• Direct Referral Dental Plan* MET185 GCERT2010-DHMO-SOB CA sob 1 This SCHEDULE OF BENEFITS lists the Covered Services available to You and Your Dependents under Your dental plan, as well as Your and Your Dependent’s costs for each Covered Service. Your and Your Dependent’s costs may include Co-Payments for a Covered Service.
  • of view of one full dental arch – Mandible (Only covered in conjunction with the surgical placement of an implant; limit of a total of only one D0364, D0365, D0366, or D0367 per calendar year) $220.00 $220.00 D0366 Cone beam CT capture and interpretation with field of view of one full dental arch – Maxilla, with or
  • The dental insurance code for the recementation of a crown is 02920. Dental codes beginning with the letter D and are followed by 4 or more numbers. eg. D1110 for an adult prophy/cleaning Dentists are only allowed to bill for dental treatment with dental codes and not allowed to use medical codes.
  • Oct 06, 2015 · Tooth splint dental code – Dental splint dental code When to use what ADA dental codes. Dental splint or tooth splint dental codes and descriptions can be confusing. If you have a question about dental splinting, we hope you will find the answer here. Tooth splint ADA dental code. D4320 and D4321 are provisional splints for periodontal teeth.
  • This list of codes applies to the policy titled Dental Services. APPLICABLE CODES This list of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. The listing of a code does not imply that the service described by the code is a covered or non-covered health service.
  • CODE DESCRIPTION AGE LIMITATION TEETH COVERED AUTHORIZATION REQUIRED BENEFIT LIMITATIONS DOCUMENTATION REQUIRED D0120 periodic oral evaluation - established patient 0-20 No One of (D0120, D0145, D0150, D0180) per 6 Month(s) Per Provider OR Group. D0140 limited oral evaluation-problem focused (Emergency Dental Services only) 0-20
  • D0340 Cephalometric film 0 TESTS AND EXAMINATIONS D0460 Pulp vitality tests 0 D0470 Diagnostic casts 0 DENTAL PROPHYLAXIS D1110 Prophylaxis - adult 0 D1120 Prophylaxis - child 0 TOPICAL FLUORIDE TREATMENT (office procedure) D1203 Topical application of fluoride - child 0 D1204 Topical application of fluoride - adult 0
  • New Codes D0251 Extra-oral posterior dental radiographic image - image limited to exposure of complete posterior teeth in both dental arches.

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D0340 Cephalometric radiographic image No Charge Not Covered D0350 Oral/Facial photographic images No Charge Not Covered D0431 Adjunctive pre‐diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures
Procedure Code Rate Effective Date Prior Authorize EXAMINATION D0120 21.35 10/1/2019 N D0140 30.50 10/1/2019 N ... D0340 60.98 10/1/2019 N D0350 30.50 10/1/2019 N

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plan administrator through its medical staff and/or dental consultants based on comparable or similar services, unless such procedure is specifically excluded in this schedule or by other terms and conditions of coverage. "nc" indicates non covered. procedure code class i. diagnostic and preventive allowance (payable @ 100% of state allowance)
D9110 is a misunderstood code as many offices code D0140 for emergency visits when treating a patient for pain or discomfort. D0140 is an evaluation code and limited to the “one evaluation per six months” or “two evaluations per year” rule. Consider reporting D9110 for...

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D0340 Cephalometric radiographic image $0.00 Capitation D0460 Pulp vitality tests $0.00 Capitation D0470 Diagnostic casts $0.00 Capitation D1110 Prophylaxis: Adult $0.00 Capitation D1120 Prophylaxis: Child $0.00 Capitation D1206 Topical application of fluoride varnish $0.00 Capitation