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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Indicates Non-covered Service

Dentistry

Dental Care Services in the Operating Room
Barrier Membrane Guided Dental Tissue Regeneration
Cone Beam Computed Tomography for Dentistry
Core Buildup, Post & Core & Pin Retention
Dental Anesthesia & Conscious Sedation
Alveoloplasty & Vestibuloplasty
Bacterial & Viral Testing of Oral Infections
Direct Restorations of Single Tooth
Dental Occlusal Guards
Dental Sealants
Dental Space Maintenance
Dentistry Documentation Requirements
Application of Dental Desensitizing Medicaments & Resins
Dental Implants
Miscellaneous Dental Diagnostic Procedures
Fixed Dental Prosthodontics
Full Mouth Debridement
Indirect Restorations for Single Tooth
Labial Dental Veneers
Endodontic Surgery
Erupted Teeth & Retained Root Extraction
Orthodontic Related Oral Surgery
Non-Pathologic Excisional Oral Surgery
Non-Surgical Dental Extractions
Non-Surgical Endodontics
Non-Surgical Periodontal Therapy
Miscellaneous Oral Surgery Procedures
Mucogingival Periodontal Surgery
Restorative Dental Procedures
Provisional Dental Splinting
Regenerative Periodontal Surgery
Removable Prosthodontics
Resective periodontal surgery
Orthodontic Treatment
Prefabricated Crowns
Topical Fluoride Treatment
Genetic Testing for Oral Disease
Non-Ionizing Diagnostic Procedures
Salivary Testing
Surgical Extraction of Impacted Teeth
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