ssue graft procedure (including donor si te surgery) subepithelial connective ti ssue graft procedures distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) Alveoloplasty, each Alveoloplasty, each (specify) Operculectomy, excision of pericoronal ti ssues D4275 soft ti ssue allograft
3 D4276 combined connective ti ssue and double pedicle graft D4277 free soft ti ssue graft procedure (including donor si te surgery), first tooth or edentulous tooth position in a graft D4278 free soft ti ssue graft procedure (including donor si te surgery), each additional contiguous tooth or edentulous tooth position in a graft D4283 autogenous connective ti ssue graft procedure (including donor and recipient surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft si te D4285 Non-autogenous connective tissue graft procedure (including recipient surgical si te and donor material) each additional contiguous D6100 Implant removal, by report D6101 Debridement of a periimplant defect and surface cleaning of exposed implant surfaces, including flap entry and closure D6102 Debridement and osseous contouring of a periimplant defect; includes surface cleaning of exposed implant surfaces and flap entry and cl osure D6103 Bone graft for repair of periimplant defect not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration D6104 Bone graft at time of implant placement D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. D7220 removal of impacted tooth - soft ti ssue D7230 removal of impacted tooth - partially bony D7240 removal of impacted tooth - completely bony
4 D7241 removal of impacted tooth - completely bony, with unusual surgical complications. D7250 surgical removal of residual tooth roots (cutting procedure) D7251 Coronectomy - intentional partial tooth removal D7260 oroantral fistula closure Repair fistula, oromaxillary (combine with if antroto included) D7261 primary closure of a sinus perforation Repair fistula, oromaxillary (combine with if antroto included) D7272 D7280 D7282 D7290 D7291 D7310 D7311 D7320 D7321 D7340 D7350 tooth transplantation (includes reimplantation from one si te to another and splinting and/or stabilization) surgical access of an unerupted tooth mobilization of erupted or malpositioned tooth to aid eruption surgical repositioning of teeth transseptal fiberotomy/supra crestal fiberotomy, by report alveoloplasty in extractions - per alveoloplasty in extractions one to three teeth or tooth spaces, per alveoloplasty not in extractions - per alveoloplasty not in extractions one to three teeth or tooth spaces, per vestibuloplasty ridge extension (secondary epithelialization) vestibuloplasty - ridge extension (including soft ti ssue grafts, muscl e reattachment, revision of soft ti ssue attachment and management of hypertrophied and hyperplastic tissue) Alveoloplasty, each Alveoloplasty, each Vestibuloplasty; anterior Vestibuloplasty; posterior, Vestibuloplasty; unilateral/posterior, Vestibuloplasty; bilateral/entire arch Vestibuloplasty, complex (including ridge extension, muscl e repositioning)
5 D7471 removal of lateral exostosis (maxilla and mandible) Excision of osseous tuberosities, dentoalveolar structure D7472 removal of torus palatinus Excision of maxillary torus palatinus D7473 D7485 D7953 removal of torus mandibularis surgical reduction of osseous tuberosity bone replacement graft for ridge preservation per si te Excision of torus mandibular Excision of osseous tuberosities, dentoalveolar structure D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure 40806, 40819, 41010, 41115, Incision of labial frenum (frenotomy) Excision of frenum, labial or buccal (frenumectomy, frenulectomy, frenectomy) Incision of lingual frenum (frenotomy) Excision of lingual frenum (frenectomy) D7963 frenuloplasty Frenoplasty (surgical revision of frenum, e.g., with Z-plasty) D7970 D7971 D7972 excision of hyperplastic ti ssue - per arch excision of pericoronal gingiva surgical reduction of fibrous tuberosity Excision of hyperplastic alveolar mucosa, each Operculectomy, excision of pericoronal ti ssues Excision of fibrous tuberosities, dentoalveolar structures
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
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 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 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 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 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 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 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 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 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 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 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 informationDental Full Schedule of Benefits Plan Design Level 3 Regular
Dental Full Schedule of Benefits Plan Design Regular The following benefit categories are payable using the 2018 CDT codes assigned by the American Dental Association (ADA). Current Dental Terminology
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 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 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 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 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 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 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 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 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 informationAll About Your Dental Coverage University of Southern California Student Dental Plan
All About Your Dental Coverage University of Southern California Student Dental Plan This Delta Dental PPO table of allowance plan offers reliable coverage for a low annual premium. You can visit any dentist
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 informationLIBERTY Dental Plan of Nevada, Inc. Provider Agreement NV Exchange Fee Schedule Effective January 1, 2018
DIAGNOSTIC D0120 Periodic oral evaluation established patient $33.24 D0140 Limited oral evaluation problem focused $33.24 D0145 Oral evaluation for a patient under three years of age and counseling with
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 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 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 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 informationPROCEDURE CODE AND DESCRIPTION
1 0 PROCEDURE CODE AND DESCRIPTION Delta Dental of Colorado 2017 Fees 2017 FEE D0120 Periodic oral evaluation - established patient $ 45.00 D0140 Limited oral evaluation - problem focused $ 71.00 D0145
More informationPROCEDURE CODE AND DESCRIPTION
1 0 PROCEDURE CODE AND DESCRIPTION Delta Dental of Colorado 2017 Fees 2017 FEE D0120 Periodic oral evaluation - established patient $ 33.00 D0140 Limited oral evaluation - problem focused $ 50.00 D0145
More informationNC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2014
NC Medicaid Dental Reimbursement Rates General Dentist, Oral Surgeon, Pediatric Dentist, Periodontist, & Orthodontist Effective Date: January 1, 2014 The inclusion of a rate on this table does not guarantee
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 informationCode 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 -
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 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 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 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 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 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 informationDeltaCare USA (DHMO) Standard Plan
SCHEDULE A Description of Benefits and Copayments DeltaCare USA (DHMO) The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions
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 informationSECTION XVIII. EssentialSmile 111, NS, INN, Family Dental, Dep 29 Schedule of Benefits
SECTION XVIII. EssentialSmile 111, NS, INN, Family Dental, Dep 29 Schedule of Benefits P.O. Box 19199 Plantation, FL 33318 Telephone: 877-760-2247 Fax: 954-370-1701 www.mysolstice.net COST-SHARING Members
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 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 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 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 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 informationNevada Medicaid Benefits Schedule of Benefits Coverage, Limitations and Prior Authorization Requirements
Coverage, and Prior Authorization Requirements PRIOR AUTHORIZATION TABLE: = Prior authorization is not required. 01 = Prior authorization is required. 02 = Prior authorization is required. Covered services
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 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 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 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 informationS800A Dental Plan MEMBER CODE DESCRIPTION COPAY MEMBER CODE DESCRIPTION COPAY
S800A Dental Plan P.O. Box 19199 Plantation, FL 33318 Telephone: 877-760-2247 Fax: 954-370-1701 www.solsticebenefits.com Members of the S800A Dental Plan are eligible to receive benefits immediately upon
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 informationDeltaCare. USA provided by Delta Dental of California. Quality. Predictable costs. Convenience
DeltaCare USA provided by Delta Dental of California We ll do whatever it takes and then some. Welcome to DeltaCare USA quality, convenience, predictable costs Find a DeltaCare USA dentist Select from
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 informationNevada Medicaid - Child Schedule of Benefits Coverage, Limitations and Prior Authorization Requirements
Diagnostic Services D0120 Periodic oral evaluation 1 (D0120) every 11 months D0140 Limited oral evaluation 3 (D0140) every 6 months D0145 Oral evaluation under age 3 1 (D0145) every 6 months, up to age
More informationDeltaCare. USA provided by Alpha Dental of Nevada, Inc. Convenience. Predictable costs. Quality
DeltaCare USA provided by Alpha Dental of Nevada, Inc. We ll do whatever it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general
More informationGROUP DENTAL PLAN. Plan Number: Plan Date: 1/1/2017. Class Plan. Administered by:
GROUP DENTAL PLAN Plan Number: 10-301392 Plan Date: 1/1/2017 Class 2 100 Plan Administered by: TABLE OF CONTENTS Name of Provision Page Number Schedule of Benefits Begins on 9040 Benefit Information,
More informationDiagnostic Treatment. D0120 Periodic oral evaluation - established patient $0 D0140 Limited oral evaluation - problem focused $0
Schedule of Benefits Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan SGX/SGXM 225-FL This Schedule of Benefits lists the services available to you under
More informationPrimecare Dental Plan Individual Plan 400B
Primecare Dental Plan Individual Whether you re a member of our dental plan, human resources or benefits professional we trust you will find our company a valuable resource for high quality and affordable
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 informationHorizon Dental Choice - Plan H
Procedures not listed on the patient charge schedule are not covered. Services not covered are the patient's responsibility at the dentist's usual fees. Diagnostic and Preventive- Oral evaluations are
More information(HMO) (HMO SNP) 2019 Dental Benefit
Imperial Insurance Company of Texas (HMO) (HMO SNP) 2019 Dental Benefit Dental care provided by H2793_154 TX Dental Benefit Dir 2019_M ENG Approved 09/12/18 IMPERIAL INSURANCE COMPANY OF TEXAS- DUAL (HMO
More informationSCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company DIRECT REFERRAL DENTAL PLAN SGX245-FL-HCR
SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company DIRECT REFERRAL DENTAL PLAN SGX245-FL-HCR This Schedule of Benefits lists the services available to you under your
More informationACCESS+ S1000A HIGH. Code Description Copay/ Reimbursement Appointments
ACCESS+ S1000A HIGH SCHEDULE OF BENEFITS Members of the Solstice ACCCESS+ S1000A HIGH dental plan are eligible to receive benefits immediately upon the effective date of coverage with: No Waiting Periods
More informationACCESS+ S1500A STANDARD
ACCESS+ S1500A STANDARD SCHEDULE OF BENEFITS Members of the Solstice ACCCESS+ S1500A HIGH dental plan are eligible to receive benefits immediately upon the effective date of coverage with: No Waiting Periods
More informationMembers can locate a participating provider at Member Services Department:
Solstice 3B-SHP/D17 Dental Plan Schedule of Benefits Members of the 3B-SHP Dental Plan are eligible to receive benefits immediately upon the effective date of coverage with: No waiting Periods No Deductibles
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 informationNevada Medicaid - Child Schedule of Benefits Coverage, Limitations and Prior Authorization Requirements
Coverage, Limitations and orization uirements Documentation/X-Ray uired Diagnostic Services D0120 Periodic oral evaluation 1 (D0120) every 11 months D0140 Limited oral evaluation 3 (D0140) every 6 months
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 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 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 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 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 informationHDS PROCEDURE CODE GUIDELINES
D4000 - D4999 Local anesthesia is usually considered to be part of Periodontal procedures. General Guidelines 1. Periodontal services are only benefited when performed on natural teeth for treatment of
More informationSECURECARE DENTAL SCHEDULE OF OUT OF NETWORK BENEFIT PAYMENTS GENERAL INFORMATION
SECURECARE DENTAL SCHEDULE OF OUT OF NETWORK S GENERAL INFORMATION This Schedule applies only to services and supplies furnished by Non-Preferred Providers. The patient will be responsible for all charges
More information2019 CDT HCPCS Updates
DECEMBER 2018 KMAP DENTAL BULLETIN 18248 2019 CDT HCPCS Updates Effective with dates of service on and after, the following dental codes will be covered under certain benefit plans for the (KMAP) for some
More informationDirect Referral Dental Plan*
Schedule of Benefits Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* MET225 This SCHEDULE OF BENEFITS lists the Covered s available to You and Your Dependents
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 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 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 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 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 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 informationQuick Reference Guide Hoosier Healthwise
Quick Reference Guide Hoosier Healthwise Coordination of Care: DentaQuest will honor all previous care authorizations from the member s enrollment in the Hoosier Healthwise program from a previous health
More informationMetLife Dental Comparison Chart
MetLife Dental Comparison Chart You may choose one of four dental plans, offered by SafeGuard, a MetLife Company and Metropolitan Life. Select one of the SafeGuard DHMO Plans or one of the MetLife IndemnityDental
More informationSolstice S700B/D1068 Dental Plan Schedule of Benefits
Solstice S7B/D168 Dental Plan Schedule of Benefits Members of the S7B Dental Plan are eligible to receive benefits immediately upon the effective date of coverage with: No waiting Periods No Deductibles
More informationMET335. Your and Your Dependent s Service. Diagnostic Treatment
Direct Referral Dental Plan* SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company MET335 This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your
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 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 informationGRCERT: ENZZ- 01/23/2017 GROUP DENTAL PLAN WAKE COUNTY PUBLIC SCHOOL SYSTEM. Plan Number:
GRCERT:010-301512-00000-02- ENZZ- 01/23/2017 GROUP DENTAL PLAN WAKE COUNTY PUBLIC SCHOOL SYSTEM Plan Number: 10-301512 Administered by: Non-Insurance Products/Services From time to time we may arrange,
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 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 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 informationPrimecare Dental Plan Individual Plan 106
Primecare Dental Plan Individual Whether you re a member of our dental plan, human resources or benefits professional we trust you will find our company a valuable resource for high quality and affordable
More informationAn Overview of Your. Dental Benefits. Educators Health Alliance
An Overview of Your Dental Benefits Educators Health Alliance 2 \ DENTAL BENEFITS OVERVIEW \ 5 A Dental Plan Exclusively for Educators Health Alliance Members Something to Smile About... The EHA makes
More information