For Dates of Service Before April 1, 2019

Dental Hygienist Allowable Services

Dental hygienists may be reimbursed for the following procedures only:

• D0191 — Assessment of a patient.
• D1110 — Prophylaxis — adult.
• D1120 — Prophylaxis — child.
• D1206 — Topical application of fluoride varnish.
• D1208 — Topical application of fluoride.
• D1351 — Sealant — per tooth.
• D4341 — Periodontal scaling and root planing — four or more teeth per quadrant.
• D4342 — Periodontal scaling and root planing — one to three teeth per quadrant.
• D4346 — Scaling in presence of generalized moderate or severe gingival inflammation — full mouth, after oral evaluation.
• D4355 — Full mouth debridement to enable comprehensive evaluation and diagnosis.
• D4910 — Periodontal maintenance.

Providers are required to obtain PA for certain specified services before delivery of that service. The procedure codes that always require PA are D4341, D4342, D4346, and D4910. Procedure code D4355 requires PA when performed on children through the age of 12.

Refer to the appropriate dental service category (i.e., diagnostic, preventative, or periodontics) for coverage limitations.