DHS 107.07(4)(a) (a) General services for purely aesthetic or cosmetic purposes.

DHS 107.07(4)(c) (c) Equivalent services performed on the same day.

DHS 107.07(4)(d) (d) Tests and laboratory examinations, other than for diagnostic casts when required by the department.

DHS 107.07(4)(e) (e) Oral hygiene instruction or training in preventive dental care as a separate procedure, including tooth brushing technique, flossing or use of special oral hygiene aids, tobacco cessation counseling, or nutritional counseling.

DHS 107.07(4)(f) (f) The following restorative services:

DHS 107.07(4)(f)1. 1. Labial veneer.

DHS 107.07(4)(f)2. 2. Temporary crowns.

DHS 107.07(4)(f)3. 3. Cement bases as a separate item.

DHS 107.07(4)(f)4. 4. Endodontic filling materials that are not approved for use by the American Dental Association.

DHS 107.07(4)(g) (g) Pulp cappings.

DHS 107.07(4)(h) (h) The following removable prosthodontic services:

DHS 107.07(4)(h)1. 1. Overlay dentures.

DHS 107.07(4)(h)2. 2. Overlay partial dentures.

DHS 107.07(4)(h)3. 3. Duplicate dentures and adjustments.

DHS 107.07(4)(i) (i) The following implant services:

DHS 107.07(4)(i)1. 1. Tooth implants.

DHS 107.07(4)(i)2. 2. Transplantations.

DHS 107.07(4)(i)3. 3. Surgical repositioning except reimplantation under sub. (3).

DHS 107.07(4)(i)4. 4. Transseptal fiberotomies.

DHS 107.07(4)(j) (j) Orthodontic services.

DHS 107.07(4)(k) (k) The following adjunctive general services:

DHS 107.07(4)(k)2. 2. Non-surgical treatment of temporomandibular joint disorder.

DHS 107.07(4)(k)3. 3. Behavior management.

DHS 107.07(4)(k)4. 4. Athletic mouthguards.

DHS 107.07(4)(k)5. 5. Local anesthesia as a separate procedure.

DHS 107.07(4)(k)6. 6. Occlusal guard, analysis and adjustment.

DHS 107.07(4)(k)7. 7. Non-covered services that are listed in s. DHS 107.03.

DHS 107.07(4)(L) (L) Professional visits, other than for the oral evaluation of a nursing home resident, or hospital calls as noted in sub. (1) (j) 4.

DHS 107.07(4m) (4m) Non-covered services; dental hygienists. The following services are not covered by MA whether or not the service is performed by a person under the supervision of a dentist or physician or by a dental hygienist who is individually certified under ch. DHS 105: