Principal Benefits & Coverage Plan Advantage 250 Plus

Transcription

1 Principal Benefits & Cverage Plan Advantage 250 Plus These prcedures are cvered benefits nly when prvided by a participating General Dentist, and they are subject t Plan limitatins, exclusins and guidelines. Members must select, and be assigned t, a CDN plan cntracted dental ffice t utilize cvered benefits. Member C-payments are payable t the dental ffice at the time f services. This schedule des nt guarantee benefits. All services are subject t eligibility and dental necessity at the time f service. Dental prcedures nt listed are available at the dental ffice s usual and custmary fee. CODE DESCRIPTION MEMBER COPAYMENT DIAGNOSTIC SERVICES ALL RADIOGRAPHS AND ALL DIAGNOSTIC IMAGES INCLUDE READING AND INTERPRETATION BY ANY CONTRACTING PROVIDER. CONTRACTED DENTISTS MAY NOT CHARGE A SURCHARGE TO INTERPRET DIAGNOSTIC IMAGES. Office Visit (includes infectin cntrl) $0.00 D0120 Peridic ral evaluatin $0.00 D0140 Limited ral evaluatin - prblem fcused $0.00 D0145 Oral evaluatin fr a patient under 3 years f age and cunseling with primary caregiver $0.00 D0150 Cmprehensive ral evaluatin - new r established patient $0.00 D0170 Re-evaluatin - limited, prblem fcused $0.00 D0171 Re-evaluatin - pst perative visit $0.00 D0180 Cmprehensive peridntal evaluatin - new r established patient $0.00 D0210 Intraral - cmplete series (including bitewings) $0.00 D0220 Intraral - periapical first image $0.00 D0230 Intraral - periapical each additinal image $0.00 D0240 Intraral - cclusal image $0.00 D0250 Extra-ral first 2D prjectin radigraphic image created using a statinary radiatin surce, $0.00 and detectr. D0270 Bitewing - single image $0.00 D0272 Bitewings - tw images $0.00 D0273 Bitewings, 3 images $0.00 D0274 Bitewings - fur images $0.00 D0277 Vertical bitewings - 7 t 8 images $0.00 D0330 Panramic image $0.00 D0350 2D Oral/facial phtgraphic images, nn-rthdntic, btained intrarally r extrarally $0.00 D0460 Pulp vitality tests $0.00 D0470 Diagnstic casts, nn-rthdntic $0.00 D0601 Caries risk assessment and dcumentatin, with a finding f lw risk $0.00 D0602 Caries risk assessment and dcumentatin, with a finding f mderate risk $0.00 D0603 Caries risk assessment and dcumentatin, with a finding f high risk $0.00 PREVENTIVE SERVICES # - PROCEDURES LIMITED TO ONCE EVERY 6 MONTHS, COVERED ONLY AT THE GENERAL DENTIST'S OFFICE. + - LIMITED TO ONE EVERY 6 MONTHS. D1110 Prphylaxis - adult # $0.00 D1110 Prphylaxis - adult (each additinal beynd the nce per every 6 mnth benefit) $45.00 D1120 Prphylaxis - child # $0.00 D1120 Prphylaxis - child (each additinal beynd the nce per every 6 mnth benefit) $35.00 D1206 Tpical Fluride Varnish. Chargeable n a per visit basis, nt per tth. + $5.00 D1208 Tpical applicatin f fluride - excluding varnish.+ $0.00 D1310 Nutritinal cunseling fr cntrl f dental disease $0.00 D1320 Tbacc cunseling fr the cntrl and preventin f ral disease $0.00 D1330 Oral hygiene instructins $0.00 D1351 Sealant - per tth D1352 Preventive resin restratin - permanent tth - including placement f a sealant in nn-carius pits and fissures D1353 Sealant repair-per tth. May nt be charged by placing prvider within 18ms f initial placement. D1354 Interim Caries arresting medicament applicatin-per tth. Des nt include dental fluride varnish applicatin.

2 CODE DESCRIPTION MEMBER COPAYMENT D1510 Space maintainer - fixed - unilateral $75.00 D1516 Space Maintainer, Fixed, mandibular. $85.00 D1517 Space Maintainer, Fixed, maxillary. $85.00 D1520 Space maintainer - remvable - unilateral $75.00 D1526 Space Maintainer, remvable, maxillary. $85.00 D1527 Space Maintainer, remvable, mandibular. $85.00 D1550 Recement r rebnd space maintainer $10.00 D1555 Remval f fixed space maintainer D1575 Distal she space maintainer - fixed - unilateral $75.00 RESTORATIVE SERVICES INCLUDES ALL BASES, LINERS, ADHESIVES, BONDING AGENTS, DESENSITIZING AGENTS, REMOVAL OF EXISTING RESTORATIONS. D2140 Amalgam - 1 surface, primary r permanent $0.00 D2150 Amalgam - 2 surfaces, primary r permanent $0.00 D2160 Amalgam - 3 surfaces, primary r permanent $0.00 D2161 Amalgam - 4 r mre surfaces, primary r permanent $0.00 D2330 Resin-based cmpsite - 1 surface, anterir $20.00 D2331 Resin-based cmpsite - 2 surfaces, anterir $30.00 D2332 Resin-based cmpsite - 3 surfaces, anterir $40.00 D2335 Resin-based cmpsite - 4 r mre surfaces r invlving incisal angle (anterir) $50.00 D2390 Resin-based cmpsite crwn, anterir $ D2391 Resin-based cmpsite - 1 surface, psterir $80.00 D2392 Resin-based cmpsite - 2 surfaces, psterir $ D2393 Resin-based cmpsite - 3 surfaces, psterir $ D2394 Resin-based cmpsite - 4 r mre surfaces, psterir $ INLAYS/ONLAYS INCLUDES ALL BASES, LINERS, ADHESIVES, BONDING AGENTS, DESENSITIZING AGENTS, REMOVAL OF EXISTING RESTORATIONS, LAB COSTS, AND TEMPORIZATION. D2510 Inlay - metallic - 1 surface $ D2520 Inlay - metallic - 2 surfaces $ D2530 Inlay - metallic - 3 r mre surfaces $ D2542 Onlay - metallic - 2 surfaces $ D2543 Onlay - metallic - 3 surfaces $ D2544 Onlay - metallic - 4 r mre surfaces $ D2610 Inlay - prcelain/ceramic - 1 surface $ D2620 Inlay - prcelain/ceramic - 2 surfaces $ D2630 Inlay - prcelain/ceramic - 3 r mre surfaces $ D2642 Onlay - prcelain/ceramic - 2 surfaces $ D2643 Onlay - prcelain/ceramic - 3 surfaces $ D2644 Onlay - prcelain/ceramic - 4 r mre surfaces $ D2650 Inlay - resin-based cmpsite - 1 surface $ D2651 Inlay - resin-based cmpsite - 2 surfaces $ D2652 Inlay - resin-based cmpsite - 3 r mre surfaces $ D2662 Onlay - resin-based cmpsite - 2 surfaces $ D2663 Onlay - resin-based cmpsite - 3 surfaces $ D2664 Onlay - resin-based cmpsite - 4 r mre surfaces $ CROWNS INCLUDES ALL BASES, LINERS, ADHESIVES, BONDING AGENTS, DESENSITIZING AGENTS, REMOVAL OF EXISTING RESTORATIONS, LAB COSTS, AND TEMPORIZATION. *COVERED ONLY AT THE GENERAL DENTIST'S OFFICE UNLESS SPECIFIC PRIOR AUTHORIZATION GIVEN BY PLAN FOR SPECIALIST TO PERFORM. D2740 Crwn - prcelain/ceramic $ D2750 Crwn - prcelain fused t high nble metal $ D2751 Crwn - prcelain fused t predminantly base metal $ D2752 Crwn - prcelain fused t nble metal $ MLR Crwn-prcelain fused t any metal fr mlars Add $75 t nnmlar cpayment fee. D2780 Crwn - 3/4 cast high nble metal $ D2781 Crwn - 3/4 cast predminantly base metal $ D2782 Crwn - 3/4 cast nble metal $ D2783 Crwn - 3/4 prcelain/ceramic $ D2790 Crwn - full cast high nble metal $ CDN2019A250+ 2

3 CODE DESCRIPTION MEMBER COPAYMENT D2791 Crwn - full cast predminantly base metal $ D2792 Crwn - full cast nble metal $ D2794 Crwn-Titanium, Includes full titanium and prcelain fused t titanium, $ MLR Crwn-Titanium, Includes full titanium and prcelain fused t titanium, fr mlars. Add $75 t nnmlar cpayment fee fr prcelain fused t titanium crwns. D2799 Prvisinal crwn further treatment r cmpletin f diagnsis necessary prir t final $0.00 impressin. D2910 Recement r rebnd inlay, nlay, veneer r partial cverage restratins. D2910 shall nly be cvered when recementing metallic substrate restratins. D2915 Recement r rebnd cast indirectly fabricated r prefabricated pst and cre D2920 Recement r rebnd crwn D2929 Prefabricated prcelain/ceramic crwn - primary tth $ D2930 Prefabricated stainless steel crwn - primary tth $50.00 D2931 Prefabricated stainless steel crwn - permanent tth $50.00 D2932 Prefabricated resin crwn $ D2933 Prefabricated stainless crwn with resin windw $ D2934 Prefabricated esthetic cated stainless steel crwn--primary tth $1, D2940 Sedative filling $10.00 D2941 Interim therapeutic restratin-primary dentitin $10.00 D2949 Restrative fundatin fr an indirect restratin $0.00 D2950 Cre buildup, including any pins when required* $20.00 D2951 Pin retentin - per tth, in additin t restratin* $5.00 D2952 Indirectly fabricated pst and cre in additin t crwn $75.00 D2953 Each additinal indirectly fabricated pst - same tth $0.00 D2954 Prefabricated pst and cre in additin t crwn* $70.00 D2955 Pst remval (nt chargeable when in cnjunctin with enddntic therapy)* $35.00 D2957 Each additinal prefabricated pst - same tth* $0.00 D2980 Crwn repair, by reprt $50.00 D2981 Inlay repair due t restrative material failure- nt allwed t be charged by same prvider within $ mnths f the riginal restratin. D2982 Onlay repair due t restrative material failure- nt allwed t be charged by same prvider within $ mnths f the riginal restratin. D2990 Resin infiltratin f incipient smth surface lesins. LABIAL VENEERS (REPLACED ONCE EVERY 5 YEARS WHEN DENTALLY NECESSARY) D2961 Labial veneer (resin laminate) - labratry $ D2962 Labial veneer (prcelain laminate) - labratry $ D2983 Veneer repair due t restrative material failure- - nt allwed t be charged by same prvider within 24 mnths f the riginal restratin $50.00 ALTERNATIVE CROWNS MANY DENTAL OFFICES OFFER PREMIUM MATERIALS AS ALTERNATIVES TO THE STANDARD PORCELAIN/CERAMIC SUBSTRATE AND PORCELAIN-FUSED-TO-METAL MATERIALS FOR DENTAL RESTORATIONS, WHICH ARE MARKETED UNDER DIFFERENT BRAND NAMES AND MAY BE AVAILABLE THROUGH YOUR CALIFORNIA DENTAL PARTICIPATING PROVIDER FOR THE FOLLOWING COPAYMENTS. *CROWNS, BRIDGES, INLAYS, AND ONLAYS, FABRICATED IN THESE PREMIUM MATERIAL ALTERNATIVES AND PREPARED AND DELIVERED ON THE SAME DAY ARE SUBJECT TO AN ADDITIONAL $ IN-OFFICE LAB FEE. THIS LIST IS UPDATED REGULARLY-CONTACT THE PLAN FOR AN UP TO DATE LIST OF CURRENTLY COVERED MATERIALS. PORCELAIN/CERAMIC SUBSTRATE CROWN CEREC, Full-Z, Bruxzir, Lava, Prismatik $ CEREC Blue Blck, e.max, Prcera $ Lava (layered), e.max (layered), Prcera (Layered) $ PORCELAIN FUSED TO HIGH NOBLE CROWN Captek, Bi-2000 $ Occlusal Gld, Design, Synspar $ ENDODONTICS (EXCLUDING FINAL RESTORATIONS) INCLUDES ALL IRRIGANTS, DISINFECTANTS, INTRACANAL MEDICAMENTS, ADHESIVES, AND FILLING MATERIALS, REMOVAL OF EXISTING RESTORATIONS, RUBBER DAM PLACEMENT, AND POST-TREATMENT TEMPORIZATION. *COVERED ONLY AT GP OFFICE UNLESS SPECIFIC PRIOR AUTHORIZATION GIVEN BY PLAN FOR SPECIALIST TO PERFORM D3110 Pulp cap - direct CDN2019A250+ 3

4 CODE DESCRIPTION MEMBER COPAYMENT D3120 Pulp cap - indirect D3220 Therapeutic pulptmy $25.00 D3221 Pulpal debridement - primary and permanent when enddntic treatment nt cmpleted n same day $25.00 D3230 Pulpal therapy (resrbable filling) - anterir, primary tth $40.00 D3240 Pulpal therapy (resrbable filling) - psterir, primary tth $40.00 D3310 Rt canal - anterir per tth $ D3320 Rt canal - premlar, per tth $ D3330 Rt canal - mlar tth, per tth $ D3331 Treatment f rt canal bstructin - subject t prper dcumentatin f cnditin and prcedure. 70%UCR See clinical guidelines. D3332 Incmplete enddntic therapy; inperable, unrestrable r fractured tth $ D3346 Retreatment f previus rt canal therapy - anterir $ D3347 Retreatment f previus rt canal therapy - premlar $ D3348 Retreatment f previus rt canal therapy - mlar $ D3351 Apexificatin/recalcificatin - initial visit $ D3352 Apexificatin/recalcificatin - interim medicatin replacement $ D3353 Apexificatin/recalcificatin - final visit (includes cmpleted rt canal) $ D3355 Pulpal regeneratin-initial visit $ D3356 Pulpal regeneratin-interim medicatin replacement $ D3357 Pulpal regeneratin-cmpletin f treatment $ D3410 Apicectmy - anterir $ D3421 Apicectmy- bicuspid (first rt) $ D3425 Apicectmy- mlar (first rt) $ D3426 Apicectmy-(each additinal rt) $ D3427 Periradicular surgery withut apicectmy $ D3430 Retrgrade filling - per rt $ D3450 Rt amputatin - per rt $ D3920 Hemisectin (including any rt remval), nt including rt canal therapy $ D3950 Canal preparatin & fitting f prefrmed dwel r pst by prvider ther than prvider placing pst.* $75.00 PERIODONTICS # - COVERED ONLY WHEN PERFORMED BY THE MEMBER'S PRIMARY GENERAL DENTIST. * - PROCEDURES LIMITED TO ONCE EVERY 6 MONTHS +-THE PLAN CONSIDERS GINGIVECTOMY PROVIDED IN ASSOCIATION WITH ANY DIRECT FILL RESTORATION TO BE INCLUDED IN THE FEE FOR THE RESTORATION. D4210 Gingivectmy r gingivplasty - 4 r mre cntiguus teeth per quadrant $ D4211 Gingivectmy r gingivplasty - 1 t 3 cntiguus teeth per quadrant $75.00 D4212 Gingivectmy r gingivplasty t allw access fr restrative prcedure, per tth + $40.00 D4240 Gingival flap prcedure - 4 r mre cntiguus teeth per quadrant $ D4241 Gingival flap prcedure - 1 t 3 cntiguus teeth per quadrant $ D4249 Clinical crwn lengthening - hard tissue. D4249, when perfrmed the same day as impressin will $ be cnsidered t be D4212.# D4260 Osseus surgery - 4 r mre cntiguus teeth per quadrant $ D4261 Osseus surgery - 1 t 3 cntiguus teeth per quadrant $ D4263 Bne replacement graft - first site in quadrant, Nt t be used fr extractin site bne grafts $ D4264 Bne replacement graft each additinal site in quadrant, Nt t be used fr extractin site bne $ grafts D4341 Peridntal scaling and rt planing - fur r mre teeth per quadrant # $65.00 D4342 Peridntal scaling and rt planing - ne t three teeth per quadrant # $50.00 D4346 Scaling in presence f generalized mderate r severe gingival inflammatin - full muth, after $0.00 ral evaluatin *, # D4346 Scaling in presence f generalized mderate r severe gingival inflammatin - full muth, after $45.00 ral evaluatin, each additinal. # D4355 Full muth debridement t enable a cmprehensive ral evaluatin and diagnsis n a subsequent visit. Nt t be cmpleted n same day as D0150, D0160, r D0180. Must be fllwed by a separate, subsequent treatment visit (D1120, D1110, D4142/D4143, D4346, D4910) r will be cnsidered by plan t be D1110/D1120) $25.00 D4381 Lcalized delivery f antimicrbial agents, per tth $60.00 D4910 Peridntal maintenance - nce every 6 mnths $50.00 D4910 Peridntal maintenance - each additinal $50.00 D4920 Unscheduled dressing change (by smene ther than treating dentist r their staff) $0.00 CDN2019A250+ 4

5 CODE DESCRIPTION MEMBER COPAYMENT D4921 Gingival Irrigatin (Per quadrant in cnjunctin with D4341/D4342. Per visit in cnjunctin with D1110/D1120, 4355, D4346 r D4910. See Clinical Guidelines) $40.00 REMOVABLE PROSTHODONTICS EXCEPT WHEN NOTED, INCLUDES ALL LAB COSTS AND POST DELIVERY ADJUSTMENTS FOR 6 MONTHS FOLLOWING DELIVERY. REPLACED ONCE EVERY 5 YEARS FROM INITIAL PLACEMENT UNDER PLAN COVERAGE & RELINED ONCE EVERY 24 MONTHS, AS PER LIMITATIONS, EXCLUSIONS, AND GUIDELINES. * RELINE, REPAIR, REBASE, AND REPLACE OF THERMOPLASTIC PARTIALS IS COVERED ONLY ON ADVANTAGE PLANS. ON ADVANTAGE PLANS ADD $25 TO LISTED COPAYMENT FOR REPAIRS/RELINES/REBASES OF THERMOPLASTIC/FLEXIBLE BASE FULL AND PARTIAL DENTURES D5110 Cmplete upper denture $ D5120 Cmplete lwer denture $ D5130 Immediate upper denture $ D5140 Immediate lwer denture $ D5211 Upper partial denture - resin base $ D5212 Lwer partial denture - resin base $ D5213 Upper partial denture - cast metal framewrk with resin denture bases $ D5214 Lwer partial denture - cast metal framewrk with resin denture bases $ D5221 Immediate maxillary partial denture - resin base $ D5222 Immediate mandibular partial denture - resin base $ D5223 Immediate maxillary partial denture - metal framewrk $ D5224 Immediate maxillary partial denture - metal framewrk $ D5225 Upper partial denture - flexible base $ D5226 Lwer partial denture - flexible base $ D5410 Adjust cmplete denture - upper $25.00 D5411 Adjust cmplete denture - lwer $25.00 D5421 Adjust partial denture - upper $20.00 D5422 Adjust partial denture - lwer $20.00 D5511 Repair brken cmplete denture base, mandibular. * $50.00 D5512 Repair brken cmplete denture base, maxillary. * $50.00 D5520 Replace missing r brken teeth - cmplete denture (each tth)* $25.00 D5611 Repair resin denture base, mandibular.* $50.00 D5612 Repair resin denture base, maxillary.* $50.00 D5621 Repair cast partial framewrk, mandibular. $50.00 D5622 Repair cast partial framewrk, maxillary. $50.00 D5630 Repair r replace brken clasp* $40.00 D5640 Replace partial denture brken teeth - per tth $25.00 D5650 Add tth t existing partial denture* $50.00 D5660 Add clasp t existing partial denture* $50.00 D5670 Replace all teeth and acrylic n cast metal framewrk (Upper) $ D5671 Replace all teeth and acrylic n cast metal framewrk (Lwer) $ D5710 Rebase cmplete upper denture $95.00 D5711 Rebase cmplete lwer denture $95.00 D5720 Rebase upper partial denture $95.00 D5721 Rebase lwer partial denture $95.00 D5730 Reline cmplete upper denture (chairside) $65.00 D5731 Reline cmplete lwer denture (chairside) $65.00 D5740 Reline upper partial denture (chairside) $65.00 D5741 Reline lwer partial denture (chairside) $65.00 D5750 Reline cmplete upper denture (labratry)* $ D5751 Reline cmplete lwer denture (labratry)* $ D5760 Reline upper partial denture (labratry)* $ D5761 Reline lwer partial denture (labratry)* $ D5820 Interim partial denture (upper) $ D5821 Interim partial denture (lwer) $ D5850 Tissue cnditining, upper $25.00 D5851 Tissue cnditining, lwer $25.00 D5876 Add metal substrate t new acrylic full denture (per arch) $ ALTERNATIVE DENTURES, FULL + PARTIAL, & RELINES MOST DENTAL OFFICES OFFER ALTERNATIVES TO STANDARD COMPLETE AND PARTIAL DENTURES AND RELINES WHICH ARE MARKETED UNDER DIFFERENT BRAND NAMES AND MAY BE AVAILABLE THROUGH YOUR CALIFORNIA DENTAL PARTICIPATING PROVIDER FOR THE FOLLOWING COPAYMENTS. THIS LIST IS UPDATED REGULARLY- CONTACT THE PLAN FOR AN UP TO DATE LIST OF CURRENTLY COVERED MATERIALS. Cmplete Denture CDN2019A250+ 5

6 CODE DESCRIPTION MEMBER COPAYMENT Cmfrt Flex - Cmplete Upper Denture $ Cmfrt Flex - Cmplete Lwer Denture $ Geneva - Cmplete Upper Denture $ Geneva - Cmplete Lwer Denture $ Partial Denture - Resin Base Simply Natural/Cmfrt Flex - Upper Partial $ Simply Natural/Cmfrt Flex - Lwer Partial $ Geneva - Upper Partial $ Geneva - Lwer Partial $ EstheticClasp - Upper Partial $ EstheticClasp - Lwer Partial $ CuSil - Upper Partial $ CuSil - Lwer Partial $ Valplast - Upper Partial $ Valplast - Lwer Partial $ Partial Denture - Cast Metal Base with Resin Saddles Cmfrt Flex - Upper Partial $ Cmfrt Flex - Lwer Partial $ Valplast - Upper Partial $ Valplast - Lwer Partial $ Denture Relines PermaSft - Cmplete Upper Denture (Labratry) $ PermaSft - Cmplete Lwer Denture (Labratry) $ PermaSft - Partial Upper Denture (Labratry) $ PermaSft - Partial Lwer Denture (Labratry) $ D D5999 VII MAXILLOFACIAL PROSTHETICS - NOT COVERED IMPLANT SERVICES INCLUDES LAB COSTS, TEMPORIZATION, AND REMOVAL OF EXISTING RESTORATIONS. MANY DENTAL OFFICES OFFER PREMIUM MATERIALS AS ALTERNATIVES TO THE STANDARD PORCELAIN/CERAMIC SUBSTRATE AND PORCELAIN-FUSED-TO-METAL MATERIALS FOR DENTAL RESTORATIONS, WHICH ARE MARKETED UNDER DIFFERENT BRAND NAMES AND MAY BE AVAILABLE THROUGH YOUR CALIFORNIA DENTAL PARTICIPATING PROVIDER FOR THE FOLLOWING COPAYMENTS. *CROWNS, BRIDGES, INLAYS, AND ONLAYS, FABRICATED IN THESE PREMIUM MATERIAL ALTERNATIVES AND PREPARED AND DELIVERED ON THE SAME DAY ARE SUBJECT TO AN ADDITIONAL $ IN-OFFICE LAB FEE. THIS LIST IS UPDATED REGULARLY-CONTACT THE PLAN FOR AN UP TO DATE LIST OF COVERED MATERIALS AND APPLICABLE COPAYMENTS. D6010 Surgical placement f implant bdy, endsteal; includes cst f, and placement f, healing cap $1, when indicated. D6056 Prefabricated abutment, includes placement $ D6058 Abutment supprted prcelain/ceramic crwn $1, D6059 Abutment supprted prcelain/high nble crwn $1, D6060 Abutment supprted prcelain/base metal crwn $1, D6061 Abutment supprted prcelain/nble metal crwn $1, D6062 Abutment supprted cast metal crwn, high nble $1, D6063 Abutment supprted cast metal crwn, base metal $ D6064 Abutment supprted cast metal crwn, nble metal $ D6065 Implant supprted prcelain/ceramic crwn $ D6066 Implant supprted prcelain/metal crwn $ D6067 Implant supprted metal crwn $ D6068 Abutment supprted retainer, prcelain/ceramic FPD $1, D6069 Abutment supprted retainer, metal FPD, high nble $1, D6070 Abut. supprt. retainer, prc./metal FPD, base metal $ D6071 Abut. supprt. retainer, prc./metal FPD, nble $1, D6072 Abut. supprt. retainer, cast metal FPD, high nble $ D6073 Abut. supprt. retainer, cast metal FPD, base metal $ D6074 Abut. supprt. retainer, cast metal FPD, nble $ D6075 Implant supprted retainer fr ceramic FPD $1, D6076 Implant supprted retainer fr prc./metal FPD $1, D6077 Implant supprted retainer fr cast metal FPD $ D6081 Scaling and debridement in the presence f inflammatin r mucsitis f a single implant, $25.00 including cleaning f the implant surfaces, withut flap entry and clsure. This prcedure is nt t be perfrmed n the same day as D1110, D4346, r D4910. D6085 Prvisinal implant crwn $0.00 D6092 Recement implant/abutment supprted crwn $45.00 CDN2019A250+ 6

7 D6093 Recement implant/abutment supprted FPD $65.00 D6094 Abutment supprted crwn, titanium $ D6194 Abut. supprted retainer crwn, FPD, titanium $ FIXED PROSTHODONTICS INCLUDES ALL BASES, LINERS, ADHESIVES, BONDING AGENTS, DESENSITIZING AGENTS, REMOVAL OF EXISTING RESTORATIONS, LAB COSTS, AND TEMPORIZATION. D6210 Pntic - cast high nble metal $ D6211 Pntic - cast predminantly base metal $ D6212 Pntic - cast nble metal $ D6214 Pntic- titanium (includes prcelain fused t titanium) $ D6240 Pntic - prcelain fused t high nble metal $ D6241 Pntic - prcelain fused t predminantly base metal $ D6242 Pntic - prcelain fused t nble metal $ MLR Pntic- prcelain fused t any metal fr mlars Add $75 t nnmlar cpayment fee. D6245 Pntic prcelain/ceramic $ D6253 Prvisinal Pntic- When final impressin nt taken and when replacing anterir tth lst r anterir prsthesis being replaced while cvered by CDN D6600 Inlay - prcelain/ceramic, 2 surfaces $ D6601 Inlay - prcelain/ceramic, 3 r mre surfaces $ D6602 Inlay - cast high nble metal, 2 surfaces $ D6603 Inlay - cast high nble metal, 3 r mre surfaces $ D6604 Inlay - cast predminantly base metal, 2 surfaces $ D6605 Inlay - cast predminantly base metal, 3 r mre surfaces $ D6606 Inlay - cast nble metal, 2 surfaces $ D6607 Inlay - cast nble metal, 3 r mre surface $ D6608 Onlay -prcelain/ceramic, 2 surfaces $ D6609 Onlay - prcelain/ceramic, 3 r mre surfaces $ D6610 Onlay - cast high nble metal, 2 surfaces $ D6611 Onlay - cast high nble metal, 3 r mre surfaces $ D6612 Onlay - cast predminantly base metal, 2 surfaces $ D6613 Onlay - cast predminantly base metal, 3 r mre surfaces $ D6614 Onlay - cast nble metal, 2 surfaces $ D6615 Onlay - cast nble metal, 3 r mre surfaces $ D6624 Inlay - titanium $ D6634 Onlay - titanium $ D6740 Crwn-prcelain/ceramic $ D6750 Crwn - prcelain fused t high nble metal $ D6751 Crwn - prcelain fused t predminantly base metal $ D6752 Crwn - prcelain fused t nble metal $ MLR Crwn-prcelain fused t any metal fr Mlars Add $75 t nnmlar cpayment fee. D6780 Crwn - 3/4 cast high nble metal $ D6781 Crwn - 3/4 cast predminantly base metal $ D6782 Crwn - 3/4 cast nble metal $ D6783 Crwn - 3/4 prcelain/ceramic $ D6790 Crwn - full cast high nble metal $ D6791 Crwn - full cast predminantly base metal $ D6792 Crwn - full cast nble metal $ D6793 Prvisinal retainer crwn - When final impressin nt taken and when replacing anterir tth lst r anterir prsthesis being replaced while cvered by CDN D6794 Crwn - titanium (includes prcelain fused t titanium) $ D6930 Recement r rebnd fixed partial denture $25.00 D6980 Fixed partial denture repair, necessitated by restrative material failure. Nt allwed t be $ charged by same prvider within 24 mnths f the riginal restratin D6985 Pediatric partial denture--fixed, temprary $ ALTERNATIVE BRIDGE MATERIALS MANY DENTAL OFFICES OFFER PREMIUM MATERIALS AS ALTERNATIVES TO THE STANDARD PORCELAIN/CERAMIC SUBSTRATE AND PORCELAIN-FUSED-TO-METAL MATERIALS FOR DENTAL RESTORATIONS, WHICH ARE MARKETED UNDER DIFFERENT BRAND NAMES AND MAY BE AVAILABLE THROUGH YOUR CALIFORNIA DENTAL PARTICIPATING PROVIDER FOR THE FOLLOWING COPAYMENTS. *CROWNS, BRIDGES, INLAYS, AND ONLAYS, FABRICATED IN THESE CDN2019A250+ 7

8 PREMIUM MATERIAL ALTERNATIVES AND PREPARED AND DELIVERED ON THE SAME DAY ARE SUBJECT TO AN ADDITIONAL $ IN-OFFICE LAB FEE. THIS LIST IS UPDATED REGULARLY-CONTACT THE PLAN FOR AN UP TO DATE LIST OF CURRENTLY COVERED MATERIALS. PORCELAIN/CERAMIC SUBSTRATE CROWN CEREC, Full-Z, Bruxzir, Lava, Prismatik $ CEREC Blue Blck, e.max, Prcera $ Lava (layered), e.max (layered), Prcera (Layered) $ PORCELAIN FUSED TO HIGH NOBLE CROWN Captek, Bi-2000 $ Occlusal Gld, Design, Synspar $ ORAL SURGERY INCLUDES SUTURES AND CLOTTING AGENTS; EXTRACTIONS INCLUDE MINOR SMOOTHING OF BONE. D7111 Extractin, crnal remnants - primary tth $25.00 D7140 Extractin, erupted tth r expsed rt $25.00 D7210 Surgical remval f erupted tth $45.00 D7220 Remval f impacted tth - sft tissue $90.00 D7230 Remval f impacted tth - partially bny $ D7240 Remval f impacted tth - cmpletely bny $ D7241 Remval f impacted tth - cmpletely bny, with unusual cmplicatins $ D7250 Surgical remval f residual tth rts (cutting prcedure) $90.00 D7251 Crnectmy - intentinal partial tth remval $ D7270 Tth reimplantatin and/r stabilizatin f accidentally displaced tth $ D7310 Alveplasty in cnjunctin with extractins - 4 r mre cntiguus teeth per quadrant $70.00 D7311 Alveplasty in cnjunctin with extractins - 1 t 3 teeth/spaces per quadrant $70.00 D7320 Alveplasty nt in cnjunctin with extractins - 4 r mre cntiguus teeth per quadrant $90.00 D7321 Alveplasty nt in cnjunctin with extractins - 1 t 3 teeth/spaces per quadrant $90.00 D7510 Incisin and drainage f abscess - intraral sft tissue $ ORTHODONTICS (ONLY WHEN PROVIDED BY PARTICIPATING ORTHODONTIST) * - COVERED FOR UP TO 24 MONTHS OF ACTIVE TREATMENT D8020 Limited rthdntic treatment f the transitinal dentitin* $1, D8030 Limited rthdntic treatment f the adlescent dentitin* $1, D8040 Limited rthdntic treatment f the adult dentitin* $1, D8050 Interceptive rthdntic treatment f the primary dentitin* $1, D8060 Interceptive rthdntic treatment f the transitinal dentitin* $1, D8070 Cmprehensive rthdntic treatment f the transitinal dentitin* $1, D8080 Cmprehensive rthdntic treatment f the adlescent dentitin* $1, D8090 Cmprehensive rthdntic treatment f the adult dentitin* $2, D8660 pre-rthdntic treatment visit examinatin t mnitr grwth and develpment $0.00 D8670 Peridic rthdntic treatment visit (as part f cntract) $0.00 D8680 Orthdntic retentin - Per Arch $ D8681 Remvable rthdntic retainer adjustment $20.00 D8695 remval f fixed rthdntic appliances fr reasns ther than cmpletin f treatment $25.00 D8999 Orthdntic Treatment Plan and Recrds(pre/pst x-rays, phts, study mdels) $ D8999 Active Orthdntic Treatment beynd 24 mnths - Per Visit. $75.00 Appliances (head gear, maxillary expansin, etc.) may be required in additin t full banding. UCR* ADJUNCTIVE GENERAL SERVICES * - COVERED ONLY FOR THE REMOVAL OF IMPACTED WISDOM TEETH (1,16,17 & 32) # - COVERED ONLY WHEN PERFORMED BY THE MEMBER'S PRIMARY GENERAL DENTIST. D9110 Palliative (emergency) treatment f dental pain - minr prcedure $0.00 D9120 Sectining f fixed partial denture (bridge) $25.00 D9210 Lcal anesthesia nt in cnjunctin with perative r surgical prcedures $0.00 D9215 Lcal anesthesia $0.00 D9222 Deep sedatin/general anesthesia first 15 minutes* $ D9223 Deep sedatin/general anesthesia - each subsequent 15 minutes* $ D9230 Analgesia, anxilysis, inhalatin f nitrus xide* D9239 Intravenus mderate (cnscius) sedatin/analgesia first 15 minutes* $ D9243 Intravenus mderate (cnscius) sedatin/analgesia each subsequent 15 minutes* $80.00 D9310 Cnsultatin & Secnd Opinin, with prir authrizatin frm Plan. Diagnstic service $25.00 prvided by dentist r physician ther than requesting dentist r physician, nt chargeable n same day as therapeutic services. D9311 Cnsultatin with a medical health care prfessinal $0.00 D9430 Office visit fr bservatin (during regularly scheduled hurs) $0.00 D9440 Office visit - after regularly scheduled hurs $35.00 CDN2019A250+ 8

9 D9450 Case presentatin, detailed and extensive treatment planning $0.00 D9999 Office visit - during regular ffice hurs in additin t ther charges $5.00 D9630 Other drugs and/r medicaments dispensed in the ffice fr hme use. $40.00 D9910 Applicatin f desensitizing medicament, per visit. (nt t be used under restratins) D9911 Applicatin f desensitizing resin fr cervical and/r rt surface, per tth (nt t be used under restratins) D9930 Treatment f cmplicatin (pst-surgical), unusual circumstances, by reprt $0.00 D9932 In ffice cleaning and inspectin f remvable cmplete upper denture. Limited t nce every 6 $10.00 mnths. D9933 In ffice cleaning and inspectin f remvable cmplete lwer denture. Limited t nce every 6 $10.00 mnths. D9934 In ffice cleaning and inspectin f remvable partial upper denture. Limited t nce every 6 $10.00 mnths. D9935 In ffice cleaning and inspectin f remvable partial lwer denture. Limited t nce every 6 $10.00 mnths. D9942 Repair/reline cclusal guard $40.00 D9943 Occlusal guard adjustment. Cverage is limited t nly sft guards that are a Plan cvered $10.00 benefit. D9944 cclusal guard hard appliance, full arch $ D9945 cclusal guard sft appliance, full arch $ D9946 cclusal guard hard appliance, partial arch $ D9951 Occlusal adjustment - limited $20.00 D9961 duplicate/cpy patient s recrds $25.00 D9972 External bleaching - per arch, perfrmed in ffice $ D9973 External bleaching - per tth $30.00 D9975 External bleaching fr hme applicatin- per arch $ D9986 Missed appintment $25.00 D9987 Cancelled appintment $25.00 D9990 certified translatin r sign-language services per visit. Cntact the Plan t arrange services at n $0.00 charge t member r prvider D9995 teledentistry synchrnus; real-time encunter# $0.00 D9996 teledentistry asynchrnus; infrmatin stred and frwarded t dentist fr subsequent review# $0.00 D9999 Brken Appintment - less than 24 ntice $25.00 D9999 Brken Specialist Appintment - less than 24 ntice $40.00 Specialty Cverage: A250+ Nt all general dentists are capable f perfrming each f the services listed herein and, based upn the Member s cnditin, certain prcedures may nt be within the scpe f practice r ability f a general dentist. In such cases, nce apprved by the Plan, the Member will be referred t a cntracted dental specialist. The csts f services prvided by a cntracted dental specialist in excess f the Member's listed cpayments (which are due and payable by the Member at the time f service) are cvered benefits fr Members with an LS after the Plan number n their identificatin card, r, fr Advantage plans thse that have NO suffix n the plan number, and they are limited t $1,000 in benefits paid by the Plan n the Member s behalf per Member per year and then a 30% discunt frm the specialist s UCR fee n cvered, apprved, services listed abve thereafter. Peddntic specialty services are cvered at a 50% discunt ff f the specialist's UCR fees n cvered, apprved, services up t $500 in benefits paid by the Plan n the Member's behalf per Member per year, and then a 30% discunt frm the specialist s UCR fee n cvered, apprved, services listed abve thereafter. A250+S A250+V Nt all general dentists are capable f perfrming each f the services listed herein and, based upn the Member s cnditin, certain prcedures may nt be within the scpe f practice r ability f a general dentist. In such cases, nce apprved by the Plan, the Member will be referred t a cntracted dental specialist. The csts f services prvided by a cntracted dental specialist in excess f the Member's listed cpayments (which are due and payable by the Member at the time f service) are cvered benefits fr Members with an S after the Plan number n their identificatin card, and the Member will pay the cpayment amunts listed n their plan benefit schedule with n annual maximum. Peddntic specialty services are cvered at a 50% discunt ff f the specialist's UCR fees n cvered, apprved, services up t $500 in benefits paid by the Plan n the Member's behalf per Member per year, and then a 30% discunt frm the specialist s UCR fee n cvered, apprved, services listed abve thereafter. Nt all general dentists are capable f perfrming each f the services listed herein and, based upn the Member s cnditin, certain prcedures may nt be within the scpe f practice r ability f a general dentist. In such cases, nce apprved by the Plan, the Member will be referred t a cntracted dental specialist. The participating cntracted dental specialist will prvide Members the cvered services listed abve at a 30% discunt frm the participating specialist's UCR fees fr the first year, and a 50% discunt thereafter, fr up t $1,000 in cvered, CDN2019A250+ 9

10 apprved, UCR services per year; and then a 30% discunt frm the specialist s UCR fee n cvered, apprved, services listed abve thereafter. Peddntic specialty services are cvered at a 50% discunt ff f the specialist's UCR fees n cvered, apprved, services up t $500 in UCR services per Member, per year, and then a 30% discunt frm the specialist s UCR fee n cvered, apprved, services listed abve thereafter. EXCLUSIONS AND LIMITATIONS Sme limitatins and exclusins are waived fr Members n Advantage Plans. See Clinical Guidelines fr specific plicies. EXCLUSIONS Treatment f fractures r dislcatins; cngenital malfrmatins; malignancies, cysts, r neplasms; r Temprmandibular Jint Syndrme (TMJ). Extractins r x-rays fr rthdntic purpses. Prescriptin Drugs and ver the cunter medicines. Any services invlving implants r experimental prcedures. Any prcedures perfrmed fr csmetic, elective r aesthetic purpses Any prcedure t replace r stabilize tth structure lst by attritin, abrasin, ersin r grinding. Any prcedure nt specifically listed as a cvered Benefit. Services prvided utside the CDN Participating General Dentist s ffice that the Member selected, r was assigned, t receive cvered services, unless expressly authrized by CDN. Services, which in the pinin f the attending CDN dentist, cannt be perfrmed in the dental ffice due t the general health and/r physical r behaviral limitatins f the Member. Services fr injuries r cnditins, which were caused by acts f war, r are cvered under Wrker s Cmpensatin r Emplyer s Liability Laws. Services which in the pinin f the attending CDN dentist are nt necessary fr the Member s dental health r which have a pr prgnsis. Expenses incurred in cnnectin with any dental prcedure started prir t the effective date f Cverage r after the terminatin date f Cverage. Hspital csts f any kind. Lss r theft f full r partial dentures. Any prcedures r appliances fr the purpse f crrecting cntur, cntact, cclusin r t change vertical dimensin. Damage t teeth due t muth jewelry, fr example tngue piercing. Services f a prsthdntist. LIMITATIONS Prphylaxis (teeth cleaning) is limited t nce every six mnths. Fluride treatment is cvered nce every 6 mnths. Bitewing x-rays are limited t ne series f fur films every 12 mnths. Full muth x-rays are limited t nce every 24 mnths. Peridntal treatments (sub-gingival curettage and rt planing) are limited t ne treatment per quadrant in any 12-mnth perid. Fixed bridgewrk will be cvered nly when a partial cannt satisfactrily restre the case. If fixed bridges are used when a partial culd satisfactrily restre the case, the fixed bridge is cnsidered ptinal treatment. CDN2019A

11 Replacement f partial dentures is limited t nce every five years frm initial placement while the member is cvered by the plan, unless necessary due t natural tth lss where the additin r replacement f teeth t the existing partial is nt feasible. Full upper and/r lwer dentures are nt t exceed ne each in any five-year perid frm initial placement while the member is cvered by the plan. Replacement will be prvided by CDN fr an existing full r partial denture nly if it is unserviceable and cannt be made serviceable by either reline r repair. Denture relines are limited t ne per arch in any 12-mnth perid. Sealants when cvered are limited t permanent first and secnd mlars. Replacement f a restratin is cvered nly when dentally necessary. Replacement f existing bridgewrk is cvered nly when it cannt be made satisfactry by repair. Services f a specialist are cvered Benefits nly when specifically listed, and when cvered, Peddntic referral and services are cvered at 50% f the peddntist s fees t a maximum f $500 per Member per year. Optinal Treatment If (1) a less expensive alternative prcedure, service r curse f treatment can be perfrmed in place f the prpsed treatment t crrect a dental cnditin, as determined by the Plan; and (2) the alternate treatment will prduce a prfessinally satisfactry result; then the maximum eligible dental expense t be cnsidered fr payment will be the less expensive treatment. Crwns are limited t five per arch per year. ADDITIONAL EXCLUSIONS AND LIMITATIONS FOR ORTHODONTICS Orthdntic treatment must be rendered by a participating CDN Orthdntist and the Member must remain eligible thrughut the perid f active rthdntic treatment. Members lsing eligibility during treatment will be charged the treating Orthdntist s usual and custmary fees fr any unfinished treatment. Orthdntic Benefits are fr 24 mnths f active treatment. Treatment in excess f 24 mnths (extended treatment) is available at the participating CDN Orthdntist s usual and custmary fees. Members whse treatment is extended because f grss nn-cmpliance r wh change Prviders while in active treatment will incur additinal charges. Unless specifically listed in the Summary f Benefits, the fllwing are nt cvered Benefits under this Evidence f Cverage and Disclsure Frm: Study Mdels and Initial Diagnstic Wrk-up X-rays fr Orthdntic Purpses Tracings and Phtgraphs Extractins fr Orthdntic purpses Phase I Orthdntic Treatment The fllwing are nt included as an rthdntic Benefit: Replacement r repair f lst r brken appliances, Re-treatment f rthdntic cases, Treatments started r in prgress prir t a Member s eligibility, Changes in treatment necessitated by an accident, Orthdntic treatment that invlves: Maxillfacial surgery, myfunctinal therapy, cleft palate, micrgnathia, macrglssia, Surgically expsing impacted teeth (i.e., Maxillary cuspids), Hrmnal imbalances r ther factrs causing grwth and develpment abnrmalities, Treatment related t temprmandibular jint disturbances (TMJ), Lingually placed direct bnded appliances and arch wires - invisible braces, Cases invlving surgical rthdntics, Severe r mutilated malcclusins. CDN2019A

12 Treatment using plastic aligners (i.e. Invisalign, Clear Crrect, Red White & Blue ). ADDITIONAL EXCLUSIONS AND LIMITATIONS FOR IMPLANTS Implants are a cvered benefit nly fr Grups n Advantage Grup Plans that have purchased the OPTIONAL CDN Implant Benefit Rider. Refer t yur included Schedule f Benefits and Cvered Services fr a listing f yur cvered benefits. All cvered implant services are subject t eligibility and dental necessity at the time f service, and must be recmmended by the dentist. Implants are limited t n mre than nce fr the same tth psitin in a five (5) year perid. Implant supprted prsthetics are limited t n mre than nce fr the same tth psitin in a five (5) year perid: when needed t replace cngenitally missing teeth; r when needed t replace natural teeth Implants, Implant supprted prsthetics, and Implant abutments are limited t n mre than tw (2) each per year. Dental prcedures nt listed are available at the dental ffice s usual and custmary fee. If yu questin a curse f treatment, a fee, r cvered benefits, DO NOT START TREATMENT until yu have cntacted Member Services tll-free at r a review f yur treatment plan and charges. Or a secnd pinin may be arranged by Member Services nly befre treatment is rendered. Califrnia Dental Netwrk, Inc is licensed by the Califrnia Department f Managed Health Care under the Knx Keene Health Care Service Plan Act (License number ). CDN2019A