EssentialSmile 122

SECTION XVIII.
EssentialSmile 122, NS, OON, Family Dental
SCHEDULE OF BENEFITS
COST-SHARING
PEDIATRIC DENTAL
CARE ESSENTIAL
HEALTH BENEFIT
Deductible
 One (1) Member
under Age 19
 Two (2) or More
Members under Age
19
Out-of-Pocket Limit
 One (1) Member
under Age 19
 Two or More
Members under Age
19
Annual Lifetime
Maximum
PEDIATRIC DENTAL
ESSENTIAL HEALTH
BENEFIT & CARE
Participating
Provider
Member
Responsibility for
Cost-Sharing
Non-Participating
Provider
Member
Responsibility for
Cost-Sharing
$100
$100
$100 per Member
$100 per Member
$350
None
$700
None
None
None
Participating
Provider
Member
Responsibility for
Cost-Sharing
Non-Participating
Provider
Member
Responsibility for
Cost-Sharing
Limits
Pediatric Dental Care

Preventive Dental
Care
0% Coinsurance
subject to Deductible
0% Coinsurance
subject to Deductible
One Dental Exam
& Cleaning Per 6
Month Period

Routine Dental
Care
0-50% Coinsurance
subject to Deductible
0-50% Coinsurance
subject to Deductible
Full mouth X-rays
or panoramic Xrays at 36 month
intervals and
bitewing X-rays at
6 to 12 month
intervals
SHI-G-SCH-0-0F-NY0614
Underwritten by Solstice Health Insurance Company, a licensed Accident and Health Insurance
Company under New York Insurance Law Section 1113(a)(3).

Endodontics
50% Coinsurance
subject to Deductible
50% Coinsurance
subject to Deductible

Periodontics
50% Coinsurance
subject to Deductible
50% Coinsurance
subject to Deductible

Prosthodontics
50% Coinsurance
subject to Deductible
50% Coinsurance
subject to Deductible

Orthodontics
50% Coinsurance
subject to Deductible
CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
PREVENTIVE DENTAL CARE D1110
Prophylaxis ‐ adult
0%
0%
D1120
Prophylaxis ‐ child
0%
0%
D1206
Topical fluoride varnish
0%
0%
D1208
Topical application of fluoride
0%
0%
One (1) time in any six (6) consecutive month where the local water supply is not fluoridated.
One (1) time in any thirty six (36) consecutive month per tooth
D1351
Sealant ‐ per tooth
0%
0%
D1510
Space maintainer ‐ fixed ‐ unilateral
0%
0%
D1515
Space maintainer ‐ fixed ‐ bilateral
0%
0%
D1520
Space maintainer ‐ removable ‐ unilateral
0%
0%
D1525
Space maintainer ‐ removable ‐ bilateral
0%
0%
D1550
Re‐cementation of space maintainer
0%
0%
D1555
Removal of fixed space maintainer
0%
0%
D8210
Removable appliance therapy
ROUTINE DENTAL CARE‐ APPOINTMENTS 50%
50%
D0120
Periodic oral evaluation
0%
0%
D0140
D0145
Limited oral evaluation ‐ problem focused
Oral evaluation for a patient under 3 years of age
Comprehensive oral evaluation ‐ new or established patient
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
D0150
D0160
Oral evaluation ‐ problem focused
Palliative (emergency) treatment of dental pain ‐ minor procedure
ROUTINE DENTAL CARE‐ RADIOGRAPHY / DIAGNOSTIC DENTISTRY
D9110
One (1) time in any six (6) consecutive month One (1) time in any six (6) consecutive month D0210
Intraoral ‐ complete series (including bitewings) 0%
0%
D0220
Intraoral ‐ periapical first images
0%
0%
D0270
Bitewing ‐ single images
0%
0%
D0272
Bitewings ‐ 2 images
0%
0%
D0273
Bitewings ‐ 3 images
0%
0%
D0274
Bitewings ‐ 4 images
0%
0%
D0330
Panoramic images
0%
0%
One (1) time in any six (6) consecutive month One (1) time in any six (6) consecutive month One (1) time in any six (6) consecutive month One (1) time per five (5) year period
Six (6) to twelve (12) month intervals
Six (6) to twelve (12) month intervals
Six (6) to twelve (12) month intervals
Six (6) to twelve (12) month intervals
Thirty six (36) month intervals
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ROUTINE DENTAL CARE‐ RESTORATIVE DENTISTRY
D2140
Amalgam ‐ 1 surface, primary or permanent
20%
20%
D2150
Amalgam ‐ 2 surfaces, primary or permanent
20%
20%
D2160
Amalgam ‐ 3 surfaces, primary or permanent
20%
20%
D2161
Amalgam ‐ 4 or more surfaces, primary or permanent
20%
20%
D2330
Resin‐based composite ‐ 1 surface, anterior
20%
20%
D2331
Resin‐based composite ‐ 2 surfaces, anterior
20%
20%
D2332
Resin‐based composite ‐ 3 surfaces, anterior
Resin‐based composite ‐ 4 or more surfaces or involving incisal angle (anterior)
20%
20%
20%
20%
D2335
D2930
Prefabricated stainless steel crown ‐ primary tooth
50%
50%
One (1) time per five (5) year period per tooth
D2931
Prefabricated stainless steel crown ‐ permanent tooth
50%
50%
One (1) time per five (5) year period per tooth
D2940
Protective restoration
ROUTINE DENTAL CARE‐ ORAL SURGERY
50%
50%
D7111
50%
50%
Extraction, coronal remnants ‐ deciduous tooth
D7140
Extraction, erupted tooth or exposed root
Frenulectomy (frenectomy or frenotomy) ‐ separate D7960
procedure
ENDODONTICS
50%
50%
50%
50%
D3110
Pulp cap ‐ direct 50%
50%
D3120
Pulp cap ‐ indirect 50%
50%
D3220
Therapeutic pulpotomy
50%
50%
D3221
Pulpal Debridement primary and permanent teeth
50%
50%
D3230
Pulpal therapy‐ anterior, primary tooth 50%
50%
D3240
Pulpal therapy‐ posterior, primary tooth 50%
50%
D3310
Endo therapy, anterior tooth 50%
50%
D3320
Endo therapy, bicuspid tooth 50%
50%
D3330
Endo therapy, molar Treatment of root canal obstruction; non‐surgical access
Incomplete Endo therapy
50%
50%
50%
50%
50%
50%
D3331
D3332
D3333
Internal root repair of perforation defects
50%
50%
D3346
Retreatment of root canal therapy ‐ anterior
50%
50%
D3347
Retreatment of root canal therapy ‐ bicuspid
50%
50%
D3348
D3421
D3425
Retreatment of root canal therapy ‐ molar
Apico/periradicular surgery ‐ bicuspid (first root)
Apico/periradicular surgery ‐ molar (first root)
50%
50%
50%
50%
50%
50%
D3426
Apico/periradicular surgery (each add root)
50%
50%
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ENDODONTICS CONT. D3430
Retrograde filling ‐ per root
50%
50%
D3450
Root amputation ‐ per root
PERIODONTICS 50%
50%
D4341
Perio Scaling/Root Planing ‐ four or more contiguous teeth or bounded spaces per quadrant
50%
50%
D4342
Perio scaling/Root Planing ‐ one to three teeth per quadrant
50%
50%
D4910
Periodontal Maintenance
50%
50%
Complete denture ‐ maxillary
50%
50%
PROSTHODONTICS ‐ REMOVABLE
D5110
D5120
Complete denture ‐ mandibular 50%
50%
D5211
Maxillary part denture ‐ resin base
50%
50%
D5212
Mandibular part denture ‐ resin base
50%
50%
D5410
Adjust complete denture ‐ maxillary
50%
50%
D5411
Adjust complete denture ‐ mandibular
50%
50%
D5421
Adjust part denture ‐ maxillary
50%
50%
D5422
Adjust part denture ‐ mandibular
50%
50%
D5510
50%
50%
50%
50%
D5610
Repair broken complete denture base
Replace missing or broken teeth ‐ complete denture (each tooth)
Repair resin denture base
50%
50%
D5620
Repair cast framework
50%
50%
D5630
Repair or replace broken clasp
50%
50%
D5520
D5640
Replace broken teeth ‐ per tooth
50%
50%
D5710
Rebase complete maxillary denture
50%
50%
D5711
Rebase complete mandibular denture
50%
50%
D5720
Rebase maxillary part denture
50%
50%
D5721
Rebase mandibular part denture
50%
50%
D5730
Reline complete maxillary denture (chairside)
50%
50%
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
PROSTHODONTICS ‐ REMOVABLE CONT.
D5731
Reline complete mandibular denture (chairside)
50%
50%
D5740
Reline maxillary part denture (chairside)
50%
50%
D5741
Reline mandibular part denture (chairside)
50%
50%
D5750
Reline complete maxillary denture (lab)
50%
50%
D5751
Reline complete mandibular denture (lab)
50%
50%
D5760
Reline Upper Part Denture (Lab)
50%
50%
D5761
Reline mandibular part denture (lab)
PROSTHODONTICS ‐ FIXED
50%
50%
D6211
Pontic ‐ cast predominantly base metal
50%
50%
One (1) time per five (5) year period per tooth
D6251
Pontic ‐ resin with predominantly base metal
50%
50%
One (1) time per five (5) year period per tooth
D6721
Crown ‐ resin with predominantly base metal
50%
50%
One (1) time per five (5) year period per tooth
D6791
Crown ‐ full cast predominantly base metal
50%
50%
One (1) time per five (5) year period per tooth
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
ORTHODONTIA
D8050
Interceptive ortho treatment of the primary dentition
Interceptive ortho treatement of the transitional dentition
Comprehensive ortho treatment of the transitional D8070
dentition
Comprehensive ortho treatment of the adolescent D8080
dentition
Comprehensive ortho treatment of the adult D8090
dentition
D8680
Ortho retention
MISCELLANEOUS SERVICES
Intravenous conscious sedation/analgesia ‐ first 30 D9241
minutes
Intravenous conscious sedation/analgesia ‐ each add D9242
15 minutes
D8060
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. Participating
Provider
Member
Responsibility for
Cost-Sharing
Non-Participating
Provider
Member
Responsibility for
Cost-Sharing
Deductible
 Individual
 Family
$50
$50 per Member
$50
$50 per Member
Out-of-Pocket Limit
 Individual
 Family
None
None
None
None
Annual Maximum
$1,000
$1,000
ADULT DENTAL CARE
& BENEFIT
Participating
Provider Member
Responsibility for
Cost-Sharing
Non-Participating
Provider Member
Responsibility for
Cost-Sharing
Limits
COST-SHARING
ADULT DENTAL CARE
Adult Dental Care

Preventive Dental
Care
0% Coinsurance
not subject to
Deductible
0% Coinsurance
not subject to
Deductible
One Dental Exam &
Cleaning Per 6 Month
Period

Routine Dental
Care
0-50% Coinsurance
X-Rays and
Examinations not
subject to
Deductible; Oral
Surgery and
Restorative after
Deductible
0-50% Coinsurance
X-Rays and
Examinations not
subject to
Deductible; Oral
Surgery and
Restorative after
Deductible
Full mouth X-rays or
panoramic X-rays at 36
month intervals and
bitewing X-rays at 6 to 12
month intervals

Endodontics
50% Coinsurance
after Deductible
50% Coinsurance
after Deductible

Periodontics
50% Coinsurance
after Deductible
50% Coinsurance
after Deductible

Prosthodontics
50% Coinsurance
after Deductible
50% Coinsurance
after Deductible
CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
PREVENTIVE DENTAL CARE D1110
Prophylaxis ‐ adult
0%
0%
D1206
Topical fluoride varnish
0%
0%
One (1) time in any six (6) consecutive month D1208
Topical application of fluoride
0%
0%
One (1) time in any six (6) consecutive month where the local water supply is not fluoridated.
D1351
Sealant ‐ per tooth
0%
0%
One (1) time in any thirty six (36) consecutive month per tooth
D1510
Space maintainer ‐ fixed ‐ unilateral
0%
0%
D1515
Space maintainer ‐ fixed ‐ bilateral
0%
0%
D1520
Space maintainer ‐ removable ‐ unilateral
0%
0%
D1525
Space maintainer ‐ removable ‐ bilateral
0%
0%
D1550
Re‐cementation of space maintainer
0%
0%
D1555
Removal of fixed space maintainer
ROUTINE DENTAL CARE‐ APPOINTMENTS
0%
0%
D0120
Periodic oral evaluation
0%
0%
D0140
Limited oral evaluation ‐ problem focused
0%
0%
D0145
Oral evaluation for a patient under 3 years of age
0%
0%
D0150
Comprehensive oral evaluation ‐ new or established patient
0%
0%
D0160
Oral evaluation ‐ problem focused
0%
0%
D0170
Re‐evaluation ‐ limited, problem focused
0%
0%
D0180
Comprehensive periodontal evaluation
Palliative (emergency) treatment of dental pain ‐ minor procedure
Consultation
0%
0%
0%
0%
20%
20%
D9440
Off Vst‐After Reg Sched Hours
ROUTINE DENTAL CARE‐ RADIOGRAPHY / DIAGNOSTIC DENTISTRY
20%
20%
D0210
0%
0%
D9110
D9310
Intraoral ‐ complete series (including bitewings) D0220
Intraoral ‐ periapical first images
0%
0%
D0230
D0240
Intraoral ‐ periapical each add images
Intraoral ‐ occlusal images
0%
0%
0%
0%
D0250
Extraoral ‐ first images
0%
0%
One (1) time in any six (6) consecutive month One (1) time in any thirty six (36) consecutive months
One (1) time in any six (6) consecutive month One (1) time per five (5) year period
One (1) time in any twelve (12) consecutive month Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ROUTINE DENTAL CARE‐ RADIOGRAPHY / DIAGNOSTIC DENTISTRY CONT. D0260
Extraoral ‐ each add images
0%
0%
D0270
Bitewing ‐ single images
0%
0%
D0272
Bitewings ‐ 2 images
0%
0%
D0273
Bitewings ‐ 3 images
0%
0%
D0274
Bitewings ‐ Four Films
0%
0%
D0277
Vertical bitewings ‐ 7 to 8 images
0%
0%
D0330
Panoramic images
0%
0%
D0340
Cephalometric radiographic images
0%
0%
D0350
Oral/facial photographic images
0%
0%
D0364
Cone beam CT capture and interpretation with limited field of view ‐ less than one whole jaw
0%
0%
D0365
Cone beam CT capture and interpretation with field of view of one full dental arch ‐ mandible
0%
0%
D0366
Cone beam CT capture and interpretation with field of view of one full dental arch ‐ maxilla, with or without cranium
0%
0%
D0367
Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium
0%
0%
D0368
Cone beam CT capture and interpretation for TMJ series including two or more exposures
0%
0%
D0369
Maxillofacial MRI capture and interpretation
0%
0%
One (1) time in any twelve (12) consecutive month Six (6) to twelve (12) month intervals
Six (6) to twelve (12) month intervals
Six (6) to twelve (12) month intervals
Six (6) to twelve (12) month intervals
Six (6) to twelve (12) month intervals
Thirty six (36) month intervals
One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ROUTINE DENTAL CARE‐ RADIOGRAPHY / DIAGNOSTIC DENTISTRY CONT. D0370
Maxillofacial ultrasound capture and interpretation
0%
0%
D0371
Sialoendoscopy capture and interpretation
0%
0%
D0380
Cone beam CT image capture with limited field of view ‐ less than one whole jaw
0%
0%
D0381
Cone beam CT image capture with field of view of one full dental arch ‐ mandible
0%
0%
D0382
Cone Beam CT image capture with field of view of one full dental arch ‐ maxilla, with or without cranium
0%
0%
D0383
Cone beam CT image capture with field of view of both jaws, with or without cranium
0%
0%
D0384
Cone beam CT image capture for TMJ series including two or more exposures 0%
0%
D0385
Maxillofacial MRI image capture
0%
0%
D0386
Maxillofacial ultrasound image capture 0%
0%
D0415
Collection of microorganisms for culture & sensitivity
0%
0%
D0431
Adjunctive pre‐diagnostic test
0%
0%
One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. One (1) time per sixty (60) months, covered only in a dental setting not a radiographic imaging center. Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ROUTINE DENTAL CARE‐ RADIOGRAPHY / DIAGNOSTIC DENTISTRY CONT. D0460
Pulp vitality tests 0%
0%
D0470
Diagnostic casts
ROUTINE DENTAL CARE‐ RESTORATIVE DENTISTRY
0%
0%
D2140
Amalgam ‐ 1 surface, primary or permanent
20%
20%
D2150
Amalgam ‐ 2 surfaces, primary or permanent
20%
20%
D2160
Amalgam ‐ 3 surfaces, primary or permanent
20%
20%
D2161
Amalgam ‐ 4 or more surfaces, primary or permanent
20%
20%
D2330
Resin‐based composite ‐ 1 surface, anterior
20%
20%
D2331
Resin‐based composite ‐ 2 surfaces, anterior
20%
20%
D2332
20%
20%
20%
20%
D2390
Resin‐based composite ‐ 3 surfaces, anterior
Resin‐based composite ‐ 4 or more surfaces or involving incisal angle (anterior)
Resin‐based composite crown, anterior
20%
20%
D2391
Resin‐based composite ‐ 1 surface, posterior
20%
20%
D2392
Resin‐based composite ‐ 2 surfaces, posterior
20%
20%
D2393
Resin‐based composite ‐ 3 surfaces, posterior
20%
20%
D2394
Resin‐based composite ‐ 4 or more surfaces, posterior
20%
20%
D2410
Gold foil ‐ 1 surface
20%
20%
D2420
Gold foil ‐ 2 surfaces
20%
20%
D2430
Gold foil ‐ 3 surfaces
20%
20%
D2510
Inlay ‐ metallic ‐ 1 surface
50%
50%
D2520
Inlay ‐ metallic ‐ 2 surfaces
50%
50%
D2530
Inlay ‐ metallic ‐ 3 or more surfaces
50%
50%
D2335
D2542
Onlay ‐ metallic‐2 surfaces
50%
50%
D2543
Onlay ‐ metallic‐3 surfaces
50%
50%
D2544
Onlay ‐ metallic‐4 or more surfaces
50%
50%
D2610
Inlay ‐ porcelain/ceramic ‐ 1 surface
20%
20%
D2620
Inlay ‐ porcelain/ceramic ‐ 2 surfaces 20%
20%
D2630
Inlay ‐ porcelain/ceramic ‐ 3 or more surfaces
20%
20%
D2642
Onlay ‐ porcelain/ceramic ‐ 2 surfaces
50%
50%
D2643
Onlay ‐ porcelain/ceramic ‐ 3 surfaces
50%
50%
D2644
Onlay ‐ porcelain/ceramic ‐ 4 or more surfaces
20%
20%
D2650
Inlay ‐ resin‐based composite ‐ 1 surface 20%
20%
D2651
Inlay ‐ resin‐based composite ‐ 2 surfaces 20%
20%
D2652
Inlay ‐ resin‐based composite ‐ 3 or more surfaces 20%
20%
D2662
Onlay ‐ resin‐based composite ‐ 2 surfaces 20%
20%
D2663
Onlay ‐ resin‐based composite ‐ 3 surfaces 20%
20%
D2664
Onlay ‐ resin‐based composite ‐ 4 or more surfaces 20%
20%
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ROUTINE DENTAL CARE‐ RESTORATIVE DENTISTRY CONT. D2710
Crown ‐ resin‐based composite (indirect)
20%
20%
D2712
Crown ‐ ¾ resin‐based composite (indirect)
20%
20%
D2720
Crown‐ resin with high noble metal
20%
20%
D2721
Crown ‐ resin with predominantly base metal
20%
20%
D2722
Crown ‐ resin with noble metal
20%
20%
D2740
Crown ‐ porcelain/ceramic substrate
50%
50%
D2750
Crown ‐ porcelain fused to high noble metal
50%
50%
D2751
Crown ‐ porcelain fused to predominantly base metal
50%
50%
D2752
Crown ‐ porcelain fused to noble metal
50%
50%
D2780
Crown ‐ 3/4 cast high noble metal
50%
50%
D2781
Crown ‐ 3/4 cast predominantly
50%
50%
D2782
Crown ‐ 3/4 cast noble metal 20%
20%
D2783
Crown ‐ 3/4 porcelain/ceramic 50%
50%
D2790
Crown ‐ full cast high noble metal
50%
50%
D2791
Crown‐Full Cast Predom Base Metal
50%
50%
D2792
Crown ‐ full cast noble metal
50%
50%
D2799
Provisional crown
20%
20%
D2910
Recement Inlay
20%
20%
D2915
Recement cast or prefabricated post & core
20%
20%
D2920
Recement crown
20%
20%
D2931
Prefabricated stainless steel crown ‐ permanent tooth
20%
20%
D2932
Prefabricated resin crown
20%
20%
D2933
Prefabricated stainless steel crown with resin window
20%
20%
D2940
Protective restoration
20%
20%
D2950
Core buildup, including any pins
50%
50%
D2951
Pin retention ‐ per tooth, in addition to restoration
20%
20%
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ROUTINE DENTAL CARE‐ RESTORATIVE DENTISTRY CONT. D2952
Post & core in addition to crown, indirectly fabricated
20%
20%
D2953
Each add indirectly fabricated post ‐ same tooth
20%
20%
D2954
Prefabricated post & core in addition to crown
50%
50%
D2955
Post removal
20%
20%
D2957
Each add prefabricated post ‐ same tooth
20%
20%
D2960
Labial veneer (resin laminate) ‐ chairside
20%
20%
D2961
Labial veneer (resin laminate) ‐ lab
20%
20%
D2962
Labial veneer (porcelain laminate) ‐ lab
20%
20%
D2970
Temp. crown (fractured tooth)
20%
20%
20%
20%
20%
20%
Additional procedure to contruct new crown under existing partial denture framework
D2980
Crown repair
ROUTINE DENTAL CARE‐ ORAL SURGERY
D2971
D7111
Extraction, coronal remnants ‐ deciduous tooth
50%
50%
D7140
Extraction, erupted tooth or exposed root
50%
50%
D7210
Surgical removal of erupted tooth
50%
50%
D7220
Removal of impacted tooth ‐ soft tissue
50%
50%
D7230
Removal of impacted tooth ‐ partly bony
50%
50%
D7240
Removal of impacted tooth ‐ completely bony
Removal of impacted tooth ‐ completely bony, surgical complications
Surgical removal of residual tooth roots (cutting procedure)
50%
50%
50%
50%
50%
50%
Oroantral fistula closure
50%
50%
50%
50%
50%
50%
D7241
D7250
D7260
50%
50%
D7285
Tooth reimplantation &/or stabilization of accidentally evulsed or displaced tooth
Surgical access of an unerupted tooth
Mobilization of erupted or malpositioned tooth to aid eruption
Biopsy of oral tissue ‐ hard (bone, tooth)
50%
50%
D7286
Biopsy of oral tissue ‐ soft 50%
50%
D7288
Brush biopsy ‐ transepithelial sample collection
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
D7270
D7280
D7282
D7310
D7311
D7320
D7321
Alveoloplasty in conjunction with extractions – 4 or more teeth
Alveoloplasty in conjunction with extractions ‐ 1 to 3 teeth
Alveoloplasty not in conjunction with extractions ‐ 4 or more teeth
Alveoloplasty not in conjunction with extractions ‐ 1 to 3 teeth
One (1) time per five (5) year period per tooth
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
ROUTINE DENTAL CARE‐ ORAL SURGERY CONT.
Removal of benign odontogenic cyst or tumor ‐ 1.25 D7450
cm
Removal of benign odontogenic cyst or tumor ‐ 1.25 D7451
cm
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
50%
50%
50%
50%
D7471
Removal of lateral exostosis (maxilla or mandible)
50%
50%
D7472
Removal of torus palatinus
50%
50%
D7473
Removal of torus mandibularis
50%
50%
D7510
Incision & drainage of abscess ‐ intraoral soft tissue
50%
50%
D7511
Incision & drainage of abscess ‐ intraoral soft tissue ‐ complicated
50%
50%
D7520
Incision & drainage of abscess ‐ extraoral soft tissue
50%
50%
D7521
Incision & drainage of abscess ‐ extraoral soft tissue ‐ complicated
50%
50%
D7910
Suture of recent small wounds up to 5 cm
50%
50%
50%
50%
50%
50%
50%
50%
D7971
Excision of Pericoronal Gingiva ENDODONTIC SERVICES
50%
50%
D3110
Pulp cap ‐ direct 50%
50%
D3120
Pulp cap ‐ indirect 50%
50%
D3220
Therapeutic pulpotomy
50%
50%
D3221
Pulpal Debridement primary and permanent teeth
50%
50%
D3230
Pulpal therapy‐ anterior, primary tooth 50%
50%
D3240
Pulpal therapy‐ posterior, primary tooth 50%
50%
D7963
Frenulectomy (frenectomy or frenotomy) ‐ separate procedure
Frenuloplasty
D7970
Excision of hyperplastic tissue ‐ per arch
D7960
D3310
Endo therapy, anterior tooth 50%
50%
D3320
Endo therapy, bicuspid tooth 50%
50%
D3330
50%
50%
50%
50%
D3332
Endo therapy, molar Treatment of root canal obstruction; non‐surgical access
Incomplete Endo therapy
50%
50%
D3333
Internal root repair of perforation defects
50%
50%
D3346
Retreatment of root canal therapy ‐ anterior
50%
50%
D3347
Retreatment of root canal therapy ‐ bicuspid
50%
50%
D3348
Retreatment of root canal therapy ‐ molar
50%
50%
D3351
Apex/recalcification ‐ initial visit
Apex/recalcification ‐ interim medication replacement
50%
50%
50%
50%
D3331
D3352
LIMITATIONS
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
ENDODONTIC SERVICES CONT.
D3353
Apex/recalcification ‐ final visit
50%
50%
D3410
Apico/periradicular surgery ‐ anterior
50%
50%
D3421
Apico/periradicular surgery ‐ bicuspid (first root)
50%
50%
D3425
Apico/periradicular surgery ‐ molar (first root)
50%
50%
D3426
Apico/periradicular surgery (each add root)
50%
50%
D3430
Retrograde filling ‐ per root
50%
50%
D3450
Root amputation ‐ per root
50%
50%
D3470
50%
50%
50%
50%
D3920
Intentional reimplantation
Surgical procedure for isolation of tooth with rubber dam
Hemisection
50%
50%
D3950
Canal prep & fitting of preformed dowel or post
50%
50%
50%
50%
50%
50%
50%
50%
50%
50%
D3910
PERIODONTIC SERVICES
D4210
D4211
D4240
D4241
Gingivectomy or gingivoplasty ‐ 4 or more contiguous teeth
Gingivectomy or gingivoplasty ‐ 1 to 3 contiguous teeth
Gingival flap procedure including root planing ‐ 4 or more contiguous teeth
Gingival flap procedure including root planing ‐ 1 to 3 contiguous teeth
D4245
Apically positioned flap
50%
50%
D4249
Clinical crown lengthening ‐ hard tissue
50%
50%
D4260
Osseous surgery‐ 4 or more contiguous teeth
50%
50%
D4261
Osseous surgery‐ 1 to 3 contiguous teeth
50%
50%
D4263
Bone replacement graft ‐ first site in quadrant
50%
50%
D4264
Bone replacement graft ‐ each add site in quadrant
50%
50%
50%
50%
50%
50%
D4266
D4267
Guided tissue regeneration ‐ resorbable barrier, per site
Guided tissue regeneration ‐ nonresorbable barrier, per site
D4270
Pedicle soft tissue graft procedure
50%
50%
D4271
50%
50%
50%
50%
D4274
Free soft tissue graft
Subepithelial connective tissue graft procedures, per tooth
Distal or proximal wedge procedure
50%
50%
D4275
Soft tissue allograft 50%
50%
D4320
Provisional splinting ‐ intracoronal
50%
50%
D4273
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
PERIODONTIC SERVICES CONT. D4321
Provisional Splinting ‐ Extracoronal
D4341
Periodontal scaling & root planing ‐ 4 or more teeth per quadrant
50%
50%
D4342
Perio scaling/Root Planing ‐ one to three teeth per quadrant
50%
50%
50%
50%
50%
50%
D4355
D4381
D4910
Full mouth debridement to enable comprehensive evaluation & diagnosis
Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth
Periodontal maintenance Unscheduled dressing change (by some other than treating dentist)
PROSTHODONTICS ‐ REMOVABLE D4920
50%
50%
50%
50%
50%
50%
D5110
Complete denture ‐ maxillary
50%
50%
D5120
Complete denture ‐ mandibular 50%
50%
D5130
Immediate denture ‐ maxillary
50%
50%
D5140
Immediate denture ‐ mandibular
50%
50%
D5211
Maxillary part denture ‐ resin base
50%
50%
D5212
Mandibular part denture ‐ resin base
Maxillary part denture ‐ cast metal framework with resin denture bases
Mandibular part denture ‐ cast metal framework with resin denture bases
50%
50%
50%
50%
50%
50%
D5213
D5214
D5225
Maxillary part denture ‐ flexible base
50%
50%
D5226
Mandibular part denture ‐ flexible base
50%
50%
50%
50%
20%
20%
D5281
D5410
Removable unilateral part denture ‐ 1 piece cast metal
Adjust complete denture ‐ maxillary
Limited to one (1) time per quadrant per consecutive twenty‐four (24) months.
Limited to one (1) time per quadrant per consecutive twenty‐four (24) months.
Limited to two (2) periodontal maintenance in any twelve (12) consecutive months, to a maximum of two (2) total prophylaxis and periodontal maintenance procedures in any twelve(12) consecutive months.
One (1) time per five (5) year period
One (1) time per five (5) year period
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
PROSTHODONTICS ‐ REMOVABLE CONT. D5411
Adjust complete denture ‐ mandibular
20%
20%
D5421
Adjust part denture ‐ maxillary
20%
20%
D5422
Adjust part denture ‐ mandibular
20%
20%
D5510
20%
20%
20%
20%
D5610
Repair broken complete denture base
Replace missing or broken teeth ‐ complete denture (each tooth)
Repair resin denture base
20%
20%
D5620
Repair cast framework
20%
20%
D5630
Repair or replace broken clasp
20%
20%
D5520
D5640
Replace broken teeth ‐ per tooth
20%
20%
D5650
Add tooth to existing part denture
20%
20%
D5660
20%
20%
20%
20%
20%
20%
D5710
Add clasp to existing part denture
Replace all teeth & acrylic on cast metal framework (maxillary) Replace all teeth & acrylic on cast metal framework (mandibular)
Rebase complete maxillary denture
20%
20%
D5711
Rebase complete mandibular denture
20%
20%
D5720
Rebase maxillary part denture
20%
20%
D5721
Rebase Lower Partial Denture
20%
20%
D5730
Reline complete maxillary denture (chairside)
20%
20%
D5731
Reline complete mandibular denture (chairside)
20%
20%
D5740
Reline maxillary part denture (chairside)
20%
20%
D5741
Reline mandibular part denture (chairside)
20%
20%
D5750
Reline complete maxillary denture (lab)
20%
20%
D5751
Reline complete mandibular denture (lab)
20%
20%
D5760
Reline maxillary part denture (lab) 20%
20%
D5761
Reline mandibular part denture (lab)
20%
20%
D5670
D5671
D5850
Tissue conditioning, maxillary
50%
50%
D5851
Tissue conditioning, mandibular
50%
50%
D5899
Unspecified removable prosthodontic procedure 50%
50%
D6210
Pontic ‐ cast high noble metal
50%
50%
D6211
Pontic ‐ cast predominantly base metal
50%
50%
D6212
Pontic ‐ cast noble metal
50%
50%
D6240
Pontic ‐ porcelain fused to high noble metal
50%
50%
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
PROSTHODONTICS ‐ FIXED CONT. D6241
Pontic ‐ porcelain fused to predominantly base metal
50%
50%
D6242
Pontic ‐ porcelain fused to noble metal
50%
50%
D6245
Pontic ‐ porcelain/ceramic 50%
50%
D6250
Pontic ‐ resin with high noble metal
50%
50%
D6251
Pontic ‐ resin with predominantly base metal
50%
50%
D6252
Pontic ‐ resin with noble metal
50%
50%
D6253
Provisional Pontic
50%
50%
D6545
Retainer ‐ cast metal for resin bonded prosthesis
50%
50%
50%
50%
D6600
Retainer ‐ porcelain/ceramic for resin bonded prosthesis
Inlay ‐ porcelain/ceramic, 2 surfaces 50%
50%
D6601
Inlay ‐ porcelain/ceramic, 3 or more surfaces
50%
50%
D6602
Inlay ‐ cast high noble metal, 2 surfaces
50%
50%
D6603
Inlay ‐ cast high noble metal, 3 or more surfaces
50%
50%
D6604
Inlay ‐ cast predominantly base metal, 2 surfaces
50%
50%
D6548
50%
50%
D6606
Inlay ‐ cast predominantly base metal, 3 or more surfaces
Inlay ‐ cast noble metal, 2 surfaces
50%
50%
D6607
Inlay ‐ cast noble metal, 3 or more surfaces
50%
50%
D6608
Onlay ‐ porcelain/ceramic, 2 surfaces
50%
50%
D6609
Onlay ‐ porcelain/ceramic, 3 or more surfaces
50%
50%
D6610
Onlay ‐ cast high noble metal, 2 surfaces
50%
50%
D6611
Onlay ‐ cast high noble metal, 3 or more surfaces
50%
50%
D6612
Onlay ‐ cast predominantly base metal, 2 surfaces
50%
50%
50%
50%
D6605
D6614
Onlay ‐ cast predominantly base metal, 3 or more surfaces
Onlay ‐ cast noble metal, 2 surfaces
50%
50%
D6615
Onlay ‐ cast noble metal, 3 or more surfaces
50%
50%
D6710
Crown ‐ indirect resin based composite 50%
50%
D6720
Crown ‐ resin with high noble metal
50%
50%
D6613
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
PROSTHODONTICS ‐ FIXED CONT. D6721
Crown ‐ resin with predominantly base metal
50%
50%
D6722
Crown ‐ resin with noble metal
50%
50%
D6740
Crown ‐ porcelain/ceramic
50%
50%
D6750
Crown ‐ porcelain fused to high noble metal
50%
50%
D6751
Crown ‐ porcelain fused to predominantly base metal
50%
50%
D6752
Crown ‐ porcelain fused to noble metal
50%
50%
D6780
Crown ‐ 3/4 cast high noble metal
50%
50%
D6781
Crown ‐ 3/4 cast predominantly base metal
50%
50%
D6782
Crown ‐ 3/4 cast noble metal
50%
50%
D6783
Crown ‐ 3/4 porcelain/ceramic
50%
50%
D6790
Crown ‐ full cast high noble metal
50%
50%
D6791
Crown ‐ full cast predominantly base metal
50%
50%
D6792
Crown ‐ full cast noble metal
50%
50%
D6930
Recement fixed part denture
50%
50%
D6940
Stress breaker
50%
50%
D6973
Core buildup for retainer including any pins
50%
50%
Coping
Fixed part denture repair necessitated by restorative D6980
material failure
MISCELLANEOUS SERVICES
50%
50%
50%
50%
D9220
Deep sedation/general anesthesia ‐ first 30 minutes
20%
20%
D9221
Deep sedation/general anesthesia ‐ each add 15 minutes 20%
20%
D9230
Analgesia, anxiolysis, inhalation of nitrous oxide
20%
20%
20%
20%
20%
20%
D6975
D9241
D9242
Intravenous conscious sedation/analgesia ‐ first 30 minutes
Intravenous conscious sedation/analgesia ‐ each add 15 minutes
D9610
Therapeutic parenteral drug, single administration
20%
20%
D9940
Occlusal guard
20%
20%
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
One (1) time per five (5) year period per tooth
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved. CODE
DESCRIPTION
NON‐
PARTICIPATING PARTICIPATING PROVIDER
PROVIDER
LIMITATIONS
MISCELLANEOUS SERVICES CONT.
D9942
Repair &/or reline of Occlusal guard
20%
20%
D9950
Occlusion analysis ‐ mounted case
20%
20%
D9951
Occlusal adjustment ‐ limited
20%
20%
D9952
Occlusal adjustment ‐ complete
20%
20%
Current Dental Terminology © 2014 American Dental Association (ADA). All rights reserved.

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