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Covered Services Comparison

DentaQuest of Illinois, LLC

Attachment AA

Covered Services Comparison for Children and Adults

  Children
(< age 21)
Adults
(> age 20)
Requires
Prior
Approval
Diagnostic Services      
Oral Exams (For children, limited to one every 6 months per dentist in an office setting, and one every 12 months in a school setting. For adults, limited to 1st visit per dentist.) X X  
X-rays X X  
Preventive Services      
Prophylaxis – Cleanings (Once every 6 months) X    
Topical Fluoride (Annual) X    
Sealants X    
Space Maintenance X    
Restorative Services      
Amalgams X X  
Resins X X  
Crowns X X Y
Sedative Fillings X X  
Endodontic Services      
Pulpotomy X    
Root Canals (For adults, limited to facial front teeth only.) X X  
Periodontal Services      
Gingivectomy X   Y
Scaling and Root Planing X X  
Removable Prosthodontic Services      
Complete Denture (upper and lower) X X Y
Partial Denture (upper and lower) X   Y
Denture Relines X X Y
Maxillofacial Prosthetics X X Y
Fixed Prosthetic Services      
Bridge X   Y
Oral and Maxillofacial Services      
Extractions X X  
Surgical Extractions X X Y
Alveoloplasty X   Y
Orthodontic Services      
Orthodontia (Coverage limited to children meeting or exceeding a score of 42 from the Modified Salzmann Index or meeting criteria for medical necessity) X   Y
Adjunctive General Services      
General Anesthesia X X Y
IV Sedation X X Y
Nitrous Oxide X X  
Conscious Sedation X X Y
Therapeutic Drug Injection X X Y
DentaQuest of Illinois, LLC September 1, 2011
Current Dental Terminology © 2011 American Dental Association. All Rights Reserved.
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