Delta MI Eligibility Report - Pro
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Ascend Eligibility
Created: February 4, 2025 at 12:42 PM
Transaction ID: cm6qrok526u5zdb0ja28m59ex
Response type
Source
Payer Web Portal
Insurance
Delta MI
Eligibility Pro delivers current, web-based eligibility checks with greater detail and accuracy, helping reduce errors and improve efficiency. Eligibility Essentials uses EDI (Electronic Data Interchange) methods that provide a more basic level of eligibility information, which may not always reflect the payer's most up-to-date data.
Appointment Coverage Details
Benefit NoteAppointment Date: 09/07/2025
| Codes | PPO | Premier | Out of Network | Co-Pay | Co-Insurance | Age Limit | Frequency | History | Waiting Period |
|---|---|---|---|---|---|---|---|---|---|
| D0120 |
80% | 90% | 50% | $0 | -- | No | 1 per year | 01/25/2024 | None |
| D0150 | 80% | 90% | 50% | $0 | -- | No | 1 per year | 01/25/2024 | None |
Appointment Date: 09/17/2025
| Codes | PPO | Premier | Out of Network | Co-Pay | Co-Insurance | Age Limit | Frequency | History | Waiting Period |
|---|---|---|---|---|---|---|---|---|---|
| D0120 | 80% | 90% | 50% | $0 | -- | No | 1 per year | 01/25/2024 | None |
| D0150 | 80% | 90% | 50% | $0 | -- | No | 1 per year | 01/25/2024 | None |
Patient
First Name
FName
Last Name
LName
Date of Birth
01-01-1900
Subscriber
First Name
FName
Last Name
LName
Subscriber ID
123456789
Date of Birth
01-01-1900
Group Name
Priority Health Medicare
Group #
9999-9999
Provider
Name
Smith
NPI
1234567893
Plan
Plan Name
Medicare Advantage PPO And Premier Traveler Plan
Insurance Type
PPO
Effective Date
01-01-2022
Plan Period
Policy Year
Plan Start
01-01-2025
Plan End
12-31-2025
COB Rule
--
Missing Tooth Clause
--
Downgrades
No
Pays on Prep or Seat
--
Insurance
Insurance Name
Delta MI
Payer ID
CDMI0
Provisions
- Space Maintainers are not a covered benefit.
- Posterior composite resin restorations are covered services.
- Inlays are not covered services and will be optioned to an amalgam or resin restoration.
Deductibles and Maximums
Deductible Met
Max Reached| Maximum | Category | DELTA DENTAL PPO | DELTA DENTAL PREMIER | OUT OF NETWORK |
|---|---|---|---|---|
| Individual | ||||
| Annual Amount | Dental Care | $2,500 | $2,500 | $2,500 |
| Annual Remaining | Dental Care | $2,500 | $2,500 | $2,500 |
Orthodontics
| Service Type | DELTA DENTAL PPO | DELTA DENTAL PREMIER | OUT OF NETWORK |
|---|---|---|---|
| Orthodontics | |||
| Individual Annual Maximum | -- | -- | -- |
| Individual Annual Maximum Remaining | -- | -- | -- |
| Lifetime Maximum | -- | -- | -- |
| Lifetime Maximum Remaining | -- | -- | -- |
| Lifetime Deductible | -- | -- | -- |
Coverage
| SERVICE TYPE | DESCRIPTION | DELTA DENTAL PPO | DELTA DENTAL PREMIER | OUT OF NETWORK | DED APPLIES | WAITING PERIOD |
|---|---|---|---|---|---|---|
| Diagnostic | ||||||
| D0120 | Routine dental exam to examine overall oral health and check for any necessary treatment needed | 100% | 100% | 100% | Yes | -- |
| D0140 | Problem focused dental exam for a specific issue | 100% | 100% | 100% | Yes | -- |
| D0150 | A thorough oral examination of the patient's dental history, usually performed on new patients | 100% | 100% | 100% | Yes | -- |
| D0180 | An examination detailing a patient's periodontal health | 100% | 100% | 100% | Yes | -- |
| D0210 | X-rays of all the teeth in the mouth | 100% | 100% | 100% | Yes | -- |
| D0220 | A diagnostic image of a single tooth that includes the tooth structure | 100% | 100% | 100% | Yes | -- |
| D0230 | An additional diagnostic image of a single tooth that include the root structure | 100% | 100% | 100% | Yes | -- |
| D0272 | 2 diagnostic bitewing x-ray images used to check for tooth decay | 100% | 100% | 100% | Yes | -- |
| D0274 | 4 diagnostic bitewing x-ray images used to check for tooth decay | 100% | 100% | 100% | Yes | -- |
| D0330 | X-ray of the entire mouth | 100% | 100% | 100% | Yes | -- |
| Preventive | ||||||
| D1110 | Professional teeth cleaning for adults | 100% | 100% | 100% | Yes | -- |
| D1120 | Professional teeth cleaning for children | -- | -- | -- | Yes | -- |
| D1206 | Application of Fluoride to all teeth using a varnish | 100% | 100% | 100% | Yes | -- |
| D1208 | Application of fluoride to all teeth excluding varnish | 100% | 100% | 100% | Yes | -- |
| D1351 | Surfaces of tooth sealed with a resin to help prevent tooth decay | -- | -- | -- | Yes | -- |
| D1510 | Permanent device on one side of the mouth where there is space, to keep teeth from moving | -- | -- | -- | Yes | -- |
| D1516 | Permanent device on upper arch of Oral Cavity, covers right and left quadrant of the upper arch to keep teeth from moving | -- | -- | -- | Yes | -- |
| D1517 | Permanent device on lower arch of Oral Cavity, covers right and left quadrant of the lower arch to keep teeth from moving | -- | -- | -- | Yes | -- |
| Basic Restorative | ||||||
| D2140 | Silver-colored filling of a cavity of one surface of a tooth | 100% | 100% | 100% | Yes | -- |
| D2150 | Silver-colored filling of a cavity on two surfaces of a tooth | 100% | 100% | 100% | Yes | -- |
| D2160 | Silver-colored filling of a cavity on three surfaces of a tooth | 100% | 100% | 100% | Yes | -- |
| D2161 | Silver-colored filling of a cavity on three or more surfaces of a tooth | 100% | 100% | 100% | Yes | -- |
| D2330 | Tooth-colored filling of a cavity of one surface of a front tooth | 100% | 100% | 100% | Yes | -- |
| D2331 | Tooth-colored filling of a cavity of two surfaces of a front tooth | 100% | 100% | 100% | Yes | -- |
| D2332 | Tooth-colored filling of a cavity of three surfaces of a front tooth | 100% | 100% | 100% | Yes | -- |
| D2335 | Tooth-colored filling of a cavity of four or more surfaces of a front tooth | 100% | 100% | 100% | Yes | -- |
| D2390 | Tooth-colored resin crown on a front tooth | 100% | 100% | 100% | Yes | -- |
| D2391 | Tooth-colored filling of a cavity of one surface of a back tooth | 100% | 100% | 100% | Yes | -- |
| D2392 | Tooth-colored filling of a cavity of two surfaces of a back tooth | 100% | 100% | 100% | Yes | -- |
| D2393 | Tooth-colored filling of a cavity of three surfaces of a back tooth | 100% | 100% | 100% | Yes | -- |
| D2394 | Tooth-colored filling of a cavity of four or more surfaces of a back tooth | 100% | 100% | 100% | Yes | -- |
| Crowns | ||||||
| D2710 | Crown restoration made of a resin based restorative material | 50% | 50% | 50% | Yes | -- |
| D2712 | Crown restoration made of a 3/4 resin based restorative material | 50% | 50% | 50% | Yes | -- |
| D2720 | Crown restoration made of a resin with high noble metal | 50% | 50% | 50% | Yes | -- |
| D2721 | Crown restoration made of a resin with predominantly base metal | 50% | 50% | 50% | Yes | -- |
| D2722 | Crown restoration made of a resin with noble metal | 50% | 50% | 50% | Yes | -- |
| D2740 | Crown restoration made of porcelain/ceramic | 50% | 50% | 50% | Yes | -- |
| D2750 | Crown restoration made of porcelain fused to high noble metal | 50% | 50% | 50% | Yes | -- |
| D2751 | Crown restoration made of porcelain fused to predominantly base metal | 50% | 50% | 50% | Yes | -- |
| D2752 | Crown restoration made of porcelain fused to noble metal | 50% | 50% | 50% | Yes | -- |
| D2753 | Crown restoration made of titanium | 50% | 50% | 50% | Yes | -- |
| D2780 | Crown restoration made of 3/4 cast high noble metal | 50% | 50% | 50% | Yes | -- |
| D2781 | Crown restoration made of 3/4 cast predominantly base metal | 50% | 50% | 50% | Yes | -- |
| D2782 | Crown restoration made of 3/4 cast noble metal | 50% | 50% | 50% | Yes | -- |
| D2783 | Crown restoration made of 3/4 porcelain/ceramic | 50% | 50% | 50% | Yes | -- |
| D2790 | Crown restoration made of full cast high noble metal | 50% | 50% | 50% | Yes | -- |
| D2791 | Crown restoration made of full cast predominantly base metal | 50% | 50% | 50% | Yes | -- |
| D2792 | Crown restoration made of full cast noble metal | 50% | 50% | 50% | Yes | -- |
| D2794 | Crown restoration made of titanium | 50% | 50% | 50% | Yes | -- |
| D2799 | Transitional crown restoration used while tissue heals, bite is adjusted and final restorations are prepared | -- | -- | -- | Yes | -- |
| Major Restorative | ||||||
| D2950 | Reconstruction or buildup of a tooth structure | 50% | 50% | 50% | Yes | -- |
| D2952 | Strengthening post and resin buildup material, indirectly fabricated, in addition to a crown | 50% | 50% | 50% | Yes | -- |
| D2954 | Strengthening post and resin buildup material, prefabricated, in addition to a crown | 50% | 50% | 50% | Yes | -- |
| Endodontics | ||||||
| D3110 | Layer of protective material to insulate nerve area and promote healing and repair | -- | -- | -- | Yes | -- |
| D3120 | Layer of protective material to insulate and protect nerve area from additional injury and promote healing and repair | -- | -- | -- | Yes | -- |
| D3220 | Removal of a portion of the main nerve area to relieve pain | 50% | 50% | 50% | Yes | -- |
| D3230 | Treatment filling to calm the nerve of a primary front tooth | 50% | 50% | 50% | Yes | -- |
| D3240 | Treatment filling to calm the nerve of a primary back tooth | 50% | 50% | 50% | Yes | -- |
| D3310 | Root canal therapy to relieve pain and preserve a front tooth | 50% | 50% | 50% | Yes | -- |
| D3320 | Root canal therapy to relieve pain and preserve a bicuspid tooth | 50% | 50% | 50% | Yes | -- |
| D3330 | Root canal therapy to relieve pain and preserve a molar tooth | 50% | 50% | 50% | Yes | -- |
| D3346 | Retreatment of previous root canal therapy to relieve pain and preserve a front tooth | 50% | 50% | 50% | Yes | -- |
| D3347 | Retreatment of previous root canal therapy to relieve pain and preserve a bicuspid tooth | 50% | 50% | 50% | Yes | -- |
| D3348 | Retreatment of previous root canal therapy to relieve pain and preserve a molar tooth | 50% | 50% | 50% | Yes | -- |
| Periodontics | ||||||
| D4341 | Cleaning and removal of plaque from four or more teeth and root surfaces as therapy for gum disease | -- | -- | -- | Yes | -- |
| D4342 | Cleaning and removal of plaque from one to three teeth and root surfaces as therapy for gum disease | -- | -- | -- | Yes | -- |
| D4355 | Complete cleaning and removal of plaque from all teeth to allow for a comprehensive dental exam | -- | -- | -- | Yes | -- |
| D4910 | Professional cleaning of teeth and gums for people with gum disease | 100% | 100% | 100% | Yes | -- |
| Prosthodontics | ||||||
| D5110 | Complete removable dentures to replace all upper teeth | 50% | 50% | 50% | Yes | -- |
| D5120 | Complete removable dentures to replace all lower teeth | 50% | 50% | 50% | Yes | -- |
| D5410 | Adjustment of upper denture | 50% | 50% | 50% | Yes | -- |
| D5411 | Adjustment of lower denture | 50% | 50% | 50% | Yes | -- |
| D5810 | Temporary upper complete denture inserted immediately after extractions | -- | -- | -- | Yes | -- |
| D5811 | Temporary lower complete denture inserted immediately after extractions | -- | -- | -- | Yes | -- |
| D5820 | Temporary upper partial delivered immediately after extractions | 50% | 50% | 50% | Yes | -- |
| D5821 | Temporary lower partial delivered immediately after extractions | 50% | 50% | 50% | Yes | -- |
| D6245 | Replacement tooth made of porcelain/ceramic | -- | -- | -- | Yes | -- |
| Implants | ||||||
| D6010 | Surgical placement of an endosteal implant | 50% | 50% | 50% | Yes | -- |
| D6058 | Crown made of porcelain/ceramic, supported by an abutment on an implant | 50% | 50% | 50% | Yes | -- |
| D6064 | Crown made of cast noble metal, supported by an abutment on an implant | 50% | 50% | 50% | Yes | -- |
| D6075 | Ceramic retainer for a fixed partial denture, supported by an implant | 50% | 50% | 50% | Yes | -- |
| D6076 | Porcelain fused to titanium/titanium alloy/high noble metal retainer for a fixed partial denture, supported by an implant | 50% | 50% | 50% | Yes | -- |
| D6194 | Titanium retainer crown for a fixed partial denture, supported by an abutment on an implant | 50% | 50% | 50% | Yes | -- |
| Oral Surgery | ||||||
| D7111 | Removal of a baby tooth that has some of the crown under the gums | 100% | 100% | 100% | Yes | -- |
| D7140 | Non-surgical removal of a tooth | 100% | 100% | 100% | Yes | -- |
| D7210 | Surgical removal of a tooth | 50% | 50% | 50% | Yes | -- |
| D7220 | Surgical removal of a tooth that is covered by the surrounding gums | 50% | 50% | 50% | Yes | -- |
| D7230 | Surgical removal of a tooth that is covered by the surrounding gums and partially covered by bone | 50% | 50% | 50% | Yes | -- |
| D7240 | Surgical removal of a tooth that is covered by the surrounding gums and completely covered by bone | 50% | 50% | 50% | Yes | -- |
| D7963 | Removal of excess tissue and removal or repositioning of muscle inside the mouth | -- | -- | -- | Yes | -- |
| Orthodontics | ||||||
| D8010 | Limited orthodontic treatment for a child | -- | -- | -- | Yes | -- |
| D8030 | Limited orthodontic treatment for an adolescent | -- | -- | -- | Yes | -- |
| D8040 | Limited orthodontic treatment for an adult | -- | -- | -- | Yes | -- |
| D8070 | Comprehensive orthodontic treatment for a child or adolescent | -- | -- | -- | Yes | -- |
| D8080 | Comprehensive orthodontic treatment for an adolescent | -- | -- | -- | Yes | -- |
| D8090 | Comprehensive orthodontic treatment for an adult | -- | -- | -- | Yes | -- |
| D8680 | Placement of an orthodontic appliance to keep patients teeth aligned | -- | -- | -- | Yes | -- |
| Adjunctive | ||||||
| D9230 | Use of nitrous oxide | -- | -- | -- | Yes | -- |
| D9944 | Removable dental guard to minimize effects of grinding the teeth or for other treatment | -- | -- | -- | Yes | -- |
| D9945 | Removable dental guard to minimize effects of grinding the teeth or for other treatment | -- | -- | -- | Yes | -- |
Frequency, History, Limitations
| Service Type | Description | Frequency Restriction | History | Limitations |
|---|---|---|---|---|
| Diagnostic | ||||
| D0120 | Routine dental exam to examine overall oral health and check for any necessary treatment needed | 2 per year | -- | -- |
| D0140 | Problem focused dental exam for a specific issue | 2 per year | 12-10-2024 01-04-2024 10-11-2023 | -- |
| D0150 | A thorough oral examination of the patient's dental history, usually performed on new patients | 2 per year | -- | -- |
| D0180 | An examination detailing a patient's periodontal health | 2 per year | -- | -- |
| D0210 | X-rays of all the teeth in the mouth | 1 per 2 years | -- | -- |
| D0220 | A diagnostic image of a single tooth that includes the tooth structure | -- | 12-10-2024 01-04-2024 10-11-2023 | -- |
| D0230 | An additional diagnostic image of a single tooth that include the root structure | -- | -- | -- |
| D0272 | 2 diagnostic bitewing x-ray images used to check for tooth decay | 1 per year | -- | -- |
| D0274 | 4 diagnostic bitewing x-ray images used to check for tooth decay | 1 per year | -- | -- |
| D0330 | X-ray of the entire mouth | 1 per 2 years | -- | -- |
| Preventive | ||||
| D1110 | Professional teeth cleaning for adults | 2 per year | -- | -- |
| D1120 | Professional teeth cleaning for children | -- | -- | -- |
| D1206 | Application of Fluoride to all teeth using a varnish | 1 per year | -- | -- |
| D1208 | Application of fluoride to all teeth excluding varnish | 1 per year | -- | -- |
| D1351 | Surfaces of tooth sealed with a resin to help prevent tooth decay | -- | -- | -- |
| D1510 | Permanent device on one side of the mouth where there is space, to keep teeth from moving | -- | -- | -- |
| D1516 | Permanent device on upper arch of Oral Cavity, covers right and left quadrant of the upper arch to keep teeth from moving | -- | -- | -- |
| D1517 | Permanent device on lower arch of Oral Cavity, covers right and left quadrant of the lower arch to keep teeth from moving | -- | -- | -- |
| Basic Restorative | ||||
| D2140 | Silver-colored filling of a cavity of one surface of a tooth | -- | -- | -- |
| D2150 | Silver-colored filling of a cavity on two surfaces of a tooth | -- | -- | -- |
| D2160 | Silver-colored filling of a cavity on three surfaces of a tooth | -- | -- | -- |
| D2161 | Silver-colored filling of a cavity on three or more surfaces of a tooth | -- | -- | -- |
| D2330 | Tooth-colored filling of a cavity of one surface of a front tooth | -- | -- | -- |
| D2331 | Tooth-colored filling of a cavity of two surfaces of a front tooth | -- | -- | -- |
| D2332 | Tooth-colored filling of a cavity of three surfaces of a front tooth | -- | -- | -- |
| D2335 | Tooth-colored filling of a cavity of four or more surfaces of a front tooth | -- | -- | -- |
| D2390 | Tooth-colored resin crown on a front tooth | -- | -- | -- |
| D2391 | Tooth-colored filling of a cavity of one surface of a back tooth | -- | -- | -- |
| D2392 | Tooth-colored filling of a cavity of two surfaces of a back tooth | -- | -- | -- |
| D2393 | Tooth-colored filling of a cavity of three surfaces of a back tooth | -- | -- | -- |
| D2394 | Tooth-colored filling of a cavity of four or more surfaces of a back tooth | -- | -- | -- |
| Crowns | ||||
| D2710 | Crown restoration made of a resin based restorative material | -- | -- | -- |
| D2712 | Crown restoration made of a 3/4 resin based restorative material | -- | -- | -- |
| D2720 | Crown restoration made of a resin with high noble metal | -- | -- | -- |
| D2721 | Crown restoration made of a resin with predominantly base metal | -- | -- | -- |
| D2722 | Crown restoration made of a resin with noble metal | -- | -- | -- |
| D2740 | Crown restoration made of porcelain/ceramic | 1 per 5 years | 01-17-2024 - #4 12-12-2023 - #13 | -- |
| D2750 | Crown restoration made of porcelain fused to high noble metal | 1 per 5 years | -- | -- |
| D2751 | Crown restoration made of porcelain fused to predominantly base metal | 1 per 5 years | -- | -- |
| D2752 | Crown restoration made of porcelain fused to noble metal | 1 per 5 years | -- | -- |
| D2753 | Crown restoration made of titanium | -- | -- | -- |
| D2780 | Crown restoration made of 3/4 cast high noble metal | 1 per 5 years | -- | -- |
| D2781 | Crown restoration made of 3/4 cast predominantly base metal | 1 per 5 years | -- | -- |
| D2782 | Crown restoration made of 3/4 cast noble metal | 1 per 5 years | -- | -- |
| D2783 | Crown restoration made of 3/4 porcelain/ceramic | 1 per 5 years | -- | -- |
| D2790 | Crown restoration made of full cast high noble metal | 1 per 5 years | -- | -- |
| D2791 | Crown restoration made of full cast predominantly base metal | 1 per 5 years | -- | -- |
| D2792 | Crown restoration made of full cast noble metal | 1 per 5 years | -- | -- |
| D2794 | Crown restoration made of titanium | -- | -- | -- |
| D2799 | Transitional crown restoration used while tissue heals, bite is adjusted and final restorations are prepared | -- | -- | -- |
| Major Restorative | ||||
| D2950 | Reconstruction or buildup of a tooth structure | -- | -- | -- |
| D2952 | Strengthening post and resin buildup material, indirectly fabricated, in addition to a crown | -- | -- | -- |
| D2954 | Strengthening post and resin buildup material, prefabricated, in addition to a crown | -- | -- | -- |
| Endodontics | ||||
| D3110 | Layer of protective material to insulate nerve area and promote healing and repair | -- | -- | -- |
| D3120 | Layer of protective material to insulate and protect nerve area from additional injury and promote healing and repair | -- | -- | -- |
| D3220 | Removal of a portion of the main nerve area to relieve pain | -- | -- | -- |
| D3230 | Treatment filling to calm the nerve of a primary front tooth | -- | -- | -- |
| D3240 | Treatment filling to calm the nerve of a primary back tooth | -- | -- | -- |
| D3310 | Root canal therapy to relieve pain and preserve a front tooth | -- | -- | -- |
| D3320 | Root canal therapy to relieve pain and preserve a bicuspid tooth | -- | -- | -- |
| D3330 | Root canal therapy to relieve pain and preserve a molar tooth | -- | -- | -- |
| D3346 | Retreatment of previous root canal therapy to relieve pain and preserve a front tooth | -- | -- | -- |
| D3347 | Retreatment of previous root canal therapy to relieve pain and preserve a bicuspid tooth | -- | -- | -- |
| D3348 | Retreatment of previous root canal therapy to relieve pain and preserve a molar tooth | -- | -- | -- |
| Periodontics | ||||
| D4341 | Cleaning and removal of plaque from four or more teeth and root surfaces as therapy for gum disease | -- | -- | -- |
| D4342 | Cleaning and removal of plaque from one to three teeth and root surfaces as therapy for gum disease | -- | -- | -- |
| D4355 | Complete cleaning and removal of plaque from all teeth to allow for a comprehensive dental exam | -- | -- | -- |
| D4910 | Professional cleaning of teeth and gums for people with gum disease | 2 per year | -- | -- |
| Prosthodontics | ||||
| D5110 | Complete removable dentures to replace all upper teeth | -- | -- | -- |
| D5120 | Complete removable dentures to replace all lower teeth | -- | -- | -- |
| D5410 | Adjustment of upper denture | -- | -- | -- |
| D5411 | Adjustment of lower denture | -- | -- | -- |
| D5810 | Temporary upper complete denture inserted immediately after extractions | -- | -- | -- |
| D5811 | Temporary lower complete denture inserted immediately after extractions | -- | -- | -- |
| D5820 | Temporary upper partial delivered immediately after extractions | -- | -- | -- |
| D5821 | Temporary lower partial delivered immediately after extractions | -- | -- | -- |
| D6245 | Replacement tooth made of porcelain/ceramic | -- | -- | -- |
| Implants | ||||
| D6010 | Surgical placement of an endosteal implant | 1 per 5 years | -- | -- |
| D6058 | Crown made of porcelain/ceramic, supported by an abutment on an implant | -- | -- | -- |
| D6064 | Crown made of cast noble metal, supported by an abutment on an implant | 1 per 5 years | -- | -- |
| D6075 | Ceramic retainer for a fixed partial denture, supported by an implant | 1 per 5 years | -- | -- |
| D6076 | Porcelain fused to titanium/titanium alloy/high noble metal retainer for a fixed partial denture, supported by an implant | 1 per 5 years | -- | -- |
| D6194 | Titanium retainer crown for a fixed partial denture, supported by an abutment on an implant | -- | -- | -- |
| Oral Surgery | ||||
| D7111 | Removal of a baby tooth that has some of the crown under the gums | -- | -- | -- |
| D7140 | Non-surgical removal of a tooth | -- | -- | -- |
| D7210 | Surgical removal of a tooth | -- | 12-12-2024 - #18 | -- |
| D7220 | Surgical removal of a tooth that is covered by the surrounding gums | -- | -- | -- |
| D7230 | Surgical removal of a tooth that is covered by the surrounding gums and partially covered by bone | -- | -- | -- |
| D7240 | Surgical removal of a tooth that is covered by the surrounding gums and completely covered by bone | -- | -- | -- |
| D7963 | Removal of excess tissue and removal or repositioning of muscle inside the mouth | -- | -- | -- |
| Orthodontics | ||||
| D8010 | Limited orthodontic treatment for a child | -- | -- | -- |
| D8030 | Limited orthodontic treatment for an adolescent | -- | -- | -- |
| D8040 | Limited orthodontic treatment for an adult | -- | -- | -- |
| D8070 | Comprehensive orthodontic treatment for a child or adolescent | -- | -- | -- |
| D8080 | Comprehensive orthodontic treatment for an adolescent | -- | -- | -- |
| D8090 | Comprehensive orthodontic treatment for an adult | -- | -- | -- |
| D8680 | Placement of an orthodontic appliance to keep patients teeth aligned | -- | -- | -- |
| Adjunctive | ||||
| D9230 | Use of nitrous oxide | -- | -- | -- |
| D9944 | Removable dental guard to minimize effects of grinding the teeth or for other treatment | -- | -- | -- |
| D9945 | Removable dental guard to minimize effects of grinding the teeth or for other treatment | -- | -- | -- |
Disclaimer: This eligibility report is for informational purposes only. The information is derived directly from the insurance indicated on the report and is not to be construed as a guarantee of payment. Inquiries regarding the accuracy of its content should be directed to the insurance company directly.