Page 89

Effective Date:

Approval Date: 89

Section 1 - Basic Services The following is a list of services that are payable under the Iowa hawk-i Dental Plan. The list includes those services most commonly provided to covered individuals. It is not an all- inclusive list of covered services. Diagnostic and Treatment Services D0120 Periodic oral evaluation - Limited to 1 every 6 months D0140 Limited oral evaluation - problem focused - Limited to 1 every 6 months D0150 Comprehensive oral evaluation - Once per dentist in a three-year period when the recipient has not seen that dentist during the three years D0180 Comprehensive periodontal evaluation - Once per dentist in a three-year period when the recipient has not seen that dentist during the three years D0210 Intraoral – complete series (including bitewings) 1 every 60 (sixty) months D0220 Intraoral - periapical first film D0230 Intraoral - periapical - each additional film D0240 Intraoral - occlusal film D0270 Bitewing - single film - Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0272 Bitewings - two films - Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0274 Bitewings - four films - Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0277 Vertical bitewings – 7 to 8 films – Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0277 Vertical bitewings – 7 to 8 films – Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0330 Panoramic film – 1 film every 60 (sixty) months Preventive Services D1120 Prophylaxis – Child - Limited to 1 every 6 months D1203 Topical application of fluoride (excluding prophylaxis) – Limited to 2 every 12 months; additional application for “At High Risk” Children* D1204 Topical application of fluoride (excluding prophylaxis) – Age 15 to 18 - 2 every 12 months; additional applications for “At High Risk” Children* D1206 Topical fluoride varnish - Less than age 19 - 2 in 12 months; additional application for “At High Risk” Children* D1351 Sealant - per tooth - unrestored permanent molars - Less than age 18. 1 sealant per tooth every 36 months D1510 Space maintainer – fixed – unilateral -- Limited to children under age 19 D1515 Space maintainer – fixed – bilateral -- Limited to children under age 19 D1520 Space maintainer - removable – unilateral -- Limited to children under age 19 D1525 Space maintainer - removable – bilateral -- Limited to children under age 19 D1550 Re-cementation of space maintainer -- Limited to children under age 19 Additional Procedures covered as Basic Services D9110 Palliative treatment of dental pain – minor procedure * “At Risk” Children –as documented by provider using caries risk assessment form