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Blue Shield of California Dental HMO Plan Enhanced Dental HMO $0* THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. ADA Code D0120 D0150 D0210 D601-603 D1110 D1351 D2330 D3310 D3330 D4341 D7111 D2740 D5110 D5120 D6240 D8080 D8090 ADA Description Office visit Diagnostic & Preventive Services Periodic oral evaluation - established patient Comprehensive oral evaluation - new or established patient Intraoral - complete series of radiographic images Caries risk management2 Prophylaxis - adult Sealant - per tooth Routine Services Resin based composite - one surface, anterior Endodontic therapy - anterior tooth (excluding final restoration) Endodontic therapy - molar tooth (excluding final restoration) Periodontal scaling and root planing - four or more teeth per quadrant Extraction of coronal remnants - deciduous tooth Major Services Crown - porcelain/ceramic substrate Complete denture - maxillary Complete denture - mandibular Pontic - porcelain fused to high noble metal Orthodontic Services Comprehensive orthodontic treatment of the adolescent dentition Comprehensive orthodontic treatment of the adult dentition None None None Member Pays $0 $0 $0 $0 $0 $0 $0 $20 $175 $355 $75 $20 $3501 $4001 $4001 $3501 $2,350 $2,650 Please Note: * 1 2 Pending regulatory approval Precious and semi-precious metals and porcelain on molar crowns, if used will be charged to the member at the dentist's cost. Caries Risk Management - CAMBRA (Caries Management by Risk Assessment) is an evaluation of a child’s risk level for caries (decay). Children assessed as having a “high risk” for caries (decay) will be allowed up to 4 fluoride varnish treatments during the calendar year along with their biannual cleanings; “medium risk” children will be allowed up to 3 fluoride varnish treatments in addition to their biannual cleanings; and “low risk” children will be allowed up to two fluoride varnish treatments in addition to biannual cleanings. When requesting additional fluoride varnish treatments, the provider must An independent member of the Blue Shield Association A45659 (1/15) Calendar year deductible per member Calendar year maximum per member Waiting Period provide a copy of the completed American Dental Association (ADA) CAMBRA form (available on the ADA website). Benefits are subject to modification for subsequently enacted state or federal legislation. Some procedures may require costs in addition to the Member copayments. Please refer to the Summary of Benefits for additional information.