Without Cost Benchmark Plan Photographic images (oral and facial) when dentally appropriate. Sharing Required Diagnostic Diagnostic Services Services (Cont’d) Without Cost Sharing (Cont’d) Endodontic WAC Required Plan must cover endodontic treatment (not including indirect pulp Endodontic See, capping) in a manner substantially equal to the base benchmark plan Treatment also, Services WAC including, at a minimum: Apexification for apical closures of anterior permanent teeth; Benchmark Plan Apicoectomy; Benchmark Plan Debridement; Benchmark Plan Direct pulp capping; Benchmark Plan Pulpal therapy; Benchmark Plan Pulp vitality tests; Benchmark Plan Pulpotomy; and Endodontic WAC Root canal treatment. Treatment (o) Root canal treatment must be covered, at a minimum, on: (Cont’d) Required WAC baby primary posterior teeth only; and permanent anterior, bicuspid and molar teeth, excluding (5)(o) teeth 1,6,17, and 32.
Diagnostic Services (Cont’d) Without Cost Sharing Required Diagnostic Services Without Cost Sharing (Cont’d) Benchmark Plan Photographic images (oral and facial) when dentally appropriate. Endodontic Treatment Endodontic Treatment (Cont’d) Required Endodontic Services Required WAC See, also, WAC Plan must cover endodontic treatment (not including indirect pulp capping) in a manner substantially equal to the base benchmark plan including, at a minimum: Apexification for apical closures of anterior permanent teeth; Benchmark Plan Apicoectomy; Benchmark Plan Debridement; Benchmark Plan Direct pulp capping; Benchmark Plan Pulpal therapy; Benchmark Plan Pulp vitality tests; Benchmark Plan Pulpotomy; and WAC (o) Root canal treatment. Root canal treatment must be covered, at a minimum, on: WAC (5)(o) baby primary posterior teeth only; and permanent anterior, bicuspid and molar teeth, excluding teeth 1,6,17, and 32.
cl-forms-19-all-filers-ind-embedded-pediatric-dent-w-ehbs.docx