ESBD_360338_1717797769305_Attachment S - DHMO Fee Schedule.pdf

UnitedHealthcare® dental plan

DHMO/Managed Care Contributory 130C/covered dental services TX D094C

ADA DESCRIPTION MEMBER PAYS ²

DIAGNOSTIC SERVICES

$0PERIODIC ORAL EVALUATION EST PTD0120

$0LTD ORAL EVALUATION - PROBLEM FOCUSD0140

$0ORAL EVAL PT<3 AND COUNSELD0145

$0COMP ORAL EVALUATION - NEW/EST PTD0150

$0DTL&EXT ORAL EVAL - PROB FOCUS RPTD0160

$0RE-EVALUATION - LTD PROBLEM FOCUSEDD0170

$5RE‐EVALUATION – POST‐OPERATIVE OFFICE VISITD0171

$0COMP PERIODONTAL EVAL - NEW/EST PTD0180

$5SCREENING OF A PATIENTD0190

$5ASSESMENT OF A PATIENTD0191

$0INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGESD0210

$0INTRAORAL PERIAPICAL FIRST RADIOGRAPHIC IMAGED0220

$0INTRAORL PERIAPICAL EA ADD RADIOGRAPHIC IMAGED0230

$0INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGED0240

$0EXTRA-ORAL - 2D PROJECTION RADIOGRAPHIC IMAGED0250

$0EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGED0251

$0BITEWING - SINGLE RADIOGRAPHIC IMAGED0270

$0BITEWINGS - TWO RADIOGRAPHIC IMAGESD0272

$0BITEWINGS - THREE RADIOGRAPHIC IMAGESD0273

$0BITEWINGS - FOUR RADIOGRAPHIC IMAGESD0274

$0VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGESD0277

$0PANORAMIC RADIOGRAPHIC IMAGED0330

$02D CEPHALOMETRIC RADIOGRAPHIC IMAGE - ACQUISITION, MEASUREMENT

AND ANALYSIS

D0340

$5INTERPRETATION OF DIAGNOSTIC IMAGED0391

$0LABORATORY PROCESSING OF MICROBIAL SPECIMEN TO INCLUDE

CULTURE AND SENSITIVITY STUDIES, PREPARATION AND TRANSMISSION OF

WRITTEN REPORT

D0414

$0COLLECT MICROORAGNISMS CULT & SENSD0415

$10VIRAL CULTURED0416

$10COLLECTION & PREP OF SALIVA SAMPLED0417

$10ANALYSIS OF SALIVA SAMPLED0418

$0COLLECTION AND PREPARATION OF GENETIC SAMPLE MATERIAL FOR

LABORATORY ANALYSIS AND REPORT

D0422

$0GENETIC TEST FOR SUSCEPTIBILITY TO DISEASES - SPECIMEN ANALYSISD0423

$0CARIES SUSCEPTIBILITY TESTSD0425

$20ADJUNCT PREDX TST NO CYTOL/BX PROCD0431

$0PULP VITALITY TESTSD0460

$0DIAGNOSTIC CASTSD0470

$0ACCESS TISS-GROSS EXAM-PREP & REPRTD0472

$0ACCESS TISS-GROSS/MICRO-PREP/REPRTD0473

$0ACSS TISS GR&MIC SURG MARG PREP/RPTD0474

$0CARIES RISK ASSESSMENT AND DOCUMENTATION, LOWD0601

$0CARIES RISK ASSESSMENT AND DOCUMENTATION, MODERATED0602

$0CARIES RISK ASSESSMENT AND DOCUMENTATION, HIGHD0603

$5OFFICE VISIT FEE - PER VISITD0999

PREVENTIVE SERVICES

$0 PROPHYLAXIS - ADULT D1110¹

$25- PROPHYLAXIS - ADULT 1 ADD. PROPHY WITHIN 6 MONTHSD1110¹

$0 PROPHYLAXIS - CHILD D1120¹

$25- PROPHYLAXIS - CHILD 1 ADD. PROPHY WITHIN 6 MONTHSD1120¹

$0TOP FLUORIDE VARNISHD1206

$0TOPICAL APPLICATION OF FLUORIDE - EXCLUDING VARNISHD1208

$0NUTRIT CNSL CONTROL DENTAL DISEASED1310

$0TOBACCO CNSL CNTRL&PREVION ORL DZD1320

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

ADA DESCRIPTION MEMBER PAYS ²

$0ORAL HYGIENE INSTRUCTIONSD1330

$8SEALANT - PER TOOTHD1351

$10PREV RESIN RESTORATION IN MOD HIGH CARIES RISK PATIENT- PERM

TOOTH

D1352

$5SEALANT REPAIR – PER TOOTHD1353

$25SPACE MAINTAINER - FIXED-UNILATERALD1510

$25SPACE MAINTAINER - FIXED-BILATERALD1515

$40SPACE MAINTAINER - REMOVABLE-UNID1520

$40SPACE MAINTAINER - REMOVABLE-BILD1525

$15RECEMENT OR RE-BOND SPACE MAINTAINERD1550

$15REMOVAL OF FIXED SPACE MAINTAINERD1555

$25DISTAL SHOE SPACE MAINTAINER – FIXED – UNILATERALD1575

UNSPECIFIED PREVENTIVE PROCEDURE, BY REPORTD1999

RESTORATIVE SERVICES

$0AMALGAM-ONE SURFACE PRIMARY/PERMD2140

$0AMALGAM-TWO SURFACES PRIMARY/PERMD2150

$0AMALGAM-3 SURFACES PRIMARY/PERMD2160

$0AMALGAM-FOUR/MORE SURF PRIM/PERMD2161

$0RESIN COMPOS - ONE SURFACE ANTERIORD2330

$0RESIN COMPOS - 2 SURFACES ANTERIORD2331

$0RESIN COMPOS - 3 SURFACES ANTERIORD2332

$0RSN COMPOS-4/> SURF/W/INCISAL ANGD2335

$40RESIN COMPOS CROWN ANTERIORD2390

$40RESIN COMPOS - 1 SURFACE POSTERIORD2391

$45RESIN COMPOS - 2 SURFACES POSTERIORD2392

$75RESIN COMPOS - 3 SURFACES POSTERIORD2393

$75RESIN COMPOS - 4/MORE SURFACES POSTD2394

$175INLAY - METALLIC - ONE SURFACED2510

$175INLAY - METALLIC - TWO SURFACESD2520

$175INLAY - METALLIC - 3/MORE SURFACESD2530

$225ONLAY - METALLIC - TWO SURFACESD2542

$225ONLAY METALLIC THREE SURFACESD2543

$225ONLAY METALLIC FOUR OR MORE SURFD2544

$250INLAY - PORCELN/CERAMIC - 1 SURFACED2610

$250INLAY - PORCELN/CERAMIC - 2 SURFD2620

$250INLAY - PORCELN/CERAM - 3/MORE SURFD2630

$250ONLAY - PORCELN/CERAMIC - 2 SURFD2642

$250ONLAY - PORCELN/CERAMIC - 3 SURFD2643

$250ONLAY - PORCELN/CERAM - 4/MORE SURFD2644

$250INLAY-RSN COMPOS COMPOS/RSN-1 SURFD2650

$250INLAY-RSN COMPOS COMPOS/RSN-2 SURFD2651

$250INLAY-RSN COMPOS COMPOS/RSN-3/>SURFD2652

$250ONLAY-RSN COMPOS COMPOS/RSN-2 SURFD2662

$250ONLAY-RSN COMPOS COMPOS/RSN-3 SURFD2663

$250ONLAY-RSN COMPOS COMPOS/RSN-4/>D2664

$150CROWN RESINBASED COMPOSITE INDIRECTD2710

$150CROWN 3/4 RESNBASED COMPOS INDIRECTD2712

$250CROWN - RESIN WITH HIGH NOBLE METALD2720*

$250CROWN - RESIN W/PREDOM BASE METALD2721

$250CROWN - RESIN WITH NOBLE METALD2722*

$300CROWN - PORCELAIN/CERAMIC SUBSTRATED2740

$250CROWN - PORCELN FUSED HI NOBLE METLD2750*

$250CROWN-PORCELN FUSD PREDOM BASE METLD2751

$250CROWN - PORCELAIN FUSED NOBLE METALD2752*

$250CROWN - 3/4 CAST HIGH NOBLE METALD2780*

$250CROWN - 3/4 CAST PREDOM BASE METLD2781

$250CROWN - 3/4 CAST NOBLE METALD2782*

$250CROWN - 3/4 PORCELAIN/CERAMICD2783

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

$250CROWN - FULL CAST HIGH NOBLE METALD2790*

$250CROWN - FULL CAST PREDOM BASE METLD2791

$250CROWN - FULL CAST NOBLE METALD2792*

$250CROWN TITANIUMD2794*

$0RECEMENT OR RE-BOND INLAY ONLAY VENEER OR PART COV RESTD2910

$0RECEMENT OR RE-BOND INDIRECTLY FABRICATED PREFAB POST & CORED2915

$0RECEMENT OR RE-BOND CROWND2920

$65REATTACHMENT OF TOOTH FRAGMENTD2921

$80PREFABRICATED PORCELAIN CROWN- PRIMARYD2929

$25PRFABR STAINLESS STEEL CROWN-PRIMD2930

$25PRFABR STAINLESS STEEL CROWN-PERMD2931

$40PREFABRICATED RESIN CROWND2932

$40PRFABR STNLSS STEEL CROWN RSN WNDOWD2933

$60PREFAB ESTHTC COATED STNLESS STEEL CROWN - PRIMARYD2934

$0SEDATIVE FILLINGD2940

$5INTERIM THERAPEUTIC RESTORATION – PRIMARY DENTITIOND2941

$50CORE BUILDUP INCLUDING ANY PINSD2950

$10PIN RETN - PER TOOTH ADDITION RESTD2951

$40POST & CORE ADD CROWN INDIRECT FABD2952

$40EA ADD INDIRECT FAB POST SAME TOOTHD2953

$25PREFABR POST&CORE ADDITION CROWND2954

$10POST REMOVALD2955

$30EA ADD PREFABR POST - SAME TOOTHD2957

$295LABIAL VENEER (LAMINATE) - CHAIRSIDED2960

$350LABIAL VENEER (RESIN LAMINATE) - LABORATORYD2961

$600LABIAL VENEER (PORCELAIN LAMINATE) - LABORATORYD2962

$50ADD PROC NEW CROWN XST PART DENTURED2971

$80COPINGD2975

$35CROWN REPAIRD2980

$5RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONSD2990

ENDODONTIC SERVICES

$0PULP CAP - DIRECTD3110

$0PULP CAP - INDIRECTD3120

$0TX PULPOT-CORONL DENTNOCEMENTL JUNCD3220

$30PULPAL DEBRID PRIMARY&PERM TEETHD3221

$60PARTIAL PULPOTOMYD3222

$40PULPAL THERAPY - ANT PRIMARY TOOTHD3230

$40PULPAL THERAPY - POST PRIMARY TOOTHD3240

$95ANTERIORD3310

$175BICUSPIDD3320

$305MOLARD3330

$85TX RC OBSTRUCTION; NON-SURG ACCESSD3331

$85INCMPL ENDO TX;INOP UNRSTR/FX TOOTHD3332

$85INTRL ROOT REPAIR PERFORATION DEFECD3333

$115RETX PREVIOUS RC THERAPY - ANTERIORD3346

$175RETX PREVIOUS RC THERAPY - BICUSPIDD3347

$300RETX PREVIOUS RC THERAPY - MOLARD3348

$70APEXIFICAT/RECALCIFICAT - INIT VSTD3351

$70APEXIFICAT/RECALCIFICAT-INTERIMD3352

$70APEXIFICAT/RECALCIFICAT-FINAL VISITD3353

$65PULPAL REGENERATION - INITIAL VISITD3355

$65PULPAL REGENERATION -INTERIM MEDICAMENT REPLACEMENTD3356

$65PULPAL REGENERATION - COMPLETION OF TREATMENTD3357

$95APICOECTOMY SURG - ANTD3410

$95APICOECTOMY SURG-BICUSPIDD3421

$95APICOECTOMY SURG - MOLARD3425

$55APICOECTOMY SURGERYD3426

$250PERIRADICULAR SURGERY WITHOUT APICOECTOMYD3427

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

$55RETROGRADE FILLING - PER ROOTD3430

$95ROOT AMPUTATION - PER ROOTD3450

$900ENDODONTIC ENDOSSEOUS IMPLANTD3460

$15SURG PROC ISOLAT TOOTH W/RUBBER DAMD3910

$90HEMISECTION NOT INCL RC THERAPYD3920

$15CANAL PREP&FIT PREFORMED DOWEL/POSTD3950

PERIODONTIC SERVICES

$115GINGIVECT/PLSTY 4/>CNTIG TEETH QUADD4210

$80GINGIVECT/PLSTY 1-3CNTIG TEETH QUADD4211

$15GINGIVECT/PLSTY WITH REST PROC/TOOTHD4212

$150GINGL FLP 4/>CNTIG/BOUND TEETH QUADD4240

$95GINGL FLP 1-3 CNTIG/BND TEETH QUADD4241

$165APICALLY POSITIONED FLAPD4245

$145CLIN CROWN LEN - HARD TISSUED4249

$325OSSEOUS SURG 4/> CNTIG TEETH QUADD4260

$225OSSEOUS SURG 1-3 CNTIG TEETH QUADD4261

$175BONE REPLACEMENT GRAFT – RETAINED NATURAL TOOTH – FIRST SITE IN

QUADRANT

D4263

$175BONE REPLCMT GRAFT - 1 SITE QUADD4263

$90BN REPLCMT GRAFT - EA ADD SITE QUADD4264

$90BONE REPLACEMENT GRAFT – RETAINED NATURAL TOOTH – EACH

ADDITIONAL SITE IN QUADRANT

D4264

$225PEDICLE SOFT TISSUE GRAFT PROCEDURED4270

$85DISTAL OR PROXIMAL WEDGE PROCEDURED4274

$85MESIAL/DISTAL WEDGE PROCEDURE, SINGLE TOOTH (WHEN NOT

PERFORMED IN CONJUNCTION WITH SURGICAL PROCEDURES IN THE SAME

ANATOMICAL AREA)

D4274

$235FREE SOFT TISSUE GRAFT PROCEDURE -1ST TOOTHD4277

$275FREE SOFT TISSUE GRAFT PROCEDURE - ADD TOOTHD4278

$75PROVISIONAL SPLINTING - INTRACORONALD4320

$75PROVISIONAL SPLINTING - EXTRACORONALD4321

$45PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUADD4341

$45PRDONTAL SCAL&ROOT PLAN 1-3 TEETHD4342

$25SCALING IN PRESENCE OF GENERALIZED MODERATE OR SEVERE GINGIVAL

INFLAMMATION – FULL MOUTH, AFTER ORAL EVALUATION

D4346

$50FULL MOUTH DEBRID COMP EVAL&DXD4355

$55LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A CONTROLLED

RELEASE VEHICLE INTO DISEASED CREVICULAR TISSUE, PER TOOTH

D4381

$30PERIODONTAL MAINTENANCED4910

$0UNSCHEDULED DRESSING CHANGED4920

$0GINGIVAL IRRIGATION ‐ PER QUADRANTD4921

REMOVABLE PROSTHODONTIC SERVICES

$275COMPLETE DENTURE - MAXILLARYD5110

$275COMPLETE DENTURE - MANDIBULARD5120

$315IMMEDIATE DENTURE - MAXILLARYD5130

$315IMMEDIATE DENTURE - MANDIBULARD5140

$250MAX PARTIAL DENTURE - RESIN BASED5211

$250MAND PARTIAL DENTUR - RESIN BASED5212

$325MAX PART DENTUR-CAST METL W/RSND5213

$325MAND PART DENTUR- CAST METL W/RSND5214

$115IMMEDIATE MAXILLARY PARTIAL DENTURE – RESIN BASE (INCLUDING ANY

CONVENTIONAL CLASPS, RESTS AND TEETH)

D5221

$115IMMEDIATE MANDIBULAR PARTIAL DENTURE – RESIN BASE (INCLUDING ANY

CONVENTIONAL CLASPS, RESTS AND TEETH)

D5222

$115IMMEDIATE MAXILLARY PARTIAL DENTURE – CASE METAL FRAMEWORK WITH

RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS

AND TEETH)

D5223

$115IMMEDIATE MANDIBULAR PARTIAL DENTURE – CASE METAL FRAMEWORK

WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS,

RESTS AND TEETH)

D5224

$325MAXILLARY PARTIAL DENTURE FLEX BASED5225

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

$325MANDIBULAR PART DENTURE FLEX BASED5226

$275REMV UNI PART DENTUR-1 PC CAST METLD5281

$10ADJUST COMPLETE DENTURE - MAXILLARYD5410

$10ADJUST COMPLETE DENTUR - MANDIBULARD5411

$10ADJUST PARTIAL DENTURE - MAXILLARYD5421

$10ADJUST PARTIAL DENTURE - MANDIBULARD5422

$30REPAIR BROKEN COMPLETE DENTURE BASED5510

$30REPL MISS/BROKEN TEETH-CMPL DENTURD5520

$30REPAIR RESIN DENTURE BASED5610

$30REPAIR CAST FRAMEWORKD5620

$30REPAIR OR REPLACE BROKEN CLASP - PER TOOTHD5630

$30REPLACE BROKEN TEETH - PER TOOTHD5640

$30ADD TOOTH EXISTING PARTIAL DENTURED5650

$30ADD CLASP EXISTING PARTIAL DENTURE - PER TOOTHD5660

$150REPL ALL TEETH&ACRYLC FRMEWRK MAXD5670

$150REPL ALL TEETH&ACRYLC FRMEWRK MANDD5671

$65REBASE COMPLETE MAXILLARY DENTURED5710

$65REBASE COMPLETE MANDIBULAR DENTURED5711

$65REBASE MAXILLARY PARTIAL DENTURED5720

$65REBASE MANDIBULAR PARTIAL DENTURED5721

$55RELINE CMPL MAXIL DENTURE CHAIRSIDED5730

$55RELINE CMPL MAND DENTURE CHAIRSIDED5731

$55RELINE MAXIL PART DENTURE CHAIRSIDED5740

$55RELINE MAND PART DENTURE CHAIRSIDED5741

$75RELINE CMPL MAXIL DENTURE LABD5750

$75RELINE CMPL MAND DENTRUE LABORATORYD5751

$75RELINE MAXIL PART DENTURE LABD5760

$75RELINE MAND PART DENTURE LABORATORYD5761

$115INTERIM PARTIAL DENTURE MAXILLARYD5820

$115INTERIM PARTIAL DENTURE MANDIBULARD5821

$20TISSUE CONDITIONING MAXILLARYD5850

$20TISSUE CONDITIONING MANDIBULARD5851

$425OVERDENTURE - COMPLETE MAXILLARYD5863

$450OVERDENTURE - COMPLETE MANDIBULARD5864

$425OVERDENTURE - PARTIAL MAXILLARYD5865

$450OVERDENTURE - PARTIAL MANDIBULARD5866

IMPLANT SERVICES

$975SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANTD6010

$825SURGICAL PLACEMENT OF A MINI-IMPLANTD6013

$220SEMI-PRECISION ATTACHMENT ABUTMENTD6052

$930DENTAL IMPLANT SUPPORTED CONNECTING BARD6055

$275PREFABRICATED ABUTMENT - INCLUDES MOD AND PLACEMENTD6056

$385CUSTOM FAB ABUTMENT - INCLUDES PLACEMENTD6057

$680ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWND6058

$670ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH

NOBLE METAL)

D6059*

$610ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN

(PREDOMINATELY BASE METAL)

D6060

$585ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE

METAL)

D6061*

$665ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL)D6062*

$580ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINATELY BASE

METAL)

D6063

$585ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL)D6064*

$690IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWND6065

$660IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWND6066*

$670IMPLANT SUPPORTED METAL CROWND6067*

$655ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPDD6068

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

$660ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD

(HIGH NOBLE METAL)

D6069

$630ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD

(PREDOMINATELY BASE METAL)

D6070

$645ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD

(NOBLE METAL)

D6071*

$635ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH NOBLE

METAL)

D6072*

$595ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINATELY

BASE METAL)

D6073

$630ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (NOBLE METAL)D6074*

$615IMPLANT SUPPORTED RETAINER FOR CERAMIC FPDD6075

$680IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPDD6076*

$630IMPLANT SUPPORTED RETAINER FOR CASE METAL FPDD6077*

$40IMPLANT MAINTENANCE PROCEDURES WHEN PROSTHESIS ARE REMOVED

AND REINSERTED, INCLUDING CLEANSING OF PROSTHESIES AND

ABUTMENTS

D6080

$180SCALING AND DEBRIDEMENT IN THE PRESENCE OF INFLAMMATION OR

MUCOSITIS OF A SINGLE IMPLANT, INCLUDING CLEANING OF THE IMPLANT

SURFACES, WITHOUT FLAP ENTRY AND CLOSURE

D6081

$165REPAIR IMPLANT SUPPORTED PROSTHESIS, BY REPORTD6090

$90REPLACEMENT OF SEMI-PRECISION OR PRECISION ATTACHMENT(MALE OR

FEMALE COMPONENT) OF IMPLANT/ABUTMENT SUPPORTED PROSTHESIS

D6091

$60RECEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED CROWND6092

$70RECEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL

DENTURE

D6093

$530ABUTMENT SUPPORTED CROWN - TITANIUMD6094*

$215REPAIR IMPLANT ABUTMENT, BY REPORTD6095

$260IMPLANT REMOVAL, BY REPORTD6100

$240DEBRIDEMENT PERI IMPLANT DEFECT OR DEFECTS SURROUNDING A

SINGLE IMPLANT

D6101

$275DEBRIDEMENT & OSSEOUS PERI IMPLANT DEFECT OR DEFECTS

SURROUNDING A SINGLE IMPLANT

D6102

$245BONE GRAFT FOR REPAIR OF PERI IMPLANT DEFECTD6103

$875IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR

EDENTULOUS ARCH – MAXILLARY

D6110

$875IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR

EDENTULOUS ARCH –

MANDIBULAR

D6111

$875IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY

EDENTULOUS ARCH – MAXILLARY

D6112

$875IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLY

EDENTULOUS ARCH – MANDIBULAR

D6113

$145D6190

$545ABUTMENT SUPPORTED RETAINER CROWN FOR FPD - TITANIUMD6194

FIXED PROSTHODONTIC SERVICES

$250PONTIC- INDIRECT RESIN BASED COMPOSITED6205

$250PONTIC - CAST HIGH NOBLE METALD6210*

$250PONTIC - CAST PREDOM BASE METALD6211

$250PONTIC - CAST NOBLE METAL D6212*

$250PONTIC TITANIUM D6214*

$250PONTIC-PORCELN FUSED HI NOBLE METL D6240*

$250PONTIC-PORCLN FUSD PREDOM BASE METLD6241

$250PONTIC - PORCELN FUSED NOBLE METAL D6242*

$300PONTIC - PORCELAIN/CERAMICD6245

$250PONTIC - RESIN W/HIGH NOBLE METAL D6250*

$250PONTIC RESIN W/PREDOM BASE METALD6251

$250PONTIC RESIN W/NOBLE METAL D6252*

$160PROVISIONAL PONTIC - FURTHER TREATMENT OR COMPLETION OF

DIAGNOSIS NECESSARY PRIOR TO FINAL IMPRESSION

D6253

$250RETAINER- CASE MTL FOR RESIN FXD PROSD6545

$300RET-PORC/CER FOR RESIN BONDED FIXED PROSD6548

$85RESIN RETAINER – FOR RESIN BONDED FIXED PROSTHESISD6549

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

$270RETAINER INLAY-PORCELAIN/CERAMIC 2 SURFACESD6600

$270RETAINER INLAY - PORCELN/CERAMIC 3/MORE SURFD6601

$175RETAINER INLAY - CAST HI NOBLE METAL 2 SURFD6602*

$175RETAINER INLAY-CAST HI NOBLE METL 3/> SURFD6603*

$175RETAINER INLAY-CAST PREDOM BASE METL 2 SURFD6604

$175RETAINER INLAY-CAST PREDOM BASE METL 3/>SURFD6605

$175RETAINER INLAY - CAST NOBLE METAL 2 SURFACESD6606*

$175RETAINER INLAY - CAST NOBLE METL 3/MORE SURFD6607*

$280RETAINER ONLAY - PORCELN/CERAMIC 2 SURFACESD6608

$280RETAINER ONLAY - PORCELN/CERAMIC 3/MORE SURFD6609

$175RETAINER ONLAY - CAST HI NOBLE METAL 2 SURFD6610*

$175RETAINER ONLAY-CAST HI NOBLE METL 3/> SURFD6611*

$175RETAINER ONLAY-CAST PREDOM BASE METL 2 SURFD6612

$175RETAINER ONLAY-CAST PREDOM BASE METL 3/>SURFD6613

$175RETAINER ONLAY - CAST NOBLE METAL 2 SURFACESD6614*

$175RETAINER ONLAY - CAST NOBLE METL 3/MORE SURFD6615*

$250RETAINER INLAY - TITANIUMD6624*

$250RETAINER ONLAY - TITANIUMD6634*

$185RETAINER CROWN - INDIRECT RESIN BASED COMPOSITED6710

$250RETAINER CROWN - RESIN WITH HIGH NOBLE METAL D6720*

$250RETAINER CROWN - RESIN PREDOMINANTLY BASE METALD6721

$250RETAINER CROWN - RESIN WITH NOBLE METAL D6722*

$300RETAINER CROWN - PORCELAIN/CERAMICD6740

$250RETAINER CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL D6750*

$250RETAINER CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METALD6751

$250RETAINER CROWN - PORCELAIN FUSED TO NOBLE METAL D6752*

$250RETAINER CROWN - 3/4 CAST HIGH NOBLE METAL D6780*

$250RETAINER CROWN - 3/4 CAST PREDOMINANTLY BASE METALD6781

$250RETAINER CROWN - 3/4 CAST NOBLE METAL D6782*

$300RETAINER CROWN - 3/4 PORCELAIN/CERAMICD6783

$250RETAINER CROWN - FULL CAST HIGH NOBLE METAL D6790*

$250RETAINER CROWN - FULL CAST PREDOMINANTLY BASE METALD6791

$250RETAINER CROWN - FULL CAST NOBLE METAL D6792*

$250RETAINER CROWN - TITANIUM D6794*

$85CONNECTOR BARD6920

$0RECEMENT OR RE-BOND FIXED PARTIAL DENTURED6930

$125STRESS BREAKERD6940

$60FIXED PARTIAL DENTURE REPAIR, BY REPORTD6980

ORAL SURGERY SERVICES

$8XTRCT CORONL RMNNTS DECIDUOUS TOOTHD7111

$8EXTRAC ERUPTED TOOTH/EXPOSED ROOTD7140

$30EXTRACTION, ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR

SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERIOSTEAL

FLAP IF INDICATED

D7210

$55REMOVAL IMPACT TOOTH - SOFT TISSUED7220

$85REMOVAL IMPACT TOOTH - PARTLY BONYD7230

$125REMOVAL IMPACTED TOOTH - CMPL BONYD7240

$150REMV IMP TOOTH-CMPL BNY W/SURG COMPD7241

$40REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)D7250

$150CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVALD7251

$225PRIMARY CLOSURE OF A SINUS PERFORATIOND7261

$50TOOTH REIMPL&/STBL ACC DISPLCDD7270

$85EXPOSURE OF AN UNERUPTED TOOTHD7280

$85SURGICAL ACCESS AN UNERUPTED TOOTHD7280

$90MOBILZ ERUPT/MALPSTN TOOTH AID ERUPD7282

$150INCISIONAL BIOPSY OF ORAL TISSUE HARDD7285

$60INCISIONAL BIOPSY OF ORAL TISSUE SOFTD7286

$20EXTOLIATIVE CYTOLOGICAL SAMPLE COLLECTIOND7287

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

$20BRUSH BIOPSYD7288

$75SURGICAL REPOSITIONING OF TEETHD7290

$40ALVEOLOPLASTY W/EXT 4/> TEETH/SPACED7310

$15ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETHD7311

$60ALVEOLOPLASTY NO EXT 4/> TEETH/SPACD7320

$25ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETHD7321

$215VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY EPITHELIALIZATION)D7340

$670VESTIBULOPLASTY - RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS,

MUSCLE REATTACHMENT, REVISION OF SOFT TISSUE ATTACHMENT

D7350

$70REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER

UP TO 1.25 CM

D7450

$110REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER

GREATER THAN 1.25 CM

D7451

$100REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION

DIAMETER UP TO 1.25 CM

D7460

$125REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION

DIAMETER GREATER THAN 1.25 CM

D7461

$85REMOVAL OF LATERAL EXOSTOSISD7471

$65REMOVAL OF TORUS PALATINUSD7472

$65REMOVAL OF TORUS MANDIBULARISD7473

$65REDUCTION OF OSSEOUS TUBEROSITYD7485

$65SURGICAL RDUC OSSEOUS TUBEROSITYD7485

$35I&D ABSCESS-INTRAORAL SOFT TISSD7510

$35I & D ABSC INTRAORAL SOFT TISS COMPD7511

$70I & D OF ABSCESS EXTRAORAL SOFT TISSUED7520

$190I & D OF ABSCESS EXTRAORAL COMPLICATEDD7521

$40REMO OF FORREIGN BODY - SKIN SUBCUTANEOUSD7530

$10OCCLUSAL ORTHOTIC DEVICE ADJUSTMENTD7881

$25SUTURE RECENT SMALL WOUNDS UP 5 CMD7910

$45FRENULECTOMY SEPARATE PROCEDURED7960

$45FRENULOPLASTYD7963

$55EXC HYPERPLASTIC TISSUE-PER ARCHD7970

$40EXCISION OF PERICORONAL GINGIVAD7971

$100SURGICAL RDUC FIBROUS TUBEROSITYD7972

ADJUNCTIVE GENERAL SERVICES

$10PALLIATVE TX DENTAL PAIN-MINOR PROCD9110

$0REGIONAL BLOCK ANESTHESIAD9211

$0TRIGEMINAL DIVISION BLOCK ANESD9212

$0LOCAL ANESTHESIAD9215

$0EVALUATION FOR DEEP SEDATION OR GENERAL ANESTHESIAD9219

$75DEEP SEDATION/GENERAL ANESTHESIA - EACH 15 MINUTE INCREMENTD9223

$30ANALGESIA ANXIOLYSIS, INHALATION OF NITROUS OXIDED9230

$70INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANALGESIA - EACH 15

MINUTE INCREMENT

D9243

$50NON-INTRAVENOUS (CONSCIOUS) SEDATION, THIS INCLUDES NON-IV

MINIMAL AND MODERATE SEDATION

D9248

$0CNSLT DX DENT/PHY NOT REQ DENT/PHYD9310

$5OV OBS - NO OTH SERVICES PERFORMEDD9430

$35OV-AFTER REGULARLY SCHEDULED HRSD9440

$0CASE PRSATION DTL&EXT TX PLANNINGD9450

$0TREATMENT OF COMPLICATIONS - POST SURG.D9930

$85OCCLUSAL GUARD BY REPORTD9940

$10OCCLUSAL GUARD ADJUSTMENTD9943

$30OCCLUSAL ADJUSTMENT - LIMITEDD9951

$90OCCLUSAL ADJUSTMENT - COMPLETED9952

$125EXTERNAL BLEACHING - PER ARCH PERFORMED IN OFFICED9972

$125EXTERNAL BLEACHING FOR HOME APPLICATION, PER ARCHD9975

$20BROKEN APPOINTMENTD9999

ORTHODONTIC SERVICES

$1,895COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION)D8070

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

$1,895COMPREHENSIVE ORTHODONTIC TREATMENT ADOLESCENT DENTITIOND8080

$1,895COMPREHENSIVE ORTHODONTIC TREATMENT ADULT DENTITIOND8090

$250PRE-ORTHODONTIC TREATMENT EXAM TO MONITOR GROWTH AND

DEVELOPMENT

D8660

$300ORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION

AND PLACEMENT OF RETAINERS)

D8680

$150a START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS, X-RAYS,TRACING, PHOTOS, AND MODELS)

D8999a

¹Additional Prophy within 6 months will be based upon the necessity recommended by the provider.

²Copays listed are also applicable in the specialist office.

*If a noble, high noble or titanium metal is used, there will be an additional charge not to exceed $150 per unit. If a base metal is used, there are no additional charges from the provider.

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

UnitedHealthcare/Select Managed Care dental exclusions and limitations

LIMITATIONS OF BENEFITS

The following are the limitation of benefits, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits:

Limited to 1 time per 6 monthsDENTAL PROPHYLAXIS1.

Limited to one time per calendar yearFLUORIDE TREATMENTS2.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.CROWNS3.

Covered only for teeth that have had root canal therapy.POST AND CORES4.

Limited to 4 quadrants per calendar year.SCALING AND ROOT PLANING5.

Limited to once every 6 months, following active therapy, exclusive of gross debridementPERIODONTAL MAINTENANCE6.

Limited to 1 time in any 2 year periodINTRAORAL COMPLETE SERIES

(INCLUDING BITEWINGS)

7.

Limited to 1 series of 4 films in any 6 month periodINTRAORAL BITEWING RADIOGRAPHS8.

Replacement of complete dentures, and fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist.

If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.

REMOVABLE PROSTHETICS/FIXED

PROSTHETICS/CROWNS, INLAYS AND

ONLAYS (MAJOR RESTORATIVE

SERVICES)

9.

Limited to 1 time per tooth per 5 years.CROWNS RETAINERS/ABUTMENTS10.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.TEMPORARY CROWNS RESTORATIONS11.

Limited to 1 time per tooth per 5 years.INLAYS/ONLAYS

RETAINERS/ABUTMENTS

12.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.INLAYS/ONLAYS RESTORATIONS13.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown -primary tooth, are limited to primary anterior teeth.

STAINLESS STEEL CROWNS14.

The maximum benefit within a 12-month period is any combination of 7 crowns or pontics (artificial teeth that are part of a fixed bridge). If more than 7 crowns and/or pontics are done for a Member within a 12-month period, the dentist's fee for any additional crowns within that period would not be limited to the listed Copayment, but instead can reflect the Dentist's Billed Changes.

CROWNS AND FIXED BRIDGES15.

Limited to repairs or adjustments performed more than 6 months after the initial insertion.ADJUSTMENTS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES OR

CROWNS

16.

Administration of I.V. sedation or general anesthesia is limited to covered oral surgical procedures involving 1 or more impacted teeth (soft tissue, partial bony or complete bony impactions).

INTRAVENOUS SEDATION OR GENERAL

ANESTHESIA

17.

That aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures - Limited to 1 time per year, to Covered Persons over the age of 30.

ADJUNCTIVE PRE-DIAGNOSTIC TEST18.

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

LIMITATIONS OF BENEFITS

The following are the limitation of benefits, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits:

(A) Pre-Authorized by us; and

(B) Coordinated by a Covered Person’s PCD. Any Covered Person who elects specialist care without prior referral by his or her PCD and approval by us is responsible for all charges incurred

• In order for specialty services to be Covered by this plan, the following referral process must be followed:

• A Covered Person’s PCD must coordinate all Dental Services.

• When the care of a Network Specialist Dentist is required, the Covered Person’s PCD must contact us and request authorization...

• If the PCD’s request for specialist referral is denied, the PCD and the Covered Person will be notifi ed of the reason for the denial. If the service in question is a Covered service, and no limitations or exclusions apply, the PCD may be asked to perform the service.

• Covered Person who receives authorized specialty services must pay all applicable Copayments associated with the services provided. When we authorize specialty dental care, a Covered Person will be referred to a Network Specialist Dentist for treatment. The Network includes Network Specialist Dentists in:

(a) endodontics; (b) oral surgery; (c) pediatric dentistry; and (d) orthodontics; and (e) periodontics, located in the Covered Person’s Service Area. If there is no Network Specialist Dentist in the Covered Person’s Service Area, we will refer the Covered Person to a Non-Participating Specialist of our choice. Except for Emergency Dental Services, in no event will we cover dental care provided to a Covered Person by a specialist not preauthorized by us to provide such services.

• Covered Person’s financial responsibility is limited to applicable Copayments. Copayments are listed in the Covered Person’s Schedule of Covered Dental Services.

ALL SPECIALTY REFERRAL SERVICES

MUST BE

19.

Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per 5 years from initial or supplemental placement

REMOVABLE PROSTHETICS/FIXED

PROSTHETICS/CROWNS, INLAYS AND

ONLAYS (MINOR RESTORATIVE

SERVICES)

20.

EXCLUSIONS OF BENEFITS

The following procedures and services are excluded and not Covered Services, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits:

Dental Services that are not Necessary.1.

Any service done for cosmetic purposes that is not listed as a Covered cosmetic service in the Schedule of Covered Dental Services.2.

Any Dental Procedure not directly associated with dental disease.3.

Any implant procedures performed which are not listed as Covered implant procedures in the Schedule of Covered Dental Services.4.

Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.5.

Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms or Congenital Anomalies of hard or soft tissue, including excision.

6.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.7.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).8.

Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.9.

Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.10.

Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services.11.

Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.12.

Services for injuries or conditions covered by Worker’s Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision. Covered Person by any municipality, county, or other political subdivision. This exclusion does not apply to any services covered by Medicaid or Medicare.

13.

Any Dental Procedure not performed in a participating dental setting. An exception is made for Emergency Dental Care, as defined in this Evidence of coverage.

14.

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060

EXCLUSIONS OF BENEFITS

The following procedures and services are excluded and not Covered Services, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits:

Costs for non-dental services related to the provision of dental services in hospitals, extended care facilities, or Member’s home are not covered. When deemed necessary by the Primary Care Dentist, the Member’s physician, and authorized by the Plan, covered dental services that are delivered in an inpatient or outpatient hospital setting are covered as indicated in the Schedule of Benefits.

15.

Any Covered Person request for: (a) specialist services or treatment which can be routinely provided by the PCD; or (b) treatment by a specialist without referral from the PCD and our approval.

16.

Any endodontic, periodontal, crown or bridge abutment procedure or appliance requested, recommended or performed for a tooth or teeth with a guarded, questionable or poor prognosis.

17.

Dental Services otherwise Covered under the Contract, but rendered after the date individual Coverage under the Contract terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Contract terminates.

18.

Replacement of a lost, missing or stolen appliance or prosthesis or the fabrication of a spare appliance or prosthesis.19.

Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment.

20.

Orthodontic Exclusions and Limitations If you require the services of an orthodontist, a referral must first be obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the member will be responsible for all costs associated with any orthodontic treatment.

If you terminate coverage after the start of orthodontic treatment, you will be responsible for any additional charges incurred for the remaining orthodontic treatment.

1. The following are not Covered orthodontic benefi ts:

• Extractions required for orthodontic purposes

• Surgical orthodontics or jaw repositioning

• Myofunctional therapy

• Cleft palate

• Micrognathia

• Macroglossia

• Hormonal imbalances

• Orthodontic retreatment when initial treatment was rendered under this plan or for changes in orthodontic treatment necessitated by any kind of accident

• Palatal expansion appliances

• Replacement or repair of lost, stolen or broken appliances or appliances damaged due to the neglect of the Covered Person

2. If a treatment plan is for less than 24 months, then a prorated portion of the full Copayment shall apply.

3. If Covered Person’s dental eligibility ends, for whatever reason, and the Covered Person is receiving orthodontic treatment under the plan, the remaining cost for that treatment will be prorated at the orthodontist’s usual fees over the number of months of treatment remaining. The Covered Person will be responsible for the payment of this balance under the terms and conditions pre-arranged with the orthodontist.

4. If the Covered Person has the orthodontist perform a “diagnostic work-up” (a consultation and diagnosis) and then decides to forgo the treatment program, the Covered Person will be charged a $50 consultation fee, plus any lab costs incurred by the orthodontist.

5. One orthodontic benefi t under this plan is available per lifetime, per Covered Person. A Covered Person may access this benefi t for either Interceptive Orthodontic Treatment or Comprehensive Orthodontic Treatment, or both. If both interceptive treatment and comprehensive treatment are necessary, and both are completed within a 24 month period, the Copayments listed will apply. If both are necessary and active treatment for both extends beyond 24 months, the provider is obligated to accept the plan Copayment only for the fi rst 24 months of active therapy. The provider may charge usual and customary fees for active treatment extending beyond the 24 month benefi t period.

21.

Treatment which requires the services of a pediatric specialist, after the Covered Person’s 8th birthday without a specialty referral and authorization22.

©2017-2018 United HealthCare Services, Inc. This plan is underwritten by National Pacific Dental, Inc.NCA-01B(v1.1) 275-6060