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Biopsies
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Extractions
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Incise and drain
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Splinting for repositioning a traumatized tooth or stabilizing an alveolar fracture
Limited to children through age 20
Prior authorization is required for all of the following:
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Bone replacement graft for ridge preservation per site
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Placement of device to facilitate eruption of impacted tooth
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Radical resection of maxilla or mandible
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Surgical repositioning of teeth
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Tooth transplantation
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Transseptal fiberotomy