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Managed DentalGuard Page 1 of 5 Texas Plan Schedule 35-M Orthodontic Plan Schedule 1 MDG Codes++ 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 Appointments & Diagnostic Services Periodic oral evaluation, participating general dentist Periodic oral evaluation, participating specialty care dentist Limited oral evaluation - problem focused, participating general dentist Limited oral evaluation - problem focused, participating specialty care dentist Comprehensive oral evaluation, participating general dentist Comprehensive oral evaluation, participating specialty care dentist Pulp vitality tests Diagnostic casts Office visit - during regular hours - participating general dentist only Consultation (by dentist other than practitioner providing treatment), participating genera dentist Consultation (by dentist other than practitioner providing treatment), participating specialty care dentist Office visit for observation - regular hours - no other service performed Emergency office visit - after regularly scheduled office hours Radiographs Patient Charge No Charge $10.00 No Charge $25.00 No Charge $25.00 No Charge No Charge $5.00 $30.00 $45.00 No Charge $50.00 0210 0220 0230 0240 0270 0272 0274 0330 Intraoral - complete series (including bitewings) Intraoral - periapical - single film Intraoral - periapical - each additional film Intraoral - occlusal - each film Bitewing - single film Bitewings - two films Bitewings - four films Panoramic film Preventive & Space Maintenance $5.00 No Charge No Charge No Charge No Charge No Charge No Charge $5.00 1110 1120 1999 Prophylaxis - adult (first 2 services in any 12 month period) + Prophylaxis - child (first 2 services in any 12 month period) + Prophylaxis - adult or child (with or without fluoride)(each additional service in same 12 month period) + Topical application of fluoride (including prophylaxis) - child (first 2 services in any 12 month period) + Topical application of fluoride (prophylaxis not included) – child (first 2 services in any 12 month period) + Topical application of fluoride (prophylaxis not included) – child (each additional service in same 12 month period) + Nutritional counseling for control of dental disease Oral hygiene instruction Sealant - per tooth - molars only Sealant - per tooth - non-molars only Space maintainer - fixed - unilateral Space maintainer - fixed - bilateral Recementation of space maintainer Restorative No Charge No Charge $60.00 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131 2140 2150 V.01266 TX Covered Services Amalgam - one surface - primary Amalgam - two surfaces - primary Amalgam - three surfaces - primary Amalgam - four or more surfaces - primary Amalgam - one surface - permanent Amalgam - two surfaces - permanent No Charge No Charge $20.00 No Charge No Charge $10.00 $35.00 $65.00 $110.00 $15.00 $10.00 $10.00 $15.00 $15.00 $8.00 $12.00 Managed DentalGuard Page 2 of 5 Texas Plan Schedule 35-M Orthodontic Plan Schedule 1 MDG Codes++ Covered Services Patient Charge Restorative (cont.) 2160 2161 2210 2330 2331 2332 2335 2336 2380 2381 2382 2385 2386 2387 2510 2520 2530 2543 2544 2740 2750 2751 2752 2790 2791 2792 2810 2999 6199 6210 6211 6212 6240 6241 6242 6520 6530 6543 6544 6750 6751 6752 6780 6790 6791 6792 6999 V.01266 TX Amalgam - three surfaces - permanent Amalgam - four or more surfaces - permanent Silicate cement - per restoration Resin/composite - one surface, anterior Resin/composite - two surfaces, anterior Resin/composite - three surfaces, anterior Resin/composite - four or more surfaces or incisal angle, anterior Composite resin crown, anterior - primary Resin/composite - one surface, posterior - primary Resin/composite - two surfaces, posterior - primary Resin/composite - three or more surfaces, posterior - primary Resin/composite - one surface, posterior - permanent Resin/composite - two surfaces, posterior - permanent Resin/composite - three or more surfaces, posterior - permanent Crown, Bridge & Other Cast Restorations Inlay - metallic - one surface ^ ** Inlay - metallic - two surfaces ^ ** Inlay - metallic - three or more surfaces ^ ** Onlay - metallic - three surfaces ^ ** Onlay - metallic - four or more surfaces ^ ** Crown - porcelain/ceramic substrate ^ Crown - porcelain fused to high noble metal ^ ** Crown - porcelain fused to predominantly base metal ^ Crown - porcelain fused to noble metal ^ Crown - full cast high noble metal ^ ** Crown - full cast predominantly base metal ^ Crown - full cast noble metal ^ Crown - 3/4 cast metallic ^ ** Crown supporting existing partial denture, in addition to crown Dental lab service - per inlay, onlay, crown or bridge unit Pontic - cast high noble metal ^ ** Pontic - cast metal predominantly base metal ^ Pontic - cast noble metal ^ Pontic - porcelain fused to high noble metal ^ ** Pontic - porcelain fused to predominantly base metal ^ Pontic - porcelain fused to noble metal ^ Inlay - abutment - metallic - two surfaces ^ ** Inlay - abutment - metallic - three or more surfaces ^ ** Onlay - abutment - metallic - three surfaces ^ ** Onlay - abutment - metallic - four or more surfaces ^ ** Crown - abutment - porcelain fused to high noble metal ^ ** Crown - abutment - porcelain fused to predominantly base metal ^ Crown - abutment - porcelain fused to noble metal ^ Crown - abutment - 3/4 cast metallic ^ ** Crown - abutment - full cast high noble metal ^ ** Crown - abutment - full cast predominantly base metal ^ Crown - abutment - full cast noble metal ^ Multiple crown and bridge unit treatment plan - per unit $14.00 $17.00 $15.00 $20.00 $25.00 $30.00 $45.00 $45.00 $30.00 $35.00 $40.00 $35.00 $50.00 $70.00 $180.00 $235.00 $235.00 $250.00 $260.00 $250.00 $230.00 $230.00 $250.00 $230.00 $230.00 $250.00 $240.00 $125.00 $75.00 $230.00 $230.00 $250.00 $230.00 $230.00 $250.00 $260.00 $265.00 $275.00 $290.00 $230.00 $230.00 $250.00 $230.00 $230.00 $230.00 $250.00 $125.00 Managed DentalGuard Page 3 of 5 Texas Plan Schedule 35-M Orthodontic Plan Schedule 1 MDG Codes++ 2910 2920 2930 2931 2932 2940 2950 2951 2952 2954 2960 6930 6970 6972 6973 3110/3120 3220 3310 3320 3330 3346 3347 3348 3410 3421 3425 3426 3430 4210 4211 4220 4240 4249 4260 4270 4271 4341 4355 4910 4920 4999 9951 V.01266 TX Covered Services Other Restorative Services Recement inlay Recement crown Prefabricated stainless steel crown Prefabricated stainless steel crown - permanent tooth Prefabricated resin crown Sedative filling Core buildup, including any pins Pin retention - per tooth, in addition to restoration Cast post & core Prefabricated post & core Labial veneer (laminate) - chairside Recement bridge Cast post & core, in addition to abutment Prefabricated post & core, in addition to abutment Core buildup for abutment, including any pins Endodontics Pulp cap Therapeutic pulpotomy Root canal - anterior Root canal - bicuspid Root canal - molar Root canal - retreatment - anterior Root canal - retreatment - bicuspid Root canal - retreatment - molar Apicoectomy/periradicular surgery – anterior Apicoectomy/periradicular surgery - bicuspid - first root Apicoectomy/periradicular surgery - molar - first root Apicoectomy/periradicular surgery - each additional root Retrograde filling - per root Periodontics Gingivectomy or gingivoplasty - per quadrant Gingivectomy or gingivoplasty - per tooth Gingival curettage, surgical - per quadrant - by report Gingival flap procedure-including root planing - per quadrant Clinical crown lengthening - hard tissue Osseous surgery - including flap entry, closure - per quadrant - five to eight teeth Pedicle soft tissue graft procedure Free soft tissue graft procedure (including donor site surgery) Periodontal scaling & root planing - per quadrant Full mouth debridement to enable evaluation & diagnosis Periodontal maintenance procedures (following active therapy) Unscheduled dressing change (by other than treating dentist) Osseous surgery - including flap entry, closure - per quadrant - one to four teeth Occlusal adjustment - limited - per visit Patient Charge $20.00 $20.00 $60.00 $60.00 $90.00 $15.00 $50.00 $15.00 $95.00 $85.00 $235.00 $15.00 $95.00 $85.00 $55.00 $10.00 $30.00 $95.00 $160.00 $170.00 $310.00 $370.00 $445.00 $135.00 $145.00 $155.00 $80.00 $35.00 $80.00 $25.00 $45.00 $190.00 $170.00 $255.00 $185.00 $205.00 $30.00 $35.00 $30.00 $25.00 $155.00 $20.00 Managed DentalGuard Page 4 of 5 Texas Plan Schedule 35-M Orthodontic Plan Schedule 1 MDG Codes++ 5110/5120 5130/5140 5211/5212 5213/5214 5410/11/21/22 5510/5610 5520/5640 5630 5650 5660 5710/11/20/21 5730/31/40/41 5750/51/60/61 5820/5821 5850/5851 5899 5999 7110 7120 7130 7210 7220 7230 7240 7241 7250 7270 7280 7281 7285 7286 7310 7320 7450 7451 7470 7510 7960 V.01266 TX Covered Services Prosthodontics (Removable) Complete denture (including routine post delivery care) ^ ^ Immediate denture (including routine post delivery care) ^ ^ Partial dentures (including routine post delivery care): Resin base - including clasps, rests, teeth ^ ^ Cast metal framework with resin base - including clasps, rests, teeth ^ ^ Repairs & adjustments: Denture adjustments Repair denture base ^ ^ ^ Replace missing or broken teeth - per tooth ^ ^ ^ Repair or replace clasp ^ ^ ^ Add tooth to existing partial ^ ^ ^ Add clasp to existing partial ^ ^ ^ Rebase denture ^ ^ ^ Reline denture (chairside) Reline denture (laboratory) ^ ^ ^ Interim partial denture (stayplate) Tissue conditioning Dental lab service - each new complete, immediate, or partial denture - per denture Dental lab service - denture repair, rebase or reline - per denture Oral Surgery Extraction - single tooth Extraction - each additional tooth Root removal - exposed roots Surgical removal of erupted tooth Removal of impacted tooth - soft tissue Removal of impacted tooth - partially bony Removal of impacted tooth - completely bony Removal of impacted tooth - completely bony, with unusual surgical complications Surgical removal of residual tooth roots (cutting procedure) Tooth reimplantation and/or stabilization of accidentally evulsed tooth Surgical exposure of impacted or unerupted tooth for orthodontic reasons Surgical exposure of impacted or unerupted tooth to aid eruption Biopsy of oral tissue - hard Biopsy of oral tissue - soft Alveoplasty in conjunction with extractions - per quadrant Alveoplasty not in conjunction with extractions - per quadrant Removal of odontogenic cyst/tumor - up to 1.25cm Removal of odontogenic cyst/tumor - over 1.25cm Removal of exostosis - maxilla or mandible Incision & drainage of intraoral abscess Frenulectomy (separate procedure) Patient Charge $345.00 $345.00 $310.00 $355.00 $20.00 $45.00 $35.00 $60.00 $45.00 $45.00 $125.00 $65.00 $120.00 $95.00 $30.00 $165.00 $35.00 $8.00 $9.00 $25.00 $30.00 $50.00 $70.00 $80.00 $90.00 $40.00 $90.00 $130.00 $90.00 $70.00 $65.00 $50.00 $70.00 $85.00 $160.00 $125.00 $40.00 $95.00 Managed DentalGuard Page 5 of 5 Texas Plan Schedule 35-M Orthodontic Plan Schedule 1 MDG Codes++ 8070/8080/8090 8070/8080/8090 8660 8670 8680 8999 9110 9215 9972 Covered Services Orthodontic Treatment (covers 24 months active treatment) Comprehensive orthodontic treatment, including fabrication and insertion of fixed banding appliance and periodic visits, up to 24 months; dependent child to age 18 (as determined by the Member’s age on the date of banding) Comprehensive orthodontic treatment, including fabrication and insertion of fixed banding appliance and periodic visits, up to 24 months; employee, spouse, or dependen child over age 18 (as determined by the Member’s age on the date of banding) Orthodontic evaluation and consultation Periodic comprehensive orthodontic treatment visit Orthodontic retention Orthodontic treatment plan and records, including x-rays, study models and photos Miscellaneous Services Palliative (emergency) treatment - per visit Local anesthesia External bleaching - per arch - take home bleaching only Patient Charge $2,285.00 $2,285.00 $100.00 No Charge $415.00 $150.00 $15.00 No Charge $165.00 ++ Covered Services are subject to exclusions, limitations and Plan provisions. Other codes may be used to describe Covered Services. + The patient charges for codes 1110, 1120, 1201 and 1203 are limited to the first two services in any 12 month period. For each additional service in the same 12 month period, see codes 1204 and 1999 for the applicable patient charge. ^ There is an additional dental lab service patient charge for these procedures. See code 6199 for the applicable patient charge. ^ ^ There is an additional dental lab service patient charge for these procedures. See code 5899 for the applicable patient charge. ^ ^ ^ There is an additional dental lab service patient charge for these procedures. See code 5999 for the applicable patient charge. ** If high noble metal is used, there may be an additional patient charge for the actual cost of the high noble metal. The total patient charge for high noble metal plus the applicable dental lab service charge may not exceed the general dentist’s actual lab bill for the service. V.01266 TX Plan Schedule 35-M is only valid for Covered Services rendered by Participating Dentists in the State of Texas. Orthodontic Plan Schedule 1 is only valid for Authorized Services rendered by Participating Orthodontic Specialty Care Dentists in the State of Texas.
