DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS

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1 DISCOUNT DENTAL PLAN COMPLETE LISTING OF MEMBER COPAYMENTS 0120 PERIODIC ORAL EXAMINATION - ESTABLISHED PATIENT LIMITED ORAL EVALUATION - PROBLEM FOCUSED COMPREHENSIVE ORAL EVALUATION - NEW OR ESTABLISHED PATIENT RE-EVALUATION - LIMITED, PROBLEM FOCUSED (ESTABLISHED PATIENT; NOT POST-OPERATIVE 21 VISIT) 0180 COMPREHENSIVE PERIODONTAL EVALUATION - NEW OR ESTABLISHED PATIENT INTRAORAL - COMPLETE SERIES OF RADIOGRAPHIC IMAGES INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE INTRAORAL - PERIAPICAL EACH ADDITIONAL RADIOGRAPHIC IMAGE INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE BITEWING, SINGLE RADIOGRAPHIC IMAGE BITEWINGS, TWO RADIOGRAPHIC IMAGES BITEWINGS, FOUR RADIOGRAPHIC IMAGES VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES PANORAMIC RADIOGRAPHIC IMAGE CEPHALOMETRIC RADIOGRAPHIC IMAGE PULP VITALITY TESTS DIAGNOSTIC CASTS PROPHYLAXIS - ADULT PROPHYLAXIS - CHILD TOPICAL APPLICATION OF FLUORIDE ORAL HYGIENE INSTRUCTIONS No Charge 1351 SEALANT - PER TOOTH SPACE MAINTAINER - FIXED - UNILATERAL SPACE MAINTAINER - FIXED - BILATERAL SPACE MAINTAINER - REMOVABLE - UNILATERAL SPACE MAINTAINER - REMOVABLE - BILATERAL RE-CEMENTATION OF SPACE MAINTAINER AMALGAM - ONE SURFACE, PRIMARY OR PERMANENT AMALGAM - TWO SURFACES, PRIMARY OR PERMANENT AMALGAM - THREE SURFACES, PRIMARY OR PERMANENT AMALGAM - FOUR OR MORE SURFACES, PRIMARY OR PERMANENT RESIN-BASED COMPOSITE - ONE SURFACE, ANTERIOR RESIN-BASED COMPOSITE - TWO SURFACES, ANTERIOR RESIN-BASED COMPOSITE - THREE SURFACES, ANTERIOR RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR 135 CUT7697-6N (2/13) CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and Blue Shield Association. Registered trademark of the Blue Cross and Blue Shield Association. Registered trademark of CareFirst of Maryland, Inc 1

2 2 DISCOUNT DENTAL PLAN 2510 INLAY - METALLIC - ONE SURFACE INLAY - METALLIC - TWO SURFACES INLAY - METALLIC - THREE OR MORE SURFACES ONLAY - METALLIC - THREE SURFACES ONLAY - METALLIC - FOUR OR MORE SURFACES INLAY - PORCELAIN/CERAMIC - ONE SURFACE INLAY - PORCELAIN/CERAMIC - TWO SURFACES CROWN - RESIN-BASED COMPOSITE(INDIRECT) CROWN - PORCELAIN/CERAMIC SUBSTRATE CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL CROWN - PORCELAIN FUSED TO NOBLE METAL CROWN - FULL CAST HIGH NOBLE METAL CROWN - FULL CAST PREDOMINANTLY BASE CROWN - FULL CAST NOBLE METAL PROVISIONAL CROWN - FURTHER TREATMENT OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR 250 TO FINAL IMPRESSION 2910 RECEMENT INLAY, ONLAY, OR PARTIAL COVERAGE RESTORATION RECEMENT CROWN PREFABRICATED STAINLESS STEEL CROWN - PRIMARY TOOTH PREFABRICATED STAINLESS STEEL CROWN - PERMANENT TOOTH PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW PROTECTIVE RESTORATION CORE BUILDUP, INCLUDING ANY PINS PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED EACH ADDITIONAL INDIRECTLY FABRICATED POST - SAME TOOTH PREFABRICATED POST AND CORE IN ADDITION TO CROWN EACH ADDITIONAL PREFABRICATED POST- SAME TOOTH PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION) PULP CAP - INDIRECT (EXCLUDING FINAL RESTORATION) THERAPEUTIC PULPOTOMY (EXCLUDING FINAL RESTORATION)- REMOVAL OF PULP CORONAL TO 90 THE DENTINOCEMENTAL JUNCTION AND APPLICATION OF MEDICAMENT 3230 PULPAL THERAPY (RESORABABLE FILLING) - ANTERIOR, PRIMARY TOOTH (EXCLUDING FINAL 100 RESTORATION) 3240 PULPAL THERAPY (RESORABABLE FILLING) - POSTERIOR, PRIMARY TOOTH (EXCLUDING FINAL 125 RESTORATION) 3310 ENDODONTIC THERAPY, ANTERIOR TOOTH (EXCLUDING FINAL RESTORATION) ENDODONTIC THERAPY, BICUSPID TOOTH (EXCLUDING FINAL RESTORATION) ENDODONTIC THERAPY, MOLAR (EXCLUDING FINAL RESTORATION) INCOMPLETE ENDODONTIC THERAPY; INOPERABLE, UNRESTORABLE OR FRACTURED TOOTH RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - ANTERIOR RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - BICUSPID RETREATMENT OF PREVIOUS ROOT CANAL THERAPY - MOLAR APICOECTOMY/PERIRADICULAR SURGERY - ANTERIOR APICOECTOMY/PERIRADICULAR SURGERY - BICUSPID (FIRST ROOT) 450

3 3 DISCOUNT DENTAL PLAN 3425 APICOECTOMY/PERIRADICULAR SURGERY - MOLAR (FIRST ROOT) APICOECTOMY/PERIADICULAR SURGERY (EACH ADDITIONAL ROOT) RETROGRADE FILLING - PER ROOT ROOT AMPUTATION - PER ROOT SURGICAL PROCEDURE FOR ISOLATION OF TOOTH WITH RUBBER DAM HEMISECTION (INCLUDING ROOT REMOVAL),NOT INCLUDING ROOT CANAL THERAPY GINGIVECTOMY OR GINGIVOPLASTY - FOUR OR MORE CONTIGUOUS TEETH OR TOOTH BOUNDED 360 SPACES PER QUADRANT 4211 GINGIVECTOMY OR GINGIVOPLASTY - ONE TO THREE CONTIGUOUS TEETH OR TOOTH BOUNDED 210 SPACES PER QUADRANT 4212 GINGIVECTOMY OR GINGIVOPLASTY TO ALLOW ACCESS FOR RESTORATIVE PROCEDURE, 210 PER TOOTH 4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING - FOUR OR MORE CONTIGUOUS TEETH OR 450 TOOTH BOUNDED SPACES PER QUADRANT 4249 CLINICAL CROWN LENGTHENING - HARD TISSUE OSSEOUS SURGERY (INCLUDING FLAP ENTRY AND CLOSURE) - FOUR OR MORE CONTIGUOUS TEETH 675 OR TOOTH BOUNDED SPACES PER QUADRANT 4263 BONE REPLACEMENT GRAFT - FIRST SITE IN QUADRANT BONE REPLACEMENT GRAFT - EACH ADDITIONAL SITE IN QUADRANT PEDICAL SOFT TISSUE GRAFT PROCEDURE SUBEPITHELIAL CONNECTIVE TISSUE GRAFT PROCEDURES, PER TOOTH DISTAL OR PROXIMAL WEDGE PROCEDURE (WHEN NOT PERFORMED IN CONJUNCTION WITH 260 SURGICAL PROCEDURES IN THE SAME ANATOMICAL AREA) 4277 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE SURGERY), FIRST TOOTH OR 490 EDENTULOUS TOOTH POSITION IN GRAFT 4278 FREE SOFT TISSUE GRAFT PROCEDURE (INCLUDING DONOR SITE SURGERY), EACH ADDITIONAL 340 CONTIGUOUS TOOTH OR EDENTULOUS TOOTH POSITION IN SAME GRAFT SITE 4320 PROVISIONAL SPLINTING - INTRACORONAL PROVISIONAL SPLINTING - EXTRACORONAL 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 COMPLETE DENTURE - MAXILLARY COMPLETE DENTURE - MANDIBULAR IMMEDIATE DENTURE - MAXILLARY IMMEDIATE DENTURE - MANDIBULAR MAXILLARY PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND 600 TEETH) 5212 MANDIBULAR PARTIAL DENTURE - RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS 600 AND TEETH) 5213 MAXILLARY PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES 750 (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) 5214 MANDIBULAR PARTIAL DENTURE - CAST METAL FRAMEWORK WITH RESIN DENTURE BASES 750 (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH) 5281 REMOVABLE UNILATERAL PARTIAL DENTURE - ONE PIECE CAST METAL (INCLUDING CLASPS AND 375 TEETH) 5410 ADJUST COMPLETE DENTURE - MAXILLARY ADJUST COMPLETE DENTURE - MANDIBULAR 42

4 DISCOUNT DENTAL PLAN 5421 ADJUST PARTIAL DENTURE - MAXILLARY ADJUST PARTIAL DENTURE - MANDIBULAR REPAIR BROKEN COMPLETE DENTURE BASE REPLACE MISSING OR BROKEN TEETH - COMPLETE DENTURE (EACH TOOTH) REPAIR RESIN DENTURE BASE REPAIR CAST FRAMEWORK REPAIR OR REPLACE BROKEN CLASP REPLACE BROKEN TEETH - PER TOOTH ADD TOOTH TO EXISTING PARTIAL DENTURE ADD CLASP TO EXISTING PARTIAL DENTURE REBASE COMPLETE MAXILLARY DENTURE REBASE COMPLETE MANDIBULAR DENTURE REBASE MAXILLARY PARTIAL DENTURE REBASE MANDIBULAR PARTIAL DENTURE RELINE COMPLETE MAXILLARY DENTURE (CHAIRSIDE) RELINE COMPLETE MANDIBULAR DENTURE (CHAIRSIDE) RELINE MAXILLARY PARTIAL DENTURE (CHAIRSIDE) RELINE MANDIBULAR PARTIAL DENTURE (CHAIRSIDE) RELINE COMPLETE MAXILLARY DENTURE (LABORATORY) RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY) RELINE MAXILLARY PARTIAL DENTURE (LABORATORY) RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY) INTERIM COMPLETE DENTURE (MAXILLARY) INTERIM COMPLETE DENTURE (MANDIBULAR) INTERIM PARTIAL DENTURE (MAXILLARY) INTERIM PARTIAL DENTURE (MAANDIBULAR) TISSUE CONDITIONING, MAXILLARY TISSUE CONDITIONING, MANDIBULAR PONTIC - CAST HIGH NOBLE METAL PONTIC - CAST PREDOMINANTLY BASE METAL PONTIC - CAST NOBLE METAL PONTIC - PORCELAIN FUSED TO HIGH NOBLE METAL PONTIC - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL PONTIC - PORCELAIN FUSED TO NOBLE METAL RETAINER - CAST METAL FOR RESIN BONDED FIXED PROSTHESIS CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METAL CROWN - PORCELAIN FUSED TO NOBLE METAL CROWN - 3/4 CAST HIGH NOBLE METAL CROWN - FULL CAST HIGH NOBLE METAL CROWN - FULL CAST PREDOMINANTLY BASE METAL CROWN - FULL CAST NOBLE METAL STRESS BREAKER PRECISION ATTACHMENT 375 4

5 DISCOUNT DENTAL PLAN 7111 EXTRACTION, CORONAL REMNANTS - DECIDIOUS TOOTH EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF 135 TOOTH, AND EXCLUDING ELEVATION OF MUCOPERIOSTEAL FLAP IF INDICATED 7220 REMOVAL OF IMPACTED TOOTH - SOFT TISSUE REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY, WITH UNUSUAL SURGICAL COMPLICATIONS SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PRCEDURE) SURGICAL ACCESS OF AN UNERUPTED TOOTH BIOPSY OF ORAL TISSUE - SOFT ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH 130 SPACES, PER QUADRANT 7320 ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS - FOUR OR MORE TEETH OR TOOTH 200 SPACES, PER QUADRANT 7510 INCISION AND DRAINAGE OF ABSCESS - INTRAORAL SOFT TISSUE INCISION AND DRAINAGE OF ABSCESS - EXTRAORAL SOFT TISSUE FRENULECTOMY ALSO KNOWN AS FRENECTOMY OR FRENOTOMY - SEPARATE PROCEDURE NOT 200 INCIDENTAL TO ANOTHER 7971 EXCISION OF PERICORONAL GINGIVA LIMITED ORTHODONTIC TREATMENT OF THE PRIMARY DENTITION LIMITED ORTHODONTIC TREATMENT OF THE TRANSITIONAL DETENTION LIMITED ORTHODONTIC TREATMENT OF THE ADOLESCENT DETENTION LIMITED ORTHODONTIC TREATMENT OF THE ADULT DENTITION INTERCEPTIVE ORTHODONTIC TREATMENT OF THE PRIMARY DETENTION INTERCEPTIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DETENTION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE TRANSITIONAL DETENTION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADOLESCENT DETENTION COMPREHENSIVE ORTHODONTIC TREATMENT OF THE ADULT DETENTION REMOVABLE APPLIANCE THERAPY FIXED APPLIANCE THERAPY PRE-ORTHODONTIC TREATMENT VISIT PERIODIC ORTHODONTIC TREATMENT VISIT (AS PART OF CONTRACT) ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF 300 RETAINER(S) 9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN, MINOR PROCEDURE INHALATION OF NITROUS OXIDE / ANXIOLYSIS, ANALGESIA INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - FIRST 30 MINUTES INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA - EACH ADDITIONAL 15 MINUTES CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN 65 REQUESTING DENTIST OR PHYSICIAN 9400 BROKEN APPOINTMENT CHARGE - PER 15 MINUTES (WITHOUT 24 HOURS PRIOR NOTICE) APPLICATION OF DESENSITIZING MEDICAMENT APPLICATION OF DESENSITIZING RESIN FOR CERVICAL AND/OR ROOT SURFACE, PER TOOTH OCCLUSAL GUARD, BY REPORT OCCLUSION ADJUSTMENT - LIMITED OCCLUSION ADJUSTMENT - COMPLETE INTERNAL BLEACHING - PER TOOTH 5 200

6 Plan Limitations In-Network The following exclusions and limitations shall apply: DISCOUNT DENTAL PLAN n Services for injuries and conditions which are covered under Workers Compensation or Employers Liability Laws; n Services which are provided without cost to the Covered Individual by any municipality, county or other political subdivision (with the exception of Medicaid); n Services which, in the opinion of the participating DENTIST, are not necessary for the Covered Individual s health; n Payment of any claim or bill will not be made for prohibited referrals; n Cosmetic, elective, or aesthetic dentistry, which in the opinion of the participating DENTIST are not necessary for the patient s dental health; n Oral surgery requiring the setting of fractures or dislocations; n Services with respect to malignancies, cysts or neoplasms, or hereditary, congenital or developmental malformations; n Dispensing of drugs, except those used as a local anesthetic; n Hospitalization for any dental procedure; n Loss or theft of bridgework or dentures previously supplied under the PLAN; n Replacement of a bridge, crown, or denture within five (5) years after the date it was originally installed; n Any implantation; n General anesthesia; n Services that cannot be performed because of the general health of the patient; n Teeth Cleaning (Prophylaxis) limited to twice per Contract Term (or Coverage Period); n Unlisted procedures will be provided at the dentist s usual and customary fees; n Services which are obtained outside the dental office in which enrolled and which are not pre-authorized by the PLAN. This does not apply to out-of-area emergency dental services; n Services rendered by a Pedodontist (Pediatric Dentist) are considered Specialty Care and must be approved by the Covered Individual s General Participating DENTIST; n All services listed on the Schedule of Benefits and Member Copayments will be provided by a general Participating Dentist or an approved Specialist; provided, however, that a general DENTIST will refer the Covered Individual or Dependent to an approved Specialist or recommend that the Covered Individual or Dependent contact an approved Specialist if it is the judgment of the DENTIST that the service or procedure must be provided by an approved Specialist, with an exception for out-of-area emergency care; n Services which cannot be performed in the dental office of the Personal Participating DENTIST or Approved Specialist due to the special needs or health related conditions of the Covered Employee and/or Dependent(s). ALL PRICES ARE EXCLUSIVE OF GOLD 6

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