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CDT PROCEDURE CODE DESCRIPTION - District Council 37

Please review the Important Participant Information for general rules on coverage, coverage maximums for dental and orthodontia care, frequency changes effective September 1, 2020, predetermination requirements and coverage exclusions. The List of DC 37 Health & Security Plan Eligible Dental Services effective September 1, 2020 is below. DC 37 HEALTH & SECURITY PLAN LIST OF COVERED DENTAL SERVICES & procedures EFFECTIVE SEPTEMBER 1, 2020 CDT PROCEDURE code DESCRIPTION D0120 Periodic oral evaluation D0140 Limited oral evaluation, problem focused D0145 Exam patient under 3 years include counsel D0150 Comprehensive oral evaluation D0170 Re-evaluation D0180 Comprehensive periodontal evaluation D0210 Intraoral complete series (including bitewings)

CDT PROCEDURE CODE DESCRIPTION D6792 Crown – full cast noble metal D6794 Crown – titanium D6930 Recement fixed partial denture D6980 Fixed partial denture repair, by report D6999 Unspecified, fixed prosthodontic procedure, by report D7111 Extract coronal remnants deciduous tooth D7140 Extraction, erupted tooth or exposed root

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DC 37 Dental Plan Complete List of Participating Panel Dentists SPECIALTY KEY July, 2018 GP = General Practitioner EN = Endodontist MS = Multiple Specialist

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(ALL THREE TYPES OF SERVICES) MUST ... - District …

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DISTRICT COUNCIL 37 HEALTH & SECURITY PLAN 125 BARCLAY STREET, NEW YORK, N.Y. 10007 (212) 815-1234 CLAIM FOR DIRECT OPTICAL REIMBURSEMENT PLEASE READ CAREFULLY: Claims filed later than 30 days from the date of service will be declared ineligible.

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