14.2.4.3 Dental Prophylaxis and Topical Fluoride Treatment
When performing fluoride treatments, procedure codes D1203 and D1120, or procedures codes D1204 and D1110 must be billed on the same date of service.
The following procedure codes may be considered for reimbursement but are not payable on the same date of service as any D4000 series (periodontal) procedure codes:
Procedure Code
Age Limitation
D1110
A = 13 through 20 years of age
D1120
A = 1 through 12 years of age
D1203
A = 1 through 12 years of age
D1204
A = 13 through 20 years of age
D1206
A = 1 and older
Texas Medicaid & Healthcare Partnership CPT only copyright 2008 American Medical Association. All rights reserved.
