Smile Generation Dental Plan – CA Fee Schedule

California
The fees listed on the Fee Schedule apply when services are provided by an in-network General
Dentist. Exclusions and Limitations apply.

Services of an in-network Specialist (Endodontist, Oral Surgeons, Periodontist, Pediatric Dentist)

are available at a 20% discount off the Specialist’s usual and customary rate.

Members who are pregnant or have diabetes have a benefit for a free electric toothbrush. This
benefit is limited to one (1) per lifetime. The toothbrush will be mailed to the member by the
toothbrush manufacturer directly. It will not be distributed at the office.

THIS PLAN IS NOT INSURANCE and is not intended to replace health insurance. This plan does
not meet the minimum creditable coverage requirements under M.G.L. c.111M and 956 CMR
5.00. This plan is not a Qualified Health Plan under the Affordable Care Act. The range of
discounts will vary depending on the type of provider and service. This plan does not pay
providers directly. Plan members must pay for all services but will receive a discount from
participating providers. The list of participating providers is at smilegenerationdentalplan.com
for dental providers. A written list of participating providers is available upon request. You may
cancel within the first 30 days after effective date or receipt of membership materials
(whichever is later) and receive a full refund, less a nominal processing fee (nominal fee for MD
residents is $5, AR residents will be refunded processing fee). Discount Plan Organization and
administrator: Careington International Corporation, 7400 Gaylord Parkway, Frisco, TX 75034;
phone 800-441-0380.

This plan is not available in Vermont.

 CALIFORNIA FEE SCHEDULE
CDT DESCRIPTION YOU PAY
Diagnostic Procedures
D0120 Periodic Oral Evaluation – Established Patient $6
D0140 Limited Oral Evaluation – Problem Focused $6-$11
D0150 Comprehensive Oral Evaluation – New Patient $6
D0160 Detailed and Extensive Oral Evaluation – Problem $11
Focused by Report
D0170 Re-Evaluation – Limited, Problem Focused (Established $12
Patient; Not Post-Operative Visit
D0171 Re-Evaluation – Post Operative Office Visit $12
D0210 Intraoral – Complete Series of Radiographic Images $12
D0220 Intraoral – Periapical First Radiographic Image $3
D0230 Intraoral – Periapical Each Additional Radiographic $2
Image
D0240 Intraoral – Occlusal Radiographic Image $7
D0270 Bitewing – Single Radiographic Image $3
D0272 Bitewings – Two Radiographic Images $4
D0273 Bitewings – Three Radiographic Images $4
D0274 Bitewings – Four Radiographic Images $5
D0330 Panoramic Radiographic Image $12
D0350 2D Cephalometric Radiographic Image-Acquisition, $2
Measurement and Analysis
D0351 3D Photographic Image $74
D0364 Cone Beam CT Capture and Interpretation with $184
Limited Field of View – Less Than One Whole Jaw
D0367 Cone Beam CT Capture and Interpretation with $184
Field of View of Both Jaws: With or Without Cranium
D0383 Cone Beam CT Image Capture with Field of View of $184
Both Jaws; With or Without Cranium
D0417 Collection and Preparation of Saliva Sample for $75-$151
Laboratory Diagnostic Testing
D0418 Analysis of Saliva Sample $12
D0431 Adjunctive Pre-Diagnostic Test Aiding in Detection of $34
Mucosal Abnormalities Including Premalignant and Malignant
Lesions, Not to Include Cytology or Biopsy Procedures

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CDT DESCRIPTION YOU PAY
D0460 Pulp Vitality Tests $7
D0470 Diagnostics Casts $146
D0472 Accession of Tissue, Gross Examination, Preparation $128
And Transmission of Written Report
Preventive Procedures
D1110 Prophylaxis – Adult $79
D1120 Prophylaxis – Child $77
D1206 Topical Application of Fluoride Varnish $48
D1208 Topical Application of Fluoride – Excluding Varnish $41
D1310 Nutritional Counseling for Control of Dental Disease $97
D1320 Tobacco Counseling for the Control and Prevention $92
Of Oral Disease
D1330 Oral Hygiene Instructions $2
D1351 Sealant – Per Tooth $67
D1352 Prevention Resin Restoration in a Moderate to High $146
Caries Risk Patient – Permanent Tooth
D1353 Sealant Repair – Per Tooth $58
D1354 Interim Caries Arresting Medicament Application $95
Per Tooth
D1510 Space Maintainer – Fixed, Unilateral – Per Quadrant $289
D1516 Space Maintainer – Fixed – Bilateral, Maxillary $405
D1517 Space Maintainer – Fixed – Bilateral, Mandibular $405
D1520 Space Maintainer – Removable, Unilateral – Per Quad $341
D1526 Space Maintainer – Removable – Bilateral, Maxillary $374
D1527 Space Maintainer – Removable – Bilateral, Mandibular $374
D1551 Re-Cement or Re-Bond Bilateral Space Maintainer $78
Maxillary
D1552 Re-Cement or Re-Bond Bilateral Space Maintainer – $67
Mandibular
D1553 Re-Cement or Re-Bond Unilateral Space Maintainer – $81
Per Quadrant
D1556 Removal of Fixed Unilateral Space Maintainer – Per $146
Quadrant
D1575 Distal Shoe Space Maintainer – Fixed, Unilat -Per Quad $273

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CDT DESCRIPTION YOU PAY
Restorative Procedures
D2140 Amalgam – One Surface, Primary or Permanent $89-$102
D2150 Amalgam – Two Surface, Primary or Permanent $97-$128
D2160 Amalgam – Three Surface, Primary or Permanent $121 - $160
D2161 Amalgam – Four Surface, Primary or Permanent $121 - $195
D2330 Resin-Based Composite – One Surface, Anterior $162
D2331 Resin-Based Composite – Two Surfaces, Anterior $196
D2332 Resin-Based Composite – Three Surfaces, Anterior $246
D2335 Resin-Based Composite – Four or More Surfaces or $311
Involving Incisal Angle (Anterior)
D2390 Resin-Based Composite Crown, Anterior $389
D2391 Resin-Based Composite – One Surface, Posterior $224
D2392 Resin-Based Composite – Two Surface, Posterior $263
D2393 Resin-Based Composite – Three Surfaces, Posterior $315
D2394 Resin-Based Composite – Four or More Surfaces, Post. $360
D2420 Gold Foil – Two Surfaces $752
D2430 Gold Foil – Three Surfaces $821
D2510 Inlay – Metallic – One Surface $195
D2520 Inlay – Metallic – Two Surfaces $195
D2530 Inlay – Metallic – Three or More Surfaces $195
D2542 Onlay – Metallic – Two Surfaces $195
D2543 Onlay – Metallic – Three Surfaces $243-$801
D2544 Onlay – Metallic – Four or More Surfaces $291-$850
D2610 Inlay – Porcelain/Ceramic – One Surface $439-$675
D2620 Inlay – Porcelain/Ceramic – Two Surfaces $439-$752
D2630 Inlay – Porcelain/Ceramic – Three or More Surfaces $439-$821
D2642 Onlay – Porcelain/Ceramic – Two Surfaces $982-$1102
D2643 Onlay – Porcelain/Ceramic – Three Surfaces $982-$1145
D2644 Onlay – Porcelain/Ceramic – Four or More Surfaces $982-$1213
D2650 Inlay – Resin-Based Composite – One Surface $626
D2651 Inlay – Resin-Based Composite – Two Surfaces $752
D2652 Inlay – Resin-Based Composite – Three or More Surfaces $776
D2662 Onlay - Resin Based Composite – Two Surfaces $776
D2663 Onlay – Resin Based Composite – Three Surfaces $850

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CDT DESCRIPTION YOU PAY
D2664 Onlay – Resin-Based Composite -Four or More $1213
Surfaces
D2710 Crown – Resin-Based Composite (Indirect) $1165
D2740 Crown – Porcelain/Ceramic $950-$1628
D2750 Crown – Porcelain Fused to High Noble $880-$1444
D2751 Crown – Porcelain Fused to Predominantly Base Metal $689-$700
D2752 Crown – Porcelain Fused to Noble Metal $738
D2780 Crown – ¾ Cast High Noble Metal $776
D2783 Crown – ¾ Porcelain Ceramic $1369
D2790 Crown – Full Cast High Noble Metal $1538
D2791 Crown – Full Cast Predominantly Base Metal $423-$573
D2792 Crown – Full Cast Noble Metal $471-$911
D2799 Provisional Crown – Further Treatment or Completion $195
Of Diagnosis Necessary Prior to Final Impression
D2910 Re-Cement or Re-Bond Inlay, Onlay, Veneer or Partial $102
Coverage Restoration
D2915 Re-Cement or Re-Bond Indirectly Fabricated or Pre- $97
Fabricated Post and Core
D2920 Re-Cement or Re-Bond Crown $100-$146
D2921 Reattachment of Tooth Fragment, Incisal Edge or $302
Cusp
D2930 Prefabricated Stainless Steel Crown – Primary Tooth $214
D2931 Prefabricated Stainless Steel Crown – Permanent $234
Tooth
D2932 Prefabricated Resin Crown $389
D2940 Protective Restoration $66
D2949 Restorative Foundation for an Indirect Restoration $252
D2950 Core Buildup, Including Any Pins When Required $289
D2952 Post and Core in Addition to Crown, Indirectly $384
Fabricated
D2954 Prefabricated Post and Core in Addition to Crown $350
D2955 Post Removal $330-$341
D2960 Labial Veneer (Resin Laminate) – Chairside $437
D2962 Labial Veneer (Porc Laminate) – Laboratory $1013-1331

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CDT DESCRIPTION YOU PAY
D2975 Coping $199
D2980 Crown Repair Necessitated by Restorative Material $384
Failure
D2981 Inlay Repair Necessitated by Restorative Material $384
Failure
D2982 Onlay Repair Necessitated by Restorative Material $384
Failure
D2983 Veneer Repair Necessitated by Restorative Material $384
Failure
Endodontic Procedures
D3110 Pulp Cap – Direct (Excluding Final Restoration) $74
D3120 Pulp Cap – Indirect (Excluding Final Restoration) $74
D3220 Therapeutic Pulpotomy (Excluding Final Restoration)- $156
Removal of Pulp Coronal to the Dentin Cemental
Junction and Application of Medicament
D3221 Pulpal Debridement, Primary and Permanent Teeth $171
D3222 Partial Pulpotomy for Apexogenesis – Permanent $226
Tooth with Incomplete Root Development
D3230 Pulpal Therapy (Resorbable Filling) – Anterior, Primary $136
Tooth (Excluding Final Restoration)
D3240 Pulpal Therapy (Resorbable Filling) – Posterior, Primary $156
Tooth (Excluding Final Restoration)
D3310 Endodontic Therapy, Anterior Tooth (Excluding Final $819
Restoration)
D3320 Endodontic Therapy, Premolar Tooth (Excluding Final $903
Restoration)
D3330 Endodontic Therapy, Molar Tooth (Excluding Final $1092
Restoration)
D3331 Treatment of Root Canal Obstruction, Non-Surgical $444
Access
D3332 Incomplete Endodontic Therapy; Inoperable, $582
Unrestorable or Fractured Tooth
D3346 Retreatment of Previous Root Canal Therapy $922
- Anterior

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 CALIFORNIA FEE SCHEDULE
CDT DESCRIPTION YOU PAY
D3347 Retreatment of Previous Root Canal Therapy $1067
- Premolar
D3348 Retreatment of Previous Root Canal Therapy $1311
- Molar
D3431 Biologic Material to Aid in Soft and Osseous Tissue $680
Regeneration in Conjunction with Periradicular Surgery
D3450 Root Amputation – Per Root $776
D3911 Hemisection (Including any Root Removal), Not $264
Including Root Canal Therapy
Periodontic Procedures
D4210 Gingivectomy or Gingivoplasty – Four or More $922
Contiguous Teeth or Tooth Bounded Spaces Per Quad
D4211 Gingivectomy or Gingivoplasty – One to Three $535
Contiguous Teeth or Tooth Bounded Spaces Per Quad
D4231 Anatomical Crown Exposure – One to Three Teeth or $2426
Tooth Bounded Spaces per Quadrant
D4249 Clinical Crown Lengthening – Hard Tissues $850
D4263 Bone Replacement Graft – Retained Natural Tooth $826
First Site in Quadrant
D4264 Bone Replacement Graft – Retained Natural Tooth – $632
Each Additional Site in Quadrant
D4266 Guided Tissue Regeneration–Resorbable Barrier, Per Site $647
D4270 Pedicle Soft Tissue Graft Procedure $613
D4274 Mesial/Distal Wedge Procedure, Single Tooth (When $748
Not Performed in Conjunction with Surgical Procedures In
The Same Anatomical Area)
D4322 Splint Intra-Coronal; Natural Teeth or Prosthetic Crown $559
D4323 Splint Extra-Coronal; Natural Teeth or Prosthetic Crown $559
D4341 Periodontal Scaling and Root Planning – Four or More $155
Teeth per Quadrant
D4342 Periodontal Scaling and Root Planning – One to Three $125
Teeth per Quadrant
D4346 Scaling in the Presence of Generalized Moderate or $95
Severe Gingival Inflammation – Full Mouth, After Oral

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CDT DESCRIPTION YOU PAY
Evaluation
D4355 Full Mouth Debridement to Enable a Comprehensive $176
Oral Evaluation and Diagnosis on a Subsequent Visit
D4381 Localized Delivery of Antimicrobial Agents via a $94
Controlled Release Vehicle into Diseased Crevicular
Tissue, per Tooth
D4910 Periodontal Maintenance $125
D4921 Gingival Irrigation – Per Quadrant $10
D4999 Full Mouth Irrigation with Gross Scale $77
D4999 Full Mouth Bacterial Decontamination $97
D4999 Bacterial Decontamination – Per Quad $65
Prosthodontic (Removable) Procedures
D5110 Complete Denture – Maxillary $826-$2459
D5120 Complete Denture – Mandibular $826-$2459
D5130 Immediate Denture – Maxillary $1548
D5140 Immediate Denture – Mandibular $1548
D5211 Maxillary Partial Denture – Resin Base (Including $632
Retentive/Clasping Material, Rests and Teeth)
D5212 Mandibular Partial Denture – Resin Base (Including $632
Retentive/Clasping Material, Rests and Teeth)
D5213 Maxillary Partial Denture – Cast Metal Framework with $1592-2091
Resin Denture Bases (Including Retentive/Clasping
Material Rests and Teeth)
D5214 Mandibular Partial Denture – Cast Metal Framework $1592-2091
With Resin Denture Bases (Including Retentive/Clasping
Materials Rests and Teeth)
D5225 Maxillary Partial Denture – Flexible Bases (Including any $1698-1777
Clasps, Rests, and Teeth)
D5226 Mandibular Partial Denture – Flexible Bases (Including $1698-1777
Any Clasps, Rest, and Teeth)
D5282 Removable Unilateral Partial Denture – One Piece Cast $315
Metal (Including Clasps and Teeth), Maxillary
D5283 Removable Unilateral Partial Denture – One Piece Cast $315
Metal (Including Clasps and Teeth), Mandibular

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CDT DESCRIPTION YOU PAY
D5410 Adjust Complete Denture – Maxillary $63
D5411 Adjust Complete Denture – Mandibular $63
D5421 Adjust Partial Denture – Maxillary $97
D5422 Adjust Partial Denture – Mandibular $97
D5511 Repair Broken Complete Denture Base, Mandibular $117
D5512 Repair Broken Complete Denture Base, Maxillary $117
D5520 Replace Missing or Broken Teeth – Complete Denture $112
(Each Tooth)
D5611 Repair Resin Partial Denture Base, Mandibular $128
D5612 Repair Resin Partial Denture Base, Maxillary $128
D5621 Repair Cast Partial Framework, Mandibular $132
D5630 Repair or Replace Broken Retentive Clasping Materials $141
Per Tooth
D5640 Replace Broken Teeth – Per Tooth $171
D5650 Add Tooth to Existing Partial Denture $189
D5660 Add Clasp to Existing Partial Denture – Per Tooth $82-$175
D5710 Rebase Complete Maxillary Denture $772
D5711 Rebase Complete Mandibular Denture $772
D5720 Rebase Maxillary Partial Denture $772
D5721 Rebase Mandibular Partial Denture $772
D5730 Reline Complete Maxillary Denture (Chairside) $321
D5731 Reline Complete Mandibular Denture (Chairside) $321
D5740 Reline Maxillary Partial Denture (Chairside) $282
D5741 Reline Mandibular Partial Denture (Chairside) $282
D5750 Reline Complete Maxillary Denture (Laboratory) $408
D5751 Reline Complete Mandibular Denture (Laboratory) $408
D5760 Reline Maxillary Partial Denture (Laboratory) $408
D5761 Reline Mandibular Partial Denture (Laboratory) $408
D5810 Interim Complete Denture (Maxillary) $922
D5811 Interim Complete Denture (Mandibular) $922
D5820 Interim Partial Denture (Maxillary) $632
D5821 Interim Partial Denture (Mandibular) $632
D5850 Tissue Conditioning – Maxillary $189
D5851 Tissue Conditioning – Mandibular $189

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CDT DESCRIPTION YOU PAY
D5862 Precision Attachment, By Report $826
D5863 Overdenture – Complete Maxillary $1941
D5864 Overdenture – Partial Maxillary $1456
D5865 Overdenture – Complete Mandibular $1941
D5866 Overdenture – Partial Mandibular $1456
D5867 Replace Precision Attachment $220
D5982 Surgical Stent $486
D5988 Surgical Splint $486
D5992 Adjust Maxillofacial Prosthetic Appliance, by Report $146
D5993 Maintenance and Cleaning of a Maxillofacial Prosthesis $117
(Extra-or Intra Oral) Other Than Required Adjustments,
By Report
Implant Procedures
D6010 Surgical Placement of Implant Body, Endosteal Implant $1663-2155
D6011 Second Stage Implant Surgery $389
D6013 Surgical Placement of Mini Implant $1441
D6051 Interim Abutment $582
D6055 Connecting Bar – Implant or Abutment Supported $2329
D6056 Prefabricated Abutment – Includes Modification $440
And Placement
D6057 Custom Fabricated Abutment – Includes Placement $700
D6058 Abutment Supported Porcelain/Ceramic Crown $1023-1345
D6059 Abutment Supported Porcelain Fused to Metal $1271
Crown (High Nobel Metal)
D6061 Abutment Supported Porcelain Fused to Metal $930
Crown (Noble Metal)
D6066 Implant Supported Crown – Porcelain Fused to High $800
Noble Alloys
D6080 Implant Maintenance Procedures when Prostheses are $208
Removed and Reinserted, Including Cleaning of
Prostheses and Abutments
D6081 Scaling and Debridement in the Presence of Inflam- $150
Mation or Mucositis of a Single Implant, Incl Cleaning
Of the Implant Surfaces without Flap Entry and Closure

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CDT DESCRIPTION YOU PAY
D6090 Repair Implant Supported Prothesis, by Report $922
D6092 Re-Cement or Re-Bond Implant/Abutment Supported $89
Crown
D6093 Re-Cement or Re-Bond Implant/Abutment Supported $175
Fixed Partial Denture
D6095 Repair Implant Abutment, By Report $121
D6100 Implant Removal, By Report $1155
D6101 Debridement of a Peri-Implant Defect or Defects $287
Surrounding a Single Implant, and Surface Cleaning of the
Exposed Implant Surfaces, Including Flap Entry and Closure
D6102 Debridement and Osseous Contouring of a Peri-Implant $384
Defect or Defects Surrounding a Single Implant and Incl.
Surface Cleaning of the Exposed Implant Surfaces,
Including Flap Entry and Closure
D6103 Bone Graft for Repair of Peri-Implant Defect – Does Not $826
Include Flap Entry and Closure
D6104 Bone Graft at Time of Implant Procedure $826
D6110 Implant/Abutment Supported Removable Denture for $1848
Edentulous Arch – Maxillary
D6111 Implant/Abutment Supported Removable Denture for $1941
Edentulous Arch – Mandibular
D6112 Implant/Abutment Supported Removable Denture for $1941
Partially Edentulous Arch - Maxillary
D6113 Implant/Abutment Supported Removable Denture for $1941
Partially Edentulous Arch – Mandibular
D6114 Implant/Abutment Supported Fixed Denture for $1340
Edentulous Arch – Maxillary
D6115 Implant/Abutment Supported Fixed Denture for $1407
Edentulous Arch – Mandibular
D6116 Implant/Abutment Supported Fixed Denture for Partially $1525
Edentulous Arch – Maxillary
D6117 Implant/Abutment Supported Fixed Denture for Partially $1602
Edentulous Arch – Mandibular
D6190 Radiographic/Surgical Implant Index, by Report $728

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CDT DESCRIPTION YOU PAY
D6199 Unspecified Implant Procedure, by Report $28136 –
$37838
Prosthodontic (Fixed) Procedures
D6210 Pontic – Cast High Noble Metal $932
D6211 Pontic – Cast Predominately Base Metal $423
D6240 Pontic – Porcelain Fused to High Nobel Metal $1014-1050
D6241 Pontic – Porcelain Fused to Predominately Base Metal $689
D6245 Pontic – Porcelain/Ceramic $1023-1260
D6254 Interim Pontic $374
D6545 Retainer – Cast metal for Resin Bonded Fixed $494
Prosthesis
D6548 Retainer – Porcelain/Ceramic for Resin Bonded Fixed $772
Prosthesis
D6740 Retainer Crown – Porcelain/Ceramic $1075-1260
D6750 Retainer Crown – Porcelain Fused to High Noble Metal $1024-1050
D6751 Retainer Crown – Porcelain Fused to Predominately $689
Base Metal
D6790 Retainer Crown – Full Cast High Nobel Metal $932
D6791 Retainer Crown – Full Cast Predominately Base Metal $423
D6795 Interim Retainer Crown $632
D6930 Re-Cement or Re-Bond Fixed Partial Denture $175
D6950 Precision Attachment $826
D6980 Fixed Partial Denture Repair Necessitated by $197
Restorative Material Failure
D6985 Pediatric Partial Denture, Fixed $347
Oral And Maxillofacial Surgery Procedures
D7111 Extraction, Coronal Remnants – Primary Tooth $156
D7140 Extraction, Erupted Tooth or Exposed Root (Evaluation $156
And/or Forceps Removal)
D7210 Extraction, Erupted Tooth Requiring Removal of Bone $312
And/or Sectioning of Tooth, and Including Elevation
Of Mucoperiosteal Flap if Indicated
D7250 Removal of Residual Tooth Roots (Cutting Procedure) $383
D7251 Coronectomy – Intentional Partial Tooth Removal $529

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CDT DESCRIPTION YOU PAY
D7260 Oroantral Fistula Closure $486
D7261 Primary Closure of a Sinus Perforation $632
D7270 Tooth Reimplantation and/or Stabilization of $1092
Accidentally Evulsed or Displaced Tooth
D7282 Mobilization of Erupted or Malpositioned Tooth to $520
Aid Eruption
D7285 Incisional Biopsy of Oral Tissue Hard (Bone, Tooth) $341
D7286 Incisional Biopsy of Oral Tissue Soft $267
D7291 Transseptal Fiberotomy/Supra Crestal Fiberotomy $272
D7293 Placement of Temporary Anchorage Device Requiring $486
Flap; Includes Device Removal
D7294 Placement of Temporary Anchorage Device Without $364
Flap; Includes Device Removal
D7295 Harvest of Bone for use in Autogenous Grafting $461
Procedure
D7321 Alveoloplasty Not in Conjunction with Extractions – $272
One to Three Teeth or Tooth Space, Per Quadrant
D7350 Vestibuloplasty – Ridge Extension (Including Soft Tissue $836
Grafts, Muscle Reattachment, Revision of Soft Tissue
Attachment and Management of Hypertrophied and
Hyperplastic Tissue)
D7410 Excision of Benign Lesion Up to 1.25 cm $243
D7411 Excision of Benign Lesion Greater Than 1.25 cm $437
D7450 Removal of Benign Odontogenic Cyst or Tumor – $272
Lesion Diameter Up to 1.25 cm
D7451 Removal of Benign Odontogenic Cyst or Tumor – $874
Lesion Diameter Greater than 1.25 cm
D7471 Removal of Lateral Exostosis (Maxilla or Mandible) $510
D7472 Removal of Torus Palatinus $486
D7485 Reduction of Osseous Tuberosity $1053
D7510 Incision and Drainage of Abscess – Intraoral Soft $134-$146
Tissue
D7520 Incision and Drainage of Abscess – Extraoral Soft Tissue $243
D7880 Occlusal Orthotic Device, By Report $597

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CDT DESCRIPTION YOU PAY
D7940 Osteoplasty – For Orthognathic Deformities $519
D7953 Bone Replacement Graft for Ridge Preservation-per Site $499
D7970 Excision of Hyperplastic Tissue – per Arch $341
D7971 Excision of Pericoronal Gingiva $277
Orthodontic Procedures
D8010 Limited Orthodontic Treatment of the Primary Dentition $1649
D8020 Limited Orthodontic Treatment of the Transitional $1649
Dentition
D8030 Limited Orthodontic Treatment of the Adolescent $1785
Dentition
D8040 Limited Orthodontic Treatment of Adult Dentition $1920
D8070 Comprehensive Orthodontic Treatment of the $4099
Transitional Dentition
D8080 Comprehensive Orthodontic Treatment of the $4099
Adolescent Dentition
D8090 Comprehensive Orthodontic Treatment of the Adult $4099
Dentition
D8210 Removable Appliance Therapy $798
D8220 Fixed Appliance Therapy $882
D8680 Orthodontic Retention (Removal of Appliances, $0-$500
Construction and Placement of Retainer(s))
D8681 Removable Orthodontic Retainer Adjustment $147
D8696 Repair of Orthodontic Appliance – Maxillary $63
D8697 Repair of Orthodontic Appliance – Mandibular $63
D8698 Re-Cement or Re-Bond Fixed Retainer – Maxillary $416
D8699 Re-Cement or Re-Bond Fixed Retainer – Mandibular $416
D8703 Replacement of Lost or Broken Retainer – Maxillary $147
D8704 Replacement of Lost or Broken Retainer – Mandibular $147
D8999 Clear Aligner Therapy $3500-5500
D8999 Unspecified Orthodontic Procedure, by Report $0-$504
Adjunctive General Procedures
D9110 Palliative (Emergency) Treatment of Dental Pain – $132
Minor Procedure
D9120 Fixed Partial Denture Sectioning $158

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CDT DESCRIPTION YOU PAY
D9215 Local Anesthesia in Conjunction with Operative or $35
Surgical Procedures
D9219 Evaluation for Moderate Sedation, Deep Sedation or $93
General Anesthesia
D9248 Non-Intravenous Conscious Sedation $243-$291
D9420 Hospital or Ambulatory Surgical Center Call $219
D9430 Office Visit for Observation (During Regularly $7
Scheduled Hours) No Other Service Performed
D9440 Office Visit After Regularly Scheduled Hours $171
D9450 Case Presentation, Detailed and Extensive $204
Treatment Planning
D9610 Therapeutic Parenteral Drug, Single Administration $120
D9612 Therapeutic Parenteral Drug, Two or More $162
Administrations Different Medications
D9630 Drugs/Medicaments Dispensed in the Office for Home $42-$73
D9910 Application of Desensitizing Medicament $93
D9911 Application of Desensitizing Resin for Cervical and/or $121
Root Surface, Per Tooth
D9920 Behavior Management, by Report $195
D9941 Fabrication of Athletic Mouthguard $267
D9944 Occlusal Guard – Hard Appliance, Full Arch $638
D9945 Occlusal Guard – Soft Appliance, Full Arch $638
D9950 Occlusion Analysis – Mounted Case $341
D9951 Occlusal Adjustment – Limited $63
D9952 Occlusal Adjustment – Complete $195
D9970 Enamel Microabrasion $44-$128
D9972 External Bleaching Per Arch – Performed in Office $341
D9973 External Bleaching Per Tooth $291
D9974 Internal Bleaching Per Tooth $291
D9975 External Bleaching for Home Appliance, Per Arch; $341
Includes Materials and Fabrication of Custom Trays
D9995 Teledentistry – Synchronous: Real Time Encounter $7
D9996 Teledentistry – Asychronous: Information Stored and $7
Forwarded to Dentist for Subsequent Review

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EXCLUSIONS AND LIMITATIONS
Exclusions
This section identifies standard exclusions for the Dental Plan. Members will be
financially responsible for the dentist’s usual and customary fee for any excluded
or otherwise ineligible services.
1. Services provided by a non-participating dentist are not covered
under the discount plan.
2. Procedures deemed not reasonably necessary or not
customarily performed, including, but not limited to: services
that have a poor prognosis and duplicate prosthetic devices or
appliances are excluded.
3. The services of an anesthesiologist are not covered. The patient is
responsible for the anesthesiologist's usual and customary rate.
4. Treatment of jaw fractures or dislocations, congenital or developmental
malformations, malignancies, cysts or neoplasms, or treatments for
Temporomandibular Joint Syndrome (TMJ) are not covered.
5. Courses of treatment which were begun prior to the Member’s
coverage effective dateand/or expenses incurred after termination of
coverage are excluded.
6. Any dental disease, defect or injury that arises out of or during any
occupational incident or exposure, for which the Member is entitled
to benefits under applicable workers’ compensation laws are not
covered by this Plan.
7. Any service not specifically listed on the Fee Schedule is excluded.
8. The services of a prosthodontist are excluded.
9. Prophylaxis benefits are excluded in the presence of periodontal disease.

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Limitations
This section identifies standard limitations for the Dental Plan. Members will be
financially responsible for the dentist’s usual and customary fee for any ineligible
services.
1. Replacement of partial dentures is limited to one per arch every five
years.
2. Replacement of full upper and lower dentures is limited to one per arch
per five-years.
3. Replacement of fixed prosthetics such as crowns, bridges, inlays, and
onlays is limited to once every five years.
4. Members who are pregnant or have diabetes have a benefit for an
additional Prophylaxis (routine cleaning) at no cost. This benefit is
limited to one (1) in any six (6) month period. The benefit is applicable
only after the Member pays for the first Prophylaxis within the same
six-month period, based on the Fee Schedule.
5. Members who are pregnant or have diabetes have a benefit for one
additional Periodontal Maintenance at no cost. This benefit is
limited to one (1) in any six (6) month period. The benefit is
applicable only after the Member pays for the first Periodontal
Maintenance within the same six-month period, based on the Fee
Schedule.
6. Members who are pregnant or have diabetes have a benefit for a free
electric toothbrush. This benefit is limited to one (1) per lifetime. The
toothbrush will be mailed to the member by the toothbrush
manufacturer directly. It will not be distributed at the office.
7. The fees listed on the Fee Schedule applies to services provided by an in
network General Dentist. Services of an in-network Specialist
(Endodontist, Oral Surgeon, Periodontist, Pediatric Dentist) are available
at a 20% discount off the Specialist’s usual and customary fee.
8. Services of a Specialist may not be available at all areas.

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9. Orthodontic Limitations:
a. A Fee for Comprehensive Orthodontics includes records and
retention and is limited to cases up to 24 months.
i. Additional months of treatment are available at an
additional charge of 80% of the office’s usual and customary
rate for treatment extension.
b. The Fee for Clear Aligner Therapy includes records and standard
retainers (e.g. Essex, lab fabricated, Polly, lingual bond, etc.).
i. Upgraded retainers (e.g Vivera) are not included in the Fee
but are available at the additional cost listed.
c. Habit inhibitor appliances are not included in the Orthodontic
Fees.
i. Such appliances are available at 80% of the office’s usual
and customary rate.
d. Replacement retainers are not included in the Orthodontic Fee’s.
i. Such appliance are available at 80% of the office’s usual and
customary rate.
e. Orthodontic appliances (e.g. retainers) provided apart from active
therapy are available at up to 80% of the office’s usual and
customary rate.
f. Replacement retainers are available at up to 80% of the office’s
usual and customary rate.

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