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PEDIATRIC DENTAL SMILE FOR KIDS DHMO HIGH (EHB) EHB High Plan Deductible $0 Out of Pocket Maximum (OOP)/per person $1,000 Out of Pocket Maximum (OOP) (2+ children) $2,000 Annual Maximum This information is a summary of benefits of the HIGH Essential Health Benefit for Children. It lists the services available to you under this dental plan as well as the Copayments associated with each procedure. This summary provides a very brief description of some of the procedures covered. For complete benefit information, members can refer to the Combined Evidence of Coverage and Disclosure Form and Schedule of Benefits on the WHA website at mywha.org; also available upon request. In-Network N/A This plan is available for individuals up to age 19. The following Copayments apply when services are performed by your assigned Primary Care Dentist or a Contracted Specialist (with prior approval from Access Dental). If Specialist Services are recommended by your Primary Care Dentist, the treatment plan must be preauthorized in writing by Access Dental prior to treatment in order for the services to be eligible for coverage. All services are subject to Exclusions and Limitations of this plan and must be medically necessary. You may be charged a Copayment FIND A PROVIDER Call or visit ACCESS DENTAL’s website to locate a participating provider in your area. Monday through Friday 8 a.m. to 6 p.m. call 877.702.8800 visit premierlife.com ADA Code Description Office Visit D0120/0110 D0150 D0210 D0330 D0220 D0274 D1120 D1203 D1310 D1330 D1351 D1525 D1550 D2140 D2150 D2160 D2161 D2330 Preventive Services Periodic Oral Exam Comprehensive Exam Full Mouth Series (FMX) Panoramic X-rays Periapical X-rays Bitewings – four films Prophylaxis (cleanings) – child Fluoride Treatment – child Nutritional counseling for control of dental disease Oral hygiene instructions Sealant – per tooth Space maintainer – removable – bilateral Recementation of space maintainer Basic Services Restorations – Amalgam (silver) 1 surface Restorations – Amalgam (silver) 2 surfaces Restorations – Amalgam (silver) 3 surfaces Restorations – Amalgam (silver) fillings four or more surfaces, primary or permanent teeth White composite filling, anterior 1 surface WHA 1071 Pediatric Dental High 1.14 for missed appointments if you do not give the dental office at least 24 hours notice of cancellation. Copayment ADA Code $0 D2331 $0 $0 $0 $0 $0 $0 $0 $0 $0 D2332 D2390 D7140 D7210 D3310 $0 $0 $0 D3320 $0 D4341 D3330 $40 D2750 $40 D6210 $40 $40 D5110 D5211 $40 D8080/8090 Description Basic Services continued White composite filling, anterior 2 surfaces White composite filling, anterior 3+ surfaces White Composite Crown Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth Root Canal Therapy – Anterior (excluding final restoration) Root Canal Therapy – Bicuspid (excluding final restoration) Root Canal Therapy – Molar (excluding final restoration) Periodontal scaling and root planing – four or more teeth per quadrant Major Services Crowns – porcelain fused to high noble metal Bridges – pontic, high cast noble metal Complete denture – maxillary Partial denture – resin base (including any conventional clasps, rests and teeth) Comprehensive orthodontic treatment of the adolescent dentition Copayment $40 $40 $40 $75 $135 $300 $365 $365 $75 $365 $365 $365 $365 $1,000