Preventive cleaning (periodontal cleaning in the presence of inflamed gums is considered to be a Basic Benefit for payment purposes), topical application of fluoride solutions, space maintainers.
Preventive. Maintenance Supplier’s Preventive Maintenance offerings and responsibilities, and the Authorized User’s associated remedies, are described in Exhibit D.
Preventive. D1110 Prophylaxis - adult $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1120 Prophylaxis - child $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish $10 1 of (D1206, D1208) per 6 months D1208 Topical application of fluoride - excluding varnish $10 1 of (D1206, D1208) per 6 months D1351 Sealant - per tooth $20 Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $20 Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - per tooth $10 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant $150 D1516 Space maintainer - fixed - bilateral, maxillary $225 D1517 Space maintainer - fixed - bilateral, mandibular $225 D1520 Space maintainer - removable, unilateral - per quadrant $150 D1526 Space maintainer - removable - bilateral, maxillary $225 D1527 Space maintainer - removable - bilateral, mandibular $225 D1551 Re-cement or re-bond bilateral space maintainer - maxillary $30 D1552 Re-cement or re-bond bilateral space maintainer - mandibular $30 D1553 Re-cement or re-bond unilateral space maintainer - per quadrant $30 D1556 Removal of fixed unilateral space maintainer- per quadrant $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant $150 1 per quadrant per lifetime; Age 8 and under Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees
Preventive. Bitewing X-Ray Cleaning Fluoride Treatments (dependents under age 17) Examinations Sealants Panoramic X-Ray (once per 24-month period)
Preventive health care services under this section of this contract received from a non-participating provider.
Preventive. Maintenance Plan [326 IAC 1-6-3]
Preventive care including but not limited to wellness exams, flea control, worm medication and vaccinations, unless you purchase coverage through our Defender/DefenderPlus endorsement.
Preventive predictive, routine and non-routine maintenance and repairs are performed on a basis that ensures reliable, long-term and safe operation, and are performed by knowledgeable, trained and experienced personnel utilizing proper equipment, tools, and procedures.
Preventive. (1) Prophylaxis: 11100, 11200, 11300, but not more than once in any period of six (6) consecutive months.
Preventive. Dental Care We will pay for preventive dental care, which includes procedures which help to prevent oral disease from occurring, including: • Prophylaxis (scaling and polishing the teeth at six (6) month intervals); • Topical fluoride application at six (6) month intervals where the local water supply is not fluoridated; • Sealants on unrestored permanent molar teeth.
