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Effective Date:

Approval Date: 92

Section 3 - Major 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. Major Restorative Services D0160 Detailed and extensive oral evaluation - problem focused, by report D2510 Inlay - metallic – one surface – An alternate benefit will be provided D2520 Inlay - metallic – two surfaces – An alternate benefit will be provided D2530 Inlay - metallic – three surfaces – An alternate benefit will be provided D2542 Onlay - metallic - two surfaces – Limited to 1 per tooth every 60 months D2543 Onlay - metallic - three surfaces – Limited to 1 per tooth every 60 months D2544 Onlay - metallic - four or more surfaces – Limited to 1 per tooth every 60 months D2740 Crown - porcelain/ceramic substrate - Limited to 1 per tooth every 60 months D2750 Crown - porcelain fused to high noble metal - Limited to 1 per tooth every 60 months D2751 Crown - porcelain fused to predominately base metal – Limited to 1 per tooth every 60 mon D2752 Crown - porcelain fused to noble metal – Limited to 1 per tooth every 60 months D2780 Crown - 3/4 cast high noble metal – Limited to 1 per tooth every 60 months D2781 Crown - 3/4 cast predominately base metal – Limited to 1 per tooth every 60 months D2783 Crown - 3/4 porcelain/ceramic– Limited to 1 per tooth every 60 months D2790 Crown - full cast high noble metal– Limited to 1 per tooth every 60 months D2791 Crown - full cast predominately base metal – Limited to 1 per tooth every 60 months D2792 Crown - full cast noble metal– Limited to 1 per tooth every 60 months D2794 Crown – titanium– Limited to 1 per tooth every 60 months D2950 Core buildup, including any pins– Limited to 1 per tooth every 60 months D2954 Prefabricated post and core, in addition to crown– Limited to 1 per tooth every 60 months D2980 Crown repair, by report Endodontic Services D3310 Anterior root canal (excluding final restoration) D3320 Bicuspid root canal (excluding final restoration) D3330 Molar root canal (excluding final restoration) D3346 Retreatment of previous root canal therapy-anterior D3347 Retreatment of previous root canal therapy-bicuspid D3348 Retreatment of previous root canal therapy-molar D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, rootresorption, etc.) D3353 Apexification/recalcification - final visit (includes completed root canal therapy, apical closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) D3425 Apicoectomy/periradicular surgery - molar (first root) D3426 Apicoectomy/periradicular surgery (each additional root) D3450 Root amputation - per root D3920 Hemisection (including any root removal) - not including root canal therapy Periodontal Services D4210 Gingivectomy or gingivoplasty – four or more teeth Limited to 1 every 36 months