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UnitedHealthcare® Select Managed Care Direct Compensation Contributory CA250/covered dental services ADA MEMBER’S COPAYMENT DESCRIPTION DIAGNOSTIC SERVICES D0120 D0140 D0145 D0150 D0160 D0170 D0180 D0190 D0191 D0210 D0220 D0230 D0240 D0250 D0260 D0270 D0272 D0273 D0274 D0277 D0290 D0330 D0340 D0391 D0415 D0416 D0417 D0418 D0421 D0425 D0431 D0460 D0470 D0472 D0473 D0474 D0601 D0602 D0603 PERIODIC ORAL EVAL ESTABLISHED PATIENT LIMITED ORAL EVAL - PROBLEM FOCUSED ORAL EVAL PATIENT <3 AND COUNSEL WITH PRIMARY CARE GIVER COMPREHENSIVE ORAL EVAL - NEW/ESTABLISHED PATIENT DETAILED & EXTENSIVE ORAL EVAL - PROBLEM FOCUSED REPRT RE-EVAL - LIMITED PROBLEM FOCUSED COMPREHENSIVE PERIODONTAL EVAL - NEW/ESTABLISHED PATIENT SCREENING OF A PATIENT ASSESSMENT OF A PATIENT $0 $0 $0 INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGES INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE INTRAORAL - PERIAPICAL EACH ADDL RADIOGRAPHIC IMAGE INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE EXTRAORAL - FIRST RADIOGRAPHIC IMAGE EXTRAORAL - EACH ADDITIONAL RADIOGRAPHIC IMAGE BITEWING - SINGLE RADIOGRAPHIC IMAGE BITEWINGS - TWO RADIOGRAPHIC IMAGES BITEWINGS - THREE RADIOGRAPHIC IMAGES BITEWINGS - FOUR RADIOGRAPHIC IMAGES VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES POST-ANTERIOR LATERAL SKULL & FACIAL RADIOGRAPHIC IMAGE PANORAMIC RADIOGRAPHIC IMAGE CEPHALOMETRIC RADIOGRAPH IMAGE INTERPRETATION OF DIAGNOSTIC IMAGE COLLECT MICROORGANISMS CULTURE & SENSITIVITY VIRAL CULTURE COLLECTION & PREPARATION OF SALIVA SAMPLE ANALYSIS OF SALIVA SAMPLE GENETIC TEST FOR SUSCEPTIBILITY TO ORAL DISEASES CARIES SUSCEPTIBILITY TESTS ADJUNCTIVE PREDIAGNOSTIC TEST PULP VITALITY TESTS DIAGNOSTIC CASTS ACCESSION OF TISSUE-GROSS EXAM, PREP & REPRT ACCESSION OF TISSUE-GROSS/MICRO EXAM PREP & REPRT ACCESSION OF TISSUE-MICRO GROSS/MICRO EXAM, INCLD ASSESS MARGIN FOR DISEASE, PREP & REPRT CARIES RISK ASSESS & DOCUMENT W/FIND LOW RISK CARIES RISK ASSESS & DOCUMENT W/FIND MODERATE RISK CARIES RISK ASSESS & DOCUMENT W/FIND HIGH RISK $0 $0 $0 $0 $0 $0 $0 Dental Plan CA D1065 MEMBER’S COPAYMENT ADA DESCRIPTION D1330 D1351 D1352 D1510 D1515 D1520 D1525 D1550 D1555 ORAL HYGIENE INSTRUCTIONS SEALANT - PER TOOTH PREV RESIN RESTORATION MOD HIGH CARIES RISK PATIENT SPACE MAINTAINER - FIXED-UNILATERAL SPACE MAINTAINER - FIXED-BILATERAL SPACE MAINTAINER - REMOVABLE-UNILATERAL SPACE MAINTAINER - REMOVABLE-BILATERAL RECEMENTATION OF SPACE MAINTAINER REMOVAL OF FIXED SPACE MAINTAINER $0 $0 $0 $0 $0 $0 $0 $0 $0 RESTORATIVE SERVICES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 PREVENTIVE SERVICES D1110 D1120 D1206 D1208 D1310 PROPHYLAXIS - ADULT PROPHYLAXIS - CHILD TOPICAL APPLICATION OF FLUORIDE VARNISH TOPICAL APPLICATION OF FLUORIDE NUTRITIONAL COUNSEL CONTROL DENTAL DISEASE $0 $0 $0 $0 $0 D1320 TOBACCO COUNSELING CONTROL & PREV ORAL DISEASE $0 D2140 D2150 D2160 D2161 D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 AMALGAM - 1 SURFACE PRIMARY/PERMANENT AMALGAM- 2 SURFACES PRIMARY/PERMANENT AMALGAM - 3 SURFACES PRIMARY/PERMANENT AMALGAM - 4/> SURFACES PRIMARY/PERMANENT RESIN-BASED COMPOSITE - 1 SURFACE, ANTERIOR RESIN COMPOSITE - 2 SURFACES, ANTERIOR RESIN COMPOSITE - 3 SURFACES, ANTERIOR RESIN COMPOSITE - 4/> SURFACES/W/INCISAL ANG RESIN COMPOSITE CROWN ANTERIOR RESIN COMPOSITE - 1 SURFACE POSTERIOR RESIN COMPOSITE - 2 SURFACES POSTERIOR RESIN COMPOSITE - 3 SURFACES POSTERIOR RESIN COMPOSITE- 4/MORE SURFACES POST INLAY - METALLIC - 1 SURFACE INLAY - METALLIC - 2 SURFACES INLAY - METALLIC - 3/> SURFACES ONLAY - METALLIC - 2 SURFACES ONLAY - METALLIC - 3 SURFACES ONLAY - METALLIC 4/> SURFACES INLAY - PORCELAIN/CERAMIC - 1 SURFACE INLAY - PORCELAIN/CERAMIC - 2 SURFACES INLAY - PORCELAIN/CERAMIC - 3/> SURFACES ONLAY - PORCELAIN/CERAMIC - 2 SURFACES ONLAY - PORCELAIN/CERAMIC - 3 SURFACES ONLAY - PORCELAIN/CERAMIC - 4/> SURFACES INLAY - RESIN BASED COMPOSITE -1 SURFACE INLAY - RESIN BASED COMPOSITE - 2 SURFACES INLAY - RESIN BASED COMPOSITE - 3/> SURFACES ONLAY - RESIN BASED COMPOSITE -2 SURFACES $0 $0 $0 $0 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 ONLAY - RESIN BASED COMPOSITE -3 SURFACES ONLAY - RESIN BASED COMPOSITE - 4/> SURFACES CROWN - RESIN BASED COMPOSITE INDIRECT CROWN - 3/4 RESIN BASED COMPOSITE INDIRECT CROWN - RESIN WITH HIGH NOBLE METAL* CROWN - RESIN WITH PREDOMINANTLY BASE METAL CROWN - RESIN WITH NOBLE METAL* CROWN - PORCELAIN/CERAMIC SUBSTRATE CROWN - PORCELAIN FUSED HIGH NOBLE METAL* CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL CROWN - PORCELAIN FUSED NOBLE METAL* CROWN - 3/4 CAST HIGH NOBLE METAL* CROWN - 3/4 CAST PREDOMINANTLY BASE METAL CROWN - 3/4 CAST NOBLE METAL* $0 $0 $0 $0 $0 $0 $0 $0 $0 D2752 D2780 D2781 D2782 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 1 400-6963 ©2015-2016 United HealthCare Services, Inc. This plan is underwritten by Dental Benefit Providers of California, Inc. MEMBER’S COPAYMENT ADA DESCRIPTION D2783 D2790 D2791 D2792 D2794 D2910 D2915 D2920 D2921 D2929 CROWN - 3/4 PORCELAIN/CERAMIC CROWN - FULL CAST HIGH NOBLE METAL* CROWN - FULL CAST PREDOMINANTLY BASE METAL CROWN - FULL CAST NOBLE METAL* CROWN TITANIUM* RECEMENT INLAY, ONLAY/PARTIAL COVERAGE RESTOR RECEMENT CAST/PREFABRICATED POST & CORE RECEMENT CROWN REATTACH TOOTH FRAGMENT, INCISAL EDGE OR CUSP PREFABRIC PORCELAIN/CERAMIC CROWN-PRIMARYTOOTH PREFARBICATED STAINLESS STEEL CROWN - PRIMARY PREFABRICATED STAINLESS STEEL CROWN - PERMANENT PREFABRICATED RESIN CROWN $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 PREFABRICATED STAINLESS STEEL CROWN RESIN WINDOW PREFABRIC ESTHTC COAT STNLS STL CRWN-PRIMARY TOOTH PROTECTIVE RESTORATION INTERIM THERAPEUTIC RESTORATION – PRIMARY DENTITION CORE BUILD-UP, INCLUDING ANY PINS PIN RETENTION - PER TOOTH ADDITION RESTORATION POST & CORE ADDITION CROWN INDIRECT FABRICATED EACH ADDL INDIRECTLY FABRICATED POST - SAME TOOTH PREFABRICATED POST & CORE ADDITION CROWN POST REMOVAL EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH LABIAL VENEER (RESIN BASED) - CHAIRSIDE LABIAL VENEER (RESIN BASED) - LABORATORY LABIAL VENEER (PORCELAIN LAMINATE) TEMPORARY CROWN ADDL PROCEDURE NEW CROWN EXIST PARTIAL DENTURE COPING CROWN REPAIR RESIN INFILTRATION INCIPIENT SMTH SURFACE LESIONS $0 $0 D2930 D2931 D2932 D2933 D2934 D2940 D2941 D2950 D2951 D2952 D2953 D2954 D2955 D2957 D2960 D2961 D2962 D2970 D2971 D2975 D2980 D2990 ADA D3356 D3357 D3410 D3421 D3425 D3426 D3427 D3430 D3450 D3460 D3910 D3920 D3950 $0 $0 $0 D4210 D4211 D4212 D4240 D4241 D4245 D4249 D4260 D4261 D4263 D4270 D4274 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 D4277 D4278 D4320 D4321 D4341 D4342 D4355 D4381 D4910 D4920 D4921 ENDODONTIC SERVICES PULP CAP - DIRECT PULP CAP - INDIRECT $0 $0 D3220 D3221 D3222 THERAPEUTIC PULPOTOMY PULPAL DEBRIDEMENT PRIMARY & PERMANENT TEETH PARTIAL PULPTOMY FOR APEXOGENESIS PERMANENT TOOTH PULPAL THERAPY - ANTERIOR PRIMARY TOOTH PULPAL THERAPY - POSTERIOR PRIMARY TOOTH ENDODONTIC THERAPY, ANTERIOR TOOTH ENDODONTIC THERAPY, BICUSPID TOOTH ENDODONTIC THERAPY, MOLAR TREATMENT ROOT CANAL OBSTRUCTION; NON-SURG ACCESS INCOMPLETED ENDODONTIC THERAPY INTERNAL ROOT REPAIR PERFORATION DEFECTS RETREATMENT PREV ROOT CANAL THERAPY - ANTERIOR RETREATMENT PREV ROOT CANAL THERAPY - BICUSPID RETREATMENT PREV ROOT CANAL THERAPY - MOLAR APEXIFICATION/RECALCIFICATION INITIAL VISIT APEXIFICATION/RECALCIFICATION INTERIM MEDICATION REPLACEMENT APEXIFICATION/RECALCIFICATION - FINAL VISIT PULPAL REGENERATION - INITIAL VISIT $0 $0 $0 D3230 D3240 D3310 D3320 D3330 D3331 D3332 D3333 D3346 D3347 D3348 D3351 D3352 D3353 D3355 MEMBER’S COPAYMENT PULPAL REGENERATION -INTERIM MEDICAMENT REPLACEMNT PULPAL REGENERATION - COMPLETION OF TREATMENT APICOECTOMY - ANTERIOR APICOECTOMY - BICUSPID APICOECTOMY - MOLAR APICOECTOMY - EACH ADDITIONAL ROOT PERIRADICULAR SURGERY WITHOUT APICOECTOMY RETROGRADE FILLING - PER ROOT ROOT AMPUTATION - PER ROOT ENDODONTIC ENDOSSEOUS IMPLANT SURGICAL PROCED ISOLATION TOOTH W/RUBBER DAM HEMISECTION NOT INCLUDIING ROOT CANAL THERAPY CANAL PREPARATION & FIT PREFORMED DOWEL/POST $0 $0 $0 $0 $0 $0 $0 $0 $0 $1950 $0 $0 $0 PERIODONTIC SERVICES $0 $0 D3110 D3120 DESCRIPTION GINGIVECTOMY/GINGIVOPLASTY 4/> CNTIG TEETH QUAD GINGIVECTOMY/GINGIVOPLASTY 1-3 CNTIG TEETH QUAD GINGIVECTOMY/GINGIVOPLASTY ALLOW ACCESS RESTOR PROC, PER TOOTH GINGIVAL FLAP - 4/>CNTIG/BOUND TEETH QUAD GINGIVAL FLAP - 1-3 CNTIG/BOUND TEETH QUAD APICALLY POSITIONED FLAP CLINICAL CROWN LENGTHENING - HARD TISSUE OSSEOUS SURGERY - 4/> CONTIGUOUS TEETH QUAD OSSEOUS SURGERY - 1-3 CONTIGUOUS TEETH QUAD BONE REPLACEMENT GRAFT - 1 SITE QUAD PEDICLE SOFT TISSUE GRAFT PROCEDURE DISTAL OR PROXIMAL WEDGE PROCEDURE - SEPARATE PROCEDURE FREE SOFT TISSUE GRAFT PROCEDURE (INCLD DONOR SITE SURGERY), FIRST TOOTH FREE SOFT TISSUE GRAFT PROCEDURE (INCLD DONOR SITE SURGERY), EACH ADDL; CONTIGUOUS TOOTH PROVISONAL SPLINTING - INTRACORONAL PROVISONAL SPLINTING - EXTRACORONAL PERIODONTAL SCAL & ROOT PLAN 4/>TEETH-QUAD PERIODONTAL SCAL & ROOT PLAN 1-3 TEETH FULL MOUTH DEBRIDEMENT COMP EVAL & DIAGNOSIS LOCAL DELIVERY ANTIMICROBIAL AGENT PER TOOTH PERIODONTAL MAINTENANCE UNSCHEDULED DRESSING CHANGE GINGIVAL IRRIGATION ‐ PER QUADRANT $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 REMOVABLE PROSTHODONTICS SERVICES $0 $0 $0 $0 $0 $0 D5110 D5120 D5130 D5140 D5211 D5212 D5213 D5214 D5225 D5226 D5281 $0 $0 $0 $0 $0 $0 $0 D5410 D5411 D5421 D5422 $0 $0 COMPLETE DENTURE - MAXILLARY COMPLETE DENTURE - MANDIBULAR IMMEDIATE DENTURE - MAXILLARY IMMEDIATE DENTURE - MANDIBULAR MAXILLARY PARTIAL DENTURE - RESIN BASE MANDIBULAR PARTIAL DENTURE - RESIN BASE MAXILLARY PARTIAL DENTURE -CAST METAL W/RESIN MANDIBULAR PARTIAL DENTURE - CAST METAL W/RESIN MAXILLARY PARTIAL DENTURE FLEX BASE MANDIBULAR PARTIAL DENTURE FLEX BASE REMOVAL UNILATERAL PARTIAL DENTURE -1 PC CAST METAL ADJUST COMPLETE DENTURE - MAXILLARY ADJUST COMPLETE DENTURE - MANDIBULAR ADJUST PARTIAL DENTURE - MAXILLARY ADJUST PARTIAL DENTURE - MANDIBULAR $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 2 400-6963 ©2015-2016 United HealthCare Services, Inc. This plan is underwritten by Dental Benefit Providers of California, Inc. MEMBER’S COPAYMENT ADA DESCRIPTION D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710 D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 REPAIR BROKEN COMPLETE DENTURE BASE REPLACE MISSING/BROKEN TEETH-COMPLETE DENTURE REPAIR RESIN DENTURE BASE REPAIR CAST FRAMEWORK REPAIR OR REPLACE BROKEN CLASP REPLACE BROKEN TEETH - PER TOOTH ADD TOOTH EXISTING PARTIAL DENTURE ADD CLASP EXISTING PARTIAL DENTURE REPLACE ALL TEETH & ACRYLIC FRAMEWORK MAXILLARY REPLACE ALL TEETH & ACRYLIC FRAMEWORK MANDIBULAR REBASE COMPLETE MAXILLARY DENTURE REBASE COMPLETE MANDIBULAR DENTURE REBASE MAXILLARY PARTIAL DENTURE REBASE MANDIBULAR PARTIAL DENTURE RELINE COMPLETE MAXILLARY DENTURE CHAIRSIDE RELINE COMPLETE MANDIBULAR DENTURE CHAIRSIDE RELINE MAXILLARY PARTIAL DENTURE CHAIRSIDE RELINE MANDIBULAR PARTIAL DENTURE CHAIRSIDE RELINE COMPLETE MAXILLARY DENTURE LABORATORY RELINE COMPLETE MANDIBULAR DENTURE LABORATORY $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 D5760 D5761 D5810 D5811 D5820 D5821 D5850 D5851 D5863 D5864 D5865 D5866 D5992 RELINE MAXILLARY PARTIAL DENTURE LABORATORY RELINE MANDIBULAR PARTIAL DENTURE LABORATORY INTERIM COMPLETE DENTURE MAXILLARY INTERIM COMPLETE DENTURE MANDIBULAR INTERIM PARTIAL DENTURE MAXILLARY INTERIM PARTIAL DENTURE MANDIBULAR TISSUE CONDITIONING MAXILLARY TISSUE CONDITIONING MANDIBULAR OVERDENTURE - COMPLETE MAXILLARY OVERDENTURE - PARTIAL MAXILLARY OVERDENTURE - COMPLETE MANDIBULAR OVERDENTURE - PARTIAL MANDIBULAR ADJUST MAXILLOFACIAL PROSTH APPLIANCE, BY REPORT $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ADA D6606 D6607 D6608 D6609 D6610 D6611 D6612 D6613 D6614 D6615 D6624 D6634 D6710 D6720 D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792 D6794 D6920 D6930 D6940 D6980 D6600 D6601 D6602 D6603 D6604 D6605 PONTIC - INDIRECT RESIN BASED COMPOSITE PONTIC - CAST HIGH NOBLE METAL* PONTIC - CAST PREDOMINANTLY BASE METAL PONTIC - CAST NOBLE METAL* PONTIC - TITANIUM* PONTIC - PORCELAIN FUSED HIGH NOBLE METAL* PONTIC - PORCELAIN FUSED PREDOMINANTLY BASE METAL PONTIC - PORCELAIN FUSED NOBLE METAL* PONTIC - PORCELAIN/CERAMIC PONTIC - RESIN W/HIGH NOBLE METAL* PONTIC - RESIN W/PREDOMINANTLY BASE METAL PONTIC - RESIN W/NOBLE METAL* PROVISIONAL PONTIC RETAINER-CAST METAL, RESIN, BOND FIXED PROSTHETIC RETAINER-PORCELAIN/CERAMIC, RESN BOND FIXED PROSTHETIC INLAY - PORCELAIN/CERAMIC 2 SURFACES INLAY - PORCELAIN/CERAMIC 3/> SURFACES INLAY - CAST HIGH NOBLE METAL 2 SURFACES* INLAY - CAST HIGH NOBLE METAL 3/> SURFACES* INLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES INLAY - CAST PREDOMINANTLY BASE METAL 3/>SURFACES $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 INLAY - CAST NOBLE METAL 2 SURFACES* INLAY - CAST NOBLE METAL 3/> SURFACES* ONLAY - PORCELAIN/CERAMIC 2 SURFACES ONLAY - PORCELAIN/CERAMIC 3/> SURFACES ONLAY - CAST HIGH NOBLE METAL 2 SURFACES* ONLAY-CAST HIGH NOBLE METAL 3/> SURFACES* ONLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES ONLAY - CAST PREDOMINANTLY BASE METAL 3/>SURFACES ONLAY - CAST NOBLE METAL 2 SURFACES* ONLAY - CAST NOBLE METAL 3/> SURFACES* INLAY TITANIUM* ONLAY TITANIUM* CROWN/INDIRECT RESIN BASED COMPOSITION CROWN - RESIN WITH HIGH NOBLE METAL* CROWN - RESIN PREDOMINANTLY BASE METAL CROWN - RESIN WITH NOBLE METAL* CROWN - PORCELAIN/CERAMIC CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL* CROWN - PORCELAIN FUSED PREDOMINANTLY BASE METAL CROWN - PORCELAIN FUSED NOBLE METAL* CROWN - 3/4 CAST HIGH NOBLE METAL* CROWN - 3/4 CAST PREDOMINANTLY BASE METAL CROWN - 3/4 CAST NOBLE METAL* CROWN - 3/4 PORCELAIN/CERAMIC CROWN - FULL CAST HIGH NOBLE METAL* CROWN - FULL CAST BASE METAL CROWN - FULL CAST NOBLE METAL* CROWN TITANIUM* CONNECTOR BAR RECEMENT FIXED PARTIAL DENTURE STRESS BREAKER FIXED PARTIAL DENTURE REPAIR $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 D6010 SURGICAL PLACEMENT IMPL BODY: ENDOSTEAL $1,950 D6013 SURGICAL PLACEMENT OF A MINI-IMPLANT $1,950 D6052 SEMI-PRECISION ATTACHMENT ABUTMENT D6053 D6057 IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE $1,840 FOR COMPLETELY EDENTULOUS ARCH IMPLANT/ABUTMENT SUPPORTED BY REMOVABLE DEN- $1,840 TURE FOR PARTIALLY EDENTULOUS ARCH CONNECTING BAR-IMPLANT SUPPORTED/ABUTMENT $540 SUPPORTED PREFABRICATED/ABUTMENT INCLUDING MODIFICA$368 TION/PLACEMENT CUSTOM FABRICATED ABUTMENT - INCLUDES IMPLANT $610 D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN D6059 ABUTMENT SUPPORTED PORCELAIN FUSED METAL $915 CROWN (HIGH NOBLE METAL)* ABUTMENT SUPPORTED PORCELAIN METAL CROWN $1,050 (PREDOMINANTLY BASE METAL) ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE $946 METAL)* ABUTMENT SUPPORTED CAST METAL CROWN (HIGH $981 NOBLE METAL)* ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMI- $854 NANTLY BASE METAL) ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE $1,168 METAL)* D6054 D6055 D6056 D6060 $0 $0 $0 $0 $0 $0 D6061 D6062 D6063 D6064 400-6963 MEMBER’S COPAYMENT IMPLANT SERVICES FIXED PROSTHODONTICS SERVICES D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 D6245 D6250 D6251 D6252 D6253 D6545 D6548 DESCRIPTION $368 $1,050 3 ©2015-2016 United HealthCare Services, Inc. This plan is underwritten by Dental Benefit Providers of California, Inc. MEMBER’S COPAYMENT ADA DESCRIPTION D6065 IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN D6066 IMPLANT SUPPORTED PORCELAIN FUSED TO METAL $1,083 CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE METAL)* IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITA$962 NIUM ALLOY, HIGH NOBLE METAL)* ABUTMENT SUPPORTED RETAINER PORCELAIN/CERAMIC $1,026 FPD ABUTMENT SUPPORTED RETAINER PORCELAIN FUSED TO $1,050 METAL FPD (PREDOMINANTLY BASE METAL) $965 ABUTMENT SUPPORTED RETAINER PORCELAIN FUSED TO D6067 D6068 D6069 D6070 ADA D7241 $1,144 D7250 D7251 D7261 D7270 D7280 D7282 D7285 D7286 D7287 D7288 D7290 D7310 METAL FPD (PREDOMINANTLY BASE METAL) D6071 D6072 D6073 D6074 D6075 DESCRIPTION ABUTMENT SUPPORTED RETAINER PORCELAIN FUSED TO $984 METAL FPD (NOBLE METAL)* ABUTMENT SUPPORTED RETAINER CAST METAL FPD (HIGH $997 NOBLE METAL)* ABUTMENT SUPPORTED RETAINER CAST METAL FPD (PRE$910 DOMINANTLY BASE METAL) ABUTMENT SUPPORTED RETAINER CAST METAL FPD $967 (NOBLE METAL)* IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD $1,018 D7311 D7320 IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (TITANIUM, TITANIUM ALLOY, OR HIGH NOBLE METAL)* IMPLANT SUPPORTED RETAINER CAST METAL FPD (TITANIUM, TITANIUM ALLOY OR HIGH NOBLE METAL)* IMPLANT MAINTENANCE PROCEDURE WHEN PROSTHESIS ARE REMOVED & INSERTED, INCLUD CLEANSING OF PROSTHESES AND ABUTMENTS REPAIR IMPLANT SUPPORTED BY PROSTHESIS, BY REPORT $992 D7321 D7340 $962 D7350 D7450 REPLACEMENT SEMI-PRECISION OR PRECISION ATTACHMENT IMPLANT/ABUTMENT PROSTHESIS BY REPORT RECEMENT IMPLANT/ABUTMENT SUPPORTED CROWN $410 $124 D6094 RECEMENT IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE ABUTMENT SUPPORTED CROWN (TITANIUM)* D6095 REPAIR IMPLANT ABUTMENT, BY REPORT D6100 IMPLANT REMOVAL, BY REPORT D6101 DEBRIDEMENT OF A PERIIMPLANT DEFECT & SURFACE CLEAN EXPOSED IMPLANT SURFACE, INCLUD FLAP ENTRY & CLOSURE DEBRIDEMENT & OSSEOUS CONTOURING OF A PERIIMPLANT DEFECT; INCLDE SURFACE CLEAN OF EXPSED IMPLANT SURFACES AND FLAP ENTRY AND CLOSURE BONE GRAFT FOR REPAIR OF PERIIMPLANT DEFECT–NOT INCLUD FLAP ENTRY & CLOSURE OR, WHEN INDICATED, PLACEMENT OF BARRER MEMBRANE OR BIOLOG MATERIAL TO AID OSSEOUS REGENERATION RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT D6076 D6077 D6080 D6090 D6091 D6092 D6093 D6102 D6103 D6190 D6194 ABUTMENT SUPPORTER RETAINER CAST METAL FPD (NOBLE METAL)* $55 D7451 D7460 $135 D7461 D7471 $79 D7472 D7473 D7485 D7510 D7511 $810 $55 $600 $0 D7520 $0 D7521 D7530 $350 D7910 D7960 $265 $835 D7963 D7970 D7971 D7972 ORAL SURGERY SERVICES D7111 D7140 D7210 D7220 D7230 D7240 EXTRACT CORONAL REMNANTS DECIDUOUS TOOTH EXTRACT ERUPTED TOOTH/EXPOSED ROOT SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING BONE AND/OR SECTIONING TOOTH REMOVAL OF IMPACTED TOOTH - SOFT TISSUE REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY 400-6963 $0 $0 $0 MEMBER’S COPAYMENT REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVAL PRIMARY CLOSURE OF SINUS PERFORATION TOOTH REIMPLANT AND/OR STABILIZATION ACCIDENT EVULSED OR DISPLACED TOOTH SURGICAL ACCESS OF UNERUPTED TOOTH MOBILIZATION OF ERUPTED/MALPOSITIONED TEETH BIOPSY OF ORAL TISUE - HARD (BONE, TOOTH) BIOPSY OF ORAL TISSUE - SOFT EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION BRUSH BIOPSY, TRANSEPITHELIAL SAMPLE COLLECTION SURGICAL REPOSITIONING OF TEETH ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE ALVEOLOPLASTY CONJNCT XTRCT 1-3 TEETH ALVEOLOPLASTY NOT IN CONJUNCT W/EXTRACTIONS - 4/> TEETH/SPACE, PER QUADRANT ALVEOLOPLASTY NOT IN CONJUNCT W/XTRCT 1-3 TEETH VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY EPITHELIALIZATION) VESTIBULOPLASTY - RIDGE EXTENSION REMOVAL BENIGN ODONTOGENIC CYST/TUMOR UP TO 1.25 CM REMOVAL BENIGN ODONTOGENIC CYST/TUMOR >1.25 CM REMOVAL BENIGN NONODONTOGENIC CYST/TUMOR UP TO 1.25 CM REMOVAL BENIGN NONODONTOGENIC CYST/TUMOR >1.25 CM REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE) REMOVAL OF TORUS PALATINUS REMOVAL OF TORUS MANDIBULARIS SURGICAL REDUCTION OF OSSEOUS TUBEROSITY INCISION & DRAINAGE ABSCESS-INTRAORAL SOFT TISSUE INCISION & DRAINAGE ABSCESS INTRAORAL SOFT TISSUE COMPLICATED INCISION & DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE INCISION & DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE COMPLICATED REMOVAL FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE REMOVAL OF REACTION PRODUCING FOREIGN BODIES, MUSCULOSKELETAL SYSTEM FRENULECTOMY-ALSO KNOWN AS FRENECTOMY OR FRENOTOMY-SEPAR PROCED NOT INCIDENTAL TO ANOTHER FRENULOPLASTY EXCISION HYPERPLASTIC TISSUE - PER ARCH EXCISION OF PERICORONAL GINGIVA SURGICAL REDUCTION FIBROUS TUBEROSITY $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 ADJUNCTIVE GENERAL SERVICES D9110 D9120 D9210 $0 $0 $0 D9211 PALLIATVE TREATMENT DENTAL PAIN - MINOR PROCEDURE FIXED PARTIAL DENTURE SECTIONING LOCAL ANESTHESIA NOT IN CONJUNCT W/OPERATIVE. SURGICAL PROCEDURE REGIONAL BLOCK ANESTHESIA $0 $0 $0 $0 4 ©2015-2016 United HealthCare Services, Inc. This plan is underwritten by Dental Benefit Providers of California, Inc. MEMBER’S COPAYMENT ADA DESCRIPTION D9212 D9215 TRIGEMINAL DIVISION BLOCK ANESTHESIA LOCAL ANESTHESIA IN CONJUNCTION W TH OPERATIVE OR SURGICAL PROCEDURE $0 $0 D9220 D9221 D9230 D9241 D9242 D9248 D9310 $0 $0 $0 $0 $0 $0 $0 D9430 D9440 D9930 D9940 DEEP SEDATION/GENERAL ANESTHESIA - 1ST 30 MIN DEEP SEDATION/GENERAL ANESTHESIA-EACH ADDL15 MIN INHALATION OF NITROUS OXIDE/ANALGESIA, ANXIOLYSIS IV CONSCIOUS SEDATION/ANALGESIA -1ST 30 MIN IV CONSCIOUS SEDATION/ANALGESIA EACH ADDL 15 MIN NON-INTRAVENOUS CONSCIOUS SEDATION CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST/ PHYSICIAN OTHER THAN REQUST DENTIST/PHYSICIAN OFFICE VISIT - OBSERV - NO OTHER SERVICES PERFORMED OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS TREATMENT OF COMPLICATIONS - POST SURGICAL OCCLUSAL GUARD BY REPORT D9951 D9952 D9971 D9972 OCCLUSAL ADJUSTMENT - LIMITED OCCLUSAL ADJUSMENT - COMPLETE ODONTOPLASTY - ONE TO THREE TEETH EXTERNAL BLEACHING - PER ARCH $0 $0 $0 $0 $0 $0 $0 $125 ORTHODONTIC SERVICES D8070 D8080 D8090 D8680 D8999 COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIOINAL DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT ADOLESCENT DENTITION COMPREHENSIVE ORTHODONTIC TREATMENT ADULT DENTITION ORTHODONTIC RETENTION (REMOVAL OF APPLICANCES, CONSTRUCTION AND PLACEMENT OF RETAINER(S) START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS, X-RAYS, TRACING, PHOTOS, AND MODELS $750 $750 $750 $150 $350 5 *An additional charge for the cost of precious metal will be applied for any procedure using noble, high noble, or titanium metal not to exceed $150 per unit. 400-6963 ©2015-2016 United HealthCare Services, Inc. This plan is underwritten by Dental Benefit Providers of California, Inc. UnitedHealthcare/Select Managed Care Dental Exclusions and Limitations 18. Limitations of Benefits The following are the limitation of benefits, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 19. DENTAL PROPHYLAXIS - limited to 1 time per 6 months. INTRAORAL - Complete Series (including bitewings) - Limited to 1 time in any 2-year period. INTRAORAL BITEWING RADIOGRAPHS - Limited to 1 series of 4 films in any 6 month period. FLUORIDE TREATMENTS - Limited to 1 time per 6 months. SCALING AND ROOT PLANING - Limited to 4 quadrants per calendar year. PERIODONTAL MAINTENANCE PROCEDURES - Limited to once every 6 months, following active therapy, exclusive of gross debridement. REMOVABLE PROSTHETICS/FIXED PROSTHETICS/CROWNS, INLAYS AND ONLAYS (Major Restorative Services) - Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per 5 years from initial or supplemental placement. REMOVABLE PROSTHETICS/FIXED PROSTHETICS/CROWNS, INLAYS AND ONLAYS (Major Restorative Services) - Replacement of complete dentures, and fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement. CROWNS - Retainers/Abutments - Limited to 1 time per tooth per 5 years. CROWNS - Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. TEMPORARY CROWNS - Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. INLAYS/ONLAYS - Retainers/Abutments - Limited to 1 time per tooth per 5 years. INLAYS/ONLAYS - Restorations - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. STAINLESS STEEL CROWNS - Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown - primary tooth, are limited to primary anterior teeth. CROWNS, FIXED BRIDGES, AND IMPLANTS - The maximum benefit within a 12 month period is any combination of 7 crowns or pontics (artificial teeth that are part of a fixed bridge). If more than 7 crowns and/ or pontics are done for a Member within a 12 month period, the dentist’s fee for any additional crowns within that period would not be limited to the listed Copayment, but instead can reflect the Dentist’s Billed Charges. POST AND CORES - Covered only for teeth that have had root canal therapy. ADJUSTMENTS TO FULL DENTURES, PARTIAL DENTURES, 20. 21. BRIDGES OR CROWNS - Limited to repairs or adjustments performed more than 6 months after the initial insertion. INTRAVENOUS SEDATION OR GENERAL ANESTHESIA Administration of I.V. sedation or general anesthesia is limited to covered oral surgical procedures involving 1 or more impacted teeth (soft tissue, partial bony or complete bony impactions). ADJUNCTIVE - Pre-Diagnostic Test that aids in detection of mucosal abnormalities including premalignant and malignant lesion, not to include cytology or biopsy procedures - Limited to 1 time per year, to Covered Persons over the age of 30. REPLACEMENT OF COMPLETE DENTURES, FIXED OR REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS, ONLAYS, AND IMPLANTS, IMPLANT CROWNS, IMPLANT PROSTHESIS Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays, onlays, and implant crowns, implant prostheses previously submitted for payment under the plan is limited to 1 time per tooth per 5 years from initial or supplemental placement. This includes retainers, habit appliances, and any fixed or removable orthodontic appliances. All Specialty Referral Services Must Be: (A) Pre-Authorized by us; and (B) Coordinated by a Covered Person’s Participating Dentist. Any Covered Person who elects specialist care without prior referral by his or her Participating Dentist and approval by us is responsible for all charges incurred. • In order for specialty services to be Covered by this plan, the following referral process must be followed: • A Covered Person’s Participating Dentist must coordinate all Dental Services. • When the care of a Network Specialist Dentist is required, the Covered Person’s Participating Dentist must contact us and request authorization. • If the Participating Dentist request for specialist referral is denied, the Participating Dentist and the Covered Person will be notified of the reason for the denial. If the service in question is a Covered service, and no limitations or exclusions apply, the Participating Dentist may be asked to perform the service. • Covered Person who receives authorized specialty services must pay all applicable Copayments associated with the services provided. When we authorize specialty dental care, a Covered Person will be referred to a Network Specialist Dentist for treatment. The Network includes Network Specialist Dentists in: (a) endodontics; (b) oral surgery; (c) pediatric dentistry; and (d) orthodontics; and (e) periodontics, located in the Covered Person’s Service Area. If there is no Network Specialist Dentist in the Covered Person’s Service Area, we will refer the Covered Person to a Non-Participating Specialist of our choice. Except for Emergency Dental Services, in no event will we cover dental care provided to a Covered Person by a specialist not preauthorized by us to provide such services. • Covered Person’s financial responsibility is limited to applicable Copayments. Copayments are listed in the Covered Person’s Schedule of Covered Dental Services. 6 400-6963 ©2015-2016 United HealthCare Services, Inc. This plan is underwritten by Dental Benefit Providers of California, Inc. 21. Any implant procedures performed which are not listed as Covered implant procedures in the Schedule of Covered Dental Services. 22. Treatment which requires the services of a pediatric specialist, after the Covered Person’s 6th birthday. Exclusion of Benefits The following procedures and services are excluded and not Covered Services, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Orthodontic Exclusions & Limitations Dental Services that are not Necessary. Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services. Any Dental Procedure not performed in a dental setting. This will not apply to Covered Emergency Dental Services. Any Dental Procedure not directly associated with dental disease. Procedures related to the reconstruction of a patient’s correct vertical dimension of occlusion (VDO). Any service done for cosmetic purposes that is not listed as a Covered cosmetic service in the Schedule of Covered Dental Services. Costs for non-dental services related to the provision of dental services in hospitals, extended care facilities, or Member’s home are not covered. When deemed necessary by the Primary Care Dentist, the Member’s physician, and authorized by the Plan, covered dental services that are delivered in an inpatient or outpatient hospital setting are covered as indicated in the Schedule of Benefits Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue. Replacement of a lost, missing or stolen appliance or prosthesis or the fabrication of a spare appliance or prosthesis. Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - The plan provides for the use of noble metals for inlays, onlays, crowns and fixed bridges. When high noble metal is used, the Covered Person must pay: (a) the Copayment for the inlay, onlay, crown or fixed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal. Placement of fixed partial dentures solely for the purpose of achieving periodontal stability. Fixed or removable prosthodontic restoration procedures or implant services for complete oral rehabilitation or reconstruction. Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare. Dental Services otherwise Covered under the Contract, but rendered after the date individual Coverage under the Contract terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Contract terminates. Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision. Any Covered Person request for: (a) specialist services or treatment which can be routinely provided by a Participating Dentist; or (b) treatment by a specialist without referral from a Participating Dentist and our approval. Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit. Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment for the temporomandibular joint. Any endodontic, periodontal, crown or bridge abutment procedure or appliance requested, recommended or performed for a tooth or teeth with a guarded, questionable or poor prognosis. Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country. If you require the services of an orthodontist, a referral must first be obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the Covered Person will be responsible for all costs associated with any orthodontic treatment. Orthodontic services Copayments are valid for authorized services rendered. If you terminate Coverage after the start of orthodontic treatment, you will be responsible for any additional charges incurred for the remaining orthodontic treatment. 1. The following are not covered orthodontic benefits: • Replacement or repair of lost, stolen or broken appliances or appliances damaged due to the neglect of the Covered Person • Treatment in progress prior to the effective date of this coverage • Extractions required for orthodontic purposes • Surgical orthodontics or jaw repositioning • Myofunctional therapy • Cleft palate • Micrognathia • Macroglossia • Hormonal imbalances • Orthodontic retreatment when initial treatment was rendered under this plan or for changes in orthodontic treatment necessitated by any kind of treatment of accident • Palatal expansion appliances • Services performed by outside laboratories 2. If a treatment plan is for less than 24 months, then a prorated portion of the full copayment shall apply. 3. If Covered Person’s dental eligibility ends, for whatever reason, and the Covered Person is receiving orthodontic treatment under the plan, the remaining cost for that treatment will be prorated at the orthodontist’s usual fees over the number of months of treatment remaining. The Covered Person will be responsible for the payment of this balance under the terms and conditions prearranged with the orthodontist. 4. If the Covered Person has the orthodontist perform a “diagnostic work-up” (a consultation and diagnosis) and then decides to forgo the treatment program, the Covered Person will be charged a $50 consultation fee, plus any lab costs incurred by the orthodontist. 5. One orthodontic benefit under this plan is available per lifetime, per Covered Person. A Covered Person may access this Comprehensive Orthodontic Treatment. If comprehensive treatment is necessary, and is completed within a 24 month period, the Copayments listed will apply. If necessary and active treatment extends beyond 24 months, the provider is obligated to accept the plan Copayment only for the first 24 months of active therapy. The provider may charge usual and customary fees for active treatment extending beyond the 24 month benefit period. 7 400-6963 ©2015-2016 United HealthCare Services, Inc. This plan is underwritten by Dental Benefit Providers of California, Inc.