Basic Dental Care - Child. Dental Check-up For Children. Schedule of Covered Services and Copayments First Smile - EarlyCare Plus Plan

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1 Schedule of Covered Services and Copayments First Smile - EarlyCare Plus Plan Services when performed by a Dental Health Services participating dentist or specialist Code Description Copayment Annual maximum...none Deductible...0 *Out-of-pocket maximum - Individual *Out-of-pocket maximum - Family According to D9986 Missed appointment... office policy According to D9987 Cancelled appointment... office policy Specialty services covered...yes *For pediatric enrollees (18 years of age and under), all copayments for essential health benefits listed under Covered Services and Copayments apply to the member out-of-pocket maximum. Copayments for non-essential health benefits services, listed as Other Covered Services do not apply to the member out-of-pocket maximum. Specialty services must be pre-authorized and are only available for children 18 and under. Dental Check-up For Children D0120 Periodic oral evaluation - established patient - once every 6 months...12 D0140 Limited oral evaluation - problem focused...12 D0150 Comprehensive oral evaluation - new or established patient...12 D0190 Screening of a patient - limit of 2 per calendar year...12 D0191 Assessment of a patient - limit of 2 per calendar year...12 D0210 Intraoral - complete series of radiographic images - once in a 3-year period...12 D0220 Intraoral - periapical first radiographic image - once in a two-year period...12 D0230 Intraoral - periapical each additional radiographic image - once in a two-year period...12 D0240 Intraoral - occlusal radiographic image...12 D0270 Bitewing - single radiographic image...12 D0272 Bitewings - two radiographic images...12 D0273 Bitewings - three radiographic images...12 D0274 Bitewings - four radiographic images - once every 12 months...12 D0330 Panoramic radiographic image - once in a 3 year period...12 D0340 Cephalometric radiographic image - once in a 2 year period...12 Code Description Copayment D0350 Oral/facial photographic images obtained intraorally or extraorally...12 D0460 Pulp vitality tests - one test per visit...12 D0470 Diagnostic casts...12 D1110 Prophylaxis - adult - once every 6 months...12 D1120 Prophylaxis - child - once every 6 months...12 D1206 Topical application of fluoride varnish...12 D1208 Topical application of fluoride - frequency is based on age of enrollee, see limitations...12 D1330 Oral hygiene instructions - Available for enrollees 8 and younger. Available once every 6 months, up to 2 times in a 12-month period...12 D1351 Sealant - per tooth - See limitations for details about frequency...12 D9543 Office Visit...12 D9630 Other drugs and/or medicaments, by report...12 D9930 Treatment of complications (post-surgical) - unusual circumstances, by report...12 Basic Dental Care - Child D1510 Space maintainer - fixed - unilateral...15 D1515 Space maintainer - fixed - bilateral...15 D1550 Re-cementation of space maintainer...15 D1555 Removal of fixed space maintainer...15 D2140 Amalgam - one surface, primary or permanent...15 D2150 Amalgam - two surfaces, primary or permanent...15 D2160 Amalgam - three surfaces, primary or permanent...15 D2161 Amalgam - four or more surfaces, primary or permanent...15 D2330 Resin-based composite - one surface, anterior...15 D2331 Resin-based composite - two surfaces, anterior...15 D2332 Resin-based composite - three surfaces, anterior...15 D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior)...15 D2390 Resin-based composite crown, anterior...15 D2391 Resin-based composite - one surface, posterior...15 D2392 Resin-based composite - two surfaces, posterior...15 D2393 Resin-based composite - three surfaces, posterior...15 D2394 Resin-based composite - four or more surfaces, posterior...15 D2710 Crown - resin-based composite (indirect)...15 D2910 Recement inlay, onlay, or partial coverage restoration...15 D2915 Recement cast or prefabricated post and core...15 D2920 Recement crown...15 D2929 Prefabricated porcelain/ceramic crown primary tooth...15 D2930 Prefabricated stainless steel crown - primary tooth WAFSECHX Current Dental Terminology 2015 American Dental Association. All rights reserved. 1

2 Code Description Copayment Code Description Copayment D2931 Prefabricated stainless steel crown - permanent tooth...15 D2932 Prefabricated resin crown...15 D2933 Prefabricated stainless steel crown with resin window...15 D2934 Prefabricated esthetic coated stainless steel crown - primary tooth...15 D2950 Core buildup, including any pins when required...15 D2952 Post and core in addition to crown, indirectly fabricated...15 D2954 Prefabricated post and core in addition to crown...15 D3120 Pulp cap - indirect (excluding final restoration)...15 D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament - Not offered on permanent teeth...15 D3221 Pulpal debridement, primary and permanent teeth - Not offered on primary teeth and excludes teeth 1, 16, 17, and D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) - Only for permanent anterior teeth...15 D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)...15 D3351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) - Only for permanent anterior teeth...15 D3352 Apexification/recalcification - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.)...15 D3430 Retrograde filling - per root...15 D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant...15 D4341 Periodontal scaling and root planing - four or more teeth per quadrant - Available for patients 13 and older. Once per quadrant per two year period...15 D4342 Periodontal scaling and root planing - one to three teeth per quadrant - Available for patients 13 and older. Once per quadrant per two year period...15 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis...15 D4910 Periodontal maintenance (limited to 1 per 3 months)...15 D5410 Adjust complete denture - maxillary...15 D5411 Adjust complete denture - mandibular...15 D5421 Adjust partial denture - maxillary...15 D5422 Adjust partial denture - mandibular...15 D5510 Repair broken complete denture base...15 D5520 Replace missing or broken teeth - complete denture (each tooth)...15 D5620 Repair cast framework...15 D5650 Add tooth to existing partial denture...15 D5660 Add clasp to existing partial denture...15 D5850 Tissue conditioning, maxillary...15 D5851 Tissue conditioning, mandibular...15 D5899 Unspecified removable prosthodontic procedure, by report...15 D6930 Recement fixed partial denture...15 D7111 Extraction, coronal remnants - deciduous tooth...15 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)...15 D7210 Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated...15 D7250 Surgical removal of residual tooth roots (cutting procedure)...15 D7283 Placement of device to facilitate eruption of impacted tooth...15 D7286 Biopsy of oral tissue - soft...15 D7288 Brush biopsy - transepithelial sample collection...15 D7510 Incision and drainage of abscess - intraoral soft tissue...15 D7971 Excision of pericoronal gingiva...15 D9110 Palliative (emergency) treatment of dental pain - minor procedure...15 D9221 Deep sedation/general anesthesia - each additional 15 minutes...15 D9230 Inhalation of nitrous oxide / anxiolysis, analgesia...15 D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes...15 D9248 Non-intravenous conscious sedation...15 D9440 Office visit - after regularly scheduled hours...15 D9610 Therapeutic parenteral drug, single administration...15 D9612 Therapeutic parenteral drugs, two or more administrations, different medications...15 D9920 Behavior management, by report Office/outpatient visit, new - When performed by your participating general dentist or contracted specialist Office/outpatient visit, established - When performed by your participating general dentist or contracted specialist Subsequent hospital care - When performed by your participating general dentist or contracted specialist Office consultation - When performed by your participating general dentist or contracted specialist Inpatient consultation - When performed by your participating general dentist or contracted specialist...15 Major Dental Care - Child D2720 Crown - resin with high noble metal D2721 Crown - resin with predominantly base metal D2722 Crown - resin with noble metal D2740 Crown - porcelain/ceramic substrate D2750 Crown - porcelain fused to high noble metal D2751 Crown - porcelain fused to predominantly base metal D2752 Crown - porcelain fused to noble metal D3310 Endodontic therapy, anterior tooth (excluding final restoration)

3 Code Description Copayment Code Description Copayment D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) D3330 Endodontic therapy, molar (excluding final restoration) D3346 Retreatment of previous root canal therapy - anterior D3347 Retreatment of previous root canal therapy - bicuspid D3348 Retreatment of previous root canal therapy - molar D3410 Apicoectomy - anterior - Only for anterior teeth D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant D5110 Complete denture - maxillary D5120 Complete denture - mandibular D5130 Immediate denture - maxillary D5140 Immediate denture - mandibular D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) D5863 Overdenture complete maxillary D5865 Overdenture complete mandibular D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth - partially bony D7240 Removal of impacted tooth - completely bony D7241 Removal of impacted tooth - completely bony, with unusual surgical complications D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7280 Surgical access of an unerupted tooth D7285 Biopsy of oral tissue - hard (bone, tooth) D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant D7410 Excision of benign lesion up to 1.25 cm D7471 Removal of lateral exostosis (maxilla or mandible) D7472 Removal of torus palatinus D7473 Removal of torus mandibularis D7485 Surgical reduction of osseous tuberosity D7520 Incision and drainage of abscess - extraoral soft tissue D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue D7880 Occlusal orthotic device, by report D7960 Frenulectomy - also known as frenectomy or frenotomy - separate procedure not incidental to another procedure - Pre-authorization is not needed for members 6 and under D7963 Frenuloplasty - Pre-authorization is not needed for members 6 and under D7970 Excision of hyperplastic tissue - per arch D7972 Surgical reduction of fibrous tuberosity D9220 Deep sedation/general anesthesia - first 30 minutes D9241 Intravenous conscious sedation/analgesia - first 30 minutes D9410 House/extended care facility call - Up to 2 calls per facility per provider D9420 Hospital or ambulatory surgical center call - Up to 1 call per provider, per day D9940 Occlusal guard, by report Medically Necessary Orthodontia Copayments for medically necessary orthodontia apply to the member Out-of-Pocket Maximum. Medically necessary orthodontia - member pays $350/year prorated monthly starting with the first month of treatment, with a maximum lifetime copayment of $700. Orthodontic Services will only be approved for enrollees with a malocclusion associated with: a. Cleft lip and palate, cleft palate, or cleft lip with alveolar process involvement; b. Craniofacial anomalies for: Hemifacial microsomia; Craniosynostosis syndromes; Arthrogryposis; or Marfan syndrome. Must be prior approved. Orthodontia (Non-Medically Necessary) Copayments for non-essential health benefits services listed under Orthodontia (Non-Medically Necessary) do not apply to the member out-of-pocket maximum. D8210 Removable appliance therapy D8220 Fixed appliance therapy D8660 Pre-orthodontic treatment examination to monitor growth and development...40 D8670 Periodic orthodontic treatment visit...10 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) D8690 Orthodontic treatment (alternative billing to a contract fee)...0 D8691 Repair of orthodontic appliance...50 D8693 Re-cement or re-bond fixed retainer

4 Code Description Copayment Code Description Copayment Other Covered Services Copayments for non-essential health benefits services listed under, Other Covered Services do not apply to the member out-of-pocket maximum. D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver...20 D0160 Detailed and extensive oral evaluation - problem focused, by report...40 D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit)...15 D0171 Re-evaluation post-operative office visit...10 D0180 Comprehensive periodontal evaluation - new or established patient...20 D0250 Extraoral - first radiographic image...10 D0260 Extraoral - each additional radiographic image...6 D0277 Vertical bitewings - 7 to 8 radiographic images...20 D0391 Interpretation of diagnostic image by a practitioner not Associated with capture of the image, including report...25 D0415 Collection of microorganisms for culture and sensitivity...35 D0425 Caries susceptibility tests...10 D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures...15 D0601 Caries risk assessment and documentation, with a finding of low risk...15 D0602 Caries risk assessment and documentation, with a finding of moderate risk...15 D0603 Caries risk assessment and documentation, with a finding of high risk...15 D1310 Nutritional counseling for control of dental disease...0 D1320 Tobacco counseling for the control and prevention of oral disease...0 D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth...50 D1353 Sealant repair per tooth...5 D1520 Space maintainer - removable - unilateral D1525 Space maintainer - removable - bilateral D2940 Protective restoration...35 D2941 Interim therapeutic restoration primary dentition...5 D2949 Restorative foundation for an indirect restoration...30 D2951 Pin retention - per tooth, in addition to restoration...35 D2953 Each additional indirectly fabricated post - same tooth...90 D2955 Post removal D2957 Each additional prefabricated post - same tooth...80 D3331 Treatment of root canal obstruction; non-surgical access D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth D3333 Internal root repair of perforation defects D3353 Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) D3355 Pulpal regeneration - initial visit D3356 Pulpal regeneration - interim medication replacement D3357 Pulpal regeneration - completion of treatment D4921 Gingival irrigation per quadrant...25 D5986 Fluoride gel carrier...30 D9210 Local anesthesia not in conjunction with operative or surgical procedures...10 D9211 Regional block anesthesia...40 D9212 Trigeminal division block anesthesia...75 D9215 Local anesthesia in conjunction with operative or surgical procedures...0 D9219 Evaluation for deep sedation or general anesthesia...40 D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician...20 D9430 Office visit for observation (during regularly scheduled hours) - no other services performed...25 D9450 Case presentation, detailed and extensive treatment planning 0 D9910 Application of desensitizing medicament...15 D9911 Application of desensitizing resin for cervical and/or root surface, per tooth...15 D9941 Fabrication of athletic mouthguard D9942 Repair and/or reline of occlusal guard...75 D9951 Occlusal adjustment - limited...35 D9952 Occlusal adjustment - complete Congenital Anomalies Coverage for the treatment of congenital anomalies is available utilizing the services and copayments listed above. For more detailed information on the terms of your coverage, please consult your Exclusions and Limitations document. Please note: The listed procedures and copayments apply when service is received at your participating general dentist. Not every dentist will perform all services. If your dentist refers you to a specialist, please contact your Member Service Specialist before proceeding. All procedures are available from Dental Health Services participating specialists. All specialty services must be preauthorized with Dental Health Services through a referral from your participating dentist. If you ever have questions about your dental coverage, call your Member Service Specialist at We are happy to help you. 4

5 Exclusions and Limitations Limitations: Diagnostic Services are covered with the following limitations: a. Intraoral complete series (D0210) is covered once in a threeyear period unless a panoramic radiograph (D0330) for the same enrollee has been performed in the same three-year period. Additional D0210 and D0330 are only covered if deemed by an orthodontist or Oral Surgeon to be medically necessary (see e.); b. Medically necessary periapical x-rays that are not included in a complete series for diagnosis in conjunction with definitive treatment; c. An occlusal intraoral x-ray once in a two-year period; d. A maximum of four bitewing x-rays (once per quadrant) once every twelve months; e. Panoramic radiograph (D0330) in conjunction with four bitewings (D0274), once in a three-year period, only when an intraoral complete series (D0210) for the same enrollee has not been paid in the same three- year period. f. Radiographs with no specific limitation are on a case-by-case basis when medically necessary. g. Oral and facial photographic images (D0350) on a case-by-case basis. Preventive Services are covered with the following limitations: a. Dental Prophylaxis (D1110 & D1120) limited to once every 6 months for enrollees 18 and under; b. Topical Fluoride Treatment (D1208) including fluoride rinse, foam or gel, including disposable trays for enrollees: i. 6 years of age and younger up to 3 times per 12-month period per enrollee; ii. 7 to 18 years of age, up to 2 times per 12 month period per enrollee; iii. Up to 3 times in a 12-month period per enrollee during orthodontic treatment; iv. Additional applications on a case-by-case basis. c. Oral hygiene instruction for enrollees 8 and younger. The benefit must inc lude individualized oral hygiene instructions, tooth brushing techniques, flossing, and use of oral hygiene aids no more than once every 6 months, up to 2 times in a 12 month period. d. Sealants (D1351) are for enrollees 18 years or younger when used on mechanically and/or chemically prepared enamel surface once per tooth in a 3-year period. For developmentally disabled performed in a two-year period. e. Space Maintainers (D1510, D1515, D1550, D1555) for enrollees 12 years of age and younger for fixed unilateral or bilateral space maintenance subject to one space maintainer per quadrant, for primary molars A, B, I, J, K, L, S and T. i. Replacement space maintainers are covered on a case-by-case basis. ii. Removal of fixed space maintainers for enrollees 18 years of age or younger. Restorative Services are covered with the following limitations: a. Two occlusal restorations for the upper molars on teeth 1, 2, 3, 14, 15, and 16 if, the restorations are anatomically separated by sound tooth structure; b. A maximum of five surfaces per tooth for permanent posterior teeth, except for upper molars and a maximum of six surfaces per tooth for teeth 1, 2, 3, 14, 15 and 16; c. A maximum of six surfaces per tooth for resin-based composite restorations for permanent anterior teeth; d. An indirect crown once every 5 years, per tooth, for permanent anterior teeth for enrollees from 12 through 18 years of age. Must be pre-authorized; e. All recementations of permanent indirect crowns for enrollees from 12 through 18 years of age; f. Prefabricated stainless steel crowns for primary posterior teeth once every 3 years; g. Prefabricated stainless steel crowns for permanent posterior teeth excluding 1, 16, 17, and 32 once every 3 years; h. Core buildup, including pins, only on permanent teeth, when performed in conjunction with a crown; i. Cast post and core or prefabricated post and core, on permanent teeth when performed in conjunction with a crown. Periodontal Services are covered with the following limitations: a. Surgical periodontal services and post-operative care for ginigivectomy/gingivoplasty. b. Non-surgical periodontal scaling and root planing for teeth scaled that are periodontically involved, once per quadrant for enrollees aged 13 and older, per enrollee per two year period when preauthorized and evidenced by x-ray. c. Periodontal maintenance for enrollees aged 13 and older, once per enrollee, per 3 month period with pre-authorization. Endodontic Services are covered with the following limitations: a. Therapeutic pulpotomy on primary teeth and pulpal debridement on permanent teeth only [excluding teeth 1, 16, 17, and 32]; b. Treatment with resorbable material for primary maxillary incisor teeth D, E, F, and G, if the entire root is present at treatment; c. Treatment for permanent anterior, bicuspid, and molar teeth [excluding teeth 1, 16, 17, and 32]. d. Retreatment for the removal of post, pin, old root canal filing material, and all procedures necessary to prepare the canal with placement of new filing material. Prosthodontic Services - Removable are covered with the following limitations: a. One resin based partial denture; replacement covered if provided at least three years after the seat date; b. One complete denture upper and lower and one replacement denture per lifetime after at least 5 years from the seat date; c. Rebasing and relining of complete or partial dentures once in a 3 year period, if performed at least 6 months from the seating date; d. Partial, complete and immediate dentures must be pre-approved. Other Limitations: a. Authorized treatment is rendered only by your selected participating dentist or participating specialist. Services provided by a dentist other than the enrollee s designated participating dentist or participating specialist, except for emergency dental conditions, are not covered. b. All services performed must be medically necessary and consistent with a diagnosis of dental disease or condition. 5

6 c. Specialty services require a referral from your participating dentist and must be pre-authorized by Dental Health Services, including a referral to a pediatric dentist. d. Optional services (all cases in which the enrollee selects a plan of treatment that is considered unnecessary by the dentist). The enrollee is responsible for fee-for-service rates. This does not apply to standard covered restorative procedures which offer a choice of material. e. Upgraded services (cases in which the enrollee selects a plan of treatment that is considered an upgraded procedure) Dental Health Services upgrade charges would apply. f. Cosmetic dentistry services for appearance only. This includes such services as the replacement of clinically acceptable amalgam fillings, veneers and bonding. g. Unsatisfactory patient-doctor relationship: Dental Health Services participating dentists reserve the right to limit or deny services to an enrollee who fails to follow the prescribed course of treatment, repeatedly fails to keep appointments, fails to pay applicable copayments, is abusive to the participating dentist or their staff, or obtains services by fraud or deception. h. Denturists - Enrollees may elect to travel to the nearest participating denturist for services. Enrollees may be able to receive services from a participating denturist as long as the service performed was within the lawful scope of the denturist s license. i. Dental procedure that cannot be performed in the dental office due to the general health and/or physical limitations of the enrollee are limited to covered services listed in this Schedule of Covered Services and Copayments. j. Not all participating dentists can perform all dental procedures, please verify what services your selected dentist can perform for you. Some complicated extractions, periodontal treatment, osseous surgery and root canal treatment may be referred to a participating specialist at the discretion of the participating general dentist. k. Coverage for services are only available during period of enrollment. l. Emergency dental condition is the emergent and acute onset of a symptom or symptoms, including severe pain that would lead a prudent layperson acting reasonably to believe that dental condition exists that requires immediate, palliative care by a licensed dentist for the relief of pain, swelling or bleeding. This does not include routine, extensive or postponable treatment. Emergency dental care is limited to palliative treatment. Enrollee must attempt to contact their plan dentist. When an enrollee s plan dentist is not able to be reached, emergency treatment can be sought at any participating dentist. In cases where a participating dentist cannot be reached, the treatment for the emergency dental condition can be completed at any licensed dentist. Plan will reimburse for procedures submitted on a Post Service Emergency Dental Care Claim Form up to $150 per occurrence beyond all applicable copayments. m. Temporomandibular joint (TMJ) disorders and related disease treatment are limited to coverage for occlusal orthotic device for months on a case by case basis. n. Medical necessity is defined under this plan as dental services and supplies provided by a participating dentist appropriate to the evaluation and treatment of disease, condition, illness or injury and consistent with the applicable standard of care. This does not include any service that is cosmetic in nature. Exclusions: The following are not covered by your dental plan. a. Services not specifically listed in the Schedule of Covered Services and Copayments. b. Work in progress: Dental work in progress (non-emergency/ temporary procedures started but not finished prior to the date of eligibility) is not covered. This includes crown preps prepared and temporized but not cemented, root canals in mid-treatment, prosthetic cases post final impression stage (sent to the lab), etc. This does not include teeth slated for root canal treatment and/or canals filled during an emergency visit. c. Benefits are only available if work is completed at the enrollee s participating dentist s or participating specialist s office. d. This Plan does not provide benefits for services or supplies to the extent that benefits are payable for them under any motor vehicle medical, motor vehicle no-fault, uninsured motorist, underinsured motorist, personal injury protection (PIP), commercial liability, homeowner s policy, or other similar type of coverage. If you ever have questions about your dental coverage, call your Member Service Specialist. We are happy to help you. Dental Health Services A Great Reason to Smile sm 100 W. Harrison St., Suite S-440, South Tower, Seattle, WA WM Dental Health Services 6