LIST OF DENTAL PROCEDURES (LOW PLAN) PREVENTIVE PROCEDURES

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1 LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. PREVENTIVE PROCEDURES VISITS AND EVAULATIONS Periodic oral evaluation. $ Comprehensive oral evaluation - new or established patient Comprehensive periodontal evaluation - new or established patient (Two evaluations will be allowed in a Benefit Period. A 0120, 0150, or 0180 counts toward this maximum allowance and 0180 will be limited to once per provider.) 1110 Prophylaxis - adult Prophylaxis - child (Prophylaxis (cleaning) will be allowed twice in a Benefit Period. A 1110, 1120 or 1201 counts toward this maximum allowance. Periodontal maintenance may be substituted for a cleaning (see requirements under Basic section. Benefits will not be available if performed on the same date as periodontal services. An adult prophylaxis is considered for individuals age 14 and over. A child prophylaxis is considered for individuals age 13 and under.) 1201 Topical fluoride and prophylaxis Topical fluoride (separate code) in conjunction with prophylaxis - child ( : Coverage for fluoride treatment is limited to persons age 18 and under and to one treatment in a Benefit Period.) SPACE MAINTAINERS Fixed space maintainer, unilateral Fixed space maintainer, bilateral Removable space maintainer, unilateral Removable space maintainer, bilateral ( : Coverage is limited to space maintenance for unerupted teeth and following extraction of primary teeth. Allowance includes all adjustments within 6 months after installation.) 1550 Recementation of space maintainer Removable appliance therapy Fixed appliance therapy ( : Coverage is limited to the correction of thumb-sucking.) MISCELLANEOUS PREVENTIVE PROCEDURES 1351 Sealant - per tooth (1351: Coverage is limited to treatment of the occlusal surface of permanent molar teeth once during a 3-year period for persons age 16 and under.) GR Rev

2 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. PREVENTIVE PROCEDURES RADIOGRAPHS Periapical radiograph - first film. $ Additional periapical film, each Intraoral - complete series (including bitewings) Panoramic film (0210 or 0330: Only one of these procedures will be allowed in any three year period.*) 0240 Intraoral, occlusal film Extraoral, first film Extraoral, each additional film Bitewing, single film Bitewing - two films Bitewing - four films Vertical bitewings - 7 to 8 films (Bitewing films are limited to 2 allowances in a Benefit Period. A 0270, 0272, 0274 or 0277 counts toward this maximum allowance. In addition, 0277 will be limited to once in a 3-year period.) *The frequency is measured forward from the last covered date of service for the procedure. GR Rev

3 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. BASIC PROCEDURES VISITS AND EVAULATIONS Limited oral evaluation - problem focused $ Re-evaluation - limited, problem focused (Established patient; not post-operative visit) (0140 and 0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a 0120 and count toward this maximum allowance.) 9440 Office visit after regularly scheduled hours (9440: Payment will be made on basis of services rendered or visit, whichever is greater.) 9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) (9310: Coverage is limited to one allowance per provider.) 9110 Palliative (emergency) treatment of dental pain - minor procedure (9110: Not covered in conjunction with other procedures, except diagnostic x-ray films.) 4355 Full mouth debridement to enable comprehensive evaluation and diagnosis (4355: Coverage is limited to once during a 5-year period.*) 4910 Periodontal maintenance (4910: This procedure is available in place of an eligible routine prophylaxis ( ) as listed above. Coverage is contingent upon evidence of full mouth active periodontal therapy and limited to 2 allowances in a Benefit Period (a 1110, 1120 or 1201 counts toward this maximum allowance Benefits will not be available if performed on the same date as other periodontal services.) 9911 Application of desensitizing resin for cervical and/or root surface, per tooth PATHOLOGY Biopsy of oral tissue - hard (bone, tooth) Biopsy of oral tissue - soft (all others) Accession of tissue, gross examination, preparation and transmission of written report *The frequency is measured forward from the last covered date of service for the procedure. GR Rev

4 BASIC PROCEDURES (Continued) (LOW PLAN) 0473 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 ( : Coverage is limited to one examination per biopsy/excision.) RESTORATIVE DENTISTRY, excluding inlays, crowns and fixed partial dentures. Amalgam Restorations 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 Restorations 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 ( : Coverage is limited to permanent bicuspid teeth.) Other Restorative Services Resin-based composite crown, anterior Prefabricated stainless steel crown - primary tooth Stainless steel crown - permanent tooth Prefabricated resin crown (2390, : Coverage is limited to persons age 18 and under. Please refer to Major procedures for persons age 19 and older.) 2951 Pin retention, per tooth, in addition to restoration (3 pins per tooth maximum) Recementation Inlay Crown Fixed Partial Denture GR Rev

5 BASIC PROCEDURES (Continued) (LOW PLAN) Full and Partial Denture Repairs, Acrylic. Repair of Complete Dentures Repair broken base. $ Replace missing or broken teeth - each tooth Repair of Partial Dentures Repair resin denture base Repair cast framework Repair or replace broken clasp Replace broken teeth (per tooth) 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) ( : Coverage for relines is limited to service dates more than 6 months after installation.) ORAL SURGERY. Extractions. Includes local anesthesia, suturing, if needed, and routine postoperative care Coronal remnants - deciduous tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Surgical Extractions. Includes local anesthesia, suturing, if needed, and routine postoperative care Surgical removal of erupted teeth Treatment of complications (post-surgical) - unusual circumstances, by report Impacted Teeth. Includes local anesthesia, suturing, if needed, and routine postoperative care Surgical removal of impacted tooth (soft tissue) Surgical removal of impacted tooth (partially bony) Surgical removal of impacted tooth (completely bony) Removal of impacted tooth (completely bony, with unusual surgical complications), by report Surgical removal of residual tooth roots (cutting procedure) Alveolar or Gingival Reconstruction Alveoplasty (without extractions) - per quadrant Alveoplasty (with extractions) - per quadrant Vestibuloplasty - ridge extension (secondary epithelialization) GR Rev

6 BASIC PROCEDURES (Continued) (LOW PLAN) 7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue). $ Cysts and Neoplasms Incision and drainage of abscess - intraoral soft tissue Incision and drainage of abscess - extraoral soft tissue Sialolithotomy Closure of salivary fistula Excision of benign lesion up to 1.25 cm Excision of benign lesion greater than 1.25 cm Excision of benign lesion, complicated Excision of malignant lesion up to 1.25 cm Excision of malignant lesion greater than 1.25 cm Excision of malignant lesion, complicated Excision of malignant tumor - lesion diameter up to 1.25 cm Excision of malignant tumor - lesion diameter greater than 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 lesion(s) by physical or chemical method, by report Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) Removal of reaction-producing foreign bodies - musculoskeletal system Radical resection of mandible with bone graft Maxillary sinusotomy for removal of tooth fragment or foreign body Oral antral fistula closure Partial ostectomy/sequestrectomy for removal of non-vital bone Miscellaneous Removal of foreign body, skin, or subcutaneous areolar tissue Frenulectomy (frenectomy or frenotomy) - separate procedure Suture of recent small wounds - up to 5 cm Complicated suture - up to 5 cm Complicated suture - greater than 5 cm Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth Surgical access of an unerupted tooth Surgical exposure of impacted or unerupted tooth to aid eruption GR Rev

7 BASIC PROCEDURES (Continued) (LOW PLAN) 7970 Excision of hyperplastic tissue, per arch Primary closure of a sinus perforation Mobilization of erupted or malpositioned tooth to aid eruption Cytology sample collection Removal of lateral exostosis - (maxilla or mandible) Removal of torus palatinus Removal of torus mandibularis ( : A maximum of 5 allowances will be considered.) 7485 Surgical reduction of osseous tuberosity ANESTHESIA Deep sedation/general anesthesia - first 30 minutes Deep sedation/general anesthesia - each additional 15 minutes Intravenous conscious sedation/analgesia - first 30 minutes Intravenous conscious sedation/analgesia - each additional 15 minutes ( : Coverage is not available without a cutting procedure. Verification of the dentist s anesthesia permit and a copy of the anesthesia report is required. A maximum of two additional units (9221 or 9242) will be considered.) GR Rev

8 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. BASIC PROCEDURES ENDODONTICS Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament. Limited to treatment of primary teeth. $ Pulpal debridement, primary and permanent teeth Pulpal therapy (resorbable filling) - anterior, primary tooth Pulpal therapy (resorbable filling) - posterior, primary tooth Root canal, anterior (excluding final restoration) Root canal, bicuspid (excluding final restoration) Root canal, molar (excluding final restoration) Incomplete endodontic therapy; inoperable or fractured tooth Internal root repair of perforation defects ( : Coverage is limited to permanent teeth. Allowance includes intraoperative films and cultures but excludes final restoration.) 3346 Retreatment of previous root canal therapy - anterior Retreatment of previous root canal therapy - bicuspid Retreatment of previous root canal therapy - molar ( : Coverage is limited to permanent teeth and to service dates more than 12 months after root canal therapy or a previous retreatment. Allowance includes intraoperative films and cultures but excludes final restoration.) 3351 Apexification/recalcification - initial visit Apexification/recalcification - interim medication replacement Apexification/recalcification - final visit Apicoectomy/periradicular surgery - anterior Apicoectomy/periradicular surgery - bicuspid (first root) Apicoectomy/periradicular surgery - molar (first root) Apicoectomy/periradicular surgery - each additional root Retrograde filling - per root Root amputation - per root Hemisection (including any root removal), not including root canal therapy PERIODONTICS. Surgical Procedures (including postoperative visits) Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant Gingivectomy or gingivoplasty - one to three teeth, per quadrant GR Rev

9 BASIC PROCEDURES (Continued) (LOW PLAN) 4240 Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant. $ Gingival flap procedure, including root planing - one to three teeth, per quadrant Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant Osseous surgery (including flap entry and closure) - one to three teeth, per quadrant Bone replacement graft - first site in quadrant Bone replacement graft - each additional site in quadrant Biologic materials to aid in soft and osseous tissue regeneration ( : Each procedure is eligible for consideration once in a 3-year period.*) 4270 Pedicle soft tissue graft procedure Free soft tissue graft procedure (including donor site) Subepithelial connective tissue graft procedures Soft tissue allograft Combined connective tissue and double pedicle graft ( , : A maximum of two sites per quadrant will be considered in a 3-year period. Coverage is limited to treatment of periodontal disease.*) 4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) Non-surgical Periodontal Procedures Periodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces per quadrant Periodontal scaling and root planing - one to three teeth, per quadrant ( : Each procedure is eligible for consideration once in a 2-year period.*) 4381 Localized delivery of chemotherapeutic agents via a controlled release vehicle into diseased crevicular tissue, per tooth (4381: A scaling and planing (4341) must be performed between 6 weeks and two years prior to treatment. A maximum of 2 sites per quadrant will be considered and the frequency is limited to once in any 2-year period.) 9951 Occlusal adjustment, limited Occlusal adjustment, complete ( : Coverage is limited to adjustment performed in conjunction with treatment of periodontal disease.) *The frequency is measured forward from the last covered date of service for the procedure. GR Rev

10 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (LOW PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. MAJOR PROCEDURES RESTORATIVE. Inlays and crowns are covered only when necessitated by decay or traumatic injury. Inlays Resin-based composite crown, anterior. $ Inlay - metallic - one surface Inlay - metallic - two surfaces Inlay - metallic - three or more surfaces Onlay - metallic - two surfaces Onlay - metallic - three surfaces Onlay - metallic - four or more surfaces Inlay porcelain/ceramic - one surface Inlay porcelain/ceramic - two surfaces Inlay - porcelain/ceramic - three or more surfaces Onlay - porcelain/ceramic - two surfaces Onlay - porcelain/ceramic - three surfaces Onlay - porcelain/ceramic - four or more surfaces Inlay - resin-based composite composite/resin - one surface Inlay - resin-based composite composite/resin - two surfaces Inlay - resin-based composite composite/resin - three surfaces Onlay - resin-based composite composite/resin - two surfaces Onlay - resin-based composite composite/resin - three surfaces Onlay - resin-based composite composite/resin - four or more surfaces Crowns Resin (indirect) Resin with high noble metal Resin with predominantly base metal Resin with noble metal Porcelain/ceramic substrate Porcelain fused to high noble metal Porcelain fused to predominantly base metal Porcelain fused to noble metal Crown - 3/4 cast high noble metal Crown - 3/4 cast predominately base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Full cast high noble metal Full cast predominantly base metal Full cast noble metal GR Rev

11 MAJOR PROCEDURES (Continued) (LOW PLAN) 2930 Prefabricated stainless steel crown - primary tooth. $ Prefabricated stainless steel crown - permanent tooth Prefabricated resin crown ( : These procedures are limited to necessary placement resulting from decay or traumatic injury. Inlays will be reimbursed at the alternate allowance of an amalgam or composite restoration.) 2950 Core build-up, including any pins Cast post and core - in addition to crown Prefabricated post and core - in addition to crown Clinical crown lengthening, hard tissue PROSTHODONTICS - FIXED. Retainers (Abutments) 6545 Retainer - cast metal for resin bonded fixed prosthesis Retainer - porcelain/ceramic for resin bonded fixed prosthesis Inlay - porcelain/ceramic, two surfaces Inlay - porcelain/ceramic, three or more surfaces Inlay - cast high noble metal, two surfaces Inlay - cast high noble metal, three or more surfaces Inlay - cast predominantly base metal, two surfaces Inlay - cast predominantly base metal, three or more surfaces Inlay - cast noble metal, two surfaces Inlay - cast noble metal, three or more surfaces Onlay - porcelain/ceramic, two surfaces Onlay - porcelain/ceramic, three or more surfaces 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 Onlay - cast noble metal, three or more surfaces Crown - resin with high noble metal Crown - resin with predominantly base metal Crown - resin with noble metal Crown - porcelain/ceramic 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 - 3/4 cast predominately base metal Crown - 3/4 cast noble metal Crown - 3/4 porcelain/ceramic Crown - full cast high noble metal Crown - full cast predominantly base metal Crown - full cast noble metal Stress breaker Cast post and core in addition to fixed partial denture retainer Cast post as part of fixed partial denture retainer Prefabricated post and core in addition to fixed partial denture retainer GR Rev

12 MAJOR PROCEDURES (Continued) (LOW PLAN) Implant Supported 6058 Abutment supported porcelain/ceramic crown Abutment supported porcelain fused to metal crown (high noble metal) Abutment supported porcelain fused to metal crown (predominantly base metal). $ Abutment supported porcelain fused to metal crown (noble metal) Abutment supported cast metal crown (high noble metal) Abutment supported cast metal crown (predominantly base metal) Abutment supported cast metal crown (noble metal) Implant supported porcelain/ceramic crown Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) Implant supported metal crown (titanium, titanium alloy, high noble metal) Abutment supported retainer for porcelain /ceramic FPD Abutment supported retainer for porcelain fused to metal FPD (high noble metal) Abutment supported retainer for porcelain fused to metal FPD (predominately base metal) Abutment supported retainer for porcelain fused to metal FPD (noble metal) Abutment supported retainer for cast metal FPD (high noble metal) Abutment supported retainer for cast metal FPD (predominately base metal) Abutment supported retainer for cast metal FPD (noble metal) Implant supported retainer for ceramic FPD Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) ( : Although implants are not a covered benefit, these procedures can qualify for benefits. Coverage is subject to the replacement and extraction provisions as defined under the limitations section of this contract.) Pontics Cast high noble metal Cast predominantly base metal Cast noble metal Porcelain fused to high noble metal Porcelain fused to predominantly base metal Porcelain fused to noble metal Porcelain/ceramic Resin with high noble metal Resin with predominantly base metal Resin with noble metal Repairs, crowns and fixed partial dentures Fixed partial denture repair, by report Crown repair, by report GR

13 MAJOR PROCEDURES (Continued) (LOW PLAN) PROSTHODONTICS - REMOVABLE. Partials and Dentures (Allowance for partial and complete dentures include adjustments within 6 months after installation. Precision attachments, implants, overdentures, specialized techniques and characterizations are considered optional and the additional expense for these shall be borne by the patient. All partial allowances include conventional clasps, rests and teeth.) 5110 Complete denture - maxillary. $ Complete denture - mandibular Immediate denture - maxillary Immediate denture - mandibular Maxillary partial denture - resin base Mandibular partial denture - resin base Maxillary partial denture - cast metal framework with resin denture bases Mandibular partial denture - cast metal framework with resin denture bases Removable unilateral partial denture - one piece cast metal Interim partial denture (maxillary) Interim partial denture (mandibular) Interim complete denture (maxillary) Interim complete denture (mandibular) Adjust complete denture - maxillary Adjust complete denture - mandibular Adjust partial denture - maxillary Adjust partial denture - mandibular ( : Coverage is limited to an adjustment with a date of service more than 6 months after installation.) 5850 Tissue conditioning, maxillary Tissue conditioning, mandibular Rebase - complete maxillary denture Rebase - complete mandibular denture Rebase - maxillary partial denture Rebase - mandibular partial denture Adding teeth to partial denture to replace extracted natural teeth Add tooth to existing partial denture Add clasp to existing partial denture Replace all teeth and acrylic on cast metal framework (maxillary) Replace all teeth and acrylic on cast metal framework (mandibular) ( : Prosthetic replacement limitation applies. See limitations section.) GR

14 PERSONAL AND DEPENDENT DENTAL CARE INSURANCE LIST OF DENTAL PROCEDURES (MIDDLE PLAN) The following is a complete list of the dental procedures for which benefits are payable under this section. No benefits are payable for a procedure that is not listed. PREVENTIVE PROCEDURES RADIOGRAPHS Periapical radiograph - first film. $ Additional periapical film, each Intraoral - complete series (including bitewings) Panoramic film (0210 or 0330: Only one of these procedures will be allowed in any three year period.*) 0240 Intraoral, occlusal film Extraoral, first film Extraoral, each additional film Bitewing, single film Bitewing - two films Bitewing - four films Vertical bitewings - 7 to 8 films (Bitewing films are limited to 2 allowances in a Benefit Period. A 0270, 0272, 0274 or 0277 counts toward this maximum allowance. In addition, 0277 will be limited to once in a 3-year period.) *The frequency is measured forward from the last covered date of service for the procedure. GR

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