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

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

1 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Periodic oral evaluation $33.09 D Limited oral evaluation problem focused $55.17 D Oral Evaluation for a patient under three years of age $34.82 counseling with primary caregiver D Comprehensive oral evaluation new or established $57.06 patient D Detailed and extensive oral evaluation problem focused, $94.72 by report D Re evaluation limited, problem focused (established $50.58 patient; not post operative visit) D Comprehensive periodontal evaluation new or $81.06 established patient D Intraoral complete series (including bitewings) $98.14 D Intraoral periapical first film $19.40 D Intraoral periapical each additional film $15.98 D Intraoral occlusal film $30.81 D Extra oral first 2D projection radiographic image $42.22 D Extra oral posterior dental radiograph $42.22 D Bitewing single film $19.40 D Bitewings two films $31.95 D Bitewings three films $38.89 D Bitewings four films $48.01 D Vertical bitewings 7 to 8 films $86.66 D Sialography $ D Other temporomandibular joint films, by report $ D Panoramic film $87.70 Lab processing for microbial specimen (separating $ D collecting and analysis like saliva and genetic codes) D Bacteriologic studies for determination of pathologic $ agents D Pulp vitality tests $52.30 D Diagnostic casts $75.69 D Prophylaxis adult $69.23 Page # 1

2 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Prophylaxis child $52.69 D Topical fluoride varnish; therapeutic application for $29.16 moderate to high caries risk patients D Topical application of fluoride (prophylaxis not included) $27.39 D Sealant per tooth $44.09 D Preventive resin restoration in a moderate to high caries $44.09 risk patient permanent tooth D Space maintainer fixed unilateral $ D Space maintainer fixed bilateral $ D Space maintainer removable unilateral $ D Space maintainer removable bilateral $ D Re cementation of space maintainer $60.49 D removal of fixed space maintainer $60.49 Distal Shoe Space Maintainer fixed unilateral (for first molars only for premature loss of second primary molars (A, J, K, T) D Scaling in the presence of generalized moderate or severe D gingival inflammation full mouth after overall evaluation D Full mouth debridement to enable comprehensive evaluation and diagnosis $ $69.23 $ D Periodontal maintenance $96.73 D Amalgam one surface, primary or permanent $72.88 D Amalgam two surfaces, primary or permanent $92.76 D Amalgam three surfaces, primary or permanent $ D Amalgam four or more surfaces, primary or permanent $ D Resin based composite one surface, anterior $89.91 D Resin based composite two surfaces, anterior $ D Resin based composite three surfaces, anterior $ D Resin based composite four or more surfaces or $ involving incisal angle (anterior) D Resin based composite crown, anterior $ D Resin based composite one surface, posterior $98.43 Page # 2

3 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Gold foil one surface $ D Gold foil two surfaces $ D Gold foil three surfaces $ D Recement inlay $62.77 D Recement cast or prefab post and core $62.77 D Recement crown $62.77 D Prefabricated stainless steel crown primary tooth $ D Prefabricated stainless steel crown permanent tooth $ D Prefabricated resin crown $ D Prefabricated stainless steel crown with resin window $ D Sedative filling $68.12 D Interim therapeutic restoration (primary tooth) $68.12 D Pin retention per tooth, in addition to restoration $45.75 D Crown repair, by report $ D Pulp cap direct (excluding final restoration) $47.33 D Pulp cap indirect (excluding final restoration) $46.38 D Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament $ D Pulpal debridement, primary and permanent teeth $ D Partial Pulpotomy for Apexogenesis with incomplete rootdevelopment $ D Anterior (excluding final restoration) $ D Bicuspid (excluding final restoration) $ D Molar (excluding final restoration) $ D Internal root repair of perforation defects $ D Retreatment of previous root canal therapy anterior $ D Retreatment of previous root canal therapy bicuspid $ D Retreatment of previous root canal therapy molar $ D Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $ D Apicoectomy/periradicular surgery anterior $ Page # 3

4 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Apicoectomy/periradicular surgery bicuspid (first root) $ D Apicoectomy/periradicular surgery molar (first root) $ D Apicoectomy/periradicular surgery (each additional root) $ D Retrograde filling per root $ D Root amputation per root $ D Surgical procedure for isolation of tooth with rubber dam $ D Hemisection (including any root removal), not including $ root canal therapy D Gingivectomy or gingivoplasty four or more contiguous $ teeth or bounded teeth spaces per quadrant D Gingivectomy or gingivoplasty one to three teeth, per $ quadrant D Gingival flap procedure, including root planing four or $ more contiguous teeth or bounded teeth spaces per quadrant D Gingival flap procedure, including root planing one to $ three teeth, per quadrant D Clinical crown lengthening hard tissue $ D Osseous surgery (including flap entry and closure) four $ or more contiguous teeth or bounded teeth spaces per quadrant D Osseous surgery (including flap entry and closure) 1 3 $ teeth/quadrant D Bone replacement graft first site in quadrant $ D Bone replacement graft each additional site in quadrant $ D Biologic materials to aid in soft and osseous tissue $ regeneration D Guided tissue regeneration resorbable barrier, per site $ D Guided tissue regeneration nonresorbable barrier, per $ site (includes membrane removal) D Surgical revision procedure, per tooth $ Page # 4

5 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Pedicle soft tissue graft procedure $ D Subepithelial connective tissue graft procedures $ D Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $ D Soft tissue allograft $ D Combined connective tissue and double pedicle graft $ D Free Soft Tissue Graft (including donor site $ surgery), first tooth or edentulous tooth position in graft D Free Soft Tissue Graft (including donor site surgery, each additional contiguous tooth or edentulous tooth position in same graft site $ D Autogenous connective tissue graft procedure each additional contiguous tooth, D Non autogenous connective tissue graft each additional contiguous tooth, position in same graft site D Periodontal scaling and root planing four or more contiguous teeth or bounded teeth spaces per quadrant. Only two quadrants are allowed per date of service. Additional quadrants will deny. $ $ $ D Periodontal scaling and root planing one to three teeth/ $ quadrant D Adjust complete denture maxillary $53.45 D Adjust complete denture mandibular $53.45 D Adjust partial denture maxillary $53.45 D Adjust partial denture mandibular $53.45 D Repair broken complete denture base, mandibular (lower arch). Once per 12 months (after 6 months from insertion) D Repair broken complete denture base, maxillary (upper arch). Once per 12 months (after 6 months from insertion) $ $ Page # 5

6 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description $98.71 D Replace missing or broken teeth complete denture (each tooth) D Repair resin partial denture base, mandibular (lower $ arch). Once per 12 months (after 6 months from D insertion) Repair resin partial denture base, maxillary (upper arch). $ Once per 12 months (after 6 months from insertion) D Repair cast partial framework, mandibular (lower arch) $ D Repair cast partial framework, maxillary (upper arch) $ D Repair or replace broken clasp $ D Replace broken teeth per tooth $98.71 D Add tooth to existing partial denture $ D Add clasp to existing partial denture $ D Replace all teeth and acrylic on cast metal framework $ (maxillary) D Replace all teeth and acrylic on cast metal framework $ (mandibular) D Rebase complete maxillary denture $ D Rebase complete mandibular denture $ D Rebase maxillary partial denture $ D Rebase mandibular partial denture $ D Reline complete maxillary denture (chair side) $ D Reline complete mandibular denture (chair side) $ D Reline maxillary partial denture (chair side) $ D Reline mandibular partial denture (chair side) $ D Reline complete maxillary denture (laboratory) $ D Reline complete mandibular denture (laboratory) $ D Reline maxillary partial denture (laboratory) $ D Reline mandibular partial denture (laboratory) $ D Tissue conditioning, maxillary $ D Tissue conditioning, mandibular $ D Recement implant/abutment supported fixed partial denture $70.33 Page # 6

7 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Recement implant/abutment supported crown $ D Recement fixed bridge $92.12 D Fixed partial denture repair, by report $ D Coronal remnants, deciduous tooth $65.79 D Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $89.91 $ D Removal of impacted tooth soft tissue $ D Removal of impacted tooth partially bony $ D Removal of impacted tooth completely bony $ D Removal of impacted tooth completely bony, with $ unusual surgical complications D Surgical removal of residual tooth roots (cutting $ procedure) D Oroantral fistula closure $ D Primary closure of a sinus perforation $ D Tooth reimplantation and/or stabilization of accidentally $ evulsed or displaced tooth D Tooth transplantation (includes reimplantation from one $ site to another and splinting and/or stabilization) D Surgical access of an unerupted tooth $ D Placement of device to facilitate eruption of impacted $ tooth D Biopsy of oral tissue hard (bone, tooth) $ D Biopsy of oral tissue soft (all others) $ D Brush biopsy transepithelial sample collection $91.73 D Transseptal fiberotomy/supra crestal fiberotomy, by report D Corticomy one to three teeth spaces per quadrant. Once per lifetime per quadrant if member has ortho coverage. (Note: any benefits paid will draw from ortho maximum) $ $ Page # 7

8 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Corticomy four or more to three teeth spaces per quadrant. Once per lifetime per quadrant if member has ortho coverage. (Note: any benefits paid will draw from ortho maximum) D Alveoloplasty in conjunction with extractions per quadrant D Alveoloplasty in conjunction with extractions 1 to 3 teeth or tooth spaces per quad D Alveoloplasty not in conjunction with extractions per quadrant D Alveoloplasty not in conjunction with extractions 1 to 3 teeth or tooth spaces per quad D Vestibuloplasty ridge extension (secondary epithelialization) D Vestibuloplasty ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) $ $ $ $ $ $ $1, D Excision of benign lesion up to 1.25 cm $ D Excision of benign lesion greater than 1.25 cm $ D Excision of benign lesion, complicated $ D Excision of malignant tumor lesion diameter up to 1.25 cm D Excision of malignant tumor lesion diameter greater than 1.25 cm D Removal of benign odontogenic cyst or tumor lesion diameter up to 1.25 cm D Removal of benign odontogenic cyst or tumor lesion diameter greater than 1.25 cm D Removal of benign nonodontogenic cyst or tumor lesion diameter up to 1.25 cm D Removal of benign nonodontogenic cyst or tumor lesion diameter greater than 1.25 cm $ $ $ $ $ $ Page # 8

9 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description $ D Destruction of lesion(s) by physical or chemical method, by report D Removal of lateral exostosis (maxilla or mandible) $ D Removal of torus palatinus $ D Removal of torus mandibularis $ D Surgical reduction of osseous tuberosity $ D Incision and drainage of abscess intraoral soft tissue $ D Incision and drainage of abcess intraoral soft tissue $ complicated D Incision and drainage of abscess extraoral soft tissue $ D Incision and drainage of abcess extraoral soft tissue $ complicated D Removal of foreign body from mucosa, skin, or $ subcutaneous alveolar tissue D Removal of reaction producing foreign bodies, $ musculoskeletal system D Partial ostectomy/sequestrectomy for removal of nonvital $ bone D Alveolus closed reduction may include stabilization of $1, teeth D Alveolus open reduction stabilization of teeth $1, D Closed reduction of dislocation $ D Manipulation under anesthesia $ D Arthrocentesis $1, D Complicated suture up to 5 cm $ D Bone replacement graft for ridge preservation $ D Frenulectomy (frenectomy or frenotomy) separate procedure $ D Frenuoplasty $ D Removal of fixed orthodontic appliances for reasons other $60.49 than completion of treatment. Once per lifetime per quadrant if member has ortho coverage. (Note: any benefits paid will draw from ortho maximum) Page # 9

10 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description $71.93 D Palliative (emergency) treatment of dental pain minor procedure D Fixed partial denture sectioning $ D Deep sedation/general anesthesia first 15 minutes $ (prep/set up time), allowed with covered surgical impacted teeth only (up to one hour) D Deep sedation /general anesthesia each subsequent 15 minute increment, allowed with covered surgical impacted teeth only (up to one hour) D Intravenous moderate (conscious) sedation/anesthesia first 15 minutes (prep/set up time), allowed with covered surgical impacted teeth only (up to one hour) D Intravenous moderate (conscious) sedation/analgesia each subsequent 15 minute increment, allowed with covered surgical impacted teeth only (up to one hour) $ $ $ D Application of desensitizing medicament $38.81 D Occlusal guard, by report $ D Occlusal adjustment limited $97.49 D Inlay metallic one surface $ D Inlay metallic two surfaces $ D Inlay metallic three or more surfaces $ D Onlay metallic two surfaces $ D Onlay metallic three surfaces $ D Onlay metallic four or more surfaces $ D Inlay porcelain/ceramic one surface $ D Inlay porcelain/ceramic two surfaces $ D Inlay porcelain/ceramic three or more surfaces $ D Onlay porcelain/ceramic two surfaces $ D Onlay porcelain/ceramic three surfaces $ D Onlay porcelain/ceramic four or more surfaces $ D Inlay resin based composite one surface $ D Inlay resin based composite two surfaces $ D Inlay resin based composite three or more surfaces $ Page # 10

11 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Onlay resin based composite two surfaces $ D Onlay resin based composite three surfaces $ D Onlay resin based composite four or more surfaces $ D Crown resin (indirect) $ D Crown 3/4 resin based composite (indirect) not include $ facial veneers D Crown resin with high noble metal $ D Crown resin with predominantly base metal $ D Crown resin with noble metal $ D Crown porcelain/ceramic substrate $ D Crown porcelain fused to high noble metal $ D Crown porcelain fused to predominantly base metal $ D Crown porcelain fused to noble metal $ D Crown 3/4 cast high noble metal $ D Crown 3/4 cast predominantly base metal $ D Crown 3/4 cast noble metal $ D Crown 3/4 porcelain/ceramic $ D Crown full cast high noble metal $ D Crown full cast predominantly base metal $ D Crown full cast noble metal $ D Crown Titanium $ D Provisional crown $ D Core buildup, including any pins $ D Cast post and core in addition to crown $ D Prefabricated post and core in addition to crown $ D Complete denture maxillary $ D Complete denture mandibular $ D Immediate denture maxillary $ D Immediate denture mandibular $ D Maxillary partial denture resin base (including any conventional clasps, rests and teeth) D Mandibular partial denture resin base (including any conventional clasps, rests and teeth) $ $ Page # 11

12 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Axillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $ $ D Immediate maxillary partial denture resin base $ D Immediate mandibular partial denture resin base $ D Immediate maxillary partial denture cast metal $ framework with resin denture bases D Immediate mandibular partial denture cast metal $ framework with resin denture bases D Maxillary partial denture flexible base $ D Mandibular partial denture flexible base $ D Removable unilateral partial denture one piece cast $ metal (including clasps and teeth) D Interim partial denture (maxillary) $ D Interim partial denture (mandibular) $ D6010* 3 Implant surgical endosteal, single tooth $1, * D6013* 3 Mini Implant, single tooth $ * D Prefabricated abutment $ D Custom Abutment $ D Implant Abut Crown $ D Abutment supported porcelain fused to metal crown (high $ noble metal) D Implant Abut Crown $ D Abutment supported porcelain fused to metal crown $ (noble metal) D Implant Abut Crown $ D Implant Abut Crown $ D Implant Abut Crown $ D Implant Abut Crown $ D Implant Abut Crown $ Page # 12

13 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Implant Abut Crown $ D Abutment supported retainer for porcelain fused to metal $ FPD (high noble metal) D Abutment supported retainer for porcelain fused to metal $ FPD (predominately base metal) D Abutment supported retainer for porcelain fused to metal $ FPD (noble metal) D Abutment supported retainer for cast metal FPD (high $ noble metal) D Abutment supported retainer for cast metal FPD $ (predominately base metal) D Abutment supported retainer for cast metal FPD (noble $ metal) D Implant supported retainer for porcelain fused to metal $ FPD (titanium, titanium alloy, or high noble metal) D Implant supported retainer for cast metal FPD (titanium, $ titanium alloy, or high noble metal) D Provisional implant crown $ D Abutment supported crown titanium $ D Implant /abutment complete denture fixed upper arch $ D Implant /abutment complete denture fixed lower arch $ D Implant /abutment partial denture fixed upper arch $ D Implant /abutment partial denture fixed lower arch $ D Abutment supported retainer crown for FPD titanium $ D Pontic indirect resin based composite $ D Pontic cast high noble metal $ D Pontic cast predominantly base metal $ D Pontic cast noble metal $ D Pontic titanium $ D Pontic porcelain fused to high noble metal $ D Pontic porcelain fused to predominantly base metal $ D Pontic porcelain fused to noble metal $ D Pontic resin with high noble metal $ Page # 13

14 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Pontic resin with predominantly base metal $ D Pontic resin with noble metal $ D Retainer cast metal for resin bonded fixed prosthesis $ D Resin retainer for resin bonded fixed prosthesis Once per $ tooth every five years. D Inlay cast high noble metal, two surfaces" $ D Inlay cast high noble metal, three or more surfaces $ D Inlay cast predominantly base metal, two surfaces $ D Inlay cast predominantly base metal, three or more $ surfaces D Inlay cast noble metal, two surfaces $ D Inlay cast noble metal, three or more surfaces $ D Onlay cast high noble metal, two surfaces $ D Onlay cast high noble metal, three or more surfaces $ D Onlay cast predominantly base metal, two surfaces $ D Onlay cast predominantly base metal, three or more $ surfaces D Onlay cast noble metal, two surfaces $ D Onlay cast noble metal, three or more surfaces $ D Inlay titanium $ D Onlay titanium $ D Crown indirect resin based composite $ D Crown resin with high noble metal $ D Crown resin with predominantly base metal $ D Crown resin with noble metal $ D Retainer Crown porcelain/ceramic $ D Crown porcelain fused to high noble metal $ D Crown porcelain fused to predominantly base metal $ D Crown porcelain fused to noble metal $ D Crown 3/4 cast high noble metal $ D Crown 3/4 cast predominantly base metal $ D Crown 3/4 cast noble metal $ D Crown full cast high noble metal $ Page # 14

15 Boston Teachers Union Health and Welfare Group No: Schedule of Covered Dental s for Delta Dental PPO Plus Premier Orthodontia Benefit Lifetime Maximum* $3,000 Description D Crown full cast predominantly base metal $ D Crown full cast noble metal $ D Crown titanium $ * Covered procedures are subject to a combined annual maximum for implants of $1,500 per person. Implant related procedures (abutments and crowns) will be applied toward the overall annual maximum of $2,400 per person. For out of network services with a non participating dentist, the payment is reduced by 20% and members are responsible for the difference between the payment and the fee charged by the dentist. *Orthodontic treatment must be administered/supervised by a licensed dentist. Mail order orthodontic kits are not covered under this plan. Current Dental Terminology 2018 American Dental Association Page # 15

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

BOSTON TEACHERS UNION PARAPROFESSIONAL HEALTH AND WELFARE FUND Schedule of Covered Dental Procedures for the Dental Plan - Effective January 1, 2009 TYPE 1 D0120 Periodic oral evaluation 27.81 D0140 Limited oral evaluation - problem focused 43.15 D0145 Oral evaluation for a patient under three years of age and 22.20 counseling with primary caregiver