practicing under PHS, IPDHs practicing under PHS may use this code for all ages. IPDHs may use this code only for members up to age 21. Covered Service Prior Authorization Additional Limits Max Proc. Description Age/ICF-IID required Allow Code age 21 age 21 & under age age 21 & & all over when 21 & all over when allowed ICF-IID allowed residents* under residents under 25.04 25.04 D1120 Prophylaxis Child YES NO NO Twice per calendar year, but $30.00 – no more than once every 150 days. Prior Authorization necessary for greater frequency. Includes oral hygiene instruction. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code. TOPICAL FLUORIDE TREATMENTS (Office Procedure) D1206 Topical Application of Fluoride Varnish YES NO NO Members age 3: twice per $12.00 calendar year, and a third treatment per calendar year is permitted for Members who either have a high caries rate or the Member has had new restorations placed in the previous eighteen (18) months.
practicing under PHS, IPDHs practicing under PHS may use this code for all ages. IPDHs may use this code only for members up to age 21. Proc. Code Description Covered Service Age/ICF-IID Prior Authorization required Additional Limits Max Allow age 21 & all residents* age 21 & over when allowed under 25.04 under age 21 & all ICF-IID residents age 21 & over when allowed under 25.04 D1120 Prophylaxis – Child YES NO NO Twice per calendar year, but no more than once every 150 days. Prior Authorization necessary for greater frequency. Includes oral hygiene instruction. Dental Hygienists practicing under PHS, IPDHs practicing under PHS, and IPDHs may use this code. $30.00 TOPICAL FLUORIDE TREATMENTS (Office Procedure) D1206 Topical Application of Fluoride Varnish YES NO NO Members age 3: twice per calendar year, and a third treatment per calendar year is permitted for Members who either have a high caries rate or the Member has had new restorations placed in the previous eighteen (18) months. $12.00
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