Primecare Dental Plan Individual Whether you re a member of our dental plan, human resources or benefits professional we trust you will find our company a valuable resource for high quality and affordable dental benefits. We carefully evaluate every dental office prior to admission to the Primecare Dental network. If you have any questions, please call one of our member service Representatives at (909) 483-8310 or toll free (800) 937-3400, or visit us at www.primecaredental.net we ll be happy to assist you. DIAGNOSTIC 0110 Comprehensive oral evaluation 0 0120 Periodic oral evaluation 0 0130 Limited oral evaluation-problem focused 0 0210 Intraoral-complete series (including bitewings) 25 0220 Intraoral-periapical-first film 0 0230 Intraoral-periapical-each additional 0 0272 Bitewings-two films 0 0274 Bitewings-four films 0 0330 Panoramic film 25 0460 Pulp vitality tests 0 0470 Diagnostic casts 25 0240 Intraoral occlusal film 10 0350 Oral/facial photographic images (all) 10 0415 Collection of microorganisms for culture and sensitivity 10 PREVENTIVE 1110 Prophylaxis-adult 35 1201 Prophylaxis-child-including topical application of fluoride 30 1330 Oral hygiene instructions 0 1351 Sealant-per tooth 15 1120 Prophylaxis child 25 1310 Nutritional counseling for control of dental disease 0 1320 Tobacco counseling for the control and prevention of disease 0 1550 Recementation of space maintainer 10 SPACE MAINTENANCE (PASSIVE APPLIANCES) (Services When Performed By A Plan General Dentist) 1510 Space maintainer-fixed unilateral 135 1515 Space maintainer-fixed bilateral 135 1520 Space maintainer-removable-unilateral 190 1525 Space maintainer-removable-bilateral 190 RESTORATIVE AMALAGAM RESTORATIONS (INCLUDING POLISHING) 2110 Amalgam-one surface, primary 35 2120 Amalgam-two surfaces, primary 40 2130 Amalgam-three surfaces, primary 50 2131 Amalgam-four or more surfaces, primary 52 2140 Amalgam-one surface, permanent 45 2150 Amalgam-two surfaces, permanent 50 2160 Amalgam-three surfaces, permanent 60 2161 Amalgam-four or more surfaces, permanent 65 Primecare Dental /2010
RESIN RESTORATIONS 2330 Resin-one surface, anterior 55 2331 Resin-two surfaces, anterior 60 2332 Resin-three surfaces, anterior 70 2335 Resin-four or more surfaces involving incisal angle (anterior) 95 2391 Resin-one surface, posterior-primary, permanent 65 2392 Resin-two surfaces, posterior-primary, permanent 80 2393 Resin-three or more surfaces, posterior-primary, permanent 115 CROWNS-SINGLE RESTORATION ONLY 2710 Crown-resin (laboratory) 195 2721 Crown-resin with predominantly base metal 285 2751 Crown-porcelain fused to predominantly base metal 375 2740 Crown porcelain ceramic substrate 575 2750 Crown porcelain fused to high noble metal 550 2783 Crown ¾ porcelain ceramic 575 2791 Crown-full cast predominantly base metal 345 2810 Crown-3/4 cast metallic 365 2910 Recement inlay 20 2920 Recement crown 30 2930 Prefabricated stainless steel crown - primary tooth 70 2931 Prefabricated stainless steel crown - permanent tooth 85 2932 Prefabricated resin crown 87 2940 Sedative filling 25 2950 Core buildup, including any pins 70 2951 Pin retention-per tooth, in addition to restoration 25 2952 Cast post and core in addition to crown 115 2954 Prefabricated post and core in addition to crown 80 Actual cost of lab additional for crowns and pontics limited to 125 ENDODONTICS PULP CAPPING 3110 Pulp cap-direct (excluding final restoration) 30 3120 Pulp cap-indirect (excluding final restoration) 32 PULPOTOMY 3220 Therapeutic Pulpotomy (excluding final restoration) 45 3310 Root Canal-Anterior (excluding final restoration) 225 3320 Root Canal-Bicuspid (excluding final restoration) 275 3330 Root Canal-Molar (excluding final restoration) 325 APICOECTOMY/PERIAPICAL SERVICES 3221 Pulpal debridement primary and permanent teeth 45 3410 Apicoectomy-anterior 160 3421 Apicoectomy-bicuspid 160 3425 Apicoectomy-molar (first root) 160 3426 Apicoectomy-(each additional root) 160 PERIODONTICS 4210 Gingivectomy or gingivoplasty - per quadrant 200 4211 Gingivectomy or gingivoplasty - per tooth 75 4220 Gingival curettage, surgical, per quadrant, by report 100 4250 Mucogingival surgery - per quadrant 390 4260 Osseous surgery (including flap entry and closure) per quadrant 390 Primecare Dental /2010
4341 Periodontal scaling and root planing - per quadrant 90 4355 Full mouth debridement 20 4381 Localized delivery of chemotherapeutic agents - per tooth 58 4263 Bone replacement graft first site in quad 180 4264 Bone replacement graft each additional site in quad 105 PROSTHODONTICS 5110 Complete denture-maxillary 520 5120 Complete denture-mandibular 520 5211 Maxillary partial denture-resin base (including any conventional clasps, rests and teeth) 400 5212 Mandibular partial denture-resin base (including any conventional clasps, rests and teeth 400 5213 Maxillary partial denture-cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 600 5214 Mandibular partial denture-cast metal framework with resin denture bases (including any conventional clasps, rest and teeth) 600 5410 Adjust complete denture-maxillary 25 5411 Adjust complete denture-mandibular 25 5421 Adjust partial denture-maxillary 25 5422 Adjust partial denture-mandibular 25 5510 Repair broken complete denture base 65 5520 Replace missing or broken teeth-complete denture (each tooth) 50 5610 Repair resin denture base 55 5670 Replace all teeth and acrylic on cast metal framework maxillary 275 5671 Replace all teeth and acrylic on cast metal framework mandibular 275 5710 Rebase complete maxillary denture 225 5711 Rebase complete mandibular denture 225 5720 Rebase maxillary partial denture 225 5721 Rebase mandibular partial denture 225 5810 Interim complete denture maxillary 400 5811 Interim complete denture mandibular 400 5862 Precision attachment by report 200 5630 Repair or replace broken clasp 65 5640 Replace broken teeth-per tooth 55 5650 Add tooth to existing partial denture 55 5660 Add clasp to existing partial denture 75 5730 Reline complete maxillary denture (chairside) 95 5731 Reline complete mandibular denture (chairside) 95 5740 Reline maxillary partial denture (chairside) 95 5741 Reline mandibular partial denture (chairside) 95 5750 Reline complete maxillary denture (laboratory) 150 5751 Reline complete mandibular denture (laboratory) 150 5760 Reline maxillary partial denture (laboratory) 150 5761 Reline mandibular partial denture (laboratory) 150 5820 Interim partial denture (maxillary) 230 5821 Interim partial denture (mandibular) 230 5850 Tissue Conditioning, maxillary 45 5851 Tissue Conditioning, mandibular 45 6211 Pontic-cast predominantly base metal 325 6241 Pontic-porcelain fused to predominantly base metal 365 6251 Pontic-resin with predominantly base metal 265 Primecare Dental /2010
6930 Recement fixed partial denture 45 6245 Pontic porcelain ceramic 575 ORAL SURGERY 7110 Single tooth 50 7120 Each additional tooth 45 7210 Surgical removal of erupted tooth 80 7220 Removal of impacted tooth - soft tissue 95 7230 Removal of impacted tooth - partially bony 135 7240 Removal of impacted tooth - completely bony 170 7310 Alveoloplasty in conjunction with extractions - per quadrant 70 7250 Surgical removal of residual tooth roots 80 GENERAL SERVICES 9999 Office visit, per visit, per patient 5 9999 Broken appointment (less than 24 hours notice given) 25 9999 Duplication of xrays 20 9110 Palliative (emergency) treatment of dental pain 20 EMERGENCY, OUT OF AREA EMERGENCY CARE(BY NON-PARTICIPATING PROVIDER) OUTPATIENT SERVICES/HOSPITALIZAION & DRUG COVERAGE AMBULANCE SERVICE/DURABLE MEDICAL EQUIPMENT MENTAL HEALTH/CHEMICAL DEPENDENCY SER./HOME HEALTH PROSTHODONCTIC SPECIALTY SERVICES REIMBURSABLE UP TO $50 NOT COVERED NOT COVERED NOT COVERED NOT COVERED Services When Performed By A Plan Specialist, By Referral Only ENDODONTICS (Services When Performed by Plan Specialist) 3310 Root canal therapy anterior traditional 426 3320 Root canal therapy bicuspid traditional 504 3330 Root canal therapy molar traditional 733 3346 Retreatment of root canal anterior 539 3347 Retreatment of root canal bicuspid 605 3348 Retreatment of root canal molar 775 3410 Apicoectomy/periadicular surgery-anterior 431 3421 Apicoectomy/periadicular surgery-bicuspid first root 546 3425 Apicoectomy/periadicular surgery molar first root 552 3426 Apicoectomy/periadicular surgery each additional root 193 3430 Retrograde filling per root in addition to apicoectomy 94 3450 Root amputation per root 298 PERIODONTICS 4210 Gingivectomy or gingivoplasty - per quadrant 247 4211 Gingivectomy or gingivoplasty - per tooth 116 4230 Anatomical crown exposure-four or more contiguous teeth per quad 640 4231 Anatomical crown exposure one to three per quad. 340 Gingival flap procedure-includes root planing 4 plus contiguous 4240 339 teeth Gingival flap procedure including root planing 1-3 contiguous 4241 teeth 171 4249 Crown lengthening hard tissue by report 459 4260 Osseous surgery four or more contiguous teeth per quad. 699 4261 Osseous surgery (including flap entry and closure) 1-3 contiguous teeth 386 Primecare Dental /2010
4263 Bone replacement graft-first site in quadrant 257 4264 Bone replacement graft-each additional site in quadrant 152 4266 Guided tissue regeneration-restorable barrier-per site 272 4267 Guided tissue regeneration-nonrestorable barrier per site 260 4270 Pedicle soft tissue graft procedure 470 4271 Free soft tissue graft procedures (including donor site surgery) 470 4273 Subepithelial connective tissue graft procedure per tooth 573 4274 Distal or proximal wedge procedure 272 4275 Soft tissue allograft 526 4276 Combined connective tissue graft procedures per tooth 1274 4320 Provisional splinting-intracornal by report 158 4321 Provisional splinting-extracoronal by report 158 4341 Periodontal scaling & root planing four or more teeth per quad 120 4342 Periodontal scaling & root planing-1-3 teeth per quad 83 4355 Full mouth debridement 66 4381 Localized delivery of antimicrobial agents-per tooth by report 31 4910 Periodontal maintenance procedures following active therapy 81 ORAL SURGERY 7210 Surgical removal of erupted tooth 127 7220 Removal of impacted tooth soft tissue 166 7230 Removal of impacted tooth partially bony 235 7240 Removal of impacted tooth completely bony 301 7241 Removal of impacted tooth completely bony with complications 333 7250 Surgical removal of residual tooth roots cutting procedures 137 7260 Oroantral fistula closure 423 7261 Primary closure of a sinus perforation 366 7270 Tooth reimplantation and/or stabilization of evulsed or displaced tooth 293 7272 Tooth transplantation (includes reimplantation from one site to another 293 7280 Surgical access of an erupted tooth 311 7285 Biopsy of oral tissue-hard (bone, tooth). Provide pathology report 148 7286 Biopsy of oral tissue-soft (all others). Provide pathology report 118 7287 Exfoliative cytological sample collection. Provide lab report 100 7288 Brush biopsy-transepithelia sample collection by report 47 7291 Transseptal fiberotomy/supra crestial fiberotomy by report 34 7310 Alveoloplasty in conjunction with extractions four or more teeth 138 7311 Alveoloplasty in conjunction with extractions-one to three teeth 69 7320 Alveoloplasty not in conjunction with extractions four or more teeth 185 7321 Alveoloplasty not in conjunction with extractions-one to three teeth 93 7340 Vestibuloplasty-ridge extension secondary epithelialization 709 7350 Vestibuloplasty ridge extension 1092 7410 Excision of benign lesion up to 1.25cm 167 7411 Excision of benign lesion greater than 1.25cm 219 7412 Excision of benign lesion-complicated by report 313 7413 Excision of malignant lesion up to 1.25cm 189 7414 Excision of malignant lesion greater than 1.25cm 245 7415 Excision of malignant lesion-complicated by report 339 Primecare Dental /2010
7440 Excision of malignant tumor-lesion diameter up to 1.25cm 210 7441 Excision of malignant tumor-lesion diameter greater than 1.25cm 283 7450 Removal of benign odontogenic cyst or tumor-lesion up to 1.25cm 180 7451 Removal of benign odontogenic cyst or tumor-lesion greater than 1.25cm 292 7460 Removal of benign nonodontogenic cyst or tumor-lesion up to 1.25cm 181 7461 Removal of benign nonodontogenic cyst or tumor-lesion greater than 1.25cm 259 7471 Removal of lateral exostosis (maxilla or mandible) 330 7472 Removal of torus palatinus 367 7473 Removal of torus mandibularis 366 7485 Surgical reduction of osseous tuberosity 246 7510 Incision and drainage of abscess Intraoral soft tissue 80 7530 Removal of a foreign body from mucosa, skin or subcutaneous alveolar tissue 82 7880 Occlusal orthotic devise (TMJ treatment appliance) by report 447 7910 Suture of recent small wounds up to 5cm 62 7911 Complicated suture up to 5cm 74 7912 Complicated suture greater than 5cm 71 7953 Bone replacement graft for ridge preservation per site 257 7960 Frenulectomry (frenectomy or frenectomy) separate procedures 204 7970 Excision of hyperplasic tissue per arch 167 7971 Excision of periocornal gingiva 64 7972 Surgical reduction of fibrous tuberosity 269 IMPLANTS 5982 Surgical stent 286 6010 Surgical placement of implant body-endosteal implant 1500 6056 Prefabricated abutment-includes placement 170 6058 Abutment supported crown-porcelain/ceramic 969 6059 Abutment supported crown porcelain fused to high noble metal 957 6060 Abutment supported crown porcelain fused to predominantly base metal 904 6061 Abutment supported crown porcelain fused to noble metal 922 6062 Abutment supported crown cast high noble metal 875 6063 Abutment supported crown cast predominantly base metal 751 6064 Abutment supported crown cast noble metal 796 6065 Implant supported crown porcelain/ceramic 908 6066 Implant supported crown high noble metal or titanium 885 6067 Abutment supported retainer for porcelain high noble metal or titanium 858 6068 Abutment supported retainer for porcelain/ceramic FPD 969 6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) 957 6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) 904 6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) 922 6072 Abutment supported retainer for cast metal FPD (high noble metal) 987 6073 Abutment supported retainer for cast metal FPD (predominantly base metal) 812 6074 Abutment supported retainer for cast metal FPD (noble metal) 875 Primecare Dental /2010
6075 Implant supported retainer for ceramic FPD 953 6076 Implant supported retainer for porcelain fused to metal FPD (high noble metal or titanium) 1045 6077 Implant supported retainer for cast metal FPD (high noble metal or titanium) 858 6092 Recement implant/abutment supported crown 36 6093 Recement implant/abutment supported fixed partial denture 53 6094 Abutment supported crown titanium 579 6194 Abutment supported retainer crown for FPD - titanium 579 PROSTHODONTICS 2790 Crown full cast high noble metal 618 2791 Crown full cast predominantly base metal 542 2792 Crown full cast noble metal 579 2794 Crown titanium 579 2960 Labial veneer (resin laminate) chairside 264 2961 Labial veneer (resin laminate) laboratory 379 5110 Complete maxillary denture 799 5120 Complete mandibular denture 799 5130 Immediate maxillary denture 858 5140 Immediate mandibular denture 858 5213 Maxillary partial denture cast metal framework with resin denture base 913 5214 Mandibular partial denture-cast metal framework with resin denture base 913 5860 Overdenture-complete by report 858 5861 Overdenture partial by report 858 5862 Precision attachment by report 233 PEDODONTICS 1120 Prophylaxis child under age 12 37 1203 Topical application of fluoride child under age 12 22 1206 Topical fluoride varnish by report 85 1351 Sealant per tooth under age 16 on permanent molars only 27 1510 Space maintainer fixed unilateral 135 1515 Space maintainer fixed bilateral 166 1520 Space maintainer removable unilateral 146 1525 Space maintainer removable bilateral 198 2140 Amalgam four or more surfaces primary or permanent 62 2150 Amalgam two surfaces primary or permanent 81 2160 Amalgam three surfaces primary or permanent 101 2161 Amalgam four or more surfaces primary or permanent 113 2330 Resin based composite one surface anterior 84 2331 Resin based composite two surfaces anterior 100 2332 Resin based composite three surfaces anterior 127 2335 Resin based composite four or more surfaces anterior 131 2390 Resin based composite crown anterior 151 2391 Resin based composite one surface posterior 86 2392 Resin based composite two surfaces posterior 124 2393 Resin based composite three surfaces posterior 152 2394 Resin based composite four or more surfaces posterior 175 2930 Prefabricated stainless steel crown primary tooth 108 2391 Prefabricated stainless steel crown permanent tooth 114 Primecare Dental /2010
2940 Sedative filling 37 3110 Pulp cap direct 30 3120 Pulp cap indirect 26 3220 Therapeutic Pulpotomy 71 3221 Pulpal debridement primary and permanent teeth 64 ORTHODONTICS 8010 Limited orthodontic treatment of the primary dentition 513 8020 Limited orthodontic treatment of the transitional dentition 1802 8040 Limited orthodontic treatment of the adult dentition 1802 8050 Interceptive orthodontic treatment of the primary dentition 513 8060 Interceptive orthodontic treatment of the transitional dentition 546 8070 Comprehensive orthodontic treatment of the transitional dentition 3604 8090 Comprehensive orthodontic treatment of the adult dentition 3604 8680 Orthodontic retention removal of appliances/construction of retainer 192 MISCELLANEOUS SERVICES 9220 Deep sedation/general anesthesia first 30 minutes 204 9221 Deep sedation/general anesthesia each additional 15 minutes 90 9230 Analgesia anxiolysis, inhalation of nitrous oxide per visit 40 9241 Intravenous conscious sedation/analgesia first 30 minutes 149 9242 Intravenous conscious sedation/analgesia each additional 15 minutes 57 9248 Non-intravenous conscious sedation 89 9430 Office visit-for observation during office hours, no other services 30 9440 Office visit after regularly scheduled office hours 52 9940 Occlusal guard by report 219 9951 Limited occlusal adjustment per visit 64 9952 Complete occlusal adjustment by report 174 9972 External bleaching per arch 146 9973 External bleaching per tooth 56 9974 Internal bleaching per tooth 123 Primecare Dental Limitations & Exclusions 1. Full mouth X-rays: Limited to one (1) set every three (3) years unless diagnostically necessary. 2. Bitewing X-Rays: Two (2) sets in any twelve (12) month period unless diagnostically necessary. 3. Sealants: Limited to molars, up to the 16 th birthday. 4. Fluoride: Up to the 18 th birthday two(2) in any twelve (12) month period. 5. Delivery of removable prosthodontics includes adjustments within six months of delivery date of service. 6. Periodontal scaling and root planning: Limited to four (4) quadrants per twenty-four (24) consecutive months in combination with routine prophylaxis. 7. The copayments listed for endodontic procedures do not include the cost of the final restoration. 8. Panoramic x-rays: One (1) in any three (3) year period unless diagnostically necessary. 9. Prophylaxis: covered once every six consecutive months. 10. Reline of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless dentally necessary. 11. Rebase of a complete or partial denture: One (1) per denture in any twelve (12) month period, unless diagnostically necessary. 12. Replacement of partial or full dentures are covered once per arch every five (5) years, except when they cannot be made functional through reline or repairs. 13. Complete or partial dentures are not to exceed one per arch in a five (5) year period unless necessary due to natural tooth loss where the addition to an existing partial or denture is not feasible. Primecare Dental /2010
14. Treatment of malignancies, cysts, or neoplasm. 15. Periodontal grafting or splinting. 16. Extractions of impacted teeth with no radiographic evidence of pathology (disease). The removal of asymptomatic third molars is not a covered benefit unless pathology (disease) exists. 17. General anesthesia, analgesia, intravenous /intramuscular sedation or the services of an anesthesiologist. 18. Elective or cosmetic dentistry that are cosmetic in nature including, but not limited to bonding, bleaching teeth, personalization or dentures, posterior composites, porcelain veneers unless covered as a benefit. 19. Orthodontic treatment in process, or extractions for orthodontic purposes. 20. Procedures, appliances or restorations whose primary purpose is to change the vertical deminsion of occlusion, correct congenital development or medically induced dental disorders including but not limited to treatment of myofunctional, myoskeletal, or tempormandibular joint disorders unless otherwise specifically listed as a covered benefit on the plans schedule of benefits. 21. Precision attachments, stress breakers, magnetic retention or overdenture attachments. 22. Cephalometric x-rays, except when performed as part of the orthodontic treatment plan and records for a covered course of comprehensive orthodontic treatment. 23. Inlays, onlays, crowns or fixed bridges started, but not completed, prior to the Member s eligibility to receive benefits under this Plan. 24. (Inlays, onlays, crowns or fixed bridges are considered to be started when the tooth or teeth are prepared, and completed when the final restoration is permanently cemented). 25. Dentures or orthodontic treatment started prior to the Member s eligibility to receive benefits under this Plan. 26. (Dentures are considered to be started when the impressions area taken. Orthodontic treatment is considered to be started when the teeth are banded). 27. Replacement of lost or stolen prosthetics or appliances including crowns, bridges, partial dentures, full dentures, and orthodontic appliance. 28. Any treatment requested, or appliances made, which are either not necessary for maintaining or improving dental health, or are for cosmetic purposes unless otherwise covered as a benefit. 29. Any procedure or treatment unable to be performed in the dental office due to the general health or physical limitation of the member. 30. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services. 31. Oral surgery requiring the setting of bone fractures or dislocations, Hospitalization, Out- patient services, Ambulance services, Durable Medical Equipment, Mental Health services, Chemical dependency services, Home Health services. 32. Dispensing of drugs supplied in a dental office. 33. Any condition for which benefits of any nature are recovered or found to be recoverable, whether by adjudication or settlement, under any Worker s Compensation or Occupational Disease Law, even though the Member fails to claim his or her rights to such benefit. 34. Any service or procedure associated with the placement, prosthodontic restoration or maintenance of a dental implant and any incremental charges to other covered services as a result of the presence of a dental implant. 35. Root canal treatment started, but not completed, prior to the Member s legibility to receive benefits under this Plan. 36. (Root canal treatment is considered to be started when the pulp chamber is opened, and completed when the permanent root canal filling material is placed.) 37. Coverage is up to twenty-four (24) months of comprehensive orthodontic treatment. If treatment goes beyond twenty four (24) months is necessary, the Member will be responsible for additional charge for each additional month of treatment based up to the participating Orthodontic Specialist Dentist s contracted fee. 38. If a Member transfer to another Participating Orthodontist after comprehensive orthodontic treatment has been started the Member will be responsible for any additional costs associated with the change in orthodontist and subsequent treatment. Primecare Dental /2010
Orthodontic Limitations and Exclusions The Plan covers orthodontic services as listed under Covered Dental Services, limited to one course of treatment in lifetime. Orthodontic services are not covered if comprehensive treatment begins before the Member is eligible for benefits under the Plan. If a Member s coverage terminates after the fixed banding appliances are inserted, the Participating Orthodontist Specialist Dentist After the termination date, the Member will be responsible for any additional monthly amounts. Orthodontic treatment shall only be provided by a member of the Plan orthodontic panel. The following are exclusions of orthodontic coverage. 1. Re-treatment of orthodontic cases, or changes in orthodontic treatment necessitated by any kind of accident. 2. Replacement or repair of orthodontic appliances damaged due to the neglect of the Member. 3. Tracings, records, study models, x-rays and photographs. 4. Initial examination, consultation, diagnosis, treatment planning, retention appliances and related visits. 5. Cephalometric x-rays. 6. Lost or broken appliances. 7. Myofunctional therapy. 8. Surgical procedures such as extractions of teeth strictly for the purpose of orthodontia. 9. Any jaw surgical procedure related to orthodontia. 10. Dental services of any nature, performed in hospital or convalescent home or anywhere outside the office or Plan provider. 11. Dispensing of drugs not normally supplied in an orthodontic practice. 12. Treatment related to Temporomandibular Join Dysfunction or hormonal imbalances. Primecare Dental /2010