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