01/01/13 Schedule Detail Listing CCTA Benefit Trust Fund

S:\Rates\2014\F12-02-DentalProvider-FeeSchedule Rev

120 PERIODIC ORAL EVALUATION ESTABLISHED PATIENT 49.00 59.00 59.00 71.00 140 LIMITED ORAL EVALUATION - PROBLEM FOCUSED 71.00 85.00 99.00 119.00 145 ORAL EVAL PT UND 3 YR AGE CNSL W/PRIM CAREGIVER 71.00

Delta Dental of Colorado EXCLUSIVE PANEL OPTION (EPO) Schedule EPO 1B List of Patient Co-Payments. * See Special Provisions on Last Page

List of Co-Payments Code edure Code Definition Co-Pay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation

Scheduled Dental Benefit Plan Schedule of Dental Allowances

Diagnostic Scheduled Dental Benefit Plan Schedule of Dental Allowances 0120 Periodic Oral Evaluation (once in 5 months after comprehensive) 20.00 0140 Limited Oral Evaluation 20.00 0150 Comprehensive Oral

Delta Dental of Colorado DENVER HEALTH AND HOSPITAL AUTHORITY GROUP #587. EXCLUSIVE PANEL OPTION (EPO) List of Patient Copayments

List of Copayments Code edure Code Definition Copay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation

RETIREE DENTAL PLAN. RETIREE DENTAL PLAN FEE SCHEDULE Page 1 of 8

D0120 periodic oral evaluation $ 30.50 D0140 limited oral evaluation problem focused $ 30.50 D0150 comprehensive oral evaluation - new or established patient $ 30.50 D0160 detailed and extensive oral evaluation

Managed DentalGuard Texas

Page 1 of 5 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131

SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE

DentiCare of Alabama, Inc. 3595 Grandview Parkway, Suite 650 Birmingham, AL 35243 SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE SECTION I: PLAN DENTIST SERVICES (Subject to Exclusions and Limitations Listed

DIAGNOSTIC/PREVENTIVE SERVICES

DIAGNOSTIC/PREVENTIVE SERVICES Diagnostic Services D0120 Periodic oral evaluation 100% 100% D0140 Limited oral evaluation problem focused 100% 100% D0150 Comprehensive oral evaluation 100% 100% D0160 Detailed

MDG Dental Plan Comparison

D0999 Office visit during regular hours, general dentist only Evaluations D0120 Periodic oral examination - established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for

GUARANTY ASSURANCE COMPANY - DINA Dental Plan SCHEDULED BENEFITS RIDER

OSHA Charge for disposables for patients protection, per person, per visit* $5.00 120 Periodic oral exam $5.00 140 Limited oral exam $30.00 150 Comprehensive oral evaluation $20.00 180 Comprehensive Perio

Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #

Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #6694 7.2011 MAXIMUM BENEFIT Calendar Year Orthodontic Lifetime CALENDAR YEAR DEDUCTIBLE WHO CAN BE COVERED

Employee Benefit Fund July 2018 ADA Codes and Plan Fees

CSEA Employee Benefit Fund July 2018 ADA Codes and Plan Fees DIAGNOSTIC D0120 periodic oral examination 40 34 42 45 48 38 30 32 31 D0140 limited oral examination (Does not look at 9110) 40 34 42 45 48

Fee Schedule Detail Procedure Procedure Description Code Fee

Fee Schedule Detail Procedure Procedure Description Code Fee D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $ 32.29 D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ 53.02 D0150 COMPREHENSIVE ORAL

Newport News Public Schools Summary Schedule of Services Delta Dental PPO EPO Plan

Newport News Public Schools Summary of Services Delta Dental PPO EPO Plan Services In-Network Out-of-Network PPO Premier All Other Diagnostic & Preventive Oral Exams & Teeth Cleanings Fluoride Applications

Delta Dental EPO City & County of Denver Group #6791 EPO

MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule

General Dentist Fee Schedule

General Dentist Fee Schedule ADA Diagnostic D0120 Periodic oral evaluation $0 $72 $72 D0140 Limited oral evaluation problem focused $77 $107 $30 D0150 Comprehensive oral evaluation new or established patient

General Dentist Fee Schedule

General Dentist Fee Schedule Diagnostic D0120 Periodic oral evaluation $0 $59 $59 D0140 Limited oral evaluation problem focused $71 $88 $17 D0150 Comprehensive oral evaluation new or established patient

This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General

This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General

ASSISTANT SECRETARY PRESIDENT

Charge Code TYPE I* Benefit Co-Insurance $21.00 0120* Periodic oral exam $21.00 Balance Billing $30.00 0140* Limited oral exam $30.00 Balance Billing $35.00 0150* Comprehensive oral evaluation $35.00 Balance

MY SMILE DENTAL PLAN FEE SCHEDULE

D0120 periodic oral evaluation D0140 limited oral evaluation problem focused D0145 exam under 3 years D0150 comprehensive oral evaluation - new or established patient D0160 detailed and extensive oral

Managed DentalGuard - Plan Schedule

D0999 Office visit during regular hours, general dentist only * $5 Evaluations D0120 Periodic oral examination established patient 0 D0140 Limited oral evaluation problem focused 0 D0145 Oral evaluation

DELTA DENTAL PPO EPO PLAN DESIGN CP070

DELTA DENTAL PPO EPO PLAN DESIGN CP070 SCHEDULE OF BENEFITS AND The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations and exclusions of the program.

GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual

Effective: January 1, 2016 Eligibility: (866) 436-3093 GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual Diagnostic D0999 Office Visit Copay - Per Person, Per Visit $9.00

Schedule of Benefits (GR-9N S )

Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2016 Effective Date: January 1, 2016 Schedule: 1A Cert Base: 1 For: DMO - All

Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE

Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: Clear Creek ISD GROUP AGREEMENT: 620318 PLAN EFFECTIVE: September 1, 2014 The benefits shown

Schedule of Benefits (GR-9N S )

Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: Roman Catholic Diocese Of Dallas GP-870560-WI Issue Date: February 9, 2015 Effective Date: January 1, 2015 Schedule: 7A Cert Base:

Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE

Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: BNSF Railway Company GROUP AGREEMENT: 727796 PLAN EFFECTIVE: January 1, 2016 The benefits

Delta Dental EPO City & County of Denver Group #6791 EPO

MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule

ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or

ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or established patient(initial exam) 0 D0160 Detailed and

LIST OF COVERED DENTAL SERVICES

LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental Services which will be considered for payment by Constitution Life Insurance Company after the expiration of any applicable

Senior Dental Insurance Scheduled Allowance

Senior Dental Insurance Scheduled Allowance LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental services which will be considered for payment by The American Progressive Life

CCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List

CCPOA PRIMARY DENTAL CCPOA s Fee-for-Service Procedure Code List Effective December 2017 We have provided these payment allowances for informational purposes only and not as a guarantee of payment. All

Concordia Plus Schedule of Benefits

Concordia Plus Schedule of Benefits Plan MD/DC 6 IMPORTANT INFORMATION ABOUT YOUR PLAN This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment,

DINA Dental. Prepaid Plan Highlights. Prepaid Plan Bi-weekly Premiums $ 7.00 $10.76 $ Employee Only Employee + One Employee + Family

DINA Dental Prepaid Plan Highlights NO Claim Forms NO Maximums NO Deductibles NO Waiting Period - Some Preventive and Diagnostic Services Provided at NO CHARGE - Over 180 procedures covered by co-payments

FEE SCHEDULE. Complete Dental Plan is a discount plan offered and administered by our organization at:

FEE SCHEDULE Complete Dental Plan is a discount plan offered and administered by our organization at: 7801 CORAL WAY SUITE # 106, MIAMI, FL 33144 (786) 326-6873 F (305) 6979785 COMPLETE DENTAL PLAN HIGHLIGHTS

D0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive

D0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive Oral Examination $43 D0160 Detailed And Extensive Oral

BOSTON TEACHERS UNION PARAPROFESSIONAL HEALTH AND WELFARE FUND Schedule of Covered Dental Procedures for the Dental Plan - Effective January 1, 2009

TYPE 1 D0120 Periodic oral evaluation 27.81 D0140 Limited oral evaluation - problem focused 43.15 D0145 Oral evaluation for a patient under three years of age and 22.20 counseling with primary caregiver

Access Dental Family DHMO

866-569-9900 HTTPS://MYDENTAL.GUARDIANLIFE.COM SCHEDULE OF BENEFITS Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Access Dental Individual & Family

2018 fee schedule. Georgia. Diagnostic Services (Performed by a General Dentist)

Diagnostic Services (Performed by a General Dentist) page 1 of 12 IS NOT A REGISTERED INSURANCE PLAN. It is a savings plan offered exclusively by Coast Dental practices to patients who do not have dental

Schedule of Benefits (GR-9N S )

Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 1A Cert Base: 1 For: DMO - All

MDG-FP-U10NYI04-SCH-NY-OFF-17

SECTION XVI MANAGED DENTALGUARD SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under Age 19 Two (2) or More Members under Age 19 Participating

LOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16

APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.

TEAMSTERSCARE DENTAL FEE SCHEDULE Effective: 01/01/ Delta Dental PPO Plus Premier National

Effective: 01/01/ - Delta Dental PPO Plus Premier National D0120 PERIODIC ORAL EXAMINATION $21.00 D0140 LIMITED EVAL PROBLEM FOCUS $38.00 D0145 ORAL EVALUATION FOR PATIENTS UNDER THREE YEARS OF AGE $21.00

LOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16

APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.

APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE

: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures

APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE

: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures

Dental Fee Schedule Dental Advantage Essentials. What is the out-of-pocket limit? Primary care dentist

Dental Fee Schedule Dental Advantage Essentials This plan covers dental services for enrolled individuals age 18 and younger, as required under the Affordable Care Act. Out-of-Pocket Limit $350 per person

Careington Corporation Care PPO Schedule CI-10

Careington Corporation Care PPO Schedule Page 1 of 5 This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this

Concordia Plus ScheduleofofBenefits

Concordia Plus ScheduleofofBenefits Benefits Concordia Plus Schedule Plan 931 Plan CACA 1131 IMPORTANT INFORMATION ABOUT YOUR PLAN ÂÂ This Schedule of Benefits provides a listing of procedures covered

PLEASE READ IMPORTANT PLAN INFORMATION AT THE END OF THIS SCHEDULE

Careington Corporation Care POS Schedule CI-4 Please Call 800-290-0523 for Customer Service ***Discount plans are not insurance*** This schedule applies to services provided by a participating General

The. Dental Plan. Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation

The Dental Plan Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation Now you can have comprehensive DENTAL coverage at a cost you can afford! Since 1981, Denta-Chek has been providing

LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule

LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule Members must select, and be assigned to, a LIBERTY Dental Plan contracted dental office to utilize covered benefits. LIBERTY Dental Plan

AmeriPlan Lime Fee Zip: 78411

AmeriPlan Lime Fee Zip: 78411 SPECIALIST FEE SCHEDULE Any AmeriPlan /Dental Plans of America member receiving treatment from a participating specialist provider (advanced degree), shall receive a 15% discount

Staywell FL Child Medicaid Plan Benefits

The following is a complete list of dental procedures for which benefits are payable under this Plan. For beneficiaries under age 21, additional coverage may be available with documentation of medical

EssentialSmile Ped 221 Schedule of Benefits

EssentialSmile Ped 221 Schedule of Benefits P.O. Box 19199 Plantation, FL 33318 Telephone: 877-760-2247 Fax: 954-370-1701 www.mysolstice.net Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx

2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees

2018 Dental Schedule of Allowances Indemnity Dental Plan for Active Plan A, Plan B, and all Retirees Schedule effective date for all Plans: January 1, 2018 Annual Deductibles For all Plans: $50 per person

State of Tennessee. Prepaid Plan. Dental Benefit Option. Sponsored by the. State of Tennessee

State of Tennessee Prepaid Plan Dental Benefit Option Sponsored by the State of Tennessee 2011 Products and services marketed by Assurant Employee Benefits are underwritten and/or provided by Union Security

Schedule of Benefits Access Dental Family DHMO

Schedule of Benefits Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Premier Access Individual & Family Plan, as well as the Copayments associated with

Please note a few important reminders to help expedite the process of dental claims/estimates:

To: Valued Members and Providers From: Member Services Date: January 2019 RE: Attached is the for all members. Note: The Plan Pays amount on the fee schedule already has the percentages factored in. The

SCHEDULE A Description of Benefits and Copayments DHMO-901

866.650.3660 WWW.PREMIERLIFE.COM SCHEDULE A Description of Benefits and Copayments DHMO-901 The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to

APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE

: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures

SCHEDULE A Description of Benefits and Copayments DHMO-PA3

SCHEDULE A Description of Benefits and s DHMO-PA3 855.280.2882 WWW.PREMIERLIFE.COM The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to the limitations

DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008

DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO TABLE OF ALLOWANCE The Delta Dental PPO table plan

EssentialSmile Ped 221 Schedule of Benefits

EssentialSmile Ped 221 Schedule of Benefits P.O. Box 9 Plantation, FL 33318 Telephone: 877 760 2247 Fax: 954 370 1701 www.mysolstice.net Members can search for a Network Provider atwww.solsticecare.com/provider

SECURECARE DENTAL SCHEDULE OF OUT OF NETWORK BENEFIT PAYMENTS GENERAL INFORMATION

SECURECARE DENTAL SCHEDULE OF OUT OF NETWORK S GENERAL INFORMATION This Schedule applies only to services and supplies furnished by Non-Preferred Providers. The patient will be responsible for all charges

Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits

Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual

Massachusetts State Health Care Professionals' Dental Fund Group Number: Schedule of Dental Benefits (Maximum Payments) Effective

D0120 I Periodic oral evaluation (maximum of two per calendar year)* 100% 100% D0140 I Limited oral evaluation - problem focused (maximum of two per calendar year) 100% 100% D0145 I Oral Evaluation under

All Participants and Beneficiaries in the Health and Benefit Trust Fund of the International Union

SUMMARY OF MATERIAL MODIFICATIONS TO THE HEALTH AND BENEFIT TRUST FUND OF THE INTERNATIONAL UNION OF OPERATING ENGINEERS LOCAL UNION NO. 94 94A 94B, AFL CIO To: From: All Participants and Beneficiaries

NDB Nevada Kids Silver In-Network Schedule of Benefits

NDB Nevada Kids Silver Diagnostic D0120 Periodic Oral Evaluation Established Patient (1 per 6 months)... No Charge D0140 Limited Oral Evaluation Problem Focused (3 per 6 months)... No Charge D0145 Oral

Improve your smile and overall well-being with. Dental Health Services. Dental Health Services. Difference today!

Improve your smile and overall well-being with Dental Health Services Great oral health is essential for your overall well-being. With a Dental Health Services plan, you can achieve a healthy smile while

DENTAL GRID - SCMEBF Page 1 of 8 Vol. 1 #7 as of 1/16/18

0120 Periodic oral evaluation - established patient $25 0140 Limited oral evaluation - problem focused $30 0150 Comprehensive oral eval.-new or established patient $35 0160 0180 Detailed & extensive oral

For a Correction Captains Association Dental Claim Form please follow this link CCA Dental Claim form.pdf

Correction Captains Association Retiree Security Benefit Fund Group #132 Summary of Benefit for Retired members: Annual maximum $3,500.00 individual Individual Ortho Lifetime max $3,500 Appliance $600,

CHOICES Patients Covered dental services

CHOICES Patients Covered dental services Important points: There is a $7 co-pay for each covered service visit at the UF College of Dentistry except for some denture therapy services which may require

Southern California Pipe Trades Administration Corporation ABREVIATED SCHEDULE OF DENTAL BENEFITS TABLE OF ALLOWANCES REVISED SEPTEMBER 30, 2016

The following is an abbreviated Schedule of Dental Benefits. All benefit payments are subject to Plan limits including the Calendar Year Deductible and any applicable coinsurance. D0120 Periodic Oral Evaluation

Summary of Benefits - Dental HMO Deluxe Plan

Office visit Office visit $5 per visit Diagnostic (exams and x-rays) D0120 Periodic oral evaluation You pay nothing D0140 Limited oral evaluation - problem focused You pay nothing D0145 Oral evaluation

IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation

D0120 IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation established patient* $ 66.50 D0140 limited oral evaluation

ATTACHMENT AA DentaQuest of Illinois, LLC

DentaQuest of Illinois, LLC 112 ATTACHMENT AA DentaQuest of Illinois, LLC HFS Dental Program Fee Schedule for and Adult Beneficiaries Rates Effective July 1, 2009 Please note: have limited dental coverage.

HumanaDental PPO 09 (High Option)

HumanaDental PPO 09 (High Option) FLORIDA ICUBA If you use IN-NETWORK provider If you use OUT-OF-NETWORK provider Plan-year deductible Annual maximum Preventive services Oral examinations X-rays Cleanings

NJAY2 State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Patient Charge Schedule

State of New Jersey Retiree Plan Cigna Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. IMPORTANT HIGHLIGHTS s pay the

HUDSON VALLEY COMMUNITY COLLEGE DENTAL BENEFITS PLAN SCHEDULE OF ALLOWANCES

HUDSON VALLEY COMMUNITY COLLEGE DENTAL BENEFITS PLAN SCHEDULE OF ALLOWANCES 1 PLAN ADMINISTERED BY DELTA DENTAL Effective January 1, 2015 Annual Maximum for all services - $1200 DIAGNOSTIC Clinical Oral

EXHIBIT A PROCEDURE DESCRIPTION MSP50809 CDT CODE

D0120 Periodic Exam 28.00 D0140 Limited Oral Evaluation Problem Focused 42.00 D0145 Oral Evaluation for a Patient Under Three Years of Age and Counseling with Primary Caregiver 38.00 D0150 Comprehensive

Frequently Used Dental Codes Intermediate/Major Category Description GOLD FOIL - TWO SURFACES

Code D2410 D2420 D2430 D2510 D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643 D2644 D2650 D2651 D2652 D2662 D2663 D2664 D2710 D2712 D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2780 D2781 D2782

Building Trades Fee Schedule as of 12/1/2015 CODE DESCRIPTION FEE D2920 RECEMENT CROWN $49.50 D2930 STAINLESS STEEL CROWN PRIMARY $133.

D0150 COMPREHENSIVE ORAL EXAM $39.00 D0210 X RAYS COMPLETE SERIES $72.00 D0220 X RAYS PERIAPICAL 1ST FILM $21.00 D0230 X RAYS PERIAPICAL EACH ADDL $11.00 D0240 X RAYS OCCLUSAL FILM $19.50 D0250 X RAYS

SECURECARE DENTAL COPAY PLAN SCHEDULE OF DENTIST COPAYMENTS

The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services

CIGNA Dental Care (*DHMO) Patient Charge Schedule

A2O07 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered

Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM

Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM SCHEDULE OF BENEFITS AND COPAYMENTS/ The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations

SECURECARE DENTAL COPAY PLAN AZ100 - SCHEDULE OF DENTIST COPAYMENTS

The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services

SECURECARE DENTAL COPAY PLAN AZ300 - SCHEDULE OF DENTIST COPAYMENTS

The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services

SECURECARE DENTAL COPAY PLAN NV100 - SCHEDULE OF DENTIST COPAYMENTS

The Copay Plan is a fee-for-service dental plan designed with convenient copays. If the treating dentist is a General Dentist, the patient is responsible for the Genteral Dentist Copay(s) for services

23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company

www.bcbsla.com 23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 1 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are

CDT updates on this schedule are subject to approval by regulatory agencies in the following states: CA, FL, MD, MO, NY, OK, TX, VA and WA

CDT updates on this schedule are subject to approval by regulatory agencies in the following states: CA, FL, MD, MO, NY, OK, TX, VA and WA SCHEDULE A Description of Benefits and Copayments The Benefits

NDB Nevada Kids Silver In-Network Schedule of Benefits

Diagnostic D0120 Periodic Oral Evaluation - Established Patient (1 Per 6 No Charge D0140 Limited Oral Evaluation - Problem Focused (As Necessary) (3 Per 6 No Charge D0145 Oral Evaluation for a Patient

SOLSTICE S700PB. CODE DESCRIPTION MEMBER'S COPAY periodontal evaluation - new or established patient CODE DESCRIPTION MEMBER'S COPAY APPOINTMENTS

SOLSTICE S700PB SCHEDULE OF BENEFITS Members of the Solstice S700 dental plan are eligible to receive benefits immediately upon the effective date of coverage with: No Waiting Periods No Deductibles No

HSCSN Table Top Reference Guide

Age Limitation Covered One per 6 months per dentist or dental group. Only one exam (D0120) every 6 months per dentist or dental D0120 iodic oral evaluation 0-20 No group. D0140 Limited oral evaluation

D Pulp vitality tests $52.30 D Diagnostic casts $75.69 D Prophylaxis adult $ Page # 1

Boston Teachers Union Health and Welfare Group No: 006318 Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D0120 1 Periodic oral evaluation