Nevada Family DHMO Plan with Essential Health Benefits Individual Schedule of Benefits

Transcription

1 Nevada Family DHMO Plan with Essential Health Benefits Individual Schedule of Benefits This Schedule of Benefits lists the services available to you under your Family DHMO Plan with Essential Health Benefits (EHB), as well as the Copayments associated with each procedure. Please review the Benefits Description and Limitations/Exclusions Section below for detailed information about how your Plan works. The following Copayments apply when services are performed by your assigned Primary Care Dentist (PCD) or a Contracted Specialty Provider (with prior approval from Premier Access, also referred to as the Plan ). If specialty services are recommended by your PCD, the treatment plan must be preauthorized in writing by the Plan prior to treatment in order for the services to be eligible for coverage. The benefits shown below are performed as deemed appropriate by the assigned Primary Care Dentist, subject to the limitations and exclusions of the program. You should discuss all treatment options with your PCD prior to services being rendered. Specialty services require prior authorization from the Plan. A referral must be submitted to the Plan by your Primary Care Dentist for approval. PLAN SUMMARY Category Deductible Annual Maximum Out of Pocket Maximum (Individual) Out of Pocket Maximum (Family) No deductible will be charged for covered benefits. No annual maximum. $350 (Child EHB ONLY) $700 (Child EHB ONLY) Procedure Category Description Procedure Codes Diagnostic Preventive Exams and X-rays Dental prophylaxis (cleaning), Topical fluoride treatment Child-ONLY* Copay Range Adult-ONLY** Co-pay Range D0100-D0999 $0 $0-$35 D1000-D1999 $0 $0-$150 Restorative Fillings, Crowns D2000-D2999 $0-$350 $0-$375 Endodontic Root Canals D3000-D3999 $0-$350 $0-$425 Periodontic Treatment of gum disease D4000-D4999 $0-$75 $0-$275 Prosthodontic Oral and Maxillofacial Surgery Dentures and Bridges Extractions of teeth and other oral surgical procedures D5000-D5999 and D6200-D6999 $0-$350 $0-$475 D7000-D7999 $0-$175 $0-$515 Orthodontics Braces D8000-D8999 $0-$350 NOT A BENEFIT Emergency Dental Services Palliative (emergency) treatment of dental pain D9110 $0-$20 $0-$50 * This plan is available for individuals up to age 19. ** This plan is available for individuals ages 19 and over. CER15_NV_DHMO_FAM Benefits provided by Access Dental Plan of Nevada, Inc. 1 P age

2 Schedule of Benefits and Limitations CODE PROCEDURE CODE DESCRIPTION Child-ONLY* Service Limits DIAGNOSTIC (D0100-D0999) Copay (Child) NC = Not Covered ADULT-ONLY ** CO-PAY SERVICE LIMITS (ADULT) Frequency limitations are calculated to the exact date. D0120 Periodic oral evaluation 1 unit per 11 months $0 1 per 12 month $0 D0140 Limited oral evaluation problem 3 units per 6 months $0 $0 focused D0145 Oral evaluation for a patient < 3yrs of 6 months up to the age $0 NC NC age of 3 years old D0150 Comprehensive oral evaluation 1 unit per year $0 1 per 12 month $0 D0160 Extensive oral evaluation problem $0 1 per 12 month $0 focused D0170 Re evaluation limited, problem $0 1 per 12 month $0 focused (established patient) D0210 Intraoral complete film series 1 unit per 11 months $0 1 per 60 month $35 D0220 Intraoral periapical first radiographic 2 units per 3 months $0 $0 image D0230 Intraoral periapical each add. 17 units per rolling $0 $0 year D0240 Intraoral occlusal film 2 units per 12 months $0 $0 D0270 Bitewing - single film 1 unit per 6 months $0 $0 D0272 Bitewings - two films 1 unit per 6 months $0 2 per 12 month $0 D0273 Bitewings three films $0 2 per 12 month $10 D0274 Bitewings - four films 1 unit per 6 months $0 2 per 12 month $10 D0277 Vertical bitewings seven to eight $0 $0 films D0290 Posterior anterior or lateral skull $0 NC NC and facial bone survey radiographic image D0322 Tomographic survey $0 NC NC D0330 Panoramic film 1 unit per 3 years $0 1 per 60 month $35 D0340 Cephalometric film 1 unit per 36 months $0 NC NC D0350 Oral/facial photo images, obtained $0 NC NC intraorally and extraorally D0360 Cone Beam CT $0 NC NC D0362 Cone Beam Two Dimensional $0 NC NC D0363 Cone Bean Three Dimensional $0 NC NC D0415 Collection of microorganisms $0 $0 D0416 Viral culture $0 NC NC D0460 Pulp vitality test $0 $0 D0470 Diagnostic casts $0 $0 D0486 Accession of Brush Biopsy $0 NC NC D0502 Other oral pathology procedures $0 NC NC D0999 Unspecified diagnostic procedure $0 NC NC PREVENTIVE (D1000-D1999) 2 P age

3 Frequency limitations are calculated to the exact date. D1110 Prophylaxis adult NC 2 per 12 month D1120 Prophylaxis child 1 unit per 6 months $0 2 per 12 month $0 $0 D1206 Topical application of fluoride 1 unit per 6 months $0 NC NC varnish D1351 Sealant Once in a lifetime $0 NC NC D1510 Space maintainer fixed - unilateral 4 units any provider and 2 units per 12 months D1515 Space maintainer fixed - bilateral 4 units any provider and 2 units per 12 D1520 Space maintainer removable - unilateral D1525 Space maintainer removable - bilateral months 4 units any provider and 2 units per 12 months 4 units any provider and 2 units per 12 months $0 $150 $0 $150 $0 NC NC $0 NC NC D1550 Re-cementation of space maintainer $0 $0 D1555 Removal of fixed space maintainer $0 NC NC RESTORATIVE (D2000-D2999) Frequency limitations are calculated to the exact date. Fillings: Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners, and acid etch procedures Crowns: There is additional co-payment of $125 per unit for treatment plans of 7 or more units. There is an additional co-payment of $75 per unit for porcelain on molars. Actual metal fees will apply for any procedure involving noble, high noble, or titanium metals. The replacement of crowns requires the existing restoration to be 5+ years old. D2140 Amalgam - one surface 1 unit per 36 months $55 $25 D2150 Amalgam - two surfaces 1 unit per 36 months $55 $25 D2160 Amalgam - three surfaces 1 unit per 36 months $75 $25 D2161 Amalgam - 4 or more surfaces 1 unit per 36 months $75 $25 D2330 Resin - one surface anterior 1 unit per 36 months $65 $35 D2331 Resin - two surfaces anterior 1 unit per 36 months $75 $35 D2332 Resin - three surfaces anterior 1 unit per 36 months $85 $35 D2335 Resin 4 or more surfaces or with 1 unit per 36 months $95 NC NC incisal angle (anterior) D2390 Resin based composite crown, 1 unit per 36 months $95 $75 anterior D2391 Resin one surface, posterior 1 unit per 36 months $75 $75 D2392 Resin two surfaces, posterior 1 unit per 36 months $85 $85 D2393 Resin three surfaces, posterior 1 unit per 36 months $95 $95 D2394 Resin four or more surfaces, $95 $100 posterior D2712 Crown ¾ resin based composite $95 NC NC D2721 Crown resin w/ base metal Once in a lifetime $350 NC NC D2740 Crown porcelain/ceramic substrate $350 NC NC D2750 Crown porcelain fused hi noble metal NC NC 1 per 60 month () D2751 Crown porcelain fused base metal Once in a lifetime $350 1 per 60 month () D2752 Crown porcelain fused noble metal NC NC 1 per 60 month () $375 $375 $375 3 P age

4 D2780 Crown ¾ cast high noble metal NC NC 1 per 60 month $375 () D2781 Crown ¾ cast base metal $350 1 per 60 month $375 () D2782 Crown ¾ cast noble metal NC NC 1 per 60 month $375 () D2783 Crown ¾ porcelain/ceramic NC NC 1 per 60 month $375 () D2790 Crown full cast high noble metal NC NC 1 per 60 month $375 () D2791 Crown full cast base metal Once in a lifetime $350 1 per 60 month $375 () D2792 Crown full case noble metal NC NC 1 per 60 month $375 () D2910 Recement inlay onlay or partial $0 $0 D2915 Recement cast or prefabricated post $0 $0 D2920 Recement crown 1 unit per 12 months $0 $0 D2930 Prefabricated stainless steel crown 1 unit per 36 months $150 $125 primary tooth D2931 Prefabricated stainless steel crown Once in lifetime $150 $125 permanent tooth D2932 Prefabricated resin crown 1 unit per 36 months $109 NC NC D2933 Prefabricated stainless steel crown D2940 Protective restoration 2 units per 6 months $50 $50 D2950 Core build up including any pins, 1 unit per 36 months $100 $100 when required D2951 Pin retention 2 units per 36 months $0 $0 D2952 Post and core in addition to crown Once in a lifetime $100 $100 D2953 Each additional indirectly fabricated post same tooth $75 NC NC D2954 Prefabricated post/core + crown Once in a lifetime $100 $100 D2955 Post removal $25 NC NC D2957 Each additional prefabricated post $20 NC NC D2960 Labial veneer $265 NC NC D2961 Lab labial veneer resin $285 NC NC D2962 Lab labial veneer porcelain Once in a lifetime $325 NC NC D2970 Temporary crown (fractured tooth) $50 NC NC D2975 Coping $25 NC NC D2980 Crown repair $65 NC NC D2999 Unspecified restorative procedure $35 NC NC ENDODONTICS (D3000-D3999) Including all pre-operative, operative and post-operative x-rays, bacteriologic cultures, diagnostic tests, local anesthesia, all irrigants, obstruction of root canals and routine follow-up care. Retreatment of a root canal, within a 24 month, is not payable to the same provider that did the original root canal. D3110 Pulp cap direct $50 $35 D3120 Pulp cap indirect $50 $35 D3220 Therapeutic pulpotomy 1 unit per 36 months $50 Limited to primary $35 teeth only D3222 Partial pulpotomy for apexogenesis $60 NC NC D3230 Pulpal therapy anterior $60 NC NC D3240 Pulpal therapy, posterior $60 NC NC D3310 Endodontic therapy, anterior tooth Once in a lifetime $300 Once in a lifetime $250 4 P age

5 D3320 Endodontic therapy, bicuspid tooth Once in a lifetime $350 Once in a lifetime $325 D3330 Endodontic therapy, molar Once in a lifetime $350 Once in a lifetime $425 D3347 Retreatment of previous root canal NC NC $475 therapy, bicuspid D3348 Retreatment of previous root canal NC NC $570 therapy, molar D3351 Apexification/recalcification initial $150 $170 D3352 Apexification/recalcification interim $50 $75 D3353 Apexification/recalcification final Once in a lifetime $105 $250 D3410 Apicoectomy, anterior $250 $345 D3421 Apicoectomy, bicuspid $300 $375 D3425 Apicoectomy, molar $350 $425 D3426 Apicoectomy (each additional) $110 $140 D3430 Retrograde filling Once in a lifetime $50 NC NC D3450 Root amputation $75 NC NC D3460 Endodontic endosseous implant $150 NC NC D3920 Tooth splitting $100 NC NC D3950 Canal prep/fitting of dowel $50 NC NC D3999 Endodontic procedure $50 NC NC PERIODONTICS (D4000-D4999) Including all pre-operative, operative and post-operative x-rays, bacteriologic cultures, diagnostic tests, local anesthesia, all irrigants, obstruction of root canals and routine follow-up care. Includes pre-operative and post operative evaluations and treatment of natural teeth under a local anesthetic Root planing is limited to 4 quadrants during any 12 consecutive months D4210 Gingivectomy/gingivoplasty per quad 4 units per 60 months $150 Co-payment is per $275 quadrant D4211 Gingivectomy/gingivoplasty per 4 units per 60 months $110 Co-payment is per $220 tooth quadrant D4230 Anatomical crown exposure four or $150 NC NC more contiguous teeth per quadrant D4231 Anatomical crown exposure one to $100 NC NC three teeth per quadrant D4240 Gingival flap procedure four or more contiguous teeth per quadrant D4241 Gingival flap procedure one to three $90 NC NC contiguous teeth per quadrant D4249 Crown lengthening- hard tissue $105 NC NC D4260 Osseous surgery per quadrant 4 units per 60 months $150 NC NC D4261 Osseous surgery one to three teeth 4 units per 60 months $100 NC NC per quadrant D4263 Bone replacement graft - first site $75 NC NC D4264 Bone replacement graft - each $35 NC NC additional D4265 Biologic materials to aid in soft $150 NC NC osseous tissue regeneration D4266 Guided tissue regeneration $150 NC NC resorbable D4267 Guided tissue regeneration nonresorbable $140 NC NC D4270 Pedicle soft tissue graft procedure $105 NC NC D4271 Free Soft Tissue Graft Procedure $75 NC NC D4273 Subepithelial tissue graft $50 NC NC D4274 Distal/proximal wedge procedure $65 NC NC 5 P age

6 D4320 Provision splinting - intracoronal $50 NC NC D4321 Provisional splinting - extracoronal $50 NC NC D4341 Periodontal scaling & root 4 units per 12 months $75 4 quadrants per 12 $150 month Co-payment is per quadrant D4342 Periodontal scaling 1 3teeth 4 units per 12 months $0 4 quadrants per 12 $75 month Co-payment is per quadrant D4355 Full mouth debridement $55 NC NC D4381 Localized delivery antimicrobial $15 NC NC agents D4910 Periodontal maintenance 1 unit per 3 months $25 2 per 12 month $25 D4999 Unspecified ontal procedure $25 NC NC PROSTHODONTICS (D5000-D5899) Frequency limitations are calculated to the exact date. For all listed dentures and partial dentures, co-payment includes after delivery adjustments and tissue conditioning, if needed, for the first 6 months after insertion. The member must continue to be eligible, and the service must be provided at the PCD s facility where the denture was originally inserted. Rebases, relines and tissue conditioning are limited to 1 per denture during any 12 consecutive months. Replacement of a denture or a partial denture requires the existing denture to be 5+ years old, unless it is due to loss of a natural functioning tooth. Replacement will be a benefit, only if the existing denture is unsatisfactory and cannot be made serviceable. D5110 Complete denture maxillary 1 unit per 60 months $350 1 per 60 month $475 D5120 Complete denture mandibular 1 unit per 60 months $350 1 per 60 month $475 D5130 Immediate denture maxillary 1 unit per 60 months $350 1 per 60 month $475 D5140 Immediate denture mandibular 1 unit per 60 months $350 1 per 60 month $475 D5211 Maxillary partial denture resin base 1 unit per 60 months $350 1 per 60 month $475 D5212 Mandibular partial denture resin 1 unit per 60 months $350 1 per 60 month $475 base D5213 Maxillary partial denture cast metal 1 unit per 60 months $350 1 per 60 month $475 D5214 Mandibular partial denture cast 1 unit per 60 months $350 1 per 60 month $475 metal D5225 Maxillary partial denture flexible NC NC 1 per 60 month $475 base D5226 Mandibular partial denture flexible NC NC 1 per 60 month $475 base D5281 Removable unilateral partial denture 1 unit per 60 months $155 NC NC D5410 Adjust complete denture maxillary 1 unit per 6 months $0 1 per 60 month $35 D5411 Adjust complete denture - 1 unit per 6 months $50 1 per 60 month $35 mandibular D5421 Adjust partial denture maxillary 1 unit per 6 months $50 1 per 60 month $35 D5422 Adjust partial denture mandibular 1 unit per 6 months $50 1 per 60 month $35 D5510 Repair broken complete denture base 1 unit per 60 months $125 $75 D5520 Replace missing or broken teeth 1 unit per 60 months $125 $75 D5610 Repair resin denture base Contraindicated any $125 Not payable within 91 of insertion $75 6 P age

7 D5620 Repair cast framework Contraindicated any D5630 Repair or replace broken clasp Contraindicated any D5640 Replace broken teeth Contraindicated any D5650 Add tooth to partial denture Contraindicated any D5660 Add clasp to partial denture Contraindicated any D5670 Replace all teeth and acrylic on cast metal framework (maxillary) D5671 Replace all teeth and acrylic on cast metal framework (mandibular) D5730 Denture reline complete maxillary (chairside) D5731 Denture reline complete mandibular (chairside) D5740 Denture reline maxillary partial denture (chairside) D5741 Denture reline mandibular partial denture D5750 Denture reline complete maxillary (laboratory) D5751 Denture reline complete mandibular (laboratory) D5760 Denture maxillary partial (laboratory) D5761 Denture mandibular partial (laboratory) D5820 Denture interim partial denture (maxillary) D5821 Denture interim partial denture (mandibular) D5850 Denture tissue conditioning, maxillary D5851 Denture tissue conditioning, maxillary $125 Not payable within 91 of insertion $75 $125 Not payable within $75 91 of insertion $125 Not payable within $75 91 of insertion $125 Not payable within $75 91 of insertion $125 Not payable within $75 91 of insertion $75 NC NC $75 NC NC 1 unit per 6 months $125 $125 1 unit per 6 months $125 $125 1 unit per 6 months $125 $125 1 unit per 6 months $125 $125 1 unit per 6 months $150 $150 1 unit per 6 months $150 $150 1 unit per 6 months $150 $125 1 unit per 6 months $150 $150 1 unit per 60 months $250 1 per 12 month $125 1 unit per 60 months $250 1 per 12 month $125 1 unit per year $75 $75 1 unit per year $75 $75 D5862 Precision attachment $50 NC NC D5899 Removable prosthodontic procedure $75 NC NC MAXILLOFACIAL PROSTHETICS (D5900-D5999) D5931 Surgical obturator $100 NC NC D5932 Postsurgical obturator $100 NC NC D5933 Refitting of obturator $100 NC NC D5936 Temp obturator prosthesis $100 NC NC D5983 Radiation applicator $100 NC NC D5984 Radiation shield $100 NC NC D5985 Radiation cone locator $100 NC NC D5988 Surgical splint Once in a lifetime $100 NC NC D5999 Maxillofacial prosthesis $100 NC NC PROSTHODONTICS, FIXED (D6200-D6999) 7 P age

8 Frequency limitations are calculated to the exact date. Prosthodontics fixed (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]). There is an additional co-payment of $125 per unit for treatment plans of 7 or more units. There is an additional co-payment of $75 per unit for porcelain on molars. Actual metal fees will apply for any procedure involving noble, high noble, or titanium metals. The replacement of retainers and pontics requires the existing bridge to be 5+ years old. Implants and implant-related procedures are not covered. D6210 Pontic cast high noble metal NC NC 1 unit per 60 month $375 D6211 Pontic cast predominately base metal NC NC 1 unit per 60 month $375 D6212 Pontic cast noble metal NC NC 1 unit per 60 month $375 D6240 Pontic porcelain fused high noble NC NC 1 unit per 60 month $375 metal D6241 Pontic porcelain fused predominately NC NC 1 unit per 60 month $375 base metal D6242 Pontic porcelain fused noble metal NC NC 1 unit per 60 month $375 D6720 Crown resin w/high noble metal NC NC 1 unit per 60 month $375 D6721 Crown resin w/predominately base NC NC 1 unit per 60 month $375 metal D6750 Crown porcelain fused high noble NC NC 1 unit per 60 month $375 metal D6751 Crown porcelain fused predominately NC NC 1 unit per 60 month $375 base metal D6752 Crown porcelain fused noble metal NC NC 1 unit per 60 month $375 D6790 Crown full cast high noble metal NC NC 1 unit per 60 month $375 D6791 Crown full cast predominately base NC NC 1 unit per 60 month $375 metal D6792 Crown full cast noble metal NC NC 1 unit per 60 month $375 D6930 Recement fixed partial denture Contraindicated any $50 $0 ORAL and MAXILLOFACIAL SURGERY (D7000-D7999) Includes pre-operative and postoperative evaluations and treatment under a local anesthetic. Removal of pathology-free 3 rd molars is not covered. Biopsy of oral tissue does not include pathology laboratory services. D7111 Extraction coronal remnants $45 Once in a lifetime, $15 D7140 Extraction erupted tooth/exposed Once in a lifetime, $75 Once in a lifetime, $15 root same tooth D7210 Surgical removal of erupted tooth Once in a lifetime, $175 Once in a lifetime, $115 same tooth D7220 Impact tooth removal soft tissue Once in a lifetime, $175 Once in a lifetime, $115 same tooth D7230 Impact tooth removal part bony Once in a lifetime, $175 Once in a lifetime, $175 same tooth D7240 Impact tooth removal comp bony Once in a lifetime, $175 Once in a lifetime, $175 same tooth D7241 Impact tooth removal bony w/comp Once in lifetime, same $175 Once in a lifetime, $175 tooth D7250 Tooth root removal Once in a lifetime $175 Once in a lifetime, $115 D7260 Oroantral fistula closure Contraindicated any $50 NC NC 8 P age

9 D7261 Primary closure sinus perforation Contraindicated any $50 NC NC D7270 Tooth reimplantation Contraindicated any $175 NC NC D7280 Surgical access on an unerupted tooth Once in a lifetime, $75 NC NC same tooth D7283 Place device impacted tooth $75 NC NC D7285 Biopsy of oral tissue hard $75 NC NC D7286 Biopsy of oral tissue soft $75 $150 D7287 Exfoliative cytological collection $75 NC NC D7288 Brush biopsy $50 NC NC D7290 Repositioning of teeth $50 NC NC D7291 Transseptal fiberotomy $75 NC NC D7292 Screw retained plate $75 NC NC D7293 Temporary anchorage device with $75 NC NC flap D7294 Temporary anchorage device w/o flap $75 NC NC D7310 Alveoplasty with extraction Four in a lifetime, $100 $130 contraindicated any provider within 3286 D7311 Alveoloplasty with extractions 1 3 $100 $105 D7320 Alveoplasty w/o extraction Four in a lifetime, $75 $195 contraindicated any provider within 3286 D7321 Alveoloplasty not w/extracts $125 $160 D7410 Excision of benign lesion up to 1.25 cm D7411 Excision benign lesion > 1.25cm D7412 Excision benign lesion, complicated D7440 Malignant tumor excision up to 1.25 cm D7441 Malignant tumor > 1.25 cm D7450 Removal of odontogenic cyst up to 1.25cm D7451 Removal of odontogenic cyst > 1.25 cm D7460 Removal of nonodontogenic cyst up to 1.25cm D7461 Removal of nonodontogenic cyst > 1.25 cm D7465 Lesion Destruction D7472 Removal of torus palatinus Twice in a lifetime $300 $515 D7473 Remove torus mandibularis Twice in a lifetime $325 $485 D7490 Maxilla or mandible resection $200 NC NC D7510 Incision & Drainage of abscess Incidental already part of another procedure $75 $75 D7511 Incision/drainage abscess intraoral $75 NC NC D7520 Incision/drainage abscess extraoral Incidental already part $75 NC NC 9 P age

10 of another procedure D7521 Incision/drainage abscess extraoral $100 NC NC D7530 Removal fb skin from mucosa $100 NC NC D7540 Removal of reaction producing fb $100 NC NC D7550 Removal of sloughed off bone D7560 Maxillary sinusotomy D7610 Maxilla open reduction $250 NC NC D7620 Maxilla closed reduction $250 NC NC D7630 Mandible open reduction $250 NC NC D7640 Mandible closed reduction $250 NC NC D7650 Malar and/or zygomatic arch open Once in a lifetime $250 NC NC D7660 Malar and/or zygomatic arch - closed Once in a lifetime $250 NC NC D7670 Alveolus closed reduction $250 NC NC D7671 Alveolus - open reduction $250 NC NC D7680 Facial bones complicated reduction $250 NC NC D7710 Maxilla - open reduction $250 NC NC D7720 Maxilla closed reduction $250 NC NC D7730 Mandible open reduction $250 NC NC D7740 Mandible closed reduction $250 NC NC D7750 Malar and/or zygomatic arch open Once in a lifetime $250 NC NC D7760 Malar and/or zygomatic arch closed $250 NC NC D7770 Alveolus open reduction $250 NC NC stabilization of teeth D7771 Alveolus closed reduction $250 NC NC stabilization of teeth D7780 Facial bones complicated reduction $250 NC NC with fixation D7810 TMJ open reduction of dislocation $250 NC NC D7820 TMJ closed reduction of dislocation $250 NC NC D7840 TMJ condylectomy $250 NC NC D7850 TMJ surgical disectomy, with/without $325 NC NC implant D7852 TMJ disc repair $325 NC NC D7854 TMJ synovectomy $325 NC NC D7858 TMJ joint reconstruction $325 NC NC D7860 TMJ arthrotomy $325 NC NC D7865 TMJ arthroplasty $325 NC NC D7870 TMJ arthrocentesis $325 NC NC D7872 TMJ arthroscopy -diagnosis $325 NC NC D7873 TMJ arthroscopy surgical: lavage $325 NC NC and lysis of adhesions D7874 TMJ arthroscopy surgical: disc $325 NC NC repositioning D7875 TMJ arthroscopy surgical: $325 NC NC synovectomy D7876 TMJ arthroscopy surgical: $325 NC NC disectomy D7877 TMJ arthroscopy surgical: $325 NC NC debridement D7880 Occlusal orthotic device $100 NC NC D7910 Suture of recent small wounds up to 5 cm $100 NC NC 10 P age

11 D7911 Complicated suture up to 5 cm $150 NC NC D7912 Complicated suture > 5 cm $100 NC NC D7940 Osteoplasty Once in a lifetime $200 NC NC D7941 Osteotomy mandibular rami Once in a lifetime $300 NC NC D7943 Osteotomy mandibular rami with Once in a lifetime $350 NC NC bone graft D7944 Osteotomy segmented or subapical $350 NC NC D7945 Osteotomy body mandible Once in a lifetime $350 NC NC D7946 Reconstruction maxilla total Once in a lifetime $350 NC NC D7947 Reconstruct maxilla segment Once in a lifetime $350 NC NC D7948 Reconstruct midface no graft Once in a lifetime $350 NC NC D7949 Reconstruct midface w/graft $350 NC NC D7951 Sinus augmentation with bone/bone $350 NC NC substitutes D7953 Bone replacement graft $350 NC NC D7955 Repair maxillofacial defects 1 unit per 24 months $100 NC NC D7960 Frenulectomy/frenotomy Three in a lifetime $150 $0 D7963 Frenuloplasty D7970 Excision hyperplastic tissue $350 NC NC D7971 Excision pericoronal gingiva $350 NC NC D7980 Sialolithotomy $350 NC NC D7981 Excision of salivary gland $350 NC NC D7982 Sialodochoplasty $350 NC NC D7983 Closure of salivary fistula $350 NC NC D7990 Emergency tracheotomy $350 NC NC D7991 Dental coronoidectomy Once in a lifetime $350 NC NC D7996 Implant mandible for augment $350 NC NC D7998 Intraoral place of fix dev $350 NC NC D7999 Oral surgery procedure, unspecified by report $75 NC NC ORTHODONTICS (D8000-D8999) (Medically Necessary) D8010 Limited dental treatment - primary $350 NC NC D8020 Limited dental treatment - transition Once in a lifetime $350 NC NC D8040 Limited dental treatment - adult $350 NC NC D8080 Comprehensive dental treatment - $350 NC NC adolescent D8090 Comprehensive dental treatment - $350 NC NC adult D8210 Removable appliance therapy $0 NC NC D8220 Fixed appliance therapy $0 NC NC D8660 Pre-orthodontic treatment visit $0 NC NC D8670 Periodic orthodontic treatment visit $100 NC NC D8680 Orthodontic retention $0 NC NC D8691 Repair of orthodontic appliance $0 NC NC D8693 Rebonding/Recementing of fixed $50 NC NC retainers D8999 Orthodontic procedure $350 NC NC ADJUNCTIVE GENERAL SERVICES (D9000-D9999) D9110 Palliative treatment of dental pain 2 units per 6 months $0 $50 D9120 Fix partial denture section $50 NC NC 11 P age

12 D9210 Local anesthesia not in conjunction with operative or surgical procedures $50 NC NC D9211 Regional block anesthesia NC NC $0 D9212 Trigeminal block anesthesia $0 $0 D9215 Local anesthesia $0 $0 D9220 General anesthesia $50 NC NC D9221 General anesthesia ea ad 15m 3 units per day $25 NC NC D9230 Inhalation of nitrous oxide/analgesia $0 $25 anxiolysis D9241 Intravenous sedation $25 NC NC D9242 Iv sedation ea ad 30 m 3 units per day $15 NC NC D9248 Sedation (non iv) $0 $30 D9310 Dental consultation $0 $50 D9410 Dental house call $75 NC NC D9420 Hospital call $150 NC NC D9430 Office visit during hours $0 $15 D9440 Office visit after hours 1 unit per 12 months $0 $15 D9610 Therapeutic parenteral drug, single $15 NC NC D9612 Therapeutic parenteral drugs, 2 or > $15 NC NC administrations D9630 Other drugs/medicaments $15 NC NC D9930 Treatment of complications $50 NC NC D9940 Dental occlusal guard $100 NC NC D9942 Repair/reline occlusal guard $25 NC NC D9950 Occlusion analysis $10 NC NC D9951 Limited occlusal adjustment $0 $25 D9952 Complete occlusal adjustment $15 $25 D9999 Adjunctive procedure, by report $0 $25 * This plan is available for individuals up to age 19. **This plan is available for individuals age 19 and over. If services for a listed procedure are performed by the assigned PCD, the member pays the specified co-payment. You may be charged for missed appointments if you do not give the dental office at least 24 hours notice of cancellation. Listed procedures, which require a dentist to provide specialized services, and are referred by the assigned PCD, must be preauthorized in writing by the Plan. The member pays the co-payment specified for such services. Procedures not listed above are not covered, however may be available at the PCD s contracted fees. Contracted fees means the PCD s fees on file with the Plan. 12 P age

13 The following dental benefits are excluded under the plan: Excluded Benefits 1. Any service that is not specifically listed as a covered benefit. 2. Services, which in the opinion of the attending dentist are not necessary to the member s dental health. 3. Experimental or investigational services, including any treatment, therapy, procedure or drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supply which is not recognized as being in accordance with generally accepted professional standards or for which the safety and efficacy have not been determined for use in the treatment for which the item or service in question is recommended or prescribed. 4. Services, which were provided without cost to the member by State government or an agency thereof, or any municipality, county or other subdivisions. 5. Additional treatment costs incurred because a dental procedure is unable to be performed in the dentist s office due to the general health and physical limitations of the member. 6. Dental Services that are received in an emergency care setting for conditions that are not emergencies if the subscriber reasonably should have known that an emergency care situation did not exist. 7. Dental expenses incurred in connection with any dental procedures started after termination of coverage or prior to the date the member became eligible for such services. 8. Procedures, appliances, or restorations to correct congenital or developmental malformations, unless specifically listed in the Benefits section above. 9. Hospital charges of any kind. 10. General anesthesia or intravenous/conscious sedation over Dispensing of drugs not normally supplied in a dental office. 12. Major surgery for fractures and dislocations. 13. Treatment of root canal obstruction 14. Loss or theft of dentures or bridgework without appropriate documentation (i.e. police report or natural disaster). 15. Malignancies. 16. The cost of precious metals used in any form of dental benefits. 17. Implants and implant-related services 18. Placement and replacement of Cantilever and Maryland/Resin-bonded bridges 19. Extraction of pathology-free teeth, including supernumerary teeth. 20. Cosmetic dental care. 13 P age