Download SECTION [XVII]. [EssentialSmile 112, NS, INN, Family Dental, Dep

SECTION [XVII].
[EssentialSmile 112, NS, INN, Family Dental, Dep 29]
SCHEDULE OF BENEFITS
COST-SHARING
Participating
Provider
Member
Responsibility for
Cost-Sharing
Non-Participating
Provider
Member
Responsibility for
Cost-Sharing
PEDIATRIC
DENTAL CARE
ESSENTIAL
HEALTH BENEFIT
Deductible
 One (1) Member
under age 19
 Two (2) or more
Members under
age 19
Out-of-Pocket Limit
 One (1) Member
under age 19
 Two (2) or more
Members under
age 19
$50
$50 per member
Non-Participating
Provider Services
Are Not Covered and
You Pay the Full
Cost
$350
$700
Deductibles,
Coinsurance and
Copayments that
make up Your Out-ofPocket Limit
accumulate on a
calendar year ending
on December 31 of
each year.
SHI-G-SCH-1-0F-NY0416
Underwritten by Solstice Health Insurance Company, a licensed Accident and Health Insurance Company under New York Insurance Law Section 1113(a)(3) Participating
Provider Member
Responsibility for
Cost-Sharing
Non-Participating
Provider Member
Responsibility for
Cost-Sharing
• Emergency Dental
Care
$10 Copayment
After Deductible
Non-Participating
Provider Services Are
Not Covered You Pay
the Full Cost
• Preventive Dental
Care
$0- $125 Copayment
After Deductible
• Routine Dental Care
$0 - $350 Copayment
After Deductible
• Endodontics
$30 - $350 Copayment
After Deductible
• Periodontics
$51 - $350 Copayment
After Deductible
• Prosthodontics
$20 - $350 Copayment
After Deductible
• Oral Surgery
$60 - $306 Copayment
After Deductible
• Orthodontics
$25 - $350 Copayment
After Deductible
Preauthorization
Treatment of
Malignancies, Cysts,
or Neoplasms,
General Anesthesia,
IV Sedation, Crowns,
Bridges, Prosthetics,
and Specialist Care
Require
Preauthorization
PEDIATRIC DENTAL
ESSENTIAL HEALTH
BENEFIT & CARE
Pediatric Dental Care
Limits
One (1) dental exam &
cleaning per six (6)
month period
Full mouth X-rays or
panoramic X-rays at
36 month intervals and
bitewing X-rays at six
month intervals
TheCopaymentslistedintheScheduleofBenefitsareforCoveredServicesprovidedbyaParticipatingProvider
whoisaGeneralDentist.
MEMBERCOSTͲ
CODE
DESCRIPTION
LIMITATIONS
SHARING
CHILD
PREVENTIVEDENTALCARE
D1110 ProphylaxisͲadult
$0
Six(6)monthintervals
D1120 ProphylaxisͲchild
$0
Six(6)monthintervals
Six(6)monthintervals
wherethelocalwater
D1206 Topicalapplicationoffluoridevarnish
$30
supplyisnot
fluoridated
Six(6)monthintervals
wherethelocalwater
D1208 TopicalapplicationoffluorideͲexcludingvarnish
$30
supplyisnot
fluoridated
D1351
SealantͲpertooth
D1510 SpacemaintainerͲfixedͲunilateral
D1515 SpacemaintainerͲfixedͲbilateral
D1520 SpacemaintainerͲremovableͲunilateral
D1525 SpacemaintainerͲremovableͲbilateral
D1550 ReͲcementorreͲbondspacemaintainer
D1555 Removaloffixedspacemaintainer
D8210 Removableappliancetherapy
ROUTINEDENTALCAREͲAPPOINTMENTS
$0
$50
$100
$75
$125
$20
$20
$100
D0120
PeriodicoralevaluationͲestablishedpatient
$0
D0140
LimitedoralevaluationͲproblemfocused
$0
D0145
Oralevaluationforapatientunder3yearsofage
$0
D0150
ComprehensiveoralevaluationͲneworestablished
patient
$0
D0160
DetailedandextensiveoralevaluationͲproblemfocused
$0
Palliative(emergency)treatmentofdentalpainͲminor
procedure
ROUTINEDENTALCAREͲRADIOGRAPHY/DIAGNOSTICDENTISTRY
D9110
One(1)timeinanythirtyͲ
six(36)consecutive
monthpertooth
Oncewithinasix(6)
monthconsecutive
period
Oncewithinasix(6)
monthconsecutive
period
OncewithinathirtyͲsix
(36)consecutivemonth
period
Oncewithinasix(6)
monthconsecutive
period
$10
ForEmergencyDental
ThirtyͲsix(36)month
intervals
D0210
IntraoralͲcompleteseriesofradiographicimages
$0
D0220
IntraoralͲperiapicalfirstradiographicimage
$0
D0270
BitewingͲsingleradiographicimage
$0
Six(6)monthintervals
CurrentDentalTerminology©2014AmericanDentalAssociation(ADA).Allrightsreserved.
MEMBERCOSTͲ
CODE
DESCRIPTION
SHARING
CHILD
ROUTINEDENTALCAREͲRADIOGRAPHY/DIAGNOSTICDENTISTRYCONT.
LIMITATIONS
D0272
BitewingsͲ2radiographicimages
$0
Six(6)monthintervals
D0273
BitewingsͲ3radiographicimages
$0
Six(6)monthintervals
D0274
BitewingsͲ4radiographicimages
$0
Six(6)monthintervals
D0330
Panoramicradiographicimage
$0
ThirtyͲsix(36)month
intervals
D2140
D2150
D2160
AmalgamͲonesurface,primaryorpermanent
AmalgamͲtwosurfaces,primaryorpermanent
AmalgamͲthreesurfaces,primaryorpermanent
$25
$40
$50
D2161
AmalgamͲfourormoresurfaces,primaryorpermanent
$65
D2330
D2331
D2332
ResinͲbasedcompositeͲonesurface,anterior
ResinͲbasedcompositeͲtwosurfaces,anterior
ResinͲbasedcompositeͲthreesurfaces,anterior
ResinͲbasedcompositeͲfourormoresurfacesorinvolving
incisalangle(anterior)
$50
$60
$80
D2335
$100
D2930
PrefabricatedstainlesssteelcrownͲprimarytooth
$75
D2931
PrefabricatedstainlesssteelcrownͲpermanenttooth
$75
D2940 Protectiverestoration
ROUTINEDENTALCAREͲORALSURGERY
D7111 Extraction,coronalremnantsͲdeciduoustooth
Extraction,eruptedtoothorexposedroot(elevation
D7140
and/orforcepsremoval)
Surgicalremovaloferuptedtoothrequiringremovalof
D7210 boneand/orsectioningoftooth,andincludingelevation
ofmucoperiostealflapifindicated
D7220 RemovalofimpactedtoothͲsofttissue
D7230 RemovalofimpactedtoothͲpartiallybony
D7240 RemovalofimpactedtoothͲcompletelybony
RemovalofimpactedtoothͲcompletelybony,with
D7241
unusualsurgicalcomplications
D7250 Surgicalremovalofresidualroots(cuttingprocedure)
D7251 Coronectomy–intentionalpartialtoothremoval
ToothreͲimplantationand/orstabilizationofaccidentally
D7270
evulsedordisplacedtooth
Toothtransplantation(includesreͲimplantationfromone
D7272
sitetoanotherandsplintingand/orstabilization)
D7280 Surgicalaccessofanuneruptedtooth
Mobilizationoferuptedormalpositionedtoothtoaid
D7282
eruption
$10
$60
$70
$132
$177
$229
$281
$306
$127
$270
$200
$100
$220
$196
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
ROUTINEDENTALCAREͲORALSURGERYCONT.
D7283
Placementofdevicetofacilitateeruptionofimpacted
tooth
$80
D7960
FrenulectomyͲalsoknownasfrenectomyorfrenotomyͲ
separateprocedurenotincidentaltoanotherprocedure
$175
D7963 Frenuloplasty
ENDODONTICS
$125
D3110
PulpcapͲdirect(excludingfinalrestoration)
$30
D3120
PulpcapͲindirect(excludingfinalrestoration)
$30
D3220
Therapeuticpulpotomy(excludingfinalrestoration)Ͳ
removalofpulpcoronaltothedentinocementaljunction
andapplicationofmedicament
$70
D3221
Pulpaldebridement,primaryandpermanentteeth
$90
D3230
D3240
D3310
D3320
Pulpaltherapy(resorbablefilling)Ͳanterior,primarytooth
(excludingfinalrestoration)
Pulpaltherapy(resorbablefilling)Ͳposterior,primary
tooth(excludingfinalrestoration)
Endodontictherapy,anteriortooth(excludingfinal
restoration)
Endodontictherapy,bicuspidtooth(excludingfinal
restoration)
$70
$60
$350
$350
D3330
Endodontictherapy,molar(excludingfinalrestoration)
$350
D3331
Treatmentofrootcanalobstruction;nonͲsurgicalaccess
$85
IncompleteEndodontictherapy;inoperable,unrestorable
orfracturedtooth
D3333 Internalrootrepairofperforationdefects
D3346 RetreatmentofpreviousrootcanaltherapyͲanterior
D3347 RetreatmentofpreviousrootcanaltherapyͲbicuspid
D3348 RetreatmentofpreviousrootcanaltherapyͲmolar
D3421 ApicoectomyͲbicuspid(firstroot)
D3425 ApicoectomyͲmolar(firstroot)
D3426 Apicoectomy(eachaddroot)
D3430 RetrogradefillingͲperroot
D3450 RootamputationͲperroot
PERIODONTICS
Periodontalscaling&rootplaningͲfourormoreteethper
D4341
quadrant
D3332
D4342
Periodontalscaling&rootplaningͲonetothreeteethper
quadrant
$75
$115
$100
$100
$100
$50
$50
$50
$65
$225
$133
Limitedto(1)per
quadrantper24months
$51
Limitedto(1)per
quadrantper24months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
PERIODONTICSCONT.
D4910
Periodontalmaintenance
$74
Oncewithinasix(6)
monthconsecutive
period
PROSTHODONTICSͲREMOVABLE
D5110
CompletedentureͲmaxillary
$350
D5120
CompletedentureͲmandibular
$350
D5211
MaxillarypartialdentureͲresinbase(includingany
conventionalclasps,restsandteeth)
$350
D5212
MandibularpartialdentureͲresinbase(includingany
conventionalclasps,restsandteeth)
$350
D5410
D5411
D5421
D5422
D5510
AdjustcompletedentureͲmaxillary
AdjustcompletedentureͲmandibular
AdjustpartialdentureͲmaxillary
AdjustpartialdentureͲmandibular
Repairbrokencompletedenturebase
ReplacemissingorbrokenteethͲcompletedenture(each
D5520
tooth)
D5610 Repairresindenturebase
D5620 Repaircastframework
D5630 RepairorreplacebrokenclaspͲpertooth
D5640 ReplacebrokenteethͲpertooth
D5710 Rebasecompletemaxillarydenture
D5711 Rebasecompletemandibulardenture
D5720 Rebasemaxillarypartialdenture
D5721 Rebasemandibularpartialdenture
D5730 Relinecompletemaxillarydenture(chairside)
D5731 Relinecompletemandibulardenture(chairside)
D5740 Relinemaxillarypartialdenture(chairside)
D5741 Relinemandibularpartialdenture(chairside)
D5750 Relinecompletemaxillarydenture(laboratory)
D5751 Relinecompletemandibulardenture(laboratory)
D5760 Relinemaxillarypartialdenture(laboratory)
D5761 Relinemandibularpartialdenture(laboratory)
PROSTHODONTICSͲFIXED
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
$20
$20
$20
$20
$120
$125
$120
$130
$130
$115
$175
$175
$170
$170
$135
$135
$135
$135
$165
$165
$165
$165
D6211
PonticͲcastpredominantlybasemetal
$350
D6251
PonticͲresinwithpredominantlybasemetal
$350
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
PROSTHODONTICSͲFIXEDCONT.
D6721
CrownͲresinwithpredominantlybasemetal
$350
D6791
CrownͲfullcastpredominantlybasemetal
$350
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
ORTHODONTIA
OrthodontictreatmentisMedicallyNecessaryonlyandlimitedtonomorethantwentyͲfour(24)monthsof
treatment,withtheinitialpaymentof20%atbandingandremainingpaymentproratedoverthecourseof
treatment.
Interceptiveorthodontictreatmentoftheprimary
D8050
$350
dentition
Interceptiveorthodontictreatmentofthetransitional
$350
D8060
dentition
Comprehensiveorthodontictreatmentofthetransitional
$350
D8070
dentition
Comprehensiveorthodontictreatmentoftheadolescent
$350
D8080
dentition
Orthodonticretention(removalofappliances,
$350
D8680
constructionandplacementofretainer(s))
MISCELLANEOUSSERVICES
Intravenousmoderate(conscious)sedation/analgesia–
$50
D9243
each15minuteincrement
COST-SHARING
Participating
Provider
Member
Responsibility for
Cost-Sharing
Non-Participating
Provider
Member
Responsibility for
Cost-Sharing
ADDITIONAL
PEDIATRIC DENTAL
CARE
Deductible
 One (1) Member
under age 19
 Two (2) or more
Members under
age 19
Out-of-Pocket Limit
 One (1) Member
under age 19
 Two (2) or more
Members under
age 19
Deductibles,
Coinsurance and
Copayments that make
up Your Out-of-Pocket
Limit accumulate on a
calendar year ending
on December 31 of
each year.
$50
$50 per member
None
None
Non-Participating
Provider Services Are
Not Covered and You
Pay the Full Cost
ADDITIONAL
PEDIATRIC DENTAL
CARE
Participating
Provider Member
Responsibility for
Cost-Sharing
Pediatric Dental Care
• Preventive Dental
Care
$0- $125 Copayment
After Deductible
• Routine Dental Care
$0 - $727 Copayment
After Deductible
• Endodontics
$30 - $350 Copayment
After Deductible
• Periodontics
$51 - $638 Copayment
After Deductible
• Prosthodontics
$20 - $793 Copayment
After Deductible
• Oral Surgery
$60 - $306 Copayment
After Deductible
• Orthodontics
$25 - $1,900
Copayment After
Deductible
Preauthorization
Treatment of
Malignancies, Cysts,
or Neoplasms,
General Anesthesia,
IV Sedation, Crowns,
Bridges, Prosthetics,
and Specialist Care
Require
Preauthorization
Non-Participating
Provider Member
Responsibility for
Cost-Sharing
Non-Participating
Provider Services Are
Not Covered You Pay
the Full Cost
Limits
One (1) dental exam &
cleaning per six (6)
month period
Full mouth X-rays or
panoramic X-rays at
36 month intervals and
bitewing X-rays at six
month intervals
TheCopaymentslistedintheScheduleofBenefitsareforCoveredServicesprovidedbyaParticipatingProvider
whoisaGeneralDentist.
MEMBERCOSTͲ
CODE
DESCRIPTION
LIMITATIONS
SHARING
CHILD
PREVENTIVEDENTALCARE
D1310 Nutritionalcounselingforcontrolofdentaldisease
$0
Tobaccocounselingforthecontrolandpreventionoforal
$0
D1320
disease
D8220 Fixedappliancetherapy
$115
ROUTINEDENTALCAREͲAPPOINTMENTS
ReͲevaluationͲlimited,problemfocused(established
$30
D0170
patient;notpostͲoperativevisit)
Oncewithinasix(6)
ComprehensiveperiodontalevaluationͲnewor
$59
D0180
monthconsecutive
establishedpatient
period
ConsultationͲdiagnosticserviceprovidedbydentistor
D9310
$58
physicianotherthanrequestingdentistorphysician
Officevisitforobservation(duringregularlyscheduled
$0
D9430
hours)Ͳnootherservicesperformed
D9440 OfficevisitͲafterregularlyscheduledhours
$35
ROUTINEDENTALCAREͲRADIOGRAPHY/DIAGNOSTICDENTISTRY
D0230
IntraoralͲperiapicaleachadditionalradiographicimage
$10
D0240
IntraoralͲocclusalradiographicimage
$18
D0250
ExtraoralͲfirstradiographicimage
$29
One(1)timeinany
twelve(12)consecutive
months
D0277
VerticalbitewingsͲ7to8radiographicimages
$43
Six(6)monthintervals
D0290
PosteriorͲanteriororlateralskullandfacialbonesurvey
radiographicimage
$150
D0320
Temporomandibularjointarthrogram,includinginjection
$250
D0321
D0322
D0340
D0350
Othertemporomandibularjointradiographicimages,by
report
Tomographicsurvey
Cephalometricradiographicimage
2Doral/facialphotographicimageobtainedintraͲorallyor
extraͲorally
$150
$150
$150
$35
D0415
Collectionofmicroorganismsforcultureandsensitivity
$20
D0425
Cariessusceptibilitytests
AdjunctivepreͲdiagnostictestthataidsindetectionof
mucosalabnormalitiesincludingpremalignantand
malignantlesions
Pulpvitalitytests
Diagnosticcasts
Accessionoftissue,grossexamination,preparationand
transmissionofwrittenreport
$10
D0431
D0460
D0470
D0472
$65
$25
$53
$65
CurrentDentalTerminology©2014AmericanDentalAssociation(ADA).Allrightsreserved.
MEMBERCOSTͲ
CODE
DESCRIPTION
SHARING
CHILD
ROUTINEDENTALCAREͲRADIOGRAPHY/DIAGNOSTICDENTISTRYCONT.
D0473
Accessionoftissue,grossandmicroscopicexamination,
preparationandtransmissionofwrittenreport
$65
Accessionoftissue,grossandmicroscopicexamination,
includingassessmentofsurgicalmarginsforpresenceof
disease
Laboratoryaccessionoftransepithelialcytologicsample,
D0486 microscopicexamination,preparationandtransmissionof
writtenreport
ROUTINEDENTALCAREͲRESTORATIVEDENTISTRY
D2390 ResinͲbasedcompositecrown,anterior
D2391 ResinͲbasedcompositeͲonesurface,posterior
D2392 ResinͲbasedcompositeͲtwosurfaces,posterior
D2393 ResinͲbasedcompositeͲthreesurfaces,posterior
$128
$76
$103
$132
D2394
ResinͲbasedcompositeͲfourormoresurfaces,posterior
$150
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
GoldfoilͲonesurface
GoldfoilͲtwosurfaces
GoldfoilͲthreesurfaces
InlayͲmetallicͲonesurface
InlayͲmetallicͲtwosurfaces
InlayͲmetallicͲthreeormoresurfaces
OnlayͲmetallicͲtwosurfaces
OnlayͲmetallicͲthreesurfaces
OnlayͲmetallicͲfourormoresurfaces
InlayͲporcelain/ceramicͲonesurface
InlayͲporcelain/ceramicͲtwosurfaces
InlayͲporcelain/ceramicͲthreeormoresurfaces
OnlayͲporcelain/ceramicͲtwosurfaces
OnlayͲporcelain/ceramicͲthreesurfaces
OnlayͲporcelain/ceramicͲfourormoresurfaces
InlayͲresinͲbasedcompositeͲonesurface
InlayͲresinͲbasedcompositeͲtwosurfaces
InlayͲresinͲbasedcompositeͲthreeormoresurfaces
OnlayͲresinͲbasedcompositeͲtwosurfaces
OnlayͲresinͲbasedcompositeͲthreesurfaces
OnlayͲresinͲbasedcompositeͲfourormoresurfaces
$100
$150
$175
$292
$338
$389
$368
$399
$415
$563
$573
$599
$568
$629
$727
$297
$328
$338
$297
$338
$399
D2710
CrownͲresinͲbasedcomposite(indirect)
$515
D2712
CrownͲ¾resinͲbasedcomposite(indirect)
$515
D2720
CrownͲresinwithhighnoblemetal
$675
D0474
LIMITATIONS
$65
$65
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
ROUTINEDENTALCAREͲRESTORATIVEDENTISTRYCONT.
D2721
CrownͲresinwithpredominantlybasemetal
$660
D2722
CrownͲresinwithnoblemetal
$615
D2740
CrownͲporcelain/ceramicsubstrate
$722
D2750
CrownͲporcelainfusedtohighnoblemetal
$706
D2751
CrownͲporcelainfusedtopredominantlybasemetal
$660
D2752
CrownͲporcelainfusedtonoblemetal
$629
D2780
CrownͲ3/4casthighnoblemetal
$660
D2781
CrownͲ3/4castpredominantlybasemetal
$660
D2782
CrownͲ3/4castnoblemetal
$615
D2783
CrownͲ3/4porcelain/ceramic
$660
D2790
CrownͲfullcasthighnoblemetal
$706
D2791
CrownͲfullcastpredominantlybasemetal
$660
D2792
CrownͲfullcastnoblemetal
$615
D2799
ProvisionalcrownͲfurthertreatmentorcompletionof
diagnosisnecessarypriortofinalimpression
$128
D2910
D2915
D2920
ReͲcementorreͲbondinlay,onlay,veneerorpartial
coveragerestoration
ReͲcementorreͲbondindirectlyfabricatedor
prefabricatedpostandcore
ReͲcementorreͲbondcrown
$15
$20
$43
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
ROUTINEDENTALCAREͲRESTORATIVEDENTISTRYCONT.
D2932
Prefabricatedresincrown
$125
D2933
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
Prefabricatedstainlesssteelcrownwithresinwindow
Corebuildup,includinganypinswhenrequired
PinretentionͲpertooth,inadditiontorestoration
Postandcoreinadditiontocrown,indirectlyfabricated
EachadditionalindirectlyfabricatedpostͲsametooth
Prefabricatedpostandcoreinadditiontocrown
Postremoval
EachadditionalprefabricatedpostͲsametooth
Labialveneer(resinlaminate)Ͳchairside
Labialveneer(resinlaminate)Ͳlaboratory
Labialveneer(porcelainlaminate)Ͳlaboratory
Additionalprocedurestoconstructnewcrownunder
existingpartialdentureframework
$150
$90
$29
$150
$105
$145
$45
$35
$281
$338
$670
Crownrepairnecessitatedbyrestorativematerialfailure
$100
D2971
D2980
ROUTINEDENTALCAREͲORALSURGERY
D7260 Oroantralfistulaclosure
D7285 IncisionalbiopsyoforaltissueͲhard(bone,tooth)
D7286 IncisionalbiopsyoforaltissueͲsoft
D7287 Exfoliativecytologicalsamplecollection
D7288 BrushbiopsyͲtransepithelialsamplecollection
Alveoloplastyinconjunctionwithextractions–fouror
D7310
moreteethortoothspaces,perquadrant
AlveoloplastyinconjunctionwithextractionsͲoneto
D7311
threeteethortoothspaces,perquadrant
AlveoloplastynotinconjunctionwithextractionsͲfouror
D7320
moreteethortoothspaces,perquadrant
AlveoloplastynotinconjunctionwithextractionsͲoneto
D7321
threeteethortoothspaces,perquadrant
RemovalofbenignodontogeniccystortumorͲlesion
D7450
diameterupto1.25cm
RemovalofbenignodontogeniccystortumorͲlesion
D7451
diametergreaterthan1.25cm
D7471 Removaloflateralexostosis(maxillaormandible)
D7472 Removaloftoruspalatinus
D7473 Removaloftorusmandibularis
D7485 Surgicalreductionofosseoustuberosity
D7510 IncisionanddrainageofabscessͲintraoralsofttissue
$89
$364
$138
$140
$90
$30
$100
$80
$155
$85
$198
$201
$306
$350
$350
$350
$95
D7511
IncisionanddrainageofabscessͲintraoralsofttissueͲ
complicated(includesdrainageofmultiplefascialspaces)
$25
D7520
IncisionanddrainageofabscessͲextraoralsofttissue
$75
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
ROUTINEDENTALCAREͲORALSURGERYCONT.
D7521
IncisionanddrainageofabscessͲextraoralsofttissueͲ
complicated(includesdrainageofmultiplefascialspaces)
$105
D7910 Sutureofrecentsmallwoundsupto5cm
D7970 ExcisionofhyperplastictissueͲperarch
D7971 Excisionofpericoronalgingiva
ENDODONTICS
Apexification/recalcificationͲinitialvisit(apical
D3351 closure/calcificrepairofperforations,rootresorption,
etc.)
Apexification/recalcificationͲinterimmedication
D3352
replacement
Apexification/recalcificationͲfinalvisit(includes
D3353 completedrootcanaltherapyͲapicalclosure/calcific
repairofperforations,rootresorption,etc.)
D3410 ApicoectomyͲanterior
$45
$140
$110
$344
D3470
IntentionalreͲimplantation(includingnecessarysplinting)
$200
D3910
Surgicalprocedureforisolationoftoothwithrubberdam
$95
D3920
Hemisection(includinganyrootremoval),notincluding
rootcanaltherapy
$210
D3950
Canalpreparationandfittingofpreformeddowelorpost
$95
$180
$127
$241
PERIODONTICS
GingivectomyorgingivoplastyͲfourormorecontiguous
D4210
teethortoothboundedspacesperquadrant
GingivectomyorgingivoplastyͲonetothreecontiguous
D4211
teethortoothboundedspacesperquadrant
Gingivalflapprocedure,includingrootplaningͲfouror
D4240 morecontiguousteethortoothboundedspacesper
quadrant
Gingivalflapprocedure,includingrootplaningͲoneto
D4241 threecontiguousteethortoothboundedspacesper
quadrant
D4245 Apicallypositionedflap
D4249 ClinicalcrownlengtheningͲhardtissue
Osseoussurgery(includingelevationofafullthicknessflap
D4260 andclosure)Ͳfourormorecontiguousteethortooth
boundedspacesperquadrant
Osseoussurgery(includingelevationofafullthicknessflap
D4261 andclosure)Ͳonetothreecontiguousteethortooth
boundedspacesperquadrant
D4263 BonereplacementgraftͲfirstsiteinquadrant
$515
D4264
$390
BonereplacementgraftͲeachadditionalsiteinquadrant
$339
$98
$284
$185
$180
$363
$638
$325
LIMITATIONS
CODE
DESCRIPTION
PERIODONTICSCONT.
Biologicmaterialstoaidinsoftandosseoustissue
D4265
regeneration
D4266
D4267
D4270
D4273
D4274
D4275
D4320
D4321
D4355
D4381
GuidedtissueregenerationͲresorbablebarrier,persite
GuidedtissueregenerationͲnonͲresorbablebarrier,per
site(includesmembraneremoval)
Pediclesofttissuegraftprocedure
Autogenousconnectivetissuegraftprocedure(including
donorandrecipientsurgicalsites)firsttooth,implant,or
edentuloustoothpositioningraft
Distalorproximalwedgeprocedure(whennotperformed
inconjunctionwithsurgicalproceduresinthesame
anatomicalarea)
NonͲautogenousconnectivetissuegraft(including
recipientsiteanddonormaterial)firsttooth,implant,or
edentuloustoothpositioningraft
ProvisionalsplintingͲintracoronal
ProvisionalsplintingͲextracoronal
Fullmouthdebridementtoenablecomprehensive
evaluationanddiagnosis
Localizeddeliveryofantimicrobialagentsviaacontrolled
releasevehicleintodiseasedcreviculartissue,pertooth
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
$390
$415
$520
$344
$335
$205
$563
$158
$319
$69
$74
PROSTHODONTICSͲREMOVABLE
D5130
ImmediatedentureͲmaxillary
$762
D5140
ImmediatedentureͲmandibular
$762
D5213
D5214
MaxillarypartialdentureͲcastmetalframeworkwithresin
denturebases(includinganyconventionalclasps,rests
andteeth)
MandibularpartialdentureͲcastmetalframeworkwith
resindenturebases(includinganyconventionalclasps,
restsandteeth)
$793
$793
D5225
MaxillarypartialdentureͲflexiblebase(includingany
clasps,restsandteeth
$788
D5226
MandibularpartialdentureͲflexiblebase(includingany
clasps,restsandteeth
$788
D5281
RemovableunilateralpartialdentureͲonepiececast
metal(includingclaspsandteeth)
$555
D5650
D5660
Addtoothtoexistingpartialdenture
AddclasptoexistingpartialdentureͲpertooth
$140
$154
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
CODE
DESCRIPTION
PROSTHODONTICSͲREMOVABLECONT.
Replaceallteethandacryliconcastmetalframework
D5670
(maxillary)
Replaceallteethandacryliconcastmetalframework
D5671
(mandibular)
D5810 Interimcompletedenture(maxillary)
D5811 Interimcompletedenture(mandibular)
D5820 Interimpartialdenture(maxillary)
D5821 Interimpartialdenture(mandibular)
D5850 Tissueconditioning,maxillary
D5851 Tissueconditioning,mandibular
D5862 Precisionattachment,byreport
Unspecifiedremovableprosthodonticprocedure,by
D5899
report
PROSTHODONTICSͲFIXED
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
$292
$292
$486
$486
$435
$435
$41
$41
$160
$20
D6210
PonticͲcasthighnoblemetal
$640
D6212
PonticͲcastnoblemetal
$615
D6240
PonticͲporcelainfusedtohighnoblemetal
$640
D6241
PonticͲporcelainfusedtopredominantlybasemetal
$558
D6242
PonticͲporcelainfusedtonoblemetal
$615
D6245
PonticͲporcelain/ceramic
$660
D6250
PonticͲresinwithhighnoblemetal
$640
D6252
PonticͲresinwithnoblemetal
$615
D6253
ProvisionalponticͲfurthertreatmentorcompletionof
diagnosisnecessarypriortofinalimpression
$255
D6545
RetainerͲcastmetalforresinbondedfixedprosthesis
$350
D6548
RetainerͲporcelain/ceramicforresinbondedfixed
prosthesis
$425
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
PROSTHODONTICSͲFIXEDCONT.
D6600 InlayͲporcelain/ceramic,twosurfaces
D6601 InlayͲporcelain/ceramic,threeormoresurfaces
D6602 InlayͲcasthighnoblemetal,twosurfaces
D6603 InlayͲcasthighnoblemetal,threeormoresurfaces
$560
$585
$485
$496
D6604
$440
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
InlayͲcastpredominantlybasemetal,twosurfaces
InlayͲcastpredominantlybasemetal,threeormore
surfaces
InlayͲcastnoblemetal,twosurfaces
InlayͲcastnoblemetal,threeormoresurfaces
OnlayͲporcelain/ceramic,twosurfaces
OnlayͲporcelain/ceramic,threeormoresurfaces
OnlayͲcasthighnoblemetal,twosurfaces
OnlayͲcasthighnoblemetal,threeormoresurfaces
OnlayͲcastpredominantlybasemetal,twosurfaces
OnlayͲcastpredominantlybasemetal,threeormore
surfaces
OnlayͲcastnoblemetal,twosurfaces
OnlayͲcastnoblemetal,threeormoresurfaces
LIMITATIONS
$476
$460
$460
$563
$599
$563
$599
$440
$476
$460
$476
D6710
CrownͲindirectresinbasedcomposite
$515
D6720
CrownͲresinwithhighnoblemetal
$640
D6722
CrownͲresinwithnoblemetal
$615
D6740
CrownͲporcelain/ceramic
$722
D6750
CrownͲporcelainfusedtohighnoblemetal
$706
D6751
CrownͲporcelainfusedtopredominantlybasemetal
$660
D6752
CrownͲporcelainfusedtonoblemetal
$686
D6780
CrownͲ3/4casthighnoblemetal
$615
D6781
CrownͲ3/4castpredominantlybasemetal
$558
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
CHILD
LIMITATIONS
PROSTHODONTICSͲFIXEDCONT.
D6782
CrownͲ3/4castnoblemetal
$615
D6783
CrownͲ3/4porcelain/ceramic
$660
D6790
CrownͲfullcasthighnoblemetal
$640
D6792
CrownͲfullcastnoblemetal
$615
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
D6930
D6940
D6950
ReͲcementorreͲbondfixedpartialdenture
$62
Stressbreaker
$145
Precisionattachment
$195
Fixedpartialdenturerepairnecessitatedbyrestorative
$85
D6980
materialfailure
ORTHODONTIA
OrthodontictreatmentisMedicallyNecessaryonlyandlimitedtonomorethantwentyͲfour(24)monthsof
treatment,withtheinitialpaymentof20%atbandingandremainingpaymentproratedoverthecourseof
treatment.
D8010 Limitedorthodontictreatmentoftheprimarydentition
$1,800
D8020
Limitedorthodontictreatmentofthetransitionaldentition
$1,900
D8030
Limitedorthodontictreatmentoftheadolescentdentition
$1,900
PreͲorthodontictreatmentexaminationtomonitorgrowth
anddevelopment
D8693 ReͲcementorreͲbondfixedretainer
D8999 Unspecifiedorthodonticprocedure,byreport
MISCELLANEOUSSERVICES
D9120 Fixedpartialdenturesectioning
Localanesthesianotinconjunctionwithoperativeor
D9210
surgicalprocedures
Localanesthesiainconjunctionwithoperativeorsurgical
D9215
procedures
Deepsedation/generalanesthesia–each15minute
D9223
increment
D9230 Inhalationofnitrousoxide/analgesia,anxiolysis
D9610 Therapeuticparenteraldrug,singleadministration
D9630 Otherdrugsand/ormedicaments,byreport
D8660
$66
$25
$250
$0
$10
$0
$50
$26
$15
$15
D9910
Applicationofdesensitizingmedicament
$30
D9940
D9942
D9950
Occlusalguard,byreport
Repairand/orrelineofocclusalguard
OcclusionanalysisͲmountedcase
$314
$45
$85
One(1)timeinany
twelve(12)consecutive
months
CODE
DESCRIPTION
MISCELLANEOUSSERVICESCONT.
D9951 OcclusaladjustmentͲlimited
D9952 OcclusaladjustmentͲcomplete
D9972 ExternalbleachingͲperarchͲperformedinoffice
MEMBERCOSTͲ
SHARING
CHILD
$69
$196
$150
LIMITATIONS
Participating
Provider
Member
Responsibility for
Cost-Sharing
Non-Participating
Provider
Member
Responsibility for
Cost-Sharing
Deductible
 Individual
 Family
$50
$50 per member
Out-of-Pocket Limit
 Individual
 Family
Non-Participating
Provider Services
Are Not Covered and
You Pay the Full
Cost
None
None
COST-SHARING
ADULT DENTAL
CARE
Deductibles,
Coinsurance and
Copayments that
make up Your Out-ofPocket Limit
accumulate on a
calendar year ending
on December 31 of
each year.
Preauthorization
Treatment of
Malignancies, Cysts
or Neoplasms,
General Anesthesia,
IV Sedation,
Crowns, Bridges,
Prosthetics, and
Specialist Care
Require
Preauthorization
TheCopaymentslistedintheScheduleofBenefitsareforCoveredServicesprovidedbyaParticipatingProvider
whoisaGeneralDentist.
SymbolLegend
CODE
DESCRIPTION
†Proceduresthatarenoteligibleata
Specialist
^AdultCopaymentsthatdonotincludethe
costofmaterialand/orlaboratoryfees.
MEMBERCOSTͲ
SHARING
ADULT
PREVENTIVEDENTALCARE
D1110 ProphylaxisͲadult
$0
D1206
Topicalapplicationoffluoridevarnish
$30
D1208
TopicalapplicationoffluorideͲexcludingvarnish
$15
D1310
Nutritionalcounselingforcontrolofdentaldisease
Tobaccocounselingforthecontrolandpreventionoforal
disease
$0
D1320
D1351
SealantͲpertooth
D8210 Removableappliancetherapy
D8220 Fixedappliancetherapy
ROUTINEDENTALCAREͲAPPOINTMENTS
LIMITATIONS
Six(6)monthintervals
Six(6)monthintervals
wherethelocalwater
supplyisnot
fluoridated
Six(6)monthintervals
wherethelocalwater
supplyisnot
fluoridated
$0
$43
One(1)timeinanythirtyͲ
six(36)consecutive
monthpertooth
$115
$115
Oncewithinasix(6)
monthconsecutive
period
D0120
PeriodicoralevaluationͲestablishedpatient
$15
D0140
LimitedoralevaluationͲproblemfocused
$15
D0150
ComprehensiveoralevaluationͲneworestablished
patient
$15
D0160
DetailedandextensiveoralevaluationͲproblemfocused,
byreport
$15
D0170
ReͲevaluationͲlimited,problemfocused(established
patient;notpostͲoperativevisit)
$15
D0180
ComprehensiveperiodontalevaluationͲnewor
establishedpatient
$15
Oncewithinasix(6)
monthconsecutive
period
$45
ForEmergencyDental
D9110
D9310
D9430
D9440
Palliative(emergency)treatmentofdentalpainͲminor
procedure
ConsultationͲdiagnosticserviceprovidedbydentistor
physicianotherthanrequestingdentistorphysician
Officevisitforobservation(duringregularlyscheduled
hours)Ͳnootherservicesperformed
OfficevisitͲafterregularlyscheduledhours
OncewithinathirtyͲsix
(36)consecutivemonth
period
Oncewithinasix(6)
monthconsecutive
period
$58
$0
$35
CurrentDentalTerminology©2014AmericanDentalAssociation(ADA).Allrightsreserved.
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
ROUTINEDENTALCAREͲRADIOGRAPHY/DIAGNOSTICDENTISTRY
D0210
IntraoralͲcompleteseriesofradiographicimages
$25
D0220
IntraoralͲperiapicalfirstradiographicimage
$14
D0230
IntraoralͲperiapicaleachadditionalradiographicimage
$10
D0240
IntraoralͲocclusalradiographicimage
$15
D0250
ExtraoralͲfirstradiographicimage
$15
D0270
BitewingͲsingleradiographicimage
$14
D0272
BitewingsͲtworadiographicimages
$15
D0273
BitewingsͲthreeradiographicimages
$15
D0274
BitewingsͲfourradiographicimages
$15
D0277
VerticalbitewingsͲ7to8radiographicimages
$29
D0290
PosteriorͲanteriororlateralskullandfacialbonesurvey
radiographicimage
$150
D0320
Temporomandibularjointarthrogram,includinginjection
$250
D0322
Othertemporomandibularjointradiographicimages,by
report
Tomographicsurvey
D0330
Panoramicradiographicimage
$25
D0340
Cephalometricradiographicimage
2Doral/facialphotographicimageobtainedintraͲorallyor
extraͲorally
Collectionofmicroorganismsforcultureandsensitivity
Cariessusceptibilitytests
AdjunctivepreͲdiagnostictestthataidsindetectionof
mucosalabnormalitiesincludingpremalignantand
malignantlesions,nottoincludecytologyorbiopsy
procedures
Pulpvitalitytests
Diagnosticcasts
Accessionoftissue,grossexamination,preparationand
transmissionofwrittenreport
$125
D0321
D0350
D0415
D0425
D0431
D0460
D0470
D0472
D0473
Accessionoftissue,grossandmicroscopicexamination,
preparationandtransmissionofwrittenreport
ThirtyͲsix(36)month
intervals
One(1)timeinany
twelve(12)consecutive
months
Six(6)totwelve(12)
monthintervals
Six(6)totwelve(12)
monthintervals
Six(6)totwelve(12)
monthintervals
Six(6)totwelve(12)
monthintervals
Six(6)totwelve(12)
monthintervals
$150
$150
$20
$20
$10
$65
$25
$53
$65
$65
ThirtyͲsix(36)month
intervals
MEMBERCOSTͲ
CODE
DESCRIPTION
SHARING
ADULT
ROUTINEDENTALCAREͲRADIOGRAPHY/DIAGNOSTICDENTISTRYCONT.
D0474
Accessionoftissue,grossandmicroscopicexamination,
includingassessmentofsurgicalmarginsforpresenceof
disease,preparationandtransmissionofwrittenreport
$65
Laboratoryaccessionoftransepithelialcytologicsample,
microscopicexamination,preparationandtransmissionof
writtenreport
ROUTINEDENTALCAREͲRESTORATIVEDENTISTRY
D2140 AmalgamͲonesurface,primaryorpermanent
D2150 AmalgamͲtwosurfaces,primaryorpermanent
D2160 AmalgamͲthreesurfaces,primaryorpermanent
D2161 AmalgamͲfourormoresurfaces,primaryorpermanent
D2330 ResinͲbasedcompositeͲonesurface,anterior
D2331 ResinͲbasedcompositeͲtwosurfaces,anterior
D2332 ResinͲbasedcompositeͲthreesurfaces,anterior
ResinͲbasedcompositeͲfourormoresurfacesorinvolving
D2335
incisalangle(anterior)
D2390 ResinͲbasedcompositecrown,anterior
D2391 ResinͲbasedcompositeͲonesurface,posterior
D2392 ResinͲbasedcompositeͲtwosurfaces,posterior
D2393 ResinͲbasedcompositeͲthreesurfaces,posterior
$125
$75
$100
$130
D2394
ResinͲbasedcompositeͲfourormoresurfaces,posterior
$150
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
GoldfoilͲonesurface
GoldfoilͲtwosurfaces
GoldfoilͲthreesurfaces
InlayͲmetallicͲonesurface
InlayͲmetallicͲtwosurfaces
InlayͲmetallicͲthreeormoresurfaces
OnlayͲmetallicͲtwosurfaces
OnlayͲmetallicͲthreesurfaces
OnlayͲmetallicͲfourormoresurfaces
InlayͲporcelain/ceramicͲonesurface
InlayͲporcelain/ceramicͲtwosurfaces
InlayͲporcelain/ceramicͲthreeormoresurfaces
OnlayͲporcelain/ceramicͲtwosurfaces
OnlayͲporcelain/ceramicͲthreesurfaces
OnlayͲporcelain/ceramicͲfourormoresurfaces
InlayͲresinͲbasedcompositeͲonesurface
InlayͲresinͲbasedcompositeͲtwosurfaces
InlayͲresinͲbasedcompositeͲthreeormoresurfaces
OnlayͲresinͲbasedcompositeͲtwosurfaces
OnlayͲresinͲbasedcompositeͲthreesurfaces
OnlayͲresinͲbasedcompositeͲfourormoresurfaces
$100
$150
$175
$290
$335
$385
$365
$395
$415
$325^
$350^
$375^
$345^
$390^
$500^
$295
$325
$335
$295
$335
$395
D0486
$65
$25
$40
$50
$65
$50
$60
$80
$100
LIMITATIONS
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
ROUTINEDENTALCAREͲRESTORATIVEDENTISTRYCONT.
D2710
CrownͲresinͲbasedcomposite(indirect)
$515
D2712
CrownͲ¾resinͲbasedcomposite(indirect)
$515
D2720
CrownͲresinwithhighnoblemetal
$340^
D2721
CrownͲresinwithpredominantlybasemetal
$340^
D2722
CrownͲresinwithnoblemetal
$340^
D2740
CrownͲporcelain/ceramicsubstrate
$340^
D2750
CrownͲporcelainfusedtohighnoblemetal
$340^
D2751
CrownͲporcelainfusedtopredominantlybasemetal
$340^
D2752
CrownͲporcelainfusedtonoblemetal
$340^
D2780
CrownͲ3/4casthighnoblemetal
$340^
D2781
CrownͲ3/4castpredominantlybasemetal
$340^
D2782
CrownͲ3/4castnoblemetal
$340^
D2783
CrownͲ3/4porcelain/ceramic
$340^
D2790
CrownͲfullcasthighnoblemetal
$340^
D2791
CrownͲfullcastpredominantlybasemetal
$340^
D2792
CrownͲfullcastnoblemetal
$340^
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
ROUTINEDENTALCAREͲRESTORATIVEDENTISTRYCONT.
D2799
D2910
D2915
D2920
ProvisionalcrownͲfurthertreatmentorcompletionof
diagnosisnecessarypriortofinalimpression
ReͲcementorreͲbondinlay,onlay,veneerorpartial
coveragerestoration
ReͲcementorreͲbondindirectlyfabricatedor
prefabricatedpost&core
ReͲcementorreͲbondcrown
$125
$15
$20
$40
D2931
PrefabricatedstainlesssteelcrownͲpermanenttooth
$115
D2932
Prefabricatedresincrown
$125
D2933
D2940
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
$150
$15
$90
$29
$150
$105
$145
$45
$35
$280
$335
$605^
D2971
Prefabricatedstainlesssteelcrownwithresinwindow
Protectiverestoration
Corebuildup,includinganypinswhenrequired
PinretentionͲpertooth,inadditiontorestoration
Postandcoreinadditiontocrown,indirectlyfabricated
EachadditionalindirectlyfabricatedpostͲsametooth
Prefabricatedpostandcoreinadditiontocrown
Postremoval
EachadditionalprefabricatedpostͲsametooth
Labialveneer(resinlaminate)Ͳchairside
Labialveneer(resinlaminate)Ͳlaboratory
Labialveneer(porcelainlaminate)Ͳlaboratory
Additionalprocedurestoconstructnewcrownunder
existingpartialdentureframework
D2980
Crownrepairnecessitatedbyrestorativematerialfailure
$100
ROUTINEDENTALCAREͲORALSURGERY
D7111 Extraction,coronalremnantsͲdeciduoustooth
Extraction,eruptedtoothorexposedroot(elevation
D7140
and/orforcepsremoval)
Surgicalremovaloferuptedtoothrequiringremovalof
D7210 boneand/orsectioningoftooth,andincludingelevation
ofmucoperiostealflapifindicated
D7220 RemovalofimpactedtoothͲsofttissue
D7230 RemovalofimpactedtoothͲpartiallybony
D7240 RemovalofimpactedtoothͲcompletelybony
RemovalofimpactedtoothͲcompletelybony,with
D7241
unusualsurgicalcomplications
Surgicalremovalofresidualtoothroots(cutting
D7250
procedure)
D7260 Oroantralfistulaclosure
ToothreͲimplantationand/orstabilizationofaccidentally
D7270
evulsedordisplacedtooth
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
$89
$65
$75
$135
$185
$229
$281
$340
$130
$360
$200
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
ROUTINEDENTALCAREͲORALSURGERYCONT.
D7280 Surgicalaccessofanuneruptedtooth
Mobilizationoferuptedormalpositionedtoothtoaid
D7282
eruption
D7285 IncisionalbiopsyoforaltissueͲhard(bone,tooth)
D7286 IncisionalbiopsyoforaltissueͲsoft
D7287 Exfoliativecytologicalsamplecollection
D7288 BrushbiopsyͲtransepithelialsamplecollection
Alveoloplastyinconjunctionwithextractions–fouror
D7310
moreteethortoothspaces,perquadrant
AlveoloplastyinconjunctionwithextractionsͲoneto
D7311
threeteethortoothspaces,perquadrant
AlveoloplastynotinconjunctionwithextractionsͲfouror
D7320
moreteethortoothspaces,perquadrant
AlveoloplastynotinconjunctionwithextractionsͲoneto
D7321
threeteethortoothspaces,perquadrant
RemovalofbenignodontogeniccystortumorͲlesion
D7450
diameterupto1.25cm
RemovalofbenignodontogeniccystortumorͲlesion
D7451
diametergreaterthan1.25cm
D7471 Removaloflateralexostosis(maxillaormandible)
D7472 Removaloftoruspalatinus
D7473 Removaloftorusmandibularis
D7485 Surgicalreductionofosseoustuberosity
D7510 IncisionanddrainageofabscessͲintraoralsofttissue
MEMBERCOSTͲ
SHARING
ADULT
$230
$200
$170
$170
$90
$30
$120
$80
$160
$85
$340
$545
$320
$350
$350
$350
$95
D7511
IncisionanddrainageofabscessͲintraoralsofttissueͲ
complicated(includesdrainageofmultiplefascialspaces)
$25
D7520
IncisionanddrainageofabscessͲextraoralsofttissue
$75
D7521
IncisionanddrainageofabscessͲextraoralsofttissueͲ
complicated(includesdrainageofmultiplefascialspaces)
$105
D7910
Sutureofrecentsmallwoundsupto5cm
$45
D7960
FrenulectomyͲalsoknownasfrenectomyorfrenotomyͲ
separateprocedurenotincidentaltoanotherprocedure
$210
D7963 Frenuloplasty
D7970 ExcisionofhyperplastictissueͲperarch
D7971 Excisionofpericoronalgingiva
ENDODONTICS
D3110 PulpcapͲdirect(excludingfinalrestoration)
D3120 PulpcapͲindirect(excludingfinalrestoration)
Therapeuticpulpotomy(excludingfinalrestoration)Ͳ
D3220 removalofpulpcoronaltothedentinocementaljunction
andapplicationofmedicament
D3221 Pulpaldebridement,primaryandpermanentteeth
$125
$140
$110
$50
$50
$85
$100
LIMITATIONS
CODE
DESCRIPTION
ENDODONTICSCONT.
Pulpaltherapy(resorbablefilling)Ͳanterior,primarytooth
D3230
(excludingfinalrestoration)
Pulpaltherapy(resorbablefilling)Ͳposterior,primary
D3240
tooth(excludingfinalrestoration)
Endodontictherapy,anteriortooth(excludingfinal
D3310
restoration)
Endodontictherapy,bicuspidtooth(excludingfinal
D3320
restoration)
MEMBERCOSTͲ
SHARING
ADULT
$75
$65
$440
$515
D3330
Endodontictherapy,molar(excludingfinalrestoration)
$660
D3331
Treatmentofrootcanalobstruction;nonͲsurgicalaccess
$95
D3410
D3421
D3425
D3426
D3430
D3450
IncompleteEndodontictherapy;inoperable,unrestorable
orfracturedtooth
Internalrootrepairofperforationdefects
RetreatmentofpreviousrootcanaltherapyͲanterior
RetreatmentofpreviousrootcanaltherapyͲbicuspid
RetreatmentofpreviousrootcanaltherapyͲmolar
Apexification/recalcificationͲinitialvisit(apical
closure/calcificrepairofperforations,rootresorption,
etc.)
Apexification/recalcificationͲinterimmedication
replacement
Apexification/recalcificationͲfinalvisit(includes
completedrootcanaltherapyͲapicalclosure/calcific
repairofperforations,rootresorption,etc.)
ApicoectomyͲanterior
ApicoectomyͲbicuspid(firstroot)
ApicoectomyͲmolar(firstroot)
ApicoectomyͲeachadditionalroot
RetrogradefillingͲperroot
RootamputationͲperroot
$340
$365
$440
$155
$70
$255
D3470
IntentionalreͲimplantation(includingnecessarysplinting)
$200
D3910
Surgicalprocedureforisolationoftoothwithrubberdam
$95
D3920
Hemisection(includinganyrootremoval),notincluding
rootcanaltherapy
$210
D3950
Canalpreparationandfittingofpreformeddowelorpost
$95
D3332
D3333
D3346
D3347
D3348
D3351
D3352
D3353
$85
$130
$540
$660
$760
$180
$125
$240
PERIODONTICSERVICES
D4210
GingivectomyorgingivoplastyͲfourormorecontiguous
teethortoothboundedspacesperquadrant
$335
LIMITATIONS
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
PERIODONTICSERVICESCONT.
D4211
GingivectomyorgingivoplastyͲonetothreecontiguous
teethortoothboundedspacesperquadrant
$95
D4263
Gingivalflapprocedure,includingrootplaningͲfouror
morecontiguousteethortoothboundedspacesper
quadrant
Gingivalflapprocedure,includingrootplaningͲoneto
threecontiguousteethortoothboundedspacesper
quadrant
Apicallypositionedflap
ClinicalcrownlengtheningͲhardtissue
Osseoussurgery(includingelevationofafullthicknessflap
andclosure)Ͳfourormorecontiguousteethortooth
boundedspacesperquadrant
Osseoussurgery(includingelevationofafullthicknessflap
andclosure)Ͳonetothreecontiguousteethortooth
boundedspacesperquadrant
BonereplacementgraftͲfirstsiteinquadrant
$515
D4264
BonereplacementgraftͲeachadditionalsiteinquadrant
$390
D4265
Biologicmaterialstoaidinsoftandosseoustissue
regeneration
$390
D4266
GuidedtissueregenerationͲresorbablebarrier,persite
$415
D4240
D4241
D4245
D4249
D4260
D4261
D4267
D4270
D4273
D4274
D4275
D4320
D4321
D4341
D4342
D4355
D4381
GuidedtissueregenerationͲnonͲresorbablebarrier,per
site(includesmembraneremoval)
Pediclesofttissuegraftprocedure
Autogenousconnectivetissuegraftprocedure(including
donorandrecipientsurgicalsites)firsttooth,implant,or
edentuloustoothpositioningraft
Distalorproximalwedgeprocedure(whennotperformed
inconjunctionwithsurgicalproceduresinthesame
anatomicalarea)
NonͲautogenousconnectivetissuegraft(including
recipientsiteanddonormaterial)firsttooth,implant,or
edentuloustoothpositioningraft
ProvisionalsplintingͲintracoronal
ProvisionalsplintingͲextracoronal
Periodontalscaling&rootplaningͲfourormoreteethper
quadrant
Periodontalscaling&rootplaningͲonetothreeteethper
quadrant
Fullmouthdebridementtoenablecomprehensive
evaluationanddiagnosis
Localizeddeliveryofantimicrobialagentsviaacontrolled
releasevehicleintodiseasedcreviculartissue,pertooth
$280
$145
$180
$360
$635
$230
$520
$340
$310
$205
$560
$155
$315
$130†
$50†
$65†
$70†
Limitedto(1)per
quadrantper24months
Limitedto(1)per
quadrantper24months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
PERIODONTICSERVICESCONT.
D4910
Periodontalmaintenance
$70
Oncewithinasix(6)
monthconsecutive
period
PROSTHODONTICSͲREMOVABLE
D5110
CompletedentureͲmaxillary
$475^
D5120
CompletedentureͲmandibular
$475^
D5130
ImmediatedentureͲmaxillary
$525^
D5140
ImmediatedentureͲmandibular
$525^
D5211
MaxillarypartdentureͲresinbase(includingany
conventionalclasps,restsandteeth)
$425^
D5212
MandibularpartdentureͲresinbase(includingany
conventionalclasps,restsandteeth)
$425^
D5213
D5214
MaxillarypartialdentureͲcastmetalframeworkwithresin
denturebases(includinganyconventionalclasps,rests
andteeth)
MandibularpartialdentureͲcastmetalframeworkwith
resindenturebases(includinganyconventionalclasps,
restsandteeth)
$550^
$550^
D5225
MaxillarypartialdentureͲflexiblebase(includingany
conventionalclasps,restsandteeth)
$550^
D5226
MandibularpartialdentureͲflexiblebase(includingany
conventionalclasps,restsandteeth)
$550^
D5281
RemovableunilateralpartialdentureͲonepiececast
metal(includingclaspsandteeth)
$325^
D5410
D5411
D5421
D5422
D5510
D5520
D5610
D5620
D5630
AdjustcompletedentureͲmaxillary
AdjustcompletedentureͲmandibular
AdjustpartialdentureͲmaxillary
AdjustpartialdentureͲmandibular
Repairbrokencompletedenturebase
ReplacemissingorbrokenteethͲcompletedenture(each
tooth)
Repairresindenturebase
Repaircastframework
RepairorreplacebrokenclaspͲpertooth
$15
$15
$15
$15
$85^
$85^
$85^
$95^
$95^
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
Limitedtoone(1)per
consecutivesixty(60)
months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
PROSTHODONTICSͲREMOVABLECONT.
D5640
D5650
D5660
ReplacebrokenteethͲpertooth
Addtoothtoexistingpartialdenture
AddclasptoexistingpartialdentureͲpertooth
Replaceallteethandacryliconcastmetalframework
D5670
(maxillary)
Replaceallteethandacryliconcastmetalframework
D5671
(mandibular)
D5710 Rebasecompletemaxillarydenture
D5711 Rebasecompletemandibulardenture
D5720 Rebasemaxillarypartialdenture
D5721 Rebasemandibularpartialdenture
D5730 Relinecompletemaxillarydenture(chairside)
D5731 Relinecompletemandibulardenture(chairside)
D5740 Relinemaxillarypartialdenture(chairside)
D5741 Relinemandibularpartialdenture(chairside)
D5750 Relinecompletemaxillarydenture(laboratory)
D5751 Relinecompletemandibulardenture(laboratory)
D5760 Relinemaxillarypartialdenture(laboratory)
D5761 Relinemandibularpartialdenture(laboratory)
D5810 Interimcompletedenture(maxillary)
D5811 Interimcompletedenture(mandibular)
D5820 Interimpartialdenture(maxillary)
D5821 Interimpartialdenture(mandibular)
D5850 Tissueconditioning,maxillary
D5851 Tissueconditioning,mandibular
D5862 Precisionattachment,byreport
Unspecifiedremovableprosthodonticprocedure,by
D5899
report
PROSTHODONTICSͲFIXED
$80^
$90^
$100^
$290
$290
$150^
$150^
$145^
$145^
$100^
$100^
$100^
$100^
$125^
$125^
$125^
$125^
$260^
$260^
$210^
$210^
$40
$40
$160
$20
D6210
PonticͲcasthighnoblemetal
$340^
D6211
PonticͲcastpredominantlybasemetal
$340^
D6212
PonticͲcastnoblemetal
$340^
D6240
PonticͲporcelainfusedtohighnoblemetal
$340^
D6241
PonticͲporcelainfusedtopredominantlybasemetal
$340^
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
PROSTHODONTICSͲFIXEDCONT.
D6242
PonticͲporcelainfusedtonoblemetal
$340^
D6245
PonticͲporcelain/ceramic
$350^
D6250
PonticͲresinwithhighnoblemetal
$340^
D6251
PonticͲresinwithpredominantlybasemetal
$340^
D6252
PonticͲresinwithnoblemetal
$340^
D6253
ProvisionalponticͲfurthertreatmentorcompletionof
diagnosisnecessarypriortofinalimpression
$255
D6545
RetainerͲcastmetalforresinbondedfixedprosthesis
$195^
D6548
RetainerͲporcelain/ceramicforresinbondedfixed
prosthesis
$270^
D6600
D6601
D6602
D6603
D6604
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6710
InlayͲporcelain/ceramic,twosurfaces
InlayͲporcelain/ceramic,threeormoresurfaces
InlayͲcasthighnoblemetal,twosurfaces
InlayͲcasthighnoblemetal,threeormoresurfaces
InlayͲcastpredominantlybasemetal,twosurfaces
InlayͲcastpredominantlybasemetal,threeormore
surfaces
InlayͲcastnoblemetal,twosurfaces
InlayͲcastnoblemetal,threeormoresurfaces
OnlayͲporcelain/ceramic,twosurfaces
OnlayͲporcelain/ceramic,threeormoresurfaces
OnlayͲcasthighnoblemetal,twosurfaces
OnlayͲcasthighnoblemetal,threeormoresurfaces
OnlayͲcastpredominantlybasemetal,twosurfaces
OnlayͲcastpredominantlybasemetal,threeormore
surfaces
OnlayͲcastnoblemetal,twosurfaces
OnlayͲcastnoblemetal,threeormoresurfaces
CrownͲindirectresinbasedcomposite
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$340^
$500
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
PROSTHODONTICSͲFIXEDCONT.
D6720
CrownͲresinwithhighnoblemetal
$340^
D6721
CrownͲresinwithpredominantlybasemetal
$340^
D6722
CrownͲresinwithnoblemetal
$340^
D6740
CrownͲporcelain/ceramic
$340^
D6750
CrownͲporcelainfusedtohighnoblemetal
$340^
D6751
CrownͲporcelainfusedtopredominantlybasemetal
$340^
D6752
CrownͲporcelainfusedtonoblemetal
$340^
D6780
CrownͲ3/4casthighnoblemetal
$340^
D6781
CrownͲ3/4castpredominantlybasemetal
$340^
D6782
CrownͲ3/4castnoblemetal
$340^
D6783
CrownͲ3/4porcelain/ceramic
$340^
D6790
CrownͲfullcasthighnoblemetal
$340^
D6791
CrownͲfullcastpredominantlybasemetal
$340^
D6792
CrownͲfullcastnoblemetal
$340^
D6930
D6940
D6950
ReͲcementorreͲbondfixedpartialdenture
Stressbreaker
Precisionattachment
Fixedpartialdenturerepairnecessitatedbyrestorative
materialfailure
$60
$145
$195
D6980
$85
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
Limitedtoone(1)per
toothperconsecutive
sixty(60)months
CODE
DESCRIPTION
ORTHODONTIAͲAdultCosmetic
D8040 Limitedorthodontictreatmentoftheadultdentition
Comprehensiveorthodontictreatmentoftheadult
D8090
dentition
MISCELLANEOUSSERVICES
D9120 Fixedpartialdenturesectioning
Localanesthesianotinconjunctionwithoperativeor
D9210
surgicalprocedures
Localanesthesiainconjunctionwithoperativeorsurgical
D9215
procedures
Deepsedation/generalanesthesia–each15minute
D9223
increment
D9230 Inhalationofnitrousoxide/analgesia,anxiolysis
Intravenousmoderate(conscious)sedation/analgesia–
D9243
each15minuteincrements
D9610 Therapeuticparenteraldrug,singleadministration
D9630 Otherdrugsand/ormedicaments,byreport
MEMBERCOSTͲ
SHARING
ADULT
LIMITATIONS
$2,000
$3,850
$0
$10
$0
$50
$25
$50
$15
$15
D9910
Applicationofdesensitizingmedicament
$20
D9940
D9942
D9950
D9951
D9952
D9972
Occlusalguard,byreport
Repairand/orrelineofocclusalguard
OcclusionanalysisͲmountedcase
OcclusaladjustmentͲlimited
OcclusaladjustmentͲcomplete
ExternalbleachingͲperarchͲperformedinoffice
$250
$40
$75
$30
$100
$150
One(1)timeinany
twelve(12)consecutive
months