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D3120 dental code

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D3120 - CDT® Dental Code CDT (dental or D) codes and related material here. Access to this feature is available in the following products: ADA CDT® Codes (Dental D Codes code list Removed CDT code D3120 from the EPA procedure code list. Aligns with WAC 182-535-1086 Added CDT codes D1510, D5110, D5120, D7140, D7472, and D7473 to the EPA procedure code list. Streamline process Updated CDT code D1515 to say bilateral in the criteria column. Correctio

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These codes are deleted effective 12/31/2020: D3427 periradicular surgery without apicoectomyD5994 periodontal medicament carrier with peripheral seal - laboratory processedD6052 semi-precision attachment abutmentD7960 frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedur TABLE OF DENTAL PROCEDURES PLEASE READ THE FOLLOWING INFORMATION CAREFULLY FOR YOUR PROCEDURE FREQUENCIES AND PROVISIONS. The attached is a list of dental procedures for which benefits are payable under this section is based upon the Current Dental Terminology, (CDT-5), copyrighted 2004, American Dental Association..

ADA Guide to Dental Procedures Reported with Area of the Oral Cavity or Tooth Anatomy (or Both) Reporting Area of the Oral Cavity and Tooth Anatomy by CDT Code Dental procedure codes, listed in numeric order, are as published in CDT 2018 (© American Dental Association) D3120 X Y D3220 X Y D3221 X Y D3222 X Y D3230 X Y D3240 X Y D3310 X. CDT Code for Dental Fillings. Back to main page. Filling is used to restore a damaged tooth back to its normal shape and function. While giving filling, a dentist normally first removes the decayed tooth material, cleans the affected are and then fills out cleaned cavity with a filling dental fee schedule - revised january 4, 2018. procedure code description fees $ age limits d0120 periodic oral evaluation $32.00 none d1208 topical application of fluoride $20.00 0 - 14 d3120 pulp cap- indirect, excluding final restoration $25.00 0 - 20 d3220 therapeutic pulpotomy $86.00 0 - 2 Diagnostic/Preventive - Oral Evaluations are Limited to a Combined Total of 4 of the Following Evaluations During a 12 Consecutive Month Period: Periodic Oral Evaluations (D0120), Comprehensive Oral Evaluations (DO150), Comprehensive Periodontal Evaluations (D0180), and Oral Evaluations for Patients Under 3 Years of Age (D0145). D9310 D943

*Usual Fees provided by ADA Dental Survey 2018. D3120 Pulp cap - indirect (excluding final restoration) $93 $28 $65 D3220 procedure codes 0210, 0270, 0272, 0274, 0330 WITH prophylaxis procedure code 1120 (DDS internal code 1140). Diagnostic procedure procedure description dental fee 2018 dental fee schedule effective may 1, 2018 d7250 surgical removal of residual tooth roots $318.00 d7270 tooth reimplantation and/or stabilization of accidentally displaced tooth $586.00 d7285 biopsy of oral tissue - hard $446.00 d7286 biopsy of oral tissue - soft $346.00 d7310 alveoloplasty in conjunction with extractions - per quadrant $315.0 Effective for dates of service on or after February 1, 2021, direct and indirect pulp caps procedure codes D3110 and D3120 will be clarified for Texas Health Steps and Children with Special Health Care Needs (CSHCN) Services Program dental services D3120 Pulp cap‐ indirect (excluding final restoration) 4/1/2021 3/31/2022 $152.00 D3220 Therapeutic pulpotomy (exluding final restoration) 4/1/2021 3/31/2022 $153.00 D3221 Pulpal debridement, primary and permanent teeth 4/1/2021 3/31/2022 $130.0 This dental code desceription refers to an indirect pulp cap. Similar to a sedative filling , an indirect pulp cap is used when a deep cavity is present. It differs however, in the type of therapeutic compounds used, and because, on occasion, a portion of the decay near the pulp may be left in place to be removed at a later date, or left in.

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Purpose. The purpose of the CDT Code is to achieve uniformity, consistency and specificity in accurately documenting dental treatment. One use of the CDT Code is to provide for the efficient processing of dental claims, and another is to populate an Electronic Health Record. On August 17, 2000 the CDT Code was named as a HIPAA standard code set Provider type 31 (Physician) is eligible for payment only for procedure codes D7450 through D7471, D7960 and D7970. (This does not exclude provider type 27 -Dentist. This brochure describes the benefits of Delta Dental's Federal Employees Dental Program under Delta Dental of California contract OPM02-FEDVIP-02AP-05 with OPM, as authorized by the FEDVIP law. The address for our administrative office is: Delta Dental of California . Federal Employees Dental Program . PO Box 537007 . Sacramento, CA 95853-700

Delta Dental is America's largest and most trusted dental benefits carrier. We cover more Americans than any other dental benefits provider - and strive to make dental coverage more accessible and affordable to a wide variety of employers, groups and individuals Dental Codes. D0120 PERIODIC ORAL EXAMINATION. D0140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED. D0145 ORAL EVALUATION FOR PATIENT UNDER THREE YEARS OF AGE AND COUNSELING W/PRIMARY CAREGIVER. D0150 COMPREHENSIVE ORAL EVALUATION NEW OR ESTABLISHED PT. D0160 DETAILED AND EXTENSIVE ORAL EVALUATION-PROBLEM FOCUSED CDT D2740. Get information about CDT D2740 dental procedure code with description : D2740 Procedure Code Description. Crown - porcelain/ceramic substrate. D2740 is used to report any porcelain or ceramic crown. Used in front teeth as they are more esthetically appealing though cost might be a considerations they are expensive, D3120 Pulp Cap - Direct (Excluding Final Restoration) Pulp Cap - Indirect (Excluding Final Restoration) 15.00 35.00 Pulpotomy D3220 D3221 Therapeutic Pulpotomy (Excluding Final Restoration) Pulpal Debridement, Primary and Permanent Teeth 60.00 70.00 Endodontic Therapy On Primary Teeth D3230 D324

d3120 pulp cap - indirect 80% pulpotomy (excluding restoration) d3220 therap pulpotomy 80% d3221 pulpal debridement 80% d3222 part pulp for apexogenesis 80% d3230 pulpal therapy ant 80% d3240 pulpal therapy post 80% d3310 anterior 80% d3320 bicuspid 80% d3330 molar 80% d3331 treat root canal obs 80% d3332 incomp endodontic 80% d3333 internal. 2021 Covered Dental Services for Peoples Health Secure Health (HMO-DSNP) Code Procedure Description crown procedure code is covered every sixty (60) months per member : ENDODONTICS . D3110 Pulp cap direct . D3120 : Pulp cap indirect . Not applicable : D3220 . Therapeutic pulpotomy . 2021 Covered Dental Services for Peoples Health Secure. CODE PATIENT PAYS CODE PATIENT PAYS $0 D0120-D0180 No Charge D0277 No Charge DMO® Dental Benefits Summary Beginning on or After 01-01-2021 Plan 67 Office Visit Copay Periapicals PROCEDURE D3120 No Charge D3346 $220 D3220 $55 D3347 $280 D3221 $10 D3348 $400 D3222 $50 D3410 (1) $17

  1. D3120 Pulp Cap - Indirect (excluding final restoration) No Charge D3220 Therapeutic Pulpotomy (excluding final restoration) $55 D3221 Pulpal Debridement, Primary and Permanent Teeth $10 D3222 Partial Pulpotomy $50 D3230 Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth $55 D3240 Pulpal Therapy (Resorbable Filling) - Posterior
  2. 2021 WellCare Dental Supplemental Codes Quick Reference Guide California Dental Plans Preventive Dental coverage includes: Oral Exams: D0120, D0140, D0150, D0160, D0170, D0171, D0180, D0190, D019
  3. Covered Services Code General Dentist Copay Specialist Dentist Copay D3120 $16 $42 Therapeutic Pulpotomy (Excluding Final Restoration) D3220 $47 $139 Pulpal Debridement - Primary/Permanent D3221 $49 $164 Partial Pulpotomy for Apexogenesis D3222 $64 $145 Pulpal Therapy Anterior - Primary D3230 $65 $146.
  4. D3120 (endodontics) therapeutic pulpotomy (excluding final restoration)- removal of pulp coronal to the dentinocemental junction and application of medicament: pulpotomy is the surgical removal of a portion of the pulp with the aim of maintaining the vitality of the remaining portion by means of an adequate dressing. to be performed on primary.
  5. Code Service Fees Code ENDODONTIC SERVICES Service D3110 D3120 D3220 D3221 D3310 D3320 D3330 D3346 D3910 Pulp Cap - Direct Pulp Cap - Indirect Therapeutic Pulpotomy Pulpal Debridement, Root Canal - Anterior Root Canal - Bicuspid Root Canal - Molar Retreat Previous Root Canal - Anterior Surgical Isolation of Tooth w/ Rubber Dam Fees $80.
  6. The group fee schedule provides members of the Dental Benefit Program with a list of procedure descriptions and discounted fees. Please enter a valid Dental Benefits Program code at the top of the page. If you need assistance, contact the Dental Cooperative at 1-877-EZ-SMILE. D3120: PULP CAP-INDIRECT (EXCLD FINAL RESTORATION) $57; D3220.

UnitedHealthcare Dental Coverage Guideline Effective 02/01/2021 Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws D3120 ; Pulp cap. 2019 schedule of dental procedures and allowable charges for the state dental plan d3120 pulp cap-indirect (excluding final restoration) nc. pulpotomy: the appropriate ada procedure code. d3310 anterior tooth (excluding final restoration) $205.40. d3320 bicuspid tooth (excluding final restoration) $237.10.

D3120 pulp cap - indirect (excluding final restoration) D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament D3221 pulpal debridement, primary and permanent teet Dental Endodontics Codes D3110-D3348. STUDY. Flashcards. Learn. Write. Spell. Test. PLAY. Match. Gravity. Created by. rebecca_martin22. Terms in this set (10) D3110. pulp cap- direct. exposed pulp is covered with a dressing or cement that protects the pulp and promotes healing and repair. D3120

Amalgam - Two Surfaces, Permanent - Dental Procedure Code Description. A filling is a direct dental restoration used to repair decayed, chipped, cracked or otherwise damaged teeth. It is called a direct restoration because the material used to repair the tooth undergoes its hardening process while in direct contact with the tooth and inside. A key area of concern for many dental practices circles around dental codes and their ability to properly code various procedures for insurance purposes. Using the correct dental procedure code is critical, and often confusing. While medical coding relies on Current Procedural Terminology (CPT), medical billing codes for dental procedures utilizes Current Dental Terminology (CDT) ADA Guide to Dental Procedures Reported with Area of the Oral Cavity or Tooth Anatomy (or Both) Reporting Area of the Oral Cavity and Tooth Anatomy by CDT Code Dental procedure codes, listed in numeric order, are as published in CDT 2018 (© American Dental Association) D3120 X Y D3220 X Y D3221 X Y D3222 X Y D3230 X Y D3240 X Y D3310 X. Dental Endodontics Codes D3110-D3348. pulp cap- direct. exposed pulp is covered with a dressing or cement that protects the pulp and promotes healing and repair. pulp cap- indirect. nearly exposed pulp is covered with protective dressing to protect pulp from additional injury and promote healing and repair formation of secondary dentin Code Short Description and Coverage Service for Persons for the Nevada Medicaid and Nevada Check Up Dental Program D3120 PULP CAP INDIRECT 00 NC NC D3220 THERAPEUTIC PULPOTOMY 00 NC NC 1 unit per 36 months D3222 PART PULP FOR APEXOGENESIS 00 NC NC.

Dental of South Georgia P.C., (Adam Diasti, DDS, DN11634), or Coast Dental of Texas, PC (Adam Diasti, DDS, Lic 32327) Coast Dental Services, Code Procedure Description Non- Member SmilePlus Member SAVE D3120 Pulp cap, indirect, excluding final restoration $98 $53 46 The ADCPA is the original, national organization of dental CPAs, consisting of 25 firms that represent more than 7,000 dentists nationwide. To learn more about the ADCPA, visit the organization's Web site at www.adcpa.org, e-mail Schiff at ASchiff@Schiffcpa.com, or visit his Web site at www.schiffcpa.com ADA Code: Common Dental Procedures: Average Price*: Your Price with Careington POS: D3110: Pulp Cap Direct (excluding final restoration)$97: $38: D3120: Pulp Cap Indirect (excluding final restoration)$96: $29: D322

CDT D3120 Dental Procedure Code / CDTDentalCodes

2019 PPO Specialist Dental Fee Schedule . Not all codes are covered benefits . Please check the member's plan for verification and limitations . CDT Description PPO Specialist D0120 Periodic Oral Examination $27 D0140 Limited Oral Evaluation Problem Focused $36 D0145 Oral Evaluation - Patient Under 3 $3 FY2021 Dental Schedule of Benefits 3 Prosthodontics to replace missing teeth are covered only for teeth † Limited to once every five plan years for the same tooth Code Service Co-payment Diagnostic Treatment D0120 Periodic oral evaluation - established patient $0 D0251 Extra-oral posterior dental radiographic image $0 D0270 Bitewing - single radiographic image $0 D3120 Pulp cap - indirect (excluding final restoration) $ Dental procedure codes not listed on this schedule will be discounted at 20% off the General Dentist's normal fee at the time of service. Participating Specialists (Board Certified or Advanced Degree) do not charge according to a fee schedule. Participating Specialists will give a 20% discount off of their normal fees

CDT® D3120 in section: Pulp Capping - Find-A-Cod

Procedure Code 0-20 Year Rate 21+ Year Rate Maximum Age Prior Authorization DENTAL FEE SCHEDULE 2020 D2393 75.80 20 D2394 90.66 20 D2710 114.45 20 D2721 126.34 20 D2740 338.88 20 D2751 338.88 20 D2920 25.27 20 D2930 101.07 20 D2931 101.07 20 D2932 101.07 20 D2933 126.34 20 D2940 26.75 20 D2950 96.61 20 D2951 2.97 20 D2954 78.77 20 D3110 19.32. 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 following list shows all codes covered for plans in the state of California. Your plan may cover some, or all of these codes

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  1. Covered Services are listed with the American Dental Association (ADA) procedure code. ADA Code Services When using a Participating Dentist3 Diagnostic services (exams and x-rays) D0120 Periodic oral evaluation $0 D0140 Limited oral evaluation - problem focused $0 D0145 Oral evaluation for a patient under three years of age $
  2. DIRECT DENTAL PLANS OF AMERICA, INC. GENERAL DENTIST FEE SCHEDULE Page 1 of 8 11178 Huron St., Suite 3, Northglenn, Colorado 80234 • 303.457.9794 • 800.377.2924 • Fax: 303.457.6956 • Email: DDP@DirectDentalPlan.com Revised January 2016 DIAGNOSTIC SERVICES ADA Code ADA Descriptio
  3. The following list of preventive and comprehensive dental codes shows all codes covered for Allwell from Absolute Total Care. Covered codes may change throughout the year. One (of D3110, D3120) per tooth per lifetime $0 D3120 Pulp cap, indirect (excluding final restoration) One (of D3110, D3120) per tooth per lifetime $0 D322
  4. Dental Care Services in an Operating Room or Ambulatory Surgery Center Page 1 of 8 Listing of a code in this guideline does not imply that the service described by the code is a covered or non-covered health D3120 : Pulp cap - indirect (excluding final restoration
  5. Aflac will pay the following benefits when a charge is incurred for covered dental treatment that occurs while coverage is in force. If a covered American Dental Association (ADA) code is revised or replaced by the ADA, Aflac will pay an amount comparable to the amount shown in the Schedule of Dental Procedures for the procedure or code shown.
  6. Endodontics services for the following dental codes: D3110 Pulp Cap — Direct (Excluding Final Restoration) D3120 Pulp Cap — Indirect (Excluding Final Restoration) Periodontics services for the following dental codes: D4342 Periodontal Scaling and Root Planing — One to Three Teeth per Quadrant; D4910 Periodontal Maintenanc
  7. Procedure codes for Covered Services labeled #### are limited to Members under age 19. The Copayments listed this section are only valid for covered services that are: (1) started and completed under this Plan, and (2) rendered by Participating Dentists in the State of New Jersey except Emergency Dental Services. CDT Code +

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  1. Finding accurate dental codes for procedures is one of the critical tasks indeed. Not everyone can do it or have the time to spend on dental coding books. Getting familiar with the dental codes is equal to gaining tremendous knowledge in dental coding. At the same time, healthcare professionals need to be particularly aware of dental coding.
  2. If a treatment code is not listed please submit a Prior Authorization for review of medical necessity. COVID-19 Changes: All Health Plan dental prior authorization approvals which are within 60 days of expiration from 3/20/2020 will be extended for 6 months. This does not apply to prior auth approvals that expired prior to 3/20/202
  3. Covered Dental Services and Patient Charges - U10TXI03 IP-MDG-DHMO-SCH-U10TXI03-TX-16 [ 1 ] 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 must pay the listed Patient Charge
  4. ing the numerator claims from dental providers, using provider taxonomy codes (see the cited specifications for more detail). OHA CCO incentive measure specifications align with EPSDT Form CMS-416 and do not use taxonomy codes in the calculation
  5. FY2021 Dental Schedule of Benefits Prosthodontics to replace missing teeth are covered only for teeth 3 † Limited to once every five plan years for the same tooth. that are lost while the plan participant is covered by this plan
  6. Covered Dental Services and Patient Charges - U10TXI04 IP-MDG-DHMO-SCH-U10TXI04-TX-17 1 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 must pay the listed Patient Charge
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When you visit a Delta Dental dentist, pay only your portion for services. Delta Dental dentists will file claim forms for you and receive payment directly from us. Many non-Delta Dental dentists ask that you pay the entire cost up front and wait for reimbursement. • Delta Dental's Online Services make getting information quick and easy Here are the new CDT 2019 codes, effective January 1, 2019. D5282: Removable unilateral partial denture—One-piece cast metal, including clasps and teeth. D5283: Removable unilateral partial denture—One-piece cast metal, including clasps and teeth, mandibular. D9613: Infiltration of sustained release therapeutic drug—Single or multiple sites Aflac will pay the following benefits when a charge is incurred for covered dental treatment that occurs while coverage is in force . If a covered ADA code* is revised or replaced by the American Dental Association, Aflac will pay an amount comparable to the amount shown in the Schedule of Dental Procedures for the procedure or code shown below

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  1. You will get your routine or basic care from your PCP. Your PCP also can coordinate the rest of the covered services you need. In most cases, you must see your PCP to get a referral before you see any other healthcare provider. CarePlus Medicare Advantage plans include: Mail-order pharmacy with no delivery fees. Dental benefits
  2. The dental professional will drill the cavity and remove any decayed tooth material. They will then thoroughly clean the site. Adding sedative material. Once all the decay is removed, the dental professional will use a sedative material to protect the pulp from bacteria until the dentin can repair itself. Filling the cavity
  3. Any procedure not listed on the QCD of America® Schedule of Dental Program Fees is available at the affiliated dentist's usual and customary fee less a 20% discount — this includes all lab fees. All fees included in the Schedule of Dental Fees are for payment at time of service
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Endodontic Procedures Listed by Insurance Codes

  1. Codes or definitions. Different codes may be used to describe these D3120 Pulp cap - Indirect (Excluding final restoration) $5.00 D3220 Pulpotomy - Removal of pulp, not part of a root canal $30.00 American Dental Association does not endorse any codes which are not included in its current publication
  2. D3120 Pulp cap-indirect (excl final restor ation.) $28 D3220 Therapeutic pulpotomy (e xcl final restoration.) $67 D3310 Root canal therapy-anterior (ex cl final restoration.) $28
  3. DENTAL PLANS WE ACCEPT. IN HOUSE DENTAL PLANS. SERVICES. SMILE GALLERY. Pulp Cap, indirect. Pulp Cap, indirect: Code D3120. Procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin. X
  4. D3120 Pul pCa -I ndirect (Exclud ig Final Res t ora ) 35.00 Pulpotomy D3220 Therapeutic Pulpotomy (Excluding Final Restoration) 60.00 D3221 Pulpal Debridement, Primary and Permanent Teeth 70.00 Endodontic Therapy On Primary Teeth D3230 Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth (Excluding Final Restoration) 96.0
  5. 2021 dental benefits reference guide CDT code Category D3110 Basic D3120 No benefit D3220, D3230, D3240 Basic D3310, D3320, D3330, D3346-D3348, D3355, D3357 Basic D3410, D3421, D3425, D3426, D3428, D3429, D3471-D3473, D3501-D3503 Basic Adjunctive services CDT code Categor

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D0120, D0140, D0150, D0160, D0170, D0171, D0180 2021 WellCare Dental Supplemental Codes Quick Reference Guide Dental Plans 1000, 1500, 2000, 2500, 3000 and 500 Code: Common Dental Procedures: Average Price* Your Price with Careington POS: D3110: Pulp Cap Direct (excluding final restoration) $97: $38: D3120: Pulp Cap Indirect (excluding final restoration) $96: $29: D3220: Therapeutic Pulpotomy (excluding final restoration) $235: $90: D3310: Endodontic Therapy - Anterior Tooth (excluding final. D3120 Pulp cap indirect 999 $24.45 0-20y 11m D3220 Therapeutic pulpotomy 999 $106.30 1 / life / tooth 0-20y 11m D3310 Endo therapy, anterior tooth 1 $435.81 Yes 1 / life / tooth 0-20y 11 2019 Dental Codes that require Prior Authorization per AHCCCS For dates of service from 1/1/2019-12/31/2019 CODES DESCRIPTIONS DIAGNOSTIC D0160 detailed and extensive oral eval-problem focused, by report D3120 pulp cap - indirect (excluding final restoration) D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp. ADDP Dental Network Schedule of Maximum Allowable Charges Procedure Code Nomenclature Allowance D0100-D0999 — Diagnostic CLINICAL ORAL EVALUATIONS D3120 Pulp cap - indirect (excluding final restoration) 20.79 PULPOTOM

CDT Code for Dental Fillings - Capline Dental Service

Indirect pulp caps (procedure code D3120) may be reimbursed when billed with procedure code D2940 for the same tooth ID, on the same date of service by the same provider. Procedure code D3221 is considered part of all endodontic procedures and will not be reimbursed separately. 14.2.6.5.3 Root Canal 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 following list shows all codes covered for plans in the state of Louisiana. Your plan may cover some, or all of these codes Code of Dental Procedure (CDT) Verses Aerosol Producing Procedure Description of Service DIAGNOSTIC SERVICES CLINICAL ORAL EVALUATIONS Periodic oral evaluation. D0472 2 D0473 2 D3120 4 D3220 4 D3221 4 D3222 4 D3230 4 D3240 4 D3310 4 D3320 4 D3330 4 D3331 4 D3332 4 D3333 4 D3346 4 D3347 4 D3348 4 D3351 4 D3352 4 D3353 4 D3355

2018 Dental Fee Schedule Effective May 1, 2018 Procedure

Dental code d3120 keyword after analyzing the system lists the list of keywords related and the list of websites with related content, in addition you can see which keywords most interested customers on the this websit Pulp cap - indirect (excluding final restoration) (D3120). Procedure in which the nearly exposed pulp is covered with a protective dressing to protect the pulp from additional injury and to promote healing and repair via formation of secondary dentin

Clarification of Direct and Indirect Pulp Caps Procedure

PO Box 2906 Milwaukee, WI 53201-2906 TEL: 800.417.7140 www.dentaquest.com January 29, 2020 Re: Effective April 1, 2020 - Benefit Limitations Update Codes D3120 - TX HHSC Medicai Dental EHB *Adult Dental Up to Age 19 19 and Older Procedure Category CDT Code Updated CDT-19 Nomenclature In-Network Member Cost Share In-Network Member Cost Share D3110 Pulp cap - direct (excluding final restoration) $20 $20 D3120 Pulp cap - indirect (excluding final restoration) $25 $2 Covered Services are listed with the American Dental Association (ADA) procedure code. ADA Code Services When using a Participating Dentist3 Diagnostic services (exams and x-rays) D0120 Periodic oral evaluation $0 D0140 Limited oral evaluation - problem focused $0 D0145 Oral evaluation for a patient under three years of age $

Pulp Cap, Indirect (Excluding Final Restoration) - Dental

Alpha Dental Programs is a single service (dental) HMO that provides you and Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. CODE DESCRIPTION D3120 Pulp cap - indirect. COVERED DENTAL CODES—ENDODONTICS D3110 Pulp cap- direct D3120 Pulp cap- indirect D3220 Therapeutic pulpotomy D3221 Pulpal Debridement D3310 Anterior (excluding final restoration) D3320 Bicuspid (excluding final restoration) D3330 Molar (excluding final restoration). Supplemental Dental Codes List The following list of preventive and comprehensive dental codes is effective as of 9/1/18. Covered codes may change throughout the year. Covered codes vary by plan. The following list shows all codes covered for plans in the state of Wisconsin. Your plan may cover some, or all of these codes DENTAL FEE SCHEDULE AND PROCEDURE CODES CDT 2016* REVISION February 2016 EFFECTIVE DATE January 1, 2016 *The CDT 2016 codes and nomenclature that follow have been obtained, or appears verbatim from the D3120 Pulp Cap - Indirect (Excluding Final Restoration) 35.00 Pulpotom

Code on Dental Procedures and Nomenclature (CDT

DELEGATED DUTIES: DENTAL THERAPISTS and ADVANCED DENTAL THERAPISTS Approved 9/24/2010 . General Supervision Indirect CDT CODE D0120 SCOPE OF PRACTICE Periodic Oral evaluation and assessment Description and notes ADT ADT D0140 . Limited Oral evaluation and assessmen It is a savings plan offered exclusively by Coast Dental and SmileCare practices to patients who do not have dental insur-ance, Medicare, Medicaid, TRICARE or a discount dental plan. Code Procedure Description Non- Member SmilePlus D3120 Pulp cap, indirect, excluding final restoration $109 $53 51

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Payment for a procedure code is based on Delta Dental's reimbursement policies, utilization review guidelines, and documentation requirements, which may include descriptions that are at variance with descriptions included in CDT codes (Code for Dental Terminology), which are owned and licensed by the American Dental Association D3120: II Pulp cap - indirect (excluding final restoration) $35.90 $57.39 D3220: II Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $94.89 $156.52 D322

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D3120 Pulp Cap - Indirect $0 D3220 Tx Pulpot - Coronl Dentnocementl Junc $0 D3221 Pulpal Debrid Primary & Perm Teeth $20 D3230 Pulpal Therapy - Ant Primary Tooth $35 D3240 Pulpal Therapy - Post Primary Tooth $35 D3310 Anterior $85 D3320 Bicuspid $135 D3330 Molar $250 D3331 Tx Rc Obstruction; Non-Surg Access $8 • The American Dental Association may periodically change CDT Codes or definitions. Different codes may be used to describe these covered procedures. Code Procedure Description Patient Charge Diagnostic/preventive - Oral evaluations are limited to a combined total of CDT Code Enhanced Fee Codes for Implants Participating Dentist - effective 07/01/18 Non-participating Dentist D6010 Surgical placement of implant body: endosteal implant 985.00 225.00 D6011 Second stage implant surgery 385.00 110.00 D6050 Surgical placement: transosteal implant 1,466.00 335.00 D605 CODE PATIENT PAYS CODE PATIENT PAYS $0 D0120-D0180 No Charge D0277 No Charge DMO® Dental Benefits Summary PROCEDURE Office Visit Copay DIAGNOSTIC Oral Evaluations D3120 No Charge D3410 (1) No Charge D3220 No Charge D3421 (1) No Charge D3221 $14 D3425 (1) No Charg