Dental Policies
Navigate directly to a letter:
-
E
- Establishment and Adoption of Utilization Review Criteria and Clinical Guidelines
- Exhibit A – Short Procedure Units (SPU)
- Exhibit AA - Frenectomy
- Exhibit B – Periodontal Clinical Criteria
- Exhibit BB - Direct Restoration
- Exhibit C - Dental Extraction
- Exhibit D - Crown
- Exhibit E – Fixed Prosthodontics
- Exhibit F – Endodontics
- Exhibit G – Radiographics
- Exhibit H – Bone Tissue Excision
- Exhibit I – Non-Restorable Tooth
- Exhibit L – Removable Prosthetics
- Exhibit M – Administration of Nitrous Oxide
- Exhibit N-Orthodontics Policy
- Exhibit N1-Orthodontics Form 03630.pdf
- Exhibit N2-Orthodontics Form 03630 Scoring Guide
- Exhibit O-General Anesthesia and IV Sedation
- Exhibit P3 - Mail Order Orthodontics
- Exhibit S – Onlay
- Exhibit T – Veneer
- Exhibit X – Implant