Dental Benefit Summary

A Division of NYSADA Dental Benefit Summary Group Number: 00506855 About Your Benefits: Good oral hygiene is important, not only for looks, but for g...
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A Division of NYSADA

Dental Benefit Summary Group Number: 00506855 About Your Benefits: Good oral hygiene is important, not only for looks, but for general health as well. A routine dental examination can detect symptoms of more than 125 diseases, including heart disease, diabetes, anemia, stomach ulcers, osteoporosis and kidney disease. Regular check ups and cleanings can save you the pain and expense of future problems. Using your dental insurance for regular dental check- ups can improve your health. Your dental insurance can also help save you money if more serious dental treatments are needed. With your PPO plan, you can visit any dentist; but you pay less out-of-pocket when you choose a PPO dentist. PPO Network Calendar year deductible Individual Waived for Charges covered for you (co-insurance) Preventive Care (e.g. cleanings) Basic Care (e.g. fillings) Major Care (e.g. crowns, dentures) Orthodontia Annual Preventive & Basic Benefit Maximum

DentalGuard Preferred In-Network Out-of-Network $50 $50 Preventive Preventive and Basic and Basic

See attached Service Payment Limits Unlimited

Annual Major Benefit Maximum

$2,200

Lifetime Ortho Maximum Dependent Age Limits

$1,200 26

If a covered person uses the services of a preferred provider, covered charges are this plan’s service payment limit for the particular service. If a covered person uses the services of a non-preferred provider, covered charges are this plan’s service payment limit for the particular service.

Unlimited

We only pay benefits for dental services which are included in this plan’s List of Covered Dental Services. There is no deductible for the services shown in the List of Covered Dental Services. We pay benefits for covered charges incurred for each such covered service up to its service payment limit, each time the service is performed. We only pay benefits for dental services which are included in this plan’s List of Covered Dental Services.

1 NYSADA Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

A Sample of Services Covered by Your Plan:

Preventive Care

Basic Care

PPO Plan pays (on average) In-network Out-of-network 100% 100% Twice per 12 month period 100% 100%

Cleaning (prophylaxis) Frequency: Fluoride Treatments No Age Limits Oral Exams Sealants (per tooth) X-rays

100% 100% 100%

100% 100% 100%

100% 100%

100% 100%

100% 100%

100% 100% Twice per 12 month period

100%

100%

100% 100% 100% 100%

100% 100% 100% 100%

Bridges and Dentures

100%

100%

Inlays, Onlays, Veneers** Single Crowns

100% 100%

100% 100%

Anesthesia* Fillings‡ Perio Surgery Periodontal Maintenance Frequency: Repair & Maintenance of Crowns, Bridges & Dentures Root Canal Scaling & Root Planing (per quadrant) Simple Extractions Surgical Extractions

Major Care

Orthodontia

Orthodontia 100% 100% Limits: Child(ren) This is only a partial list of dental services. Your certificate of benefits will show exactly what is covered and excluded. **Crowns, Inlays, Onlays and Labial Veneers are covered only when needed because of decay or injury and only when the tooth cannot be restored with amalgam or composite filing material. When Orthodontia coverage is for "Child(ren)" only, the orthodontic appliance must be placed prior to the age of 19; If full-time status is required by your plan in order to remain insured after a certain age; then orthodontic maintenance may continue as long as full-time student status is maintained. If Orthodontia coverage is for "Adults and Child(ren)" this limitation does not apply. The total number of cleanings and periodontal maintenance procedures are combined in a 12 month period. *General Anesthesia – restrictions apply. ‡Fillings – restrictions may apply to composite fillings.

Manage Your Benefits:

Find A Dentist:

Enrolled members and their dependents can access helpful, secure information about their Guardian benefits at www.guardiananytime.com

Visit www.GuardianLife.com Under “Contact Us”, Click on “Find A Provider”

EXCLUSIONS AND LIMITATIONS n Important Information about Guardian’s DentalGuard Indemnity and

DentalGuard Preferred PPO plans: This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental disease, defect, or injury. The plan does not pay for: oral hygiene services (except as covered under preventive services), orthodontia (unless expressly provided for), cosmetic or experimental treatments (unless they are expressly provided for), any treatments to the extent benefits are payable by any other payor or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The plan limits benefits for diagnostic consultations and for

preventive, restorative, endodontic, periodontic, and prosthodontic services. The services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the final arbiter of coverage. Contract # GP-1-DG2000 et al. n Special Limitation: Teeth lost or missing before a covered person becomes insured by this plan. A covered person may have one or more congenitally missing teeth or have lost one or more teeth before he became insured by this plan. We won’t pay for a prosthetic device which replaces such teeth unless the device also replaces one or more natural teeth lost or extracted after the covered person became insured by this plan. R3 – DG2000

2

NYSADA Benefit Summary The Guardian Life Insurance Company of America, 7 Hanover Square, New York, NY 10004

BENEFIT DESIGN

CDT CODE PROCEDURE D0120 Periodic oral evaluation - established patient D0140 Limited Oral Evaluation Oral evaluation for a patient under three years of D0145 age and counseling with primary caregiver Comprehensive oral evaluation - new or established D0150 patient D0170 Re-evaluation-limited, problem focused D0171 Re-evaluation-post-operative office visit Comprehensive periodontal evaluation - new or D0180 established patient

PV PV

Category

Schedule Amt 23.00 23.00

PV

23.00

PV

23.00

PV PV

23.00 23.00

PV

23.00

D0190

Screening of a Patient

N/C

16.00

D0191 D0210 D0220 D0230 D0240 D0250 D0260

Assessment of a Patient Intraoral complete series (including bitewings) Intraoral periapical - first film Intraoral periapical - each additional film Intraoral occlusal film Extraoral - first film Extraoral - each additional film

N/C PV PV PV PV PV PV

16.00 60.00 10.00 5.00 23.00 39.00 62.00

D0270

Bitewings - single film

PV

7.00

D0272 D0273 D0274 D0277

Bitewings - two films Bitewings - three films Bitewings - four films Bitewings, vertical - seven to eight films Posterior-anterior or lateral skull & facial bone survey film Panoramic x-ray (Panorex, Panelipse, Pan) Adjunctive prediagnostic test that aids in detection of mucusal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures Diagnostic casts

PV PV PV PV

20.00 21.50 23.00 45.00

N/C

21.00

PV

49.00

BS

0.00

BS

0.00

Accession of tissue, gross examination, preparation BS and transmission of written report

0.00

D0290 D0330 D0431 D0470 D0472

D0473

D0474

D0480 D0484 D0485

Accession of tissue, gross and microscopic examination, preparation and transmission of written report Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report Consultation on slides prepared elsewhere Consultation, including preparation of slides from biopsy - material supplied by referring source

BS

0.00

BS

0.00

BS

0.00

BS

0.00

BS

0.00

D0486

Laboratory accession of brush biopsy sample, microscopic examination, preparation and transmission of written report

BS

44.00

D1110

Prophylaxis - Adult

PV

34.00

D1120 D1203 D1204

Prophylaxis - Child Topical application of fluoride - child Topical application of fluoride - adult

PV PV PV

34.00 34.00 34.00

D1206

Topical fluoride varnish; therapeutic application for PV moderate to high caries risk patients

34.00

D1208

Topical application of fluoride

PV

25.00

D1351

Topical Application of sealants - per tooth

PV

0.00

D1352

Preventive resin restoration in a moderate to high caries risk patient - permanent tooth

PV

0.00

D1510

Fixed - unilateral band type

PV

185.00

D1515

Fixed - fixed bilateral, stainless steel crown type

PV

185.00

D1520 D1525 D1550

Removable, unilateral type Removable - bilateral type - flipper for child Recementation of space maintainers

PV PV PV

185.00 185.00 20.00

D1555

Removal of fixed space maintainer

PV

20.00

D2140

Amalgam - one surface, primary or permanent

BS

34.00

D2150

Amalgam - two surfaces, primary or permanent

BS

49.00

D2160

Amalgam - three surfaces, primary or permanent

BS

70.00

D2161

Amalgam - four or more surfaces, primary or permanent

BS

70.00

D2330

Composite resin - one surface, anterior

BS

39.00

D2331 D2332

56.00 77.00

D2390

Composite resin - two surfaces, anterior BS Composite resin - three surfaces, anterior BS Composite resin - four or more surfaces or involving BS incisal angle Resin - based composite crown, anterior BS

D2391

Resin - based composite - one surface - posterior

BS

39.00

D2392

Resin - based composite - two surfaces - posterior

BS

56.00

D2393

Resin - based composite - three surfaces - posterior BS

77.00

D2394

Resin - based composite - four or more surfaces posterior

77.00

D2335

BS

77.00 77.00

D2410

Gold foil - one surface

BS

33.00

D2420 D2430

Gold foil - two surfaces Gold foil - three surfaces

BS BS

48.00 68.00

D2510

Inlay - gold, one surface

MJ

143.00

D2520 D2530 D2542 D2543 D2544 D2610 D2620 D2630 D2642 D2643

Inlay - gold, two surfaces Inlay - gold, three surfaces Onlay - metallic two surfaces Onlay - metallic three surfaces Onlay - metallic four or more surfaces Inlay - porcelain, one surface Inlay - porcelain, two surfaces Inlay - porcelain, three surfaces Onlay - porcelain/ceramic - two surfaces Onlay - porcelain/ceramic - three surfaces

MJ MJ MJ MJ MJ MJ MJ MJ MJ MJ

192.00 350.00 192.00 350.00 350.00 143.00 192.00 350.00 143.00 192.00

D2644

Onlay - porcelain/ceramic - four or more surfaces

MJ

350.00

D2650 D2651 D2652 D2662 D2663

Inlay - composite/resin, one surface Inlay - composite/resin, two surface Inlay - composite/resin, three surface Onlay - composite/resin - two surfaces Onlay - composite/resin - three surfaces

MJ MJ MJ MJ MJ

57.00 108.00 147.00 143.00 192.00

D2664

Onlay - composite/resin - four or more surfaces

MJ

350.00

D2710 D2712

Crown - resin based composite (indirect) Crown - 3/4 resin (indirect)

MJ MJ

183.00 183.00

D2720

Resin w/high noble metal crown

MJ

399.00

D2721 D2722 D2740 D2750

MJ MJ MJ MJ

257.00 257.00 425.00 459.00

MJ

402.00

MJ

402.00

D2780 D2781 D2782 D2783

Resin w/predom base metal crown Resin w/noble metal crown Porcelain Porcelain fused to gold (ceramco, PFM) Porcelain fused to non-precious metal (ceramco, PFM) Porcelain fused to semi-precious metal (ceramco, PFM) Gold (3/4 cast) Non-precious metal (3/4 cast) Semi-precious metal (3/4 cast) Porcelain (3/4 porcelain/ceramic)

MJ MJ MJ MJ

438.00 438.00 183.00 402.00

D2790

Gold (full cast)

MJ

447.00

D2791

Non-precious metal (full cast)

MJ

183.00

D2792

Semi-precious metal (full cast)

MJ

183.00

D2794 D2910 D2915 D2920

Crown - Titanium Recement inlays Recement cast or prefabricated post and core Recement crowns

MJ BS BS MJ

402.00 29.00 402.00 29.00

D2930

Pre-fab stainless steel crown (deciduous tooth)

BS

85.00

D2751 D2752

D2931

Pre-fab stainless steel crown (permanent tooth)

BS

85.00

D2932 D2933

Pre-fab resin crown BS Pre-fab stainless steel crown with resin window BS Prefabricated esthetic coated stainless steel crown BS primary tooth Protective restoration BS Core buildup, including any pins MJ Pin retention per pin in addition to restoration BS Post and core in addition to crown, indirectly MJ fabricated Each additional indirectly fabricated post - same MJ tooth

85.00 85.00

D2934 D2940 D2950 D2951 D2952 D2953

85.00 29.00 92.00 22.00 125.00 12.00

D2954

Prefabricated post and core - in addition to crown

MJ

125.00

D2960

Labial veneer, laminate

MJ

237.00

D2961 D2962

MJ MJ

79.00 250.00

MJ

0.00

D2980

Labial veneer, resin laminate Labial veneer, porcelain laminate Additional procedures to construct new crown under existing partial denture framework Crown repair

BS

60.00

D3110

Pulp cap - direct (excluding final restoration)

BS

25.00

D3120

Pulp cap - indirect (excluding final restoration)

BS

25.00

D3220

Therapeutic pulpotomy (excluding final restoration) BS

73.00

D3221

Pulpal debridement, primary and permanent teeth

BS

44.00

D3222

Partial pulpotomy for apexogenesis - permanent tooth with incomplete root-development

BS

73.00

BS

77.00

BS

84.00

BS

371.00

BS

403.00

BS

525.00

BS

111.00

BS

186.00

BS

111.00

D2971

D3333

Pulpal therapy - anterior primary tooth (excluding final restoration) Pulpal therapy - posterior primary tooth (excluding final restoration) Endodontic therapy, anterior tooth (excluding final restoration) Endodontic therapy, bicuspid tooth (excluding final restoration) Endodontic therapy, molar (excluding final restoration) Treatment of root canal obstruction; non-surgical access Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Internal root repair of perforation defects

D3346

Retreatment-anterior, by report

BS

371.00

D3347 D3348 D3351

Retreatment-bicuspid, by report Retreatment-molar, by report Apexification/recalcification initial visit

BS BS BS

403.00 525.00 111.00

D3352

Apexification/recalcification initial medicated repair

BS

74.00

D3353

Apexification/recalcification final visit

BS

260.00

D3230 D3240 D3310 D3320 D3330 D3331 D3332

D3410

Apicoectomy/periradicular surgery - anterior

BS

224.00

D3421 D3425 D3426 D3430 D3450

Apicoectomy/periradicular surgery - bicuspid Apicoectomy/periradicular surgery - molar Apicoectomy - per tooth each additional tooth Retrograde filling, per root Root resection, per root (amputation)

BS BS BS BS BS

224.00 224.00 168.00 112.00 224.00

D3920

Hemisection, not including root canal treatment

BS

81.00

D3950

Canal prep & fitting preformed dowel/post Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant

N/C

23.00

MJ

289.00

MJ

74.00

MJ

74.00

D4210

D4211

D4212

Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

D4240

Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces, MJ per quadrant

112.00

D4245

Gingival flap procedure, including root planing - one to three contiguous teeth to tooth bounded spaces BS per quadrant Apically positioned flap BS

D4249

Crown lengthening - hard/soft tissue (By report)

BS

112.00

D4260

Osseous surgery (including flap entry and closure) four or more contiguous teeth or tooth bounded BS spaces per quadrant

445.00

D4261

Osseous surgery (including flap entry and closure) BS one to three contiguous teeth or tooth bounded spaces per quadrant

81.00

D4263

Bone replacement graft - first site in quadrant

BS

222.00

BS

445.00

BS

0.00

BS

0.00

BS MJ

0.00 112.00

BS

0.00

BS

0.00

BS

269.00

BS

0.00

BS

224.00

D4241

D4274

Bone replacement graft - each additional site in quadrant Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) Surgical revision procedure, per tooth Pedicle soft tissue grafts Subepithelial connective tissue graft procedures, per tooth Distal or proximal wedge

D4275

Soft tissue allograft

D4264 D4266 D4267 D4268 D4270 D4273

D4276 D4277

Combined connective tissue and double pedicle graft, per tooth Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft

78.00 445.00

D4278

D4341 D4342 D4355 D4910 D4920

Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site Periodontal scaling and root planing - four or more teeth, per quadrant Periodontal scaling and root planing - one to three teeth, per quadrant Full mouth debridement to enable comprehensive evaluation and diagnosis Periodontal maintenance Unscheduled dressing change (by other than treating dentist)

BS

168.00

BS

73.00

BS

51.00

BS

0.00

BS

34.00

N/C

91.00

D5110

Complete denture - upper

MJ

447.00

D5120 D5130 D5140

Complete denture - lower Immediate denture - upper Immediate denture - lower Upper - w/resin base, including clasps, rests and teeth Lower - w/resin base, including clasps, rests and teeth Upper - w/metal base, resin saddles including clasps, rests & teeth Lower - w/metal base, resin saddles including clasps, rests & teeth Maxillary partial denture - flexible base (including any clasps, rests and teeth) Mandibular partial denture - flexible base (including any clasps, rests and teeth) Removable unilateral partial denture/1 piece metal base casting/clasp attachments, per unit (including pontics) Adjust complete dentures (upper)

MJ MJ MJ

478.00 447.00 478.00

MJ

533.00

MJ

533.00

MJ

533.00

MJ

533.00

MJ

533.00

MJ

533.00

MJ

257.00

BS

29.00

Adjust complete denture (lower) Partial denture (upper) Partial denture (lower) Repair broken denture base Replace missing/broken tooth, each tooth Repair resin saddle or base Repair cast framework Repair or replace broken clasp Replace broken teeth, per tooth Adding tooth to existing partial denture (not involving clasp or abutment tooth) Adding clasp to existing partial denture (involving clasp or abutment tooth) Replace all teeth and acrylic on cast metal framework (maxillary) Replace all teeth and acrylic on cast metal framework (mandibular)

BS BS BS BS BS BS BS BS BS

29.00 29.00 29.00 81.00 38.00 81.00 81.00 38.00 0.00

BS

57.00

BS

129.00

BS

0.00

BS

0.00

Rebase complete upper denture (Jumpcase)

BS

268.00

D5211 D5212 D5213 D5214 D5225 D5226 D5281 D5410 D5411 D5421 D5422 D5510 D5520 D5610 D5620 D5630 D5640 D5650 D5660 D5670 D5671 D5710

D5711 D5720 D5721 D5730 D5731 D5740 D5741 D5750 D5751 D5760 D5761 D5810 D5811

Rebase complete lower denture (Jumpcase) Rebase upper partial denture (Jumpcase) Rebase lower partial denture (Jumpcase) Reline complete upper denture (chairside) Reline complete lower denture (chairside) Reline upper partial denture (chairside) Reline lower partial denture (chairside) Reline complete upper denture (lab) Reline complete lower denture (lab) Reline upper partial denture (lab) Reline lower partial denture (lab) Denture - temporary (complete) upper Denture - temporary (complete) lower

BS BS BS BS BS BS BS BS BS BS BS N/C N/C

268.00 268.00 268.00 73.00 73.00 73.00 73.00 139.00 139.00 139.00 139.00 447.00 447.00

D5820

Denture - temporary (partial-stayplate) upper

MJ

143.00

D5821

Denture - temporary (partial-stayplate) lower

MJ

143.00

D5850

Tissue conditioning, upper denture

BS

48.00

D5851

Tissue conditioning, lower denture

BS

143.00

D6010

Surgical placement of implant body; endosteal implant

N/C

0.00

0.00

D6057 D6058

Second stage implant surgery N/C Surgical placement of interim implant body for N/C transitional prosthesis: endosteal implant Surgical placement of mini implant N/C Implant/abutment supported removable denture for MJ completely edentulous arch Implant/abutment supported removable denture for MJ partially edentulous arch Custom abutment - includes placement N/C Abutment supported porcelain/ceramic crown MJ

D6059

Abutment supported porcelain fused to gold crown

MJ

459.00

MJ

402.00

MJ

402.00

MJ

447.00

MJ

402.00

MJ

402.00

MJ

425.00

MJ

459.00

MJ

402.00

D6011 D6012 D6013 D6053 D6054

D6060 D6061 D6062 D6063 D6064 D6065 D6066 D6067 D6068 D6069 D6070

Abutment supported porcelain fused to nonprecious metal Abutment supported porcelain fused to semiprecious metal Abutment supported cast metal crown (gold) Abutment supported cast metal crown (nonprecious metal) Abutment supported cast metal crown (semiprecious metal) Implant supported porcelain/ceramic crown Implant supported porcelain fused to metal crown (titanium or gold) Implant supported metal crown (titanium or gold)

Abutment supported retainer for porcelain/ceramic MJ FPD Abutment supported retainer for porcelain fused to MJ gold FPD Abutment supported retainer for porcelain fused to MJ metal FPD (non-precious)

0.00 0.00 478.00 478.00 0.00 425.00

425.00 459.00 402.00

D6094 D6095 D6100

Abutment supported retainer for porcelain fused to metal FPD (semi-precious) Abutment supported retainer for cast metal FPD (gold) Abutment supported retainer for cast metal FPD (non-precious metal) Abutment supported retainer for cast metal FPD (semi-precious metal) Implant supported retainer for ceramic FPD Implant supported retainer for porcelain fused to metal FPD (titanium or gold) Implant supported retainer for cast metal FPD (titanium or gold) Implant/abutment supported fixed denture for completely edentulous arch Implant/abutment supported fixed denture for partially edentulous arch Repair implant supported prosthesis, by report Recement implant/abutment supported crown Recement implant/abutment supported fixed partial denture Abutment supported crown - titanium Repair implant abutment, by report Implant removal, by report

D6110

Implant Supported Removable Full Denture - Max

MJ

478.00

D6111

Implant Supported Removable Full Denture - Mand MJ

478.00

D6112 D6113

MJ MJ

533.00 533.00

MJ

478.00

MJ

478.00

MJ

478.00

MJ

478.00

MJ

478.00

D6205

Implant Supported Removable Partial - Max Implant Supported Removable Partial - Mand Implant/abutment supported fixed denture for edentulous arch maxillary Implant/abutment supported fixed denture for edentulous arch mandibular Implant/abutment supported fixed denture for partially edentulous arch maxillary Implant/abutment supported fixed denture for partially edentulous arch mandibular Abutment supported retainer crown for FPD titanium Indirect resin based composite pontic

MJ

183.00

D6210

Cast gold

MJ

237.00

D6211 D6212 D6214

Cast non-precious Cast semi-precious Pontic - titanium

MJ MJ MJ

182.00 182.00 237.00

D6240

Porcelain fused to gold (PFM)

MJ

451.00

D6241 D6242 D6245

Porcelain fused to non-precious metal (PFM) Porcelain fused to semi-precious metal (PFM) Pontic - porcelain/ceramic

MJ MJ MJ

315.00 315.00 315.00

D6071 D6072 D6073 D6074 D6075 D6076 D6077 D6078 D6079 D6090 D6092 D6093

D6114 D6115 D6116 D6117 D6194

MJ

402.00

MJ

459.00

MJ

402.00

MJ

402.00

MJ

459.00

MJ

459.00

MJ

402.00

MJ

478.00

MJ

478.00

N/C MJ

60.00 29.00

MJ

29.00

MJ N/C N/C

402.00

D6250

Resin w/high noble metal pontic

MJ

394.00

D6251 D6252

Resin w/predom base metal pontic Resin w/noble metal pontic Resin bonded retainer cast metal for acid etch bridge (Maryland bridge) Resin bonded retainer porcelain/ceramic for acid etch bridge (Maryland)

MJ MJ

172.00 172.00

MJ

257.00

MJ

315.00

D6549

Resin Retainer - Resin Bonded Fixed Prosth

MJ

129.00

D6600

Inlay - porcelain/ceramic, two surfaces

MJ

192.00

D6601

Inlay - porcelain/ceramic, three or more surfaces

MJ

350.00

D6602

Inlay - cast high noble metal, two surfaces Inlay - cast high noble metal, three or more surfaces

MJ

192.00

MJ

350.00

Inlay - cast predominantly base metal, two surfaces MJ

192.00

D6545 D6548

D6603 D6604

D6606

Inlay - cast predominantly base metal, three or more surfaces Inlay - cast noble metal, two surfaces

D6607

Inlay - cast noble metal, three or more surfaces

MJ

350.00

D6608

Onlay - porcelain/ceramic, two surfaces

MJ

192.00

D6609

Onlay - porcelain/ceramic, three or more surfaces

MJ

350.00

D6610

MJ

192.00

MJ

350.00

MJ

192.00

MJ

350.00

D6614

Onlay - cast high noble metal, two surfaces Onlay - cast high noble metal, three or more surfaces Onlay - cast predominantly base metal, two surfaces Onlay - cast predominantly base metal, three or more surfaces Onlay - cast noble metal, two surfaces

MJ

192.00

D6615

Onlay - cast noble metal, three or more surfaces

MJ

350.00

D6624 D6634 D6710

Inlay - titanium Onlay - titanium Crown - indirect resin based composite

MJ MJ MJ

350.00 350.00 183.00

D6720

Resin w/high noble metal abutment

MJ

399.00

D6721 D6722 D6740 D6750 D6751 D6752 D6780 D6781 D6782 D6783 D6790 D6791 D6792

Resin w/predom base metal abutment Resin w/noble metal abutment Porcelain/ceramic abutment Porcelain fused to gold Porcelain fused to non-precious metal Porcelain fused to semi-precious metal Gold (3/4 cast) Non-precious metal (3/4 cast) Semi-precious metal (3/4 cast) Porcelain/ceramic (3/4) Gold (full cast) Non-precious metal (full cast) Semi-precious metal (full cast)

MJ MJ MJ MJ MJ MJ MJ MJ MJ MJ MJ MJ MJ

257.00 257.00 459.00 459.00 402.00 402.00 438.00 438.00 438.00 438.00 447.00 183.00 183.00

D6605

D6611 D6612 D6613

MJ

350.00

MJ

192.00

D6794 D6920 D6930 D6940 D6980 D6985 D7111 D7140 D7210 D7220 D7230 D7240

MJ MJ BS MJ BS MJ BS BS BS BS BS BS

447.00 0.00 29.00 100.00 64.00 185.00 43.00 43.00 81.00 117.00 190.00 250.00

BS

250.00

BS BS

81.00 375.00

BS

278.00

BS

0.00

BS

130.00

N/C BS

260.00 95.00

BS

190.00

BS

0.00

D7285 D7286

Crown - titanium Connector bar Recement bridge Stress breaker Bridge repair, by report Pediatric partial denture, fixed Extraction, coronal remnants - deciduous tooth Extraction, erupted tooth or exposed root Extraction of tooth - erupted Removal of soft tissue impacted tooth (STI) Removal of partial bony impacted tooth (PBI) Removal of full bony impacted tooth (FBI) Removal of full bony impacted tooth, difficult (FBID) Surgical removal of residual root coronectomy - intentional partial tooth removal Oral antral fistula closure (and/or antral root recovery) Primary closure of a sinus perforation Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth. Includes splinting and/or stabilization. Tooth transplantation Surgical access of an unerupted tooth Mobilization of erupted or malpositioned tooth to aid eruption Placement of device to facilitate eruption of impacted tooth Biopsy of oral tissue - hard Biopsy of oral tissue - soft

BS BS

74.00 74.00

D7287

Cytology sample collection

BS

0.00

D7288

Brush Biopsy - transepithelial sample collection harvest of bone for use in autogenous grafting procedures

BS

74.00

BS

0.00

D7241 D7250 D7251 D7260 D7261 D7270 D7272 D7280 D7282 D7283

D7295 D7310

Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces per quadrant

BS

112.00

D7311

Alveoloplasty in conjunction with extractions, one to BS three teeth or tooth spaces per quadrant

185.00

D7320

Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces per quadrant

BS

112.00

D7321

Alveoloplasty not in conjunction with extractions, one to three teeth or tooth spaces, per quadrant

BS

129.00

BS

174.00

D7350

Vestibuloplasty per arch - uncomplicated Vestibuloplasty, per arch - complicated - including ridge extension, soft tissue grafts, and management of hypertrophied and hyperplastic tissue

BS

185.00

D7410

Excision of benign lesion up to 1.25 cm

BS

0.00

D7411 D7412 D7413

Excision of benign lesion greater than 1.25 cm Excision of benign lesion, complicated Excision of malignant lesion up to 1.25 cm

BS BS BS

0.00 0.00 0.00

D7340

D7414

Excision of malignant lesion greater than 1.25 cm

BS

0.00

D7415

Excision of malignant lesion, complicated Excision of malignant tumor - lesion diameter up to 1.25 cm Excision of malignant tumor - lesion diameter over 1.25 cm Removal of benign odontogenic cyst or tumor lesion diameter up to 1.25 cm Removal of benign odontogenic cyst or tumor lesion diameter greater than 1.25 cm Removal of benign nonodontogenic cyst or tumor lesion diameter up to 1.25 cm Removal of benign nonodontogenic cyst or tumor lesion diameter greater than 1.25 cm Destruction of lesions by physical methods (By report)

BS

0.00

BS

0.00

BS

0.00

BS

185.00

BS

200.00

BS

185.00

BS

200.00

BS

0.00

D7471

Removal of lateral exostosis (maxilla or mandible)

BS

155.00

D7472 D7473 D7485 D7490 D7510

Removal of torus palatinus Removal of torus mandibularis Surgical reduction of osseous tuberosity Radical resection of maxilla or mandible Incision and drainage of abscess Incision and drainage of abscess - intraoral soft tissue Incision and drainage of abscess - extraoral Incision and drainage of abscess- extraoral soft tissue Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue

BS BS BS N/C BS

155.00 155.00 0.00 554.00 52.00

BS

52.00

BS

74.00

BS

52.00

N/C

55.00

D7440 D7441 D7450 D7451 D7460 D7461 D7465

D7511 D7520 D7521 D7530 D7540

Removal of foreign bodies - musculoskeletal system N/C

D7963 D7970 D7971 D7972 D7980 D7981 D7982 D7983

Partial ostectomy / sequestrectomy for removal of non-vital bone Maxillary sinusotomy for removal of tooth fragment or foreign body Condylectomy (By report) Meniscectomy (By report) Suture of recent small wounds up to 5 cm Suture of complex wounds up to 5 cm Suture of complex wounds over 5 cm Frenulectomy - separate procedure (frenectomy or frenotomy) Frenuloplasty Excision of hyperplastic tissue - per arch Excision of pericoronal gingiva Surgical reduction of fibrous tuberosity Sialolithotomy Excision of salivary gland Sialodochoplasty Closure of salivary fistula

D8010

Limited orthodontic treatment of primary dentition

D7550 D7560 D7840 D7850 D7910 D7911 D7912 D7960

D8020 D8030

Limited orthodontic treatment of transitional dentition Limited orthodontic treatment of adolescent dentition

112.00

N/C

99.00

BS

148.00

N/C N/C N/C N/C N/C

1,287.00 39.00 74.00 74.00 74.00

BS

224.00

BS BS BS BS BS BS BS BS

358.00 118.00 185.00 78.00 142.00 0.00 0.00 224.00

OR

1,200.00

OR

1,200.00

OR

1,200.00

D8040 D8050 D8060 D8070 D8080 D8090

Limited orthodontic treatment of adult dentition Interceptive orthodontic treatment of primary dentition Interceptive orthodontic treatment of transitional dentition Comprehensive orthodontic treatment of transitional dentition Comprehensive orthodontic treatment of adolescent dentition Comprehensive orthodontic treatment of adult dentition

OR

1,200.00

OR

1,200.00

OR

1,200.00

OR

1,200.00

OR

1,200.00

OR

1,200.00

D8210

Removable

PV

554.00

D8220 D8660 D8670

PV OR OR

554.00 250.00 1,200.00

OR

1,200.00

OR

1,200.00

PV

42.00

D9120 D9212

Fixed or cemented Pre-orthodontic treatment visit Periodic orthodontic treatment visit - adult Orthodontic retention (removal of appliances & placement of retainer) Orthodontic treatment (alternate billing to contract fee) Palliative (emergency) treatment of dental pain, minor procedures Fixed partial denture sectioning Trigeminal division block

BS N/C

29.00 38.00

D9220

Deep sedation/general anesthesia - first 30 minutes BS

D8680 D8690 D9110

D9221 D9230 D9241 D9242 D9248 D9310

D9430 D9440 D9610 D9612 D9930 D9940 D9942 D9951 D9952

Deep sedation/general anesthesia - each additional 15 minutes Analgesia - Nitrous oxide (ONLY covered w/operative or surgical procedures) Intravenous conscious sedation/analgesia - first 30 minutes Intravenous conscious sedation/analgesia - each additional 15 minutes Non-intravenous conscious sedation

73.00

BS

29.00

BS

29.00

BS

73.00

BS

29.00

BS

69.00

Consultation - diagnostic service provided by dentist or physician other than requesting dentist or BS physician practitioner providing treatment

59.00

Office visit - during regularly scheduled office hours PV (no operative services performed) Office visit - after regularly scheduled office hours PV (no operative services performed) Therapeutic parenteral drug, single administration Therapeutic parenteral drugs, two or more administrations, different medications Complications (post-surgical, unusual circumstances) By report Occlusal guards (By report) Repair and/ or reline of an occlusal guard Occlusal adjustment - limited Occlusal adjustment - complete

23.00 26.00

BS

0.00

BS

0.00

N/C

91.00

BS BS BS N/C

222.50 33.00 52.00 95.00