Concordia Plus Schedule of Benefits

Transcription

1 Concordia Pls Schedle of Benefits Plan IMPORTANT INFORMATION ABOUT YOUR PLAN This schedle of benefits provides a listing of procedres covered by yor plan. For procedres that reqire a copayment, the amont to be paid is shown in the colmn titled. Yo pay these copayments to the dental office at the time of service. Yo mst select a United Concordia Primary Dental Office (PDO) to receive covered services. Yor PDO will perform the below procedres or refer yo to a specialty care dentist for frther care. Treatment by an Ot-of-Network dentist is not covered, except as described in the Certificate of Coverage. Only procedres listed on this Schedle of Benefits are Covered Services. For services not listed (not covered), Yo are responsible for the fll fee charged by the dentist. Procedre codes and member Copayments may be pdated to meet American Dental Association () Crrent Dental Terminology (CDT) in accordance with national standards. In-Network Dentists will charge an additional $125 for the se of precios (high noble) or semi precios (noble) metal. For a complete description of yor plan, please refer to the Certificate of Coverage and the Schedle of Exclsions and Limitations in addition to this Schedle of Benefits. If yo have any qestions abot yor United Concordia dental plan, please call or Cstomer Service Department toll-free at or access or website at CLINICAL ORAL EVALUATIONS D12 Periodic Oral Evalation - Established Patient D1 Limited Oral Evalation - Problem Focsed D15 Oral Evalation For A Patient Under 3 Years Of Age And Conseling With Primary Caregiver D15 Comprehensive Oral Evalation - New Or Established Patient D16 Detailed And Extensive Oral Evalation - Problem Focsed, By Report D17 Re-Evalation-Limited, Problem Focsed (Established Patient; Not Post-Operative Visit) D171 Re Evalation Post-Operative Office Visit D18 Comprehensive Periodontal Evalation RADIOGRAPHS/DIAGNOSTIC IMAGING (inclding interpretation) D21 Intraoral - Complete Series Of Radiographic Images D22 Intraoral- Periapical First Radiographic Image D23 Intraoral- Periapical Each Additional Radiographic Image D2 Intraoral - Occlsal Radiographic Image D25 Extra-oral - 2D Projection Radiographic Image Created Using A Stationary Radiation Sorce, And Detector D251 Extra-oral Posterior Dental Radiographic Image D27 Bitewing - Single Radiographic Image D272 Bitewings - Two Radiographic Images D273 Bitewings - Three Radiographic Images D27 Bitewings - For Radiographic Images D277 Vertical Bitewings - 7 To 8 Radiographic Images D33 Panoramic Radiographic Image D3 2D Cephalometric Radiographic Image - Acqisition, Measrement And Analysis RADIOGRAPHS/DIAGNOSTIC IMAGING (inclding interpretation) D35 2D Oral/Facial Photographic Image Obtained Intra Orally Or Extra Orally TESTS AND EXAMINATIONS D15 Collection Of Microorganisms For Cltre And Sensitivity D16 Viral Cltre D17 Collection And Preparation Of Saliva Sample For Laboratory Diagnostic Testing 15 D18 Analysis Of Saliva Sample 15 D22 Collection and Preparation Of Genetic Sample Material For Laboratory Analysis And Report D23 Genetic Test for Ssceptibility To Diseases - Specimen Analysis D25 Caries Ssceptibility Tests D31 Adjnctive Pre-Diagnostic Test That Aids In Detection Of Mcosal Abnormalities Inclding Premalignant And Malignant Lesions, Not To Inclde Cytology Or Biopsy Procedres D6 Plp Vitality Tests D7 Diagnostic Casts ORAL PATHOLOGY LABORATORY D72 Accession Of Tisse, Gross Examination, Preparation And Transmission Of Written Report D73 Accession Of Tisse, Gross And Microscopic Examination, Preparation And Transmission Of Written Report D7 Accession Of Tisse, Gross And Microscopic Examination, Inclding Assessment Of Srgical Margins For Presence Of Disease, Preparation And Transmission Of Written Report D52 Other Oral Pathology Procedres, By Report D61 Caries Risk Assessment And Docmentation, With A Finding Of Low Risk CA Base 9 (1/12) Crrent Dental Terminology 218 American Dental Association. All rights reserved.

2 ORAL PATHOLOGY LABORATORY D62 Caries Risk Assessment And Docmentation, With A Finding Of Moderate Risk D63 Caries Risk Assessment And Docmentation, With A Finding Of High Risk DENTAL PROPHYLAXIS D111 Prophylaxis, Adlt D112 Prophylaxis, Child TOPICAL FLUORIDE TREATMENT (office procedre) D126 Topical Application Of Floride Varnish D1 Topical Application Of Floride Exclding Varnish OTHER PREVENTIVE SERVICES D131 Ntritional Conseling For The Control Of Dental Disease D132 Tobacco Conseling For The Control And Prevention Of Oral Disease D133 Oral Hygiene Instrction D1351 Sealant - Per Tooth D1353 Sealant Repair - Per Tooth D135 Interim Caries Arresting Medicament Application - Per Tooth 15 SPACE MAINTENANCE (passive appliances) D151 Space Maintainer - Fixed, Unilateral (Tooth Nmbers Or Tooth Area Reqired) D1516 Space Maintainer - Fixed - bilateral, maxillary D1517 Space Maintainer - Fixed - bilateral, mandiblar D152 Space Maintainer - Removable, Unilateral D1526 Space Maintainer - Removable - bilateral, maxillary D1527 Space Maintainer - Removable - bilateral, mandiblar D155 Re Cement Or Re Bond Space Maintainer D1555 Removal Of Fixed Space Maintainer D15 Distal shoe space maintainers - fixed - nilateral AMALGAM RESTORATIONS (inclding polishing) D21 Amalgam - One Srface, Primary Or Permanent D215 Amalgam - Two Srfaces, Primary Or Permanent D216 Amalgam - Three Srfaces, Primary Or Permanent D2161 Amalgam - For Or More Srfaces, Primary Or Permanent RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D233 Resin-Based Composite - One Srface, Anterior D2331 Resin-Based Composite - Two Srfaces, Anterior D2332 Resin-Based Composite - Three Srfaces, Anterior D2335 Resin-Based Composite - For Or More Srfaces Or Involving Incisal Angle (Anterior) D239 Resin-Based Composite Crown, Anterior D2391 Resin-Based Composite - One Srface, Posterior 85 D2392 Resin-Based Composite - Two Srfaces, Posterior 19 RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D2393 Resin-Based Composite - Three Srfaces, Posterior 133 D239 Resin-Based Composite - For Or More Srfaces, Posterior 1 INLAY/ONLAY RESTORATIONS D251 Inlay - Metallic - One Srface 26 D252 Inlay - Metallic - Two Srfaces 27 D253 Inlay - Metallic - Three Or More Srfaces D252 Onlay - Metallic-Two Srfaces D253 Onlay - Metallic - Three Srfaces D25 Onlay - Metallic - For Or More Srfaces 3 CROWNS - SINGLE RESTORATIONS ONLY D271 Crown-Resin-Based Composite (Indirect) 25 D2712 Crown - 3/ Resin-Based Composite (Indirect) 25 D272 Crown, Resin With High Noble Metal 6 D2721 Crown, Resin With Predominantly Base Metal 6 D2722 Crown, Resin With Noble Metal 6 D27 Crown, Porcelain/Ceramic D2 Crown, Porcelain Fsed To High Noble Metal 6 D21 Crown-Porcelain Fsed To Predominantly 6 Base Metal D22 Crown, Porcelain Fsed To Noble Metal 6 D278 Crown - 3/ Cast High Noble Metal 6 D2781 Crown - 3/ Cast Predominantly Base Metal 6 D2782 Crown - 3/ Cast Noble Metal 6 D2783 Crown - 3/ Porcelain/Ceramic D279 Crown, Fll Cast High Noble Metal 6 D2791 Crown - Fll Cast Predominantly Base Metal 6 D2792 Crown, Fll Cast Noble Metal 6 D279 Crown-Titanim 6 D2799 Provisional Crown - Frther Treatment Or Completion Of Diagnosis Necessary Prior To Final Impression OTHER RESTORATIVE SERVICES D291 Re-Cement Or Re Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration D2915 Re Cement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core D292 Re-Cement Or Re Bond Crown D293 Prefabricated Stainless Steel Crown - Primary Tooth 8 D2931 Prefabricated Stainless Steel Crown - Permanent Tooth 1 D2932 Prefabricated Resin Crown 1 D2933 Prefabricated Stainless Steel Crown With Resin Window 1 D293 Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth 1 D29 Protective Restoration D299 Restorative Fondation For An Indirect Restoration D295 Core Bildp Inclding Any Pins When Reqired D2951 Pin Retention - Per Tooth, In Addition To Restoration D2952 Post And Core In Addition To Crown, Indirectly Fabricated CA Base 9 (1/12) Crrent Dental Terminology 218 American Dental Association. All rights reserved.

3 OTHER RESTORATIVE SERVICES D2953 Each Additional Indirectly Fabricated Post - Same Tooth 1 D295 Prefabricated Post And Core In Addition To Crown D2955 Post Removal D2957 Each Additional Prefabricated Post - Same Tooth 1 D2971 Additional Procedres To Constrct New Crown Under Existing Partial Dentre Framework 25 D298 Crown Repair Necessitated By Restorative Material Failre D2981 Inlay Repair Necessitated By Restorative Material Failre D2982 Onlay Repair Necessitated By Restorative Material Failre PULP CAPPING D311 Plp Cap - Direct (Exclding Final Restoration) D312 Plp Cap - Indirect (Exclding Final Restoration) PULPOTOMY D322 Therapetic Plpotomy (Exclding Final Restoration) D3221 Plpal Debridement, Primary And Permanent Teeth D3222 Partial Plpotomy For Apexogenesis- Permanent Tooth With Incomplete Root Development ENDODONTIC THERAPY ON PRIMARY TEETH D323 Plpal Therapy (Resorbable Filling)-Anterior, Primary Tooth (Exclding Final Restoration) D32 Plpal Therapy (Resorbable Filling)-Posterior, Primary Tooth (Exclding Final Restoration) ENDODONTIC THERAPY (inclding treatment plan, clinical procedres and follow-p care) D331 Endodontic Therapy, Anterior Tooth (Exclding Final Restoration) 2 D332 Endodontic Therapy, Premolar Tooth (Exclding Final Restoration) 3 D333 Endodontic Therapy, Molar Tooth (Exclding Final Restoration) ENDODONTIC RETREATMENT D336 Retreatment Of Previos Root Canal Therapy - Anterior D337 Retreatment Or Previos Root Canal Therapy - Premolar D338 Retreatment Of Previos Root Canal Therapy - Molar APEXIFICATION/RECALCIFICATION PROCEDURES D3351 Apexification/Recalcification Initial Visit (Apical Closre / Calcific Repair Of Perforations, Root Resorption, Etc.) 8 D3352 Apexification/Recalcification - Interim Medication Replacement (Apical Closre/Calcific Repair Of Perforations, Root Resorption, Plpal Space Disinfection, Etc.) 55 D3353 Apexification/Recalcification-Final Visit (Incldes Completed Root Canal Therapy- Apical Closre/Calcific Repair Of Perforations, Root Resorption, Etc.) 55 D3355 Plpal Regeneration - Initial Visit 8 APEXIFICATION/RECALCIFICATION PROCEDURES D3356 Plpal Regeneration - Interim Medication Replacement 55 D3357 Plpal Regeneration - Completion Of Treatment 55 APICOECTOMY/PERIRADICULAR SERVICES D31 Apicoectomy - Anterior D321 Apicoectomy - Premolar (First Root) D325 Apicoectomy - Molar (First Root) D326 Apicoectomy (Each Additional Root) D327 Periradiclar Srgery Withot Apicoectomy D33 Retrograde Filling - Per Root D35 Root Amptation - Per Root OTHER ENDODONTIC PROCEDURES D391 Srgical Procedre For Isolation Of Tooth With Rbber Dam D392 Hemisection (Inclding Any Root Removal) Not Inclding Root Canal Therapy D395 Canal Preparation And Fitting Of Preformed Dowel Or Post SURGICAL SERVICES (inclding sal postoperative care) D21 Gingivectomy Or Gingivoplasty - For Or More Contigos Teeth Or Tooth Bonded Spaces Per Qadrant D211 Gingivectomy Or Gingivoplasty - One To Three Contigos Teeth Or Tooth Bonded Spaces Per Qadrant D212 Gingivectomy Or Gingivoplasty To Allow Access For Restorative Procedre, Per Tooth D2 Gingival Flap Procedre, Inclding Root Planing - For Or More Contigos Teeth Or Tooth Bonded Spaces Per Qadrant D21 Gingival Flap Procedre, Inclding Root Planing - One To Three Contigos Teeth Or Tooth Bonded Spaces Per Qadrant D25 Apically Positioned Flap D29 Clinical Crown Lengthening-Hard Tisse D26 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) For Or More Contigos Teeth Or Tooth Bonded Spaces Per Qadrant D261 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) One To Three Contigos Teeth Or Tooth Bonded Spaces Per Qadrant D263 Bone Replacement Graft - Retained Natral Tooth - First Site In Qadrant 12 D26 Bone Replacement Graft - Retained Natral Tooth - Each Additional Site In Qadrant 92 D27 Mesial/Distal Wedge Procedre, Single Tooth (When Not Performed In Conjnction With Srgical Procedres In The Same Anatomical Area) NON-SURGICAL PERIODONTAL SERVICES D31 Periodontal Scaling And Root Planing - For Or More Teeth Per Qadrant D32 Periodontal Scaling And Root Planing - One To Three Teeth Per Qadrant D36 Scaling In Presence Of Generalized Moderate Or Severe Gingival Inflammation - Fll Moth, After Oral Evalation CA Base 9 (1/12) Crrent Dental Terminology 218 American Dental Association. All rights reserved.

4 NON-SURGICAL PERIODONTAL SERVICES REPAIRS TO COMPLETE DENTURES D355 Fll Moth Debridement To Enable a Comprehensive Oral Evalation And Diagnosis on a Sbseqent Visit D381 Localized Delivery Of Antimicrobial Agents Via Controlled Release Vehicle Into Diseased Creviclar Tisse, Per Tooth 3 OTHER PERIODONTAL SERVICES D91 Periodontal Maintenance D92 Unschedled Dressing Change (By Someone Other Than Treating Dentist Or Their Staff) D921 Gingival Irrigation - Per Qadrant 25 COMPLETE DENTURES (inclding rotine post delivery care) D511 Complete Dentre - Maxillary 1 D512 Complete Dentre - Mandiblar 1 D513 Immediate Dentre - Maxillary 12 D51 Immediate Dentre - Mandiblar 12 PARTIAL DENTURES (inclding rotine post-delivery care) D5211 Maxillary Partial Dentre - Resin Base (Inclding Retentive/Clasping Materials, Rests 7 D5212 Mandiblar Partial Dentre - Resin Base (Inclding Retentive/Clasping Materials, Rests 7 D5213 Maxillary Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D521 Mandiblar Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rest And Teeth) D5221 Immediate Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 7 D5222 Immediate Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 7 D5223 Immediate Maxillary Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D522 Immediate Mandiblar Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D5225 Maxillary Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 86 D5226 Mandiblar Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 86 D52 Removable nilateral partial dentre - one piece cast metal (inclding clasps and teeth), maxillary 9 D53 Removable nilateral partial dentre - one piece cast metal (inclding clasps and teeth), mandiblar 9 ADJUSTMENTS TO DENTURES D51 Adjst Complete Dentre - Maxillary D511 Adjst Complete Dentre - Mandiblar D521 Adjst Partial Dentre - Maxillary D522 Adjst Partial Dentre - Mandiblar REPAIRS TO COMPLETE DENTURES D5511 Repair Broken Complete Dentre Base, Mandiblar D5512 Repair Broken Complete Dentre Base, Maxillary D552 Replace Missing Or Broken Teeth-Complete Dentre (Each Tooth) REPAIRS TO PARTIAL DENTURES D5611 Repair Resin Partial Dentre Base, Mandiblar D5612 Repair Resin Partial Dentre Base, Maxillary D5621 Repair Cast Partial Framework, Mandiblar D5622 Repair Cast Partial Framework, Maxillary D563 Repair Or Replace Broken Retentive Clasping Materials - Per Tooth D56 Replace Broken Teeth-Per Tooth D565 Add Tooth To Existing Partial Dentre D566 Add Clasp To Existing Partial Dentre - Per Tooth D567 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary) 9 D5671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandiblar) 9 DENTURE REBASE PROCEDURES D571 Rebase Complete Maxillary Dentre D5711 Rebase Complete Mandiblar Dentre D572 Rebase Maxillary Partial Dentre D5721 Rebase Mandiblar Partial Dentre DENTURE RELINE PROCEDURES D573 Reline Complete Maxillary Dentre (Chairside) D5731 Reline Complete Mandiblar Dentre (Chairside) D57 Reline Maxillary Partial Dentre (Chairside) D571 Reline Mandiblar Partial Dentre (Chairside) D5 Reline Complete Maxillary Dentre (Laboratory) 2 D51 Reline Complete Mandiblar Dentre (Laboratory) 2 D576 Reline Maxillary Partial Dentre (Laboratory) 2 D5761 Reline Mandiblar Partial Dentre (Laboratory) 2 D581 Interim Complete Dentre (Maxillary) 12 D5811 Interim Complete Dentre (Mandiblar) 12 D582 Interim Partial Dentre (Maxillary) 5 D5821 Interim Partial Dentre (Mandiblar) 5 OTHER REMOVABLE PROSTHETIC SERVICES D585 Tisse Conditioning, Maxillary D5851 Tisse Conditioning, Mandiblar D5863 Overdentre - Complete Maxillary 1 D586 Overdentre - Partial Maxillary D5865 Overdentre - Complete Mandiblar 1 D5866 Overdentre - Partial Mandiblar FIXED PARTIAL DENTURE PONTICS D625 Pontic - Indirect Resin Based Composite D621 Pontic-Cast High Noble Metal 5 D6211 Pontic-Cast Predominatly Base Metal 5 D6212 Pontic-Cast Noble Metal 5 D621 Pontic - Titanim 5 CA Base 9 (1/12) Crrent Dental Terminology 218 American Dental Association. All rights reserved.

5 FIXED PARTIAL DENTURE PONTICS D62 Pontic-Porcelain Fsed To High Noble Metal 5 D621 Pontic-Porcelain Fsed To Predominantly 5 Base Metal D622 Pontic-Porcelain Fsed To Noble Metal 5 D625 Pontic - Procelain/Ceramic D625 Pontic, Resin With High Noble Metal 5 D6251 Pontic, Resin With Predominantly Base Metal 5 D6252 Pontic, Resin With Noble Metal 5 FIXED PARTIAL DENTURE RETAINTERS - INLAYS/ONLAYS D655 Retainer-Cast Metal For Resin Bonded Fixed Prosthesis 7 D658 Retainer - Porcelain/Ceramic For Resin Bonded Fixed Prosthesis 15 D659 Resin Retainer - For Resin Bonded Fixed Prosthesis 7 D662 Retainer Inlay - Cast High Noble Metal, Two Srfaces 27 D663 Retainer Inlay - Cast High Noble Metal, Three Or More Srfaces D66 Retainer Inlay - Cast Predominantly Base 27 Metal, Two Srfaces D665 Retainer Inlay - Cast Predominantly Base Metal, Three Or More Srfaces D666 Retainer Inlay - Cast Noble Metal, Two 27 Srfaces D667 Retainer Inlay - Cast Noble Metal, Three Or More Srfaces D661 Retainer Onlay - Cast High Noble Metal, Two Srfaces D6611 Retainer Onlay - Cast High Noble Metal, Three Or More Srfaces D6612 Retainer Onlay - Cast Predominantly Base Metal, Two Srfaces D6613 Retainer Onlay - Cast Predominantly Base Metal, Three Or More Srfaces D661 Retainer Onlay - Cast Noble Metal, Two Srfaces D6615 Retainer Onlay - Cast Noble Metal, Three Or More Srfaces D662 Retainer Inlay - Titanim D663 Retainer Onlay - Titanim 3 FIXED PARTIAL DENTURE RETAINERS - CROWNS D671 Retainer Crown - Indirect Resin Based Composite D672 Retainer Crown, Resin With High Noble Metal 6 D6721 Retainer Crown, Resin With Predominantly 6 Base Metal D6722 Retainer Crown, Resin With Noble Metal 6 D67 Retainer Crown - Porcelain/Ceramic D6 Retainer Crown, Porcelain Fsed To High 6 Noble Metal D61 Retainer Crown - Porcelain Fsed To 6 Predominantly Base Metal D62 Retainer Crown, Porcelain Fsed To Noble 6 Metal D678 Retainer Crown, 3/ Cast High Noble Metal 6 D6781 Retainer Crown - 3/ Cast Predominantly Base 6 Metal D6782 Retainer Crown - 3/ Cast Noble Metal 6 D6783 Retainer Crown - 3/ Porcelain/Ceramic D679 Retainer Crown, Fll Cast High Noble Metal 6 FIXED PARTIAL DENTURE RETAINERS - CROWNS D6791 Retainer Crown, Fll Cast Predominantly Base Metal 6 D6792 Retainer Crown, Fll Cast Noble Metal 6 D679 Retainer Crown - Titanim 6 OTHER FIXED PARTIAL DENTURE SERVICES D693 Re Cement Or Re-Bond Fixed Partial Dentre D69 Stress Breaker 9 D695 Precision Attachment 135 D698 Fixed Partial Dentre Repair Necessitated By Restorative Material Failre EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D7111 Extraction, Coronal Remnants - Primary Tooth D71 Extraction, Erpted Tooth Or Exposed Root (Elevation And/Or Forceps Removal) SURGICAL EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D721 Extraction, Erpted Tooth Reqiring Removal Of Bone And/Or Sectioning Of Tooth, And Inclding Elevation Of Mcoperiosteal Flap If Indicated D722 Removal Of Impacted Tooth - Soft Tisse D723 Removal Of Impacted Tooth - Partially Bony D72 Removal Of Impacted Tooth - Completely Bony D721 Removal Of Impacted Tooth - Completely Bony, With Unsal Srgical Complications D725 Removal Of Residal Tooth Roots (Ctting Procedre) D7251 Coronectomy-Intentional Partial Tooth Removal OTHER SURGICAL PROCEDURES D7 Exposre Of An Unerpted Tooth D73 Placement Of Device To Facilitate Erption Of Impacted Tooth D75 Incisional Biopsy Of Oral Tisse Hard (Bone, Tooth) D76 Incisional Biopsy Of Oral Tisse Soft D78 Brsh Biopsy - Transepithelial Sample Collection 5 ALVEOLOPLASTY (srgical preparation of ridge for dentres) D731 Alveoloplasty In Conjnction With Extractions - For Or More Teeth Or Tooth Spaces, Per Qadrant D7311 Alveoloplasty In Conjction With Extractions - One To Three Teeth Or Tooth Spaces, Per Qandrant D732 Alveoloplasty Not In Conjnction With Extractions - For Or More Teeth Or Tooth Spaces, Per Qadrant D7321 Alveoloplasty Not In Conjnction With Extractions - One To Three Teeth Or Tooth Spaces, Per Qadrant SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS D75 Removal Of Benign Odontogenic Cyst Or Tmor - Lesion Diameter Up To 1.25 Cm D751 Removal Of Benign Odontogenic Cyst Or Tmor - Lesion Diameter Greater Than 1.25 Cm 9 EXCISION OF BONE TISSUE CA Base 9 (1/12) Crrent Dental Terminology 218 American Dental Association. All rights reserved.

6 EXCISION OF BONE TISSUE UNCLASSIFIED TREATMENT D771 Removal Of Lateral Exostosis (Maxilla Or Mandible) D772 Removal Of Tors Palatins D773 Removal Of Tors Mandiblaris D785 Redction Of Osseos Tberosity 6 SURGICAL INCISION D1 Incision And Drainage Of Abscess - Intraoral Soft Tisse D11 Incision And Drainage Of Abscess - Intraoral Soft Tisse - Complicated (Incldes Drainage Of Mltiple Fascial Spaces) 15 D2 Incision And Drainage Of Abscess - Extraoral Soft Tisse D21 Incision And Drainage Of Abscess - Extraoral Soft Tisse - Complicated (Incldes Drainage Of Mltiple Fascial Spaces) 25 REPAIR OF TRAUMATIC WOUNDS D791 Stre Of Recent Small Wonds Up To 5 Cm 15 OTHER REPAIR PROCEDURES D796 Frenlectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedre Not Incidental To Another Procedre D7963 Frenloplasty D797 Excision Of Hyperplastic Tisse - Per Arch D7971 Excision Pericoronal Gingival LIMITED ORTHODONTIC TREATMENT D81 Limited Orthodontic Treatment Of Primary 15 D82 Limited Orthodontic Treatment Of Transitional 15 D83 Limited Orthodontic Treatment Of Adolescent 15 D8 Limited Orthodontic Treatment Of The Adlt 15 INTERCEPTIVE ORTHODONTIC TREATMENT D85 Interceptive Orthodontic Treatment Of Primary 15 D86 Interceptive Orthodontic Treatment Of Transitional 15 COMPREHENSIVE ORTHODONTIC TREATMENT D87 Comprehensive Orthodontic Treatment Of Transitional 15 D88 Comprehensive Orthodontic Treatment Of Adolescent 15 D89 Comprehensive Orthodontic Treatment Of Adlt 2 MINOR TREATMENT TO CONTROL HARMFUL HABITS D821 Removable Appliance Therapy For Control Of Harmfl Habits D822 Fixed Appliance Therapy For Control Of Harmfl Habits OTHER ORTHODONTIC SERVICES D866 Pre Orthodontic Treatment Examination To Monitor Growth And Development 3 D867 Periodic Orthodontic Treatment Visit D868 Orthodontic Retention (Removal Of Appliances, Constrction And Placement Of Retainer(S) 2 U Orthodontic Records Fee 265 D911 Palliative (Emergency) Treatment Of Dental Pain, Minor Procedres D912 Fixed Partial Dentre Sectioning 2 ANESTHESIA D921 Local Anesthesia (Not In Conjnction With Operative Or Srgical Procedres) D9211 Regional Block Anesthesia D9212 Trigeminal Division Block Anesthesia D9215 Local Anesthesia In Conjnction With Operative Or Srgical Procedres D9219 Evalation For Moderate Sedation, Deep Sedation Or General Anesthesia D9222 Deep Sedation/General Anesthesia - First 15 Mintes 8 D9223 Deep Sedation/General Anesthesia - Each Sbseqent 15 Minte Increment 8 D9239 Intravenos Moderate (Conscios) Sedation/Analgesia - First 15 Mintes 85 D923 Intravenos Moderate (Conscios) Sedation/Analgesia - Each Sbseqent 15 Minte Increment 85 PROFESSIONAL CONSULTATION D931 Consltation - Diagnostic Service Provided By Dentist Or Physician Other Than Reqesting Dentist Or Physician D9311 Consltation With A Medical Health Care Professional PROFESSIONAL VISITS D93 Office Visit For Observation (Dring Reglarly Schedled Hors) - No Other Services Performed D9 Office Visit After Reglarly Schedled Hors D95 Case Presentation, Detailed And Extensive Treatment Planning MISCELLANEOUS SERVICES D9932 Cleaning And Inspection Of Removable Complete Dentre, Maxillary D9933 Cleaning And Inspection Of Removable Complete Dentre, Mandiblar D993 Cleaning And Inspection Of Removable Partial Dentre, Maxillary D9935 Cleaning And Inspection Of Removable Partial Dentre, Mandiblar D992 Repair And/Or Reline Of Occlsal Gard 35 D993 Occlsal Gard Adjstment 3 D99 Occlsal Gard - hard appliance, fll arch 12 D996 Occlsal Gard - hard appliance, partial arch 12 D9951 Occlsal Adjstment (Limited) D9952 Occlsal Adjstment (Complete) D9986 Missed Appointment 2 D9987 Cancelled appointment 2 D999 Certified translation or sign-langage services - per visit D9991 Dental Case Management - Addressing Appointment Compliance Barriers D9992 Dental Case Management - Care Coordination D9993 Dental Case Management - Motivational Interviewing D999 Dental Case Management - Patient Edcation To Improve Oral Health Literacy CA Base 9 (1/12) Crrent Dental Terminology 218 American Dental Association. All rights reserved.

7 MISCELLANEOUS SERVICES D9995 Teledentistry - Synchronos; Real-Time Enconter D9996 Teledentistry - Asynchronos; Information Stored and Forwarded to Dentist for Sbseqent Review BLEACHING D99 External Bleaching For Home Application, Per 125 Arch, Incldes Materials And Fabrication Of Cstom Trays FOOTNOTES U Charges for the se of precios (high noble) or semi precios (noble) metal are not inclded in the copayment for crowns, bridges, pontics, inlays and onlays. The decision to se these materials is a cooperative effort between the provider and the patient, based on the professional advice of the provider. Providers are expected to charge no more than an additional $125 for these materials. Please Report Under D8999 "Unspecified Orthodontic Procedre, By Report." Records Inclde All Diagnostic Procedres, Sch As Cephalometric Films, Fll Moth X-Rays, Models, And Treatment Plans. CA Base 9 (1/12) Crrent Dental Terminology 218 American Dental Association. All rights reserved.

8 SCHEDULE OF EXCLUSIONS & LIMITATIONS EXCLUSIONS: Except as specifically provided in this Certificate, no coverage will be provided for services, spplies or charges: 1. Not specifically listed in the Schedle of Benefits as a Covered Service. 2. Provided to s otside of the office in which the is enrolled and which are not pre-athorized by the Company (inclding specialty care services). 3. Which in the opinion of the treating dentist, or the Company, are not clinically necessary, or do not have a reasonable, favorable prognosis.. That are necessary de to lack of cooperation with the treating dentist, or failre to comply with a professionally prescribed Treatment Plan. 5. Started or incrred prior to the s eligibility nder the Company or after the Termination Date of coverage with the Company. 6. For consltations by a Specialty Care Dentist for services not specifically listed on the Schedle of Benefits as a Covered Service. 7. That do not meet accepted standards of dental treatment, which are Experimental or Investigative in natre or are considered enhancements to standard dental treatment as determined by the Company. 8. For hospitalization and associated costs for rendering services in a hospital. 9. Determined by the Company to be the responsibility of Worker s Compensation or employer s liability or health care plan, or payable nder any Federal Government or state program, or for treatment of any atomobile related injry in which the is entitled to payment nder an atomobile insrance policy, or for services for which benefits are payable nder any other insrance. 1. For prescription or non-prescription drgs, home care items, vitamins or dietary spplements. 11. Which are principally Cosmetic in natre, inclding, bt not limited to, bleaching, veneer facings, personalization or characterization of crowns, bridges and/or dentres as determined by the Company. 12. For diagnostic services and treatment of jaw joint problems by any method. These jaw joint problems inclde sch conditions as temporomandiblar joint (TMJ) syndrome and craniomandiblar disorders or other conditions of the joint linking the jaw bone and the complex of mscles, nerves and other tisses related to that joint. 13. For services and/or appliances that alter the vertical dimension or alter, restore or maintain the occlsion, inclding, bt not limited to, fll moth rehabilitation, splinting, appliances or any other method. 1. That restore tooth strctre lost de to attrition, erosion or abrasion. 15. For replacement of lost, missing, stolen or damaged prosthetic device or orthodontic appliance or for dplicate dentres, prosthetic devices or any dplicative device. 16. For the following, which are not inclded as orthodontic benefits retreatment of orthodontic cases, changes in orthodontic treatment necessitated by patient non-cooperation, repair of orthodontic appliances, replacement of lost or stolen appliances, special appliances (inclding, bt not limited to, headgear, orthopedic appliances, bite planes, fnctional appliances or palatal expanders), myofnctional therapy, cases involving orthognathic srgery, extractions for orthodontic prposes, and treatment in excess of twenty-for (2) months. 17. For implants, srgical insertion and/or removal of, and any appliances and/or prosthetics attached to implants. 18. Reqired becase of, or in connection with, acts of war, declared or ndeclared. 19. For elective procedres, inclding, bt not limited to, prophylactic extractions of third molars. LIMITATIONS The following services will be sbject to Limitations as set forth below: 1. Referral to a Specialty Care Dentist is limited to orthodontics, oral srgery, periodontics, endodontics, and pediatric dentists. 2. Coverage for referral to a pediatric Specialty Care Dentist ends on a s 7 th birthday. However, exceptions for physical or mental handicaps or medically compromised children, when confirmed by a physician, may be considered on an individal basis with prior approval from the Company. 3. mst remain in the Plan dring the period of time they are ndergoing orthodontic treatment. Any early termination can reslt in additional charges for all nfinished work. This limitation only applies to sbscriber termination, not grop termination.. Sealants one (1) per tooth per three (3) year period throgh age ten (1) on permanent first molars and throgh age fifteen (15) on permanent second molars. 5. In the case a Dental Emergency involving pain or a condition reqiring immediate treatment occrring more than fifty (5) miles from the s home, the Plan covers necessary diagnostic and therapetic dental procedres administered by a dentist p to a maximm of $1 for each emergency visit. 6. Periodontal maintenance following active periodontal therapy - two (2) per twelve (12) consective months in combination with rotine prophylaxis. 7. Periodontal scaling and root planing - one (1) per twenty-for (2) consective month period per area of the moth. 8. Srgical periodontal procedres - one (1) per thirty-six (36) consective month period per area of the moth. 9. Root canal retreatment one (1) per tooth per lifetime. 1. Panoramic or fll moth x-rays - one (1) every three (3) years. 11. One (1) set of bitewing x-rays per six (6) consective months. 12. Prophylaxis - one (1) per six (6) consective months, nless otherwise specified in the Schedle of Benefits. 13. Floride treatment - one (1) per six (6) consective months throgh age eighteen (18). 1. Crown lengthening - one (1) per tooth per lifetime. 15. Dentre relining or rebasing - integral if provided within six (6) months of insertion by the same dentist. This limitation does not apply to immediate dentres. 16. Sbseqent dentre relining or rebasing - limited to one (1) every thirty-six (36) consective months thereafter. 17. Administration of I.V. sedation or general anesthesia is limited to covered oral srgical procedres involving one or more impacted teeth (soft tisse, partial bony or complete bony impactions). NPEL (6/)

9 Governing Administrative Gidelines Alternative Treatment Occasionally, the Panel Dental Office and/or the member may consider alternative treatment plans. In those instances where the member agrees to an alternative treatment plan rather than the benefit provided by United Concordia, the cost for sch treatment will be based pon the following formla: Provider s Usal Fee Provider s Usal Fee s FEE of the alternate treatment less of the entitled benefit pls Copayment = CHARGED for the entitled benefit TO MEMBER Fixed Prosthetics (Bridges) Services mst be diagnosed and prescribed by the participating provider to be eligible for coverage. The member is eligible for fixed bridge restoration when: there is a posterior one-sided space involving one or two adjacent teeth, and front and back anchor teeth; the bridge will replace incisor teeth missing in the pper or lower anterior segments defined as cspid to cspid (#6-11 or #22-27); anchor teeth and occlsion are clinically healthy, reslting in a favorable prognosis. The Plan does not cover a fixed bridge when: there are missing teeth on both sides of the moth in the same arch (bridges crrently in place are not considered missing teeth nless nserviceable). * anterior (front) and posterior (back) spaces (missing teeth) are present in the same arch. In this case, a partial dentre is the covered benefit.* replacing a serviceable partial dentre or fixed bridge; the bridge is sed to realign misaligned teeth, inclding diastemas (spaces between teeth); the member is nder the age of 16 and having permanent teeth replaced; one or more anchor teeth is an implant. *Note: The term missing teeth doesnot inclde third molars for the prpose of this gideline. In addition, missing teethdo not apply to this gideline if the resltant space is closed to less than 1/2 of the width of a bicspid. Bridge Ineligibility Bridge Eligibility