Hansel

6/17/25, 8:15 PM Planet DDS VBS New - Employer Group #237832 Insurance Plan Information (Expanded) Search Carriers DELTA DENTAL PLAN (GA) (POB 1809) Old Insurance Company DELTA DENTAL (GA-1809, 94276) New Insurance Company PO Box 1809 Ins Address Alpharetta City State GA Zip Code 30023 - Phone # 94276 Carrier - PayerID Electronic Payer ID MASTEC INC Group/Employer/Plan Name Group # - Last Verified Date Ins Rep Name - Update Verification Date Lataysha/WEBSITE Other Possible Employer Names Manager Use Only Audit Performed By Audit Peformed General DDS Type Audit Performed Date Expanded OrthoCoverage* Most Recent Audit Yes Verification Tier # of Verification Requests Expanded Current Verification Request ID 0 648,601 not HMO-Discount and New Ver PGID 4093 Allow Edit Do not import to Denticon Edit Access Date/Time Allow Offshore Edit Provider Network Status & Fee Schedules VerificationFormType New Verification Provider Type General Practice Plan Type Provider Network Status Name of Fee Schedule Used? Assignment of benefits to the doctor? Coordination of Benefits Used? Is there also a Plan/Group Specific Fee Schedule? Field information PPO In Delta Dental PPO Yes Standard (Birthday Rule) No General Information Renewal Type Contract Year Anniversary (MM/DD) Calendar Year 01/01 Category Breakdown Individual Maximum $ Individual Deductible $ $2,000.00 Family Maximum $ $50.00 Family Deductible $ $99,999.00 $150.00 Deductible Apply? Preventive % 100% No 100% No 80% Yes Waiting period No Waiting Period 50% Yes Waiting Period No Waiting Period Denture Replacement Clause: 1 every 60 months (Type 1) Diagnostic % (Type 2) Basic % (Type 3) Major % (Type 4) Missing Tooth Clause Crown Replacement Clause: Ortho Coverage Ortho % No 1 every 60 months Bridge Replacement Clause: 1 every 60 months Yes 50% Ortho Maximum $ $2,000.00 (Type 5) Ortho Deductible? Ortho Age Limitation No No Age limit Ortho Wait Period ? No Waiting Period Is Periodic Billing Required? No - Automatic Quarterly ****Confirm if age is age up to or through**** D7880 - Orthotic Device Additional Information/Notes 0% D8040 - Limited Ortho Adult 50% D8080 - Ortho - Invisalign 50% Maximum applies to all services. Exams and X-Rays Category Frequency Periodic Exam (D0120) Diagnostic 2 every 1 calendar year Limited Exam (D0140) Diagnostic 2 every 1 Share freq with routine exams? https://pdds.quickbase.com/db/bg6jxhhdq?a=printr&rid=237832&dfid=27 1/7 6/17/25, 8:15 PM Planet DDS VBS New calendar year Comprehensive Exam (D0150) Diagnostic Comprehensive Perio Eval (D0180) Diagnostic Full Mouth Series - FMX (D0210) Diagnostic 1 per Lifetime Share freq with routine exams? Is this allowed once per provider? Is this ***Confirm if frequency is to the calendar yr, month, or to day*** Periapical X-ray - PA's (D0220) Any restrictions such as Shares Frequency with PANO BWX and PA's in the same day turn to FMX If $ amount of x-rays taken >= the cost of an FM one FMX Diagnostic Additional PA's (D0230) Bite Wing X-rays (D0274) 1 every 36 months OTHER - SEE PLAN NOTES Diagnostic Frequency ****Confirm if age is age up to or through**** 2 every 1 calendar year Child Age Limit No Age limit Child Age Limit Frequency ***Confirm if frequency is to the calendar yr, month, or to day*** PANORAMIC x-ray (D0330) Diagnostic 1 every 36 months Shares Frequency with FMX Preventive Services Category Frequency Age Limitation Prophylaxis - Adult (D1110) Preventive 4 every 1 calendar year ****Confirm if age is age up to or through**** Prophylaxis - Child (D1120) Preventive 4 every 1 calendar year up to 14 Fluoride (D1208) Preventive 1 every 1 calendar year up to 19 Sealants (D1351) Preventive 1 every 36 months up to 14 Restrictions First and second permanent molars only. Space maintainers (D1510-D1527) Preventive 1 per Lifetime up to 14 Restrictions LL, LR, UL, UR Restorative Services Posterior Composite (D2391-D2394) Category Downgraded to a ? Description Frequency Basic Yes - Downgrade to Amalgam on molars only. 1 every 24 months Porcelain or Ceramic Inlay (D2620) Not Covered Porcelain or Ceramic Onlay (D2642) Not Covered Crown Porcelain Fused to Hi Noble Metal (D2750) Prefab SS Crown Primary Tooth (D2930) Post and Core in Addition to Crown (D2952) Can D2950-D2954 be done same day as a Root Canal? Prosthesis pay at the time of Prep or Seat? Major No Basic Major Yes Seat Endodontic Services Pulp Cap Direct (D3110) Pulp Cap Indirect (D3120) Basic Not Covered Pulpal Therapy Anterior Primary (D3220) Basic Pulpal Therapy Posterior Primary (D3240) Basic Anterior Root Canal (D3310) Basic Molar Root Canal (D3330) Basic Retreat Molar Endodontics (D3348) Basic Periodontic Services Category Gingiv Flap Rtpln 4+T/Per Quad (D4240) Basic Gingi Flap Rtpln 1-3t Pr Quad (D4241) Basic Crown Lengthening (D4249) Basic Periodontal Surgery (D4260) Basic Osseous Surgery 1-3t Pr Quad (D4261) Basic Is a Periodontal Graft Covered (D4263) Basic Subepithelial Conn Tiss Graft (D4273) Basic Soft Tissue Allograft (D4275) Basic Free Soft Tissue Graft (D4277) Basic Provsnl Splinting Extracoronal (D4321) Restrictions Benefit is limited to once per tooth within a 3 year period. Benefit available only when performed on natural teeth; not a benefit in conjunction with extractions, extraction sites or implant procedures. Not Covered Frequency https://pdds.quickbase.com/db/bg6jxhhdq?a=printr&rid=237832&dfid=27 Restrictions/Other Info 2/7 6/17/25, 8:15 PM Planet DDS VBS New Basic Periodontal Scaling/Root Plaining (D4341) 1 every 24 months Basic Full Mouth Debridement (D4355) Can we perform more than one quad per visit? 1 per Lifetime Yes Is pre-authorization x-rays required? Restrictions No required? Following active periodontal therapy, allow completion of a 30 day postoperative period before performing this procedure. D4355 is not billable to the patient when performed on the same date of service, by the same provider as D0180. Describe Restrictions Preventive Perio Maintenance (D4910) Are charting and Describe Share freq with D1110 Not Covered Arrestin/Antimicrobial Agent (D4381) Yes - 2 quads per visit max 4 every 1 calendar year Are Charting & Share freq with D1110 Yes Is active treatment x-rays required? No required? Removable Prosthetics Dentures (D5110) Major Partial/Denture Adjustment (D5410) Basic Partial/Denture Teeth Replacement (D5670) Basic Partial/Denture Reline (D5751) Basic Restrictions Any adjustment or repair made to a denture within six months of installation is included in the fee for the original treatment. Other adjustments are limited to once per arch within a 6 month period. Implants Implant Coverage (D6010) Major Implant Crowns (D6059) Major Downgrade - Base metal crown Bridges - Fixed (D6750) Major Downgraded to Bridge/Partial - Base metal Bridge or RPD Oral Surgery Services Simple Extractions (D7140) Basic Surgical Extractions (D7240) Basic Do surgical procedures need to be filed with Medical Insurance (D7240 and above) Ridge Augmentation Covered (D7953) Frenectomy (D-) Not Covered Basic Miscellaneous Services Emergency/Palliative Treatment (D9110) General Anesthesia-30 Min (D9223) Preventive Basic Nitrous Oxide Sedation (D9230) Not Covered Occlusal Guard, By Rpt (D9944-D9946) Not Covered Occlusal Adjustment Limited (D9951) Not Covered Comments Guidelines IN CONJUNCTION WITH ORAL SURGERY, ENDO, OR PERIO PROCEDURE OF THE SAME DATE OF SERVICE. BENEFIT IS LIMITED TO 4 PER DATE OF SERVICE- EACH 15-MINUTE INCREMENT. Frequency Bruxism or Osseous Surgery Periapical X-ray - PA's (D0220) - Benefit is based on professional determination. Comments Verified By Current Subscriber Name Rajil, Hansel # Missing Logan Closed Status of Current Verification 0 Complete Locked Inactive Date -:34 AM Missing Fields Export to Denticon Export Insurance Information INSURANCE INFORMATION Insurance Company Address City State Zip Code Phone # Electronic Payer ID Group/Employer/Plan Name **Group # Last Verified Date Ins Rep Name : : : : : : : : : : : DELTA DENTAL (GA-1809, 94276) PO Box 1809 Alpharetta GA 30023 - MASTEC INC- Lataysha/WEBSITE PROVIDER NETWORK STATUS AND FEE SCHEDULES Plan Type Network Status Fee Schedule Used? Assignment of benefits to the doctor? Coordination of Benefits Used? Is there also a Plan/Group Specific Fee Schedule? : : : : : : PPO In Delta Dental PPO Yes Standard (Birthday Rule) No GENERAL INFORMATION Renewal Type **Contract Year Anniversary (MM/DD) : Calendar Year : 01/01 CATEGORY BREAKDOWN **Individual Maximum $ **Family Maximum $ : $2000 : $99999 https://pdds.quickbase.com/db/bg6jxhhdq?a=printr&rid=237832&dfid=27 3/7 6/17/25, 8:15 PM **Individual Deductible $ **Family Deductible $ **Preventive %(Type 1)% Deductible Applies **Diagnostic %(Type 2)% Deductible Applies **Basic %(Type 3)% Deductible Applies Waiting Period **Major %(Type 4)% Deductible Applies Waiting Period Missing Tooth Clause (MTC) Crown Replacement Clause: Bridge Replacement Clause: Denture Replacement Clause: Ortho Coverage **Ortho %(Type 5)% **Ortho Maximum $ Ortho Deductible? Ortho Deductible $ Ortho Age Limitation Ortho Wait Period ? Is Periodic Billing Required? **D7880 - Orthotic Device% **D8040 - Limited Ortho Adult% **D8080 - Ortho - Invisalign% **Additional Information/Notes Planet DDS VBS New : : : : : : : : : : : : : : : : : : : : : : : : : : : : $50 $150 100% No 100% No 80% Yes No Waiting Period 50% Yes No Waiting Period No 1 every 60 months 1 every 60 months 1 every 60 months Yes 50% $2000 No $0 No Age limit No Waiting Period No - Automatic Quarterly 0% 50% 50% Maximum applies to all services. EXAMS AND X-RAYS **Periodic Exam (D0120) : Diagnostic Frequency : 2 every 1 calendar year **Emergency Exam (D0140) : Diagnostic Frequency : 2 every 1 calendar year **Comprehensive Exam (D0150) : Diagnostic Frequency : 1 per Lifetime **Comprehensive PerioEval New/Established Patient(D0180) : Diagnostic **Full Mouth Series - FMX (D0210) : Diagnostic Frequency : 1 every 36 months Shares Frequency with PANO : Yes Restrictions : If $ amount of x-rays taken >= the cost of an FMX all x-rays will be paid as one FMX **Periapical X-ray - PAs (D0220) : Diagnostic Additional PAs (D0230) : OTHER - SEE PLAN NOTES **Bite Wing X-rays (D0274) : Diagnostic Frequency : 2 every 1 calendar year Age Limit : No Age limit **PANORAMIC x-ray (D0330) : Diagnostic Frequency : 1 every 36 months Shares Frequency with FMX : Yes PREVENTIVE SERVICES **Prophylaxis - Adult (D1110) Frequency **Prophylaxis - Child (D1120) Frequency Age Limit **Fluoride - Adult (D1208) Frequency Age Limit **Sealants (D1351) Frequency Age Limit Restrictions **Space maintainers (D1510-D1527) Frequency Age Limit Restrictions : : : : : : : : : : : : : : : : Preventive 4 every 1 calendar year Preventive 4 every 1 calendar year up to 14 Preventive 1 every 1 calendar year up to 19 Preventive 1 every 36 months up to 14 First and second permanent molars only. Preventive 1 per Lifetime up to 14 LL, LR, UL, UR RESTORATIVE SERVICES **Posterior Composite fillings (D2391) Downgrade **Frequency Description **Porcelain or Ceramic Inlay (D2620) **Porcelain or Ceramic Onlay (D2642) **Crown Porcelain Fused to Hi Noble Metal (D2750) Downgrade Prosthesis pay at the time of Prep or Seat? **Prefab SS Crown Primary Tooth (D2930) **Post and Core in Addition to Crown (D2952) Can D2950-D2954 be done same day as a Root Canal? : : : : : : : : : : : : Basic Yes - Downgrade to Amalgam 1 every 24 months on molars only. Not Covered Not Covered Major No Seat Basic Major Yes ENDODONTIC SERVICES **Pulp Cap Direct/Indirect (D3110-D3120) **Pulpal Therapy Anterior Primary (D3220) **Pulpal Therapy Posterior Primary (D3240) **Anterior Root Canal (D3310) **Molar Root Canal (D3330) **Retreat Molar Endodontics (D3348) : : : : : : Basic Basic Basic Basic Basic Basic PERIODONTIC SERVICES **Gingiv Flap Rtpln 4+T/Per Quad (D4240) **Gingi Flap Rtpln 1-3t Pr Quad (D4241) : Basic : Basic https://pdds.quickbase.com/db/bg6jxhhdq?a=printr&rid=237832&dfid=27 4/7 6/17/25, 8:15 PM Planet DDS VBS New - **Clinical Crwn Lngthng Hard Tissue (D4249) **Periodontal Surgery (D4260) **Osseous Surgery 1-3t Pr Quad (D4261) **Is a Periodontal Graft Covered (D4263) Describe Restrictions **Free Soft Tissue Graft (D4277) **Subepithelial Conn Tiss Graft (D4273) **Soft Tissue Allograft (D4275) **Provsnl Splinting Extracoronal (D4321) **Periodontal Scaling/Root Plaining (D4341) Frequency Will multiple quads be paid if done on same visit? Are charting and X-rays required (D4341)? Is pre-authorization required (D4341) **Full Mouth Debridement (D4355) Frequency Describe Restrictions Share freq with D1110 **Arrestin/Antimicrobial Agent (D4381) **Perio Maintenance (D4910) Frequency Share freq with D1110 Are Charting and X-rays required (D4910) Is active treatment required? (D4910) : : : : : : : : : : : : : : : : : : : : : : : : Basic Basic Basic Basic Benefit is limited to once per tooth within a 3 year period. Benefit available only wh Basic Basic Basic Not Covered Basic 1 every 24 months Yes - 2 quads per visit max Yes No Basic 1 per Lifetime Following active periodontal therapy, allow completion of a 30 day post-operative peri Yes Not Covered Preventive 4 every 1 calendar year Yes Yes No REMOVABLE PROSTHETICS **Dentures/Partials - Fixed and Removable (D5110-D5226) **Partial/Denture Adjustment (D5410) Restrictions (D5410) : Major : Basic : Any adjustment or repair made to a denture within six months of installation is includ IMPLANTS **Implant Coverage (D6010) **Implant Crowns (D6059) Downgrade (D6059) **Bridges - Fixed (D6750) Downgraded to Bridge/Partial (D5410 or D6750) : : : : : Major Major No Major No ORAL SURGERY SERVICES **Oral surgery-Simple Extractions (D7140) : Basic **Surgical Extractions (D7240) : Basic Do surgical procedures need to be filed with Medical Ins : No **Ridge Augmentation Covered (D7953) : Not Covered **Frenulectomy / Frenectomy / Frenotomy (D7960) : Basic MISCELLANEOUS SERVICES **Emergency Treatment/Palliative (D9110) : Preventive **General Anesthesia-30 Min (D9223) : Basic Guidelines : IN CONJUNCTION WITH ORAL SURGERY, ENDO, OR PERIO PROCEDURE OF THE SAME DATE OF SERVICE BENEFIT IS LIMITED TO 4 PER DATE OF SERVICE- EACH 15-MINUTE INCREMENT. **Nitrous Oxide Sedation (D9230) : Not Covered **Occlusal Guard, By Rpt (D9942-D9946) : Not Covered **Occlusal Adjustment Limited (D9951) : Not Covered **Comments : Periapical X-ray - PA's (D0220) - Benefit is based on professional determination. Export Insurance Information (html Full) INSURANCE INFORMATION Insurance Company....................................... Address................................................. City.................................................... State................................................... Zip Code................................................ Phone #................................................. Electronic Payer ID..................................... Group/Employer/Plan Name................................ **Group #............................................... Last Verified Date...................................... Ins Rep Name............................................ : : : : : : : : : : : DELTA DENTAL (GA-1809, 94276) PO Box 1809 Alpharetta GA 30023 - MASTEC INC- Lataysha/WEBSITE PROVIDER NETWORK STATUS AND FEE SCHEDULES Plan Type............................................... Network Status.......................................... Fee Schedule Used?...................................... Assignment of benefits to the doctor?................... Coordination of Benefits Used?.......................... Is there also a Plan/Group Specific Fee Schedule?....... : : : : : : PPO In Delta Dental PPO Yes Standard (Birthday Rule) No GENERAL INFORMATION Renewal Type............................................ : Calendar Year **Contract Year Anniversary (MM/DD)..................... : 01/01 CATEGORY BREAKDOWN **Individual Maximum $.................................. **Family Maximum $...................................... **Individual Deductible $............................... **Family Deductible $................................... **Preventive %(Type 1)%................................. Deductible Applies...................................... **Diagnostic %(Type 2)%................................. Deductible Applies...................................... **Basic %(Type 3)%...................................... Deductible Applies...................................... Waiting Period.......................................... **Major %(Type 4)%...................................... Deductible Applies...................................... Waiting Period.......................................... : : : : : : : : : : : : : : $2000 $99999 $50 $150 100% No 100% No 80% Yes No Waiting Period 50% Yes No Waiting Period https://pdds.quickbase.com/db/bg6jxhhdq?a=printr&rid=237832&dfid=27 5/7 6/17/25, 8:15 PM Planet DDS VBS New - Missing Tooth Clause.................................... Crown Replacement Clause:............................... Bridge Replacement Clause:.............................. Denture Replacement Clause:............................. Ortho Coverage.......................................... **Ortho %(Type 5)%...................................... **Ortho Maximum $....................................... Ortho Deductible?....................................... Ortho Deductible $...................................... Ortho Age Limitation.................................... Ortho Wait Period ?..................................... Is Periodic Billing Required?........................... **D7880 - Orthotic Device%.............................. **D8040 - Limited Ortho Adult%.......................... **D8080 - Ortho - Invisalign%........................... **Additional Information/Notes.......................... : : : : : : : : : : : : : : : : No 1 every 60 months 1 every 60 months 1 every 60 months Yes 50% $2000 No $0 No Age limit No Waiting Period No - Automatic Quarterly 0% 50% 50% Maximum applies to all services. EXAMS AND X-RAYS **Periodic Exam (D0120)................................. Frequency............................................... **Emergency Exam (D0140)................................ Frequency............................................... **Comprehensive Exam (D0150)............................ Frequency............................................... **Comprehensive PerioEval New/Established Patient(D0180) **Full Mouth Series - FMX (D0210)....................... Frequency............................................... Shares Frequency with PANO.............................. Restrictions............................................ **Periapical X-ray - PAs (D0220)........................ Additional PAs (D0230).................................. **Bite Wing X-rays (D0274).............................. Frequency............................................... Age Limit............................................... **PANORAMIC x-ray (D0330)............................... Frequency............................................... Shares Frequency with FMX............................... : : : : : : : : : : : : : : : : : : : Diagnostic 2 every 1 calendar year Diagnostic 2 every 1 calendar year Diagnostic 1 per Lifetime Diagnostic Diagnostic 1 every 36 months Yes If $ amount of x-rays taken >= the cost of an FMX all x-rays will be paid as one FMX Diagnostic OTHER - SEE PLAN NOTES Diagnostic 2 every 1 calendar year No Age limit Diagnostic 1 every 36 months Yes PREVENTIVE SERVICES **Prophylaxis - Adult (D1110)........................... Frequency............................................... **Prophylaxis - Child (D1120)........................... Frequency............................................... Age Limit............................................... **Fluoride - Adult (D1208).............................. Frequency............................................... Age Limit............................................... **Sealants (D1351)...................................... Frequency............................................... Age Limit............................................... Restrictions............................................ **Space maintainers (D1510-D1527)....................... Frequency............................................... Age Limit............................................... Restrictions............................................ : : : : : : : : : : : : : : : : Preventive 4 every 1 calendar year Preventive 4 every 1 calendar year up to 14 Preventive 1 every 1 calendar year up to 19 Preventive 1 every 36 months up to 14 First and second permanent molars only. Preventive 1 per Lifetime up to 14 LL, LR, UL, UR RESTORATIVE SERVICES **Posterior Composite fillings (D2391).................. Downgrade............................................... **Frequency............................................. **Description........................................... **Porcelain or Ceramic Inlay (D2620).................... **Porcelain or Ceramic Onlay (D2642).................... **Crown Porcelain Fused to Hi Noble Metal (D2750)....... Downgrade............................................... Prosthesis pay at the time of Prep or Seat?............. **Prefab SS Crown Primary Tooth (D2930)................. **Post and Core in Addition to Crown (D2952)............ Can D2950-D2954 be done same day as a Root Canal?....... : : : : : : : : : : : : Basic Yes - Downgrade to Amalgam 1 every 24 months on molars only. Not Covered Not Covered Major No Seat Basic Major Yes ENDODONTIC SERVICES **Pulp Cap Direct/Indirect (D3110-D3120)................ **Pulpal Therapy Anterior Primary (D3220)............... **Pulpal Therapy Posterior Primary (D3240).............. **Anterior Root Canal (D3310)........................... **Molar Root Canal (D3330).............................. **Retreat Molar Endodontics (D3348)..................... : : : : : : Basic Basic Basic Basic Basic Basic PERIODONTIC SERVICES **Gingiv Flap Rtpln 4+T/Per Quad (D4240)................ **Gingi Flap Rtpln 1-3t Pr Quad (D4241)................. **Clinical Crwn Lngthng Hard Tissue (D4249)............. **Periodontal Surgery (D4260)........................... **Osseous Surgery 1-3t Pr Quad (D4261).................. **Is a Periodontal Graft Covered (D4263)................ Describe Restrictions................................... **Free Soft Tissue Graft (D4277)........................ **Subepithelial Conn Tiss Graft (D4273)................. **Soft Tissue Allograft (D4275)......................... **Provsnl Splinting Extracoronal (D4321)................ **Periodontal Scaling/Root Plaining (D4341)............. Frequency............................................... Will multiple quads be paid if done on same visit?...... Are charting and X-rays required (D4341)?............... Is pre-authorization required (D4341)................... **Full Mouth Debridement (D4355)........................ Frequency............................................... Describe Restrictions................................... Share freq with D1110................................... **Arrestin/Antimicrobial Agent (D4381)................. **Perio Maintenance (D4910)............................. Frequency............................................... Share freq with D1110................................... Are Charting and X-rays required (D4910)................ Is active treatment required? (D4910)................... : : : : : : : : : : : : : : : : : : : : : : : : : : Basic Basic Basic Basic Basic Basic Benefit is limited to once per tooth within a 3 year period. Benefit available only when performed Basic Basic Basic Not Covered Basic 1 every 24 months Yes - 2 quads per visit max Yes No Basic 1 per Lifetime Following active periodontal therapy, allow completion of a 30 day post-operative period before per Yes Not Covered Preventive 4 every 1 calendar year Yes Yes No https://pdds.quickbase.com/db/bg6jxhhdq?a=printr&rid=237832&dfid=27 6/7 6/17/25, 8:15 PM Planet DDS VBS New - REMOVABLE PROSTHETICS **Dentures/Partials - Fixed and Removable (D5110-D5226). : Major **Partial/Denture Adjustment (D5410).................... : Basic Restrictions (D5410).................................... : Any adjustment or repair made to a denture within six months of installation is included in the fee IMPLANTS **Implant Coverage (D6010).............................. **Implant Crowns (D6059)................................ Downgrade (D6059)....................................... **Bridges - Fixed (D6750)............................... Downgraded to Bridge/Partial (D5410 or D6750)........... : : : : : Major Major No Major No ORAL SURGERY SERVICES **Oral surgery-Simple Extractions (D7140)............... **Surgical Extractions (D7240).......................... Do we file codes D7240 and above w/Medical Ins?......... **Ridge Augmentation Covered (D7953).................... **Frenulectomy / Frenectomy / Frenotomy (D7960)......... : : : : : Basic Basic No Not Covered Basic MISCELLANEOUS SERVICES **Emergency Treatment/Palliative (D9110)................ : Preventive **General Anesthesia-30 Min (D9223)..................... : Basic Guidelines.............................................. : IN CONJUNCTION WITH ORAL SURGERY, ENDO, OR PERIO PROCEDURE OF THE SAME DATE OF SERVICE. BENEFIT IS LIMITED TO 4 PER DATE OF SERVICE- EACH 15-MINUTE INCREMENT. **Nitrous Oxide Sedation (D9230)........................ : Not Covered **Occlusal Guard, By Rpt (D9944-D9946).................. : Not Covered **Occlusal Adjustment Limited (D9951)................... : Not Covered **Comments.............................................. : Periapical X-ray - PA's (D0220) - Benefit is based on professional determination. Verified By............................................. : Hansel Rajil Created on July 13, 2023 at 1:53 PM (PDT). Last updated by Sadaya, Trixy on July 18, 2023 at 8:34 AM (PDT). Owned by Rajil, Hansel. https://pdds.quickbase.com/db/bg6jxhhdq?a=printr&rid=237832&dfid=27 7/7