Age-One Tools

Insurance Coding for Pediatric Care (age-one+)

Procedure Code

Description of Service

Age Limits

Prior Authorization

Benefit Limitation


Oral Evaluation Under 3
Years of Age




two of (D0120, DO145) per 12 month's per patient per (provider or location). Twice per calendar year.


Prophylaxis- Child




Two of (D110, D1120) per 12 month's per patient. Includes minor scaling procedures.


Topical Fluoride Varnish




One of (D1206, D1208) per 1 day's per patient per (provider or location).  Cannot be billed with D1208 or same date of service by the same provider or location.


Topical application of 
Fluoirde- Under 21




One of D1208 or D1206 per 1 Day's per patient per (provide or location).  Cannot be billed with D1206 on same date of service by the samee provider or location

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Caries Management Risk Assessment

The Massachusetts Dental Society (MDS) recognizes that caries risk assessment and management tools can assist dentists with decisions regarding treatment based upon caries risk and patient compliance for children of all ages. There are several biological predisposing factors and social indicators that can help evaluate anticipated risk.

Risk varies by patient and evaluating risk is an important aspect in dental care management and treatment. 

risk assessment picture

Risk Assessment Tools

These tools are designed to aid in the implementation of oral health risk assessment during dental exam. These forms allow you to identify factors that might increase a patient's risk for cavities and other oral health problems. These forms can be shared with medical colleagues to help improve a patient's overall health. Review these sample forms and then download and print the ones that work best with your patients.

Risk Assessment Sample Forms
  • Caries Management by Risk Assessment Form (CAMBRA)  (children ages 0-5)This methodology treats dental caries as an infectious disease that is curable and preventable, and employs risk assessment techniques. The risk assessment and the weight of the entire disease process, not just the cavitated stage of lesion, make CAMBRA different from the traditional restorative approach in treating dental caries and dental decay.
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Tools For Parents/Caretakers

As a dentist, you are in a unique position to provide education and guidance on oral health to parents and caretakers. The following forms will help you provide clear communication to parents and caretakers.


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