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TABLE OF DENTAL PROCEDURES PLEASE READ …

9232 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
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My Smile Dental Plan Fee Schedule

MY SMILE DENTAL PLAN FEE SCHEDULE PLAN C2011S 3 | P a g e Code Description Schedule D2780 crown – ¾ cast high noble metal $ 540.00
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CDT-4 CODE ON DENTAL PROCEDURES AND

american dental association cdt-2011/2012 code on dental procedures and nomenclature effective january 1, 2011 d0100–d0999 diagnostic clinical oral evaluations
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Dental Clinical Criteria and Documentation

04-01-2005 2 • Permanent bicuspid teeth must have pathologic destruction to the tooth by caries or trauma, and should involve three or more surfaces and at least one cusp.
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HumanaOne Dental Discount Plan

***Discount plans are not insurance*** This schedule applies to services provided by a participating General Dentist and is an extensive list of most
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