D8080 and D8090 - all inclusive fee includes D8080 Comprehensive Orthodontic Treatment of The Yes No Yes appliances, brackets, treatment $2,725.00 Adolescent Dentition visits, one appliance repair or Comprehensive Orthodontic Treatment of The Adult Yes No YES replacement, and one retainer Dentition repair or replacement. Covered $2,725.00 to age 21 TREATMENT TO CONTROL HARMFUL HABITS D8210 Removable Appliance Therapy Yes No Yes $375.00 D8220 Appliance Therapy Yes No Yes $375.00 ORTHODONTIC SERVICES D8660 Pre-Orthodontic Treatment Visit Yes No No $22.50 Covered Service Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code under age 21 age 21 & under age age 21 & & all over when 21 & all over allowed ICF-IID when residents* under residents allowed 25.04 25.04 Periodic Orthodontic Treatment Visit (as part of YES No YES Cannot be billed in conjunction $66.00 contract) with D8070, D8080, D8090 D8680 Orthodontic Retention (removal of appliances, No No Not Covered construction and placement of retainer(s)) D8690 Orthodontic Treatment (alternative billing to a contract No No Not Covered fee) D8691 Repair of Orthodontic Appliance YES NO YES $75.00 D8692 Replacement of Lost or Broken Retainer YES NO NO $125.00
D8080 and D8090 - all inclusive fee includes D8080 Comprehensive Orthodontic Treatment of The Adolescent Dentition Yes No Yes appliances, brackets, treatment visits, one appliance repair or $2,725.00 Comprehensive Orthodontic Treatment of The Adult Dentition Yes No YES replacement, and one retainer repair or replacement. Covered to age 21 $2,725.00 TREATMENT TO CONTROL HARMFUL HABITS D8210 Removable Appliance Therapy Yes No Yes $375.00 D8220 Appliance Therapy Yes No Yes $375.00 ORTHODONTIC SERVICES D8660 Pre-Orthodontic Treatment Visit Yes No No $22.50 Proc. Code Description Covered Service Age/ICF-IID Authorization required Additional Limits Max Allow under age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed 25.04 Periodic Orthodontic Treatment Visit (as part of contract) YES No YES Cannot be billed in conjunction with D8070, D8080, D8090 $66.00 D8680 Orthodontic Retention (removal of appliances, construction and placement of retainer(s)) No No Not Covered D8690 Orthodontic Treatment (alternative billing to a contract fee) No No Not Covered D8691 Repair of Orthodontic Appliance YES NO YES $75.00 D8692 Replacement of Lost or Broken Retainer YES NO NO $125.00
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