RFP_26_041_Attachment 2_DHMO S200B PBC Access Enhanced summary.pdf

CODE

INN

COPAY

OON

REIMBURSEMENT

D0120 $0 $20

D0140 $0 $20

D0145 $0 $20

D0150 $0 $20

D0160 $0 $20

D0170 $0 $20

D0171 $0

D0180 $0 $20

D0210 $0 $25

D0220 $4 $4

D0230 $2 $2

D0240 $0

D0250 $0

D0251 $0

D0270 $0 $10

D0272 $0 $15

D0273 $0 $20

D0274 $0 $23

D0277 $20 $25

D0310 $150

D0320 $250

D0321 $150

D0322 $150

D0330 $35 $25

D0340 $75

D0350 $20 $15

D0364 $140

D0365 $130

D0366 $130

*Detailed and extensive oral evaluation - problem focused, by report

Re-evaluation - limited, problem focused (established patient; not post-operative visit)

Re-evaluation – post-operative office visit

*Comprehensive periodontal evaluation - new or established patient

RADIOGRAPHY / DIAGNOSTIC DENTISTRY

*Intraoral - complete series of radiographic images

DESCRIPTION

APPOINTMENTS

*Periodic oral evaluation - established patient

Limited oral evaluation - problem focused

*Oral evaluation for a patient under three years of age and counseling with primary caregiver

*Comprehensive oral evaluation - new or established patient

*Bitewings - two radiographic images

*Bitewings - three radiographic images

*Bitewings - four radiographic images

*Vertical bitewings - 7 to 8 radiographic images

Sialography

Temporomandibular joint arthrogram, including injection

Intraoral - periapical first radiographic image

Intraoral - periapical each additional radiographic image

Intraoral - occlusal radiographic image

Extra-oral – 2d projection radiographic image created using a stationary radiation source, and detector

*Extra-oral posterior dental radiographic image

*Bitewing - single radiographic image

*Cone beam ct capture and interpretation with field of view of one full dental arch – mandible

*Cone beam ct capture and interpretation with field of view of one full dental arch – maxilla, with or without cranium

Other temporomandibular joint radiographic images, by report

Tomographic survey

*Panoramic radiographic image

2d cephalometric radiographic image – acquisition, measurement and analysis

2d oral/facial photographic image obtained intra-orally or extra-orally

*Cone beam ct capture and interpretation with limited field of view – less than one whole jaw

S200B-PBC Access+

Members of S200B-PBC Access+ dental plan are eligible to receive benefits immediately upon the effective date of coverage with: · No Waiting Periods

· No Deductibles

· Out-of-Network Services covered at a Schedule Reimbursement to the member

The Member copayments listed are offered by a participating in-network provider. The Member receives:

· Most diagnostic & preventive care at No Charge

· Cosmetic & orthodontia treatment covered

Members can choose a participating provider at www.SolsticeBenefits.com

Member Services Department: 1.877.760.2247

The patient/Member is ultimately responsible for verifications to the accuracy and appropriateness of all fees applicable to any dental benefit provided by a network provider. We urge all of our Members to verify all fees for proposed treatment via the “Schedule of Benefits” and/or with our Member Services Department prior to treatment.

The following benefits are payable under the Policy. An "*" or a "†" denotes limitaƟons and/or addiƟonal fees on certain benefits. See the Limitations and Additional Fees section below for details. A “^” indicate copays for additional services.

Marketing Use ONLY

COPAY

OON

REIMBURSEMENT

D0367 $175

D0368 $130

D0369 $180

D0370 $160

D0371 $160

D0380 $140

D0381 $130

D0382 $130

D0383 $175

D0384 $130

D0385 $160

D0386 $160

D0393 $0

D0394 $0

D0395 $0

D0415 $0

D0425 $0

D0431 $65

D0460 $0

D0470 $0

D0472 $0

D0473 $0

D0474 $0

D0480 $0

D0486 $0

D0502 $0

D0600 $0

D0601 $0

D0602 $0

D0603 $0

D0701 $35 $25

D0702 $75

D0703 $20 $15

D0705 $0

D0706 $0

D0707 $2 $2

D0708 $0 $10

D0709 $0 $25

D0999 $0

D1110 $0 $35

D1110 $15^

D1120 $0 $25

D1120 $15^

D1206 $5

D1208 $0 $10

D1310 $0

D1320 $0

D1330 $0

D1351 $0 $20

D1352 $0

D1353 $0

D1354 $20

D1355 $20

D1510 $0 $50

D1516 $0 $75

DESCRIPTION

*Cone beam ct capture and interpretation with field of view of both jaws; with or without cranium

*Cone beam ct capture and interpretation for tmj series including two or more exposures

*Maxillofacial mri capture and interpretation

*Cone beam ct image capture for tmj series including two or more exposures

*Maxillofacial mri image capture

*Maxillofacial ultrasound image capture

*Treatment simulation using 3d image volume

*Digital subtraction of two or more images or image volumes of the same modality

*Fusion of two or more 3d image volumes of one or more modalities

*Maxillofacial ultrasound capture and interpretation

*Sialoendoscopy capture and interpretation

*Cone beam ct image capture with limited field of view – less than one whole jaw

*Cone beam ct image capture with field of view of one full dental arch – mandible

*Cone beam ct image capture with field of view of one full dental arch – maxilla, with or without cranium

*Cone beam ct image capture with field of view of both jaws; with or without cranium

Accession of tissue, gross and microscopic examination, preparation and transmission of written report

Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report

Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report

Other oral pathology procedures, by report

Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum

Collection of microorganisms for culture and sensitivity

Caries susceptibility tests

Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures

Pulp vitality tests

Diagnostic casts

Accession of tissue, gross examination, preparation and transmission of written report

*Extra-oral posterior dental radiographic image – image capture only

*Intraoral – occlusal radiographic image – image capture only

*Intraoral – periapical radiographic image – image capture only

*Intraoral – bitewing radiographic image – image capture only

*Intraoral – complete series of radiographic images – image capture only

Unspecified diagnostic procedure, by report

Caries risk assessment and documentation, with a finding of low risk

Caries risk assessment and documentation, with a finding of moderate risk

Caries risk assessment and documentation, with a finding of high risk

*Panoramic radiographic image – image capture only

*2-D cephalometric radiographic image – image capture only

*2-D oral/facial photographic image obtained intra-orally or extra-orally – image capture only

*Topical application of fluoride – excluding varnish

Nutritional counseling for control of dental disease

Tobacco counseling for the control and prevention of oral disease

Oral hygiene instructions

*Sealant - per tooth

*Preventive resin restoration in a moderate to high caries risk patient – permanent tooth

PREVENTIVE DENTISTRY

*Prophylaxis - adult

Prophylaxis - adult additional

*Prophylaxis - child

Prophylaxis - child additional

*Topical application of fluoride varnish

Sealant repair – per tooth

*Interim caries arresting medicament application – per tooth

Caries preventive medicament application – per tooth

*Space maintainer - fixed - unilateral

*Space maintainer – fixed – bilateral, maxillary

COPAY

OON

REIMBURSEMENT

D1517 $0 $75

D1520 $0 $50

D1526 $0 $75

D1527 $0 $75

D1551 $10

D1552 $10

D1553 $10

D1556 $10

D1557 $10

D1558 $10

D1575 $0

D2140 $0 $15

D2150 $0 $20

D2160 $0 $25

D2161 $0 $25

D2330 $20 $15

D2331 $32 $20

D2332 $40 $25

D2335 $70 $25

D2390 $100

D2391 $45

D2392 $65

D2393 $80

D2394 $95

D2410 $65

D2420 $90

D2430 $120

D2510 $80

D2520 $90

D2530 $115

D2542 $250

D2543 $270

D2544 $290

D2610 $225*

D2620 $250*

D2630 $275*

D2642 $310*

D2643 $340*

D2644 $350*

D2650 $180

D2651 $200

D2652 $250

D2662 $225

D2663 $245

D2664 $275

D2710 $195

D2712 $195

D2720 $195*

D2721 $195*

D2722 $195*

D2740 $195*

D2750 $195*

D2751 $195*

D2752 $195*

D2753 $195*

D2780 $195*

*Space maintainer – fixed – bilateral, mandibular

*Space maintainer - removable - unilateral

*Space maintainer – removable – bilateral, maxillary

*Space maintainer – removable – bilateral, mandibular

Re-cement or re-bond bilateral space maintainer - maxillary

Re-cement or re-bond bilateral space maintainer - mandibular

DESCRIPTION

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

Re-cement or re-bond unilateral space maintainer - per quadrant

Removal of fixed unilateral space maintainer - per quadrant

Removal of fixed bilateral space maintainer - maxillary

Removal of fixed bilateral space maintainer - mandibular

Distal shoe space maintainer – fixed – unilateral

RESTORATIVE DENTISTRY

Resin-based composite - four or more surfaces, posterior

Gold foil - one surface

Gold foil - two surfaces

Gold foil - three surfaces

Inlay - metallic - one surface

Inlay - metallic - two surfaces

Resin-based composite - three surfaces, anterior

Resin-based composite - four or more surfaces or involving incisal angle (anterior)

Resin-based composite crown, anterior

Resin-based composite - one surface, posterior

Resin-based composite - two surfaces, posterior

Resin-based composite - three surfaces, posterior

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 - one surface

Inlay - resin-based composite - 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

*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

Inlay - resin-based composite - three or more surfaces

Onlay - resin-based composite - two surfaces

Onlay - resin-based composite - three surfaces

Onlay - resin-based composite - four or more surfaces

*Crown - resin-based composite (indirect)

*Crown - ¾ resin-based composite (indirect)

*Crown - porcelain fused to noble metal

*Crown - porcelain fused to titanium and titanium alloys

*Crown - 3/4 cast high noble metal

COPAY

OON

REIMBURSEMENT

D2781 $195*

D2782 $195*

D2783 $195*

D2790 $195*

D2791 $195*

D2792 $195*

D2794 $195*

D2799 $125

D2910 $10

D2915 $10

D2920 $10

D2921 $10

D2928 $34*

D2929 $34*

D2930 $35

D2931 $40

D2932 $90

D2933 $135

D2940 $5

D2941 $5

D2949 $20

D2950 $35

D2951 $10

D2952 $80

D2953 $95

D2954 $75

D2955 $20

D2957 $30

D2960 $200

D2961 $225*

D2962 $350*

D2971 $45

D2975 $95

D2980 $95

D2981 $95

D2982 $95

D2983 $95

D2990 $29

D3110 $10

D3120 $10

D3220 $20

D3221 $95

D3222 $75

D3230 $40

D3240 $40

D3310 $100

D3320 $175

D3330 $210

D3331 $85

D3332 $75

D3333 $125

D3346 $250

D3347 $285

D3348 $350

D3351 $90

D3352 $90

*Crown - 3/4 porcelain/ceramic

*Crown - full cast high noble metal

*Crown - full cast predominantly base metal

*Crown - full cast noble metal

*Crown - titanium

*Provisional crown– further treatment or completion of diagnosis necessary prior to final impression

DESCRIPTION

*Crown - 3/4 cast predominantly base metal

*Crown - 3/4 cast noble metal

Prefabricated stainless steel crown - primary tooth

Prefabricated stainless steel crown - permanent tooth

Prefabricated resin crown

Prefabricated stainless steel crown with resin window

Protective restoration

Interim therapeutic restoration – primary dentition

Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration

Re-cement or re-bond indirectly fabricated or prefabricated post and core

Re-cement or re-bond crown

Reattachment of tooth fragment, incisal edge or cusp

*Prefabricated porcelain/ceramic crown – permanent tooth

*Prefabricated porcelain/ceramic crown – primary tooth

Post removal

Each additional prefabricated post - same tooth

Labial veneer (resin laminate) - direct

Labial veneer (resin laminate) - indirect

Labial veneer (porcelain laminate) - indirect

Additional procedures to construct new crown under existing partial denture framework

Restorative foundation for an indirect restoration

Core buildup, including any pins when required

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

ENDODONTIC SERVICES

Pulp cap - direct (excluding final restoration)

Pulp cap - indirect (excluding final restoration)

Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament

Pulpal debridement, primary and permanent teeth

Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development

Coping

Crown repair necessitated by restorative material failure

Inlay repair necessitated by restorative material failure

Onlay repair necessitated by restorative material failure

Veneer repair necessitated by restorative material failure

Resin infiltration of incipient smooth surface lesions

Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth

Internal root repair of perforation defects

Retreatment of previous root canal therapy - anterior

Retreatment of previous root canal therapy - premolar

Retreatment of previous root canal therapy - molar

Apexification/recalcification – initial visit (apical closure / calcific repair of perforations, root resorption, etc.)

Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)

Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)

Endodontic therapy, anterior tooth (excluding final restoration)

Endodontic therapy, premolar tooth (excluding final restoration)

Endodontic therapy, molar tooth (excluding final restoration)

Treatment of root canal obstruction; non-surgical access

Apexification/recalcification – interim medication replacement

COPAY

OON

REIMBURSEMENT

D3353 $90

D3410 $96

D3421 $300

D3425 $150

D3426 $75

D3428 $32

D3429 $25

D3430 $55

D3431 $150

D3432 $150

D3450 $85

D3460 $535

D3470 $175

D3471 $96

D3472 $300

D3473 $150

D3501 $96

D3502 $96

D3503 $96

D3910 $95

D3920 $80

D3950 $75

D4210 $175

D4211 $66

D4212 $40

D4240 $163

D4241 $150

D4245 $150

D4249 $175

D4260 $375

D4261 $325

D4263 $450

D4264 $325

D4265 $325

D4266 $325

D4267 $325

D4268 $0

D4270 $235

D4273 $280

D4274 $100

D4275 $502

D4276 $65

D4277 $215

D4278 $75

D4283 $250

D4285 $392

D4320 $100

D4321 $100

D4341 $36†

D4342 $29†

D4346 $35†

Apicoectomy (each additional root)

Bone graft in conjunction with periradicular surgery – per tooth, single site

Bone graft in conjunction with periradicular surgery – each additional contiguous tooth in the same surgical site

Retrograde filling - per root

Biologic materials to aid in soft and osseous tissue regeneration in conjunction with periradicular surgery

Guided tissue regeneration, resorbable barrier, per site, in conjunction with periradicular surgery

DESCRIPTION

Apexification/recalcification - final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.)

Apicoectomy - anterior

Apicoectomy - premolar (first root)

Apicoectomy - molar (first root)

Surgical exposure of root surface without apicoectomy or repair of root resorption – anterior

Surgical exposure of root surface without apicoectomy or repair of root resorption – premolar

Surgical exposure of root surface without apicoectomy or repair of root resorption – molar

Surgical procedure for isolation of tooth with rubber dam

Hemisection (including any root removal), not including root canal therapy

Canal preparation and fitting of preformed dowel or post

Root amputation - per root

Endodontic endosseous implant

Intentional reimplantation (including necessary splinting)

Surgical repair of root resorption – anterior

Surgical repair of root resorption – premolar

Surgical repair of root resorption – molar

Apically positioned flap

Clinical crown lengthening – hard tissue

Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant

Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant

Bone replacement graft – retained natural tooth – first site in quadrant

Bone replacement graft – retained natural tooth – each additional site in quadrant

PERIODONTIC SERVICES

Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant

Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant

Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth

Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant

Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant

Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)

Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft

Combined connective tissue and double pedicle graft, per tooth

Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft

Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site

Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

Biologic materials to aid in soft and osseous tissue regeneration

Guided tissue regeneration - resorbable barrier, per site

Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal)

Surgical revision procedure, per tooth

Pedicle soft tissue graft procedure

Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft

Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

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

Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation

COPAY

OON

REIMBURSEMENT

D4355 $35†

D4381 $45† D4910 $40

D4910 $100^ D4920 $20 D4921 $15 D4999 $0

D5110 $210*

D5120 $210*

D5130 $210*

D5140 $210*

D5211 $210*

D5212 $210*

D5213 $220*

D5214 $220* D5221 $230* D5222 $230*

D5223 $240*

D5224 $240*

D5225 $220*

D5226 $220*

D5282 $235*

D5283 $235*

D5410 $8

D5411 $8

D5421 $10

D5422 $10

D5511 $15*

D5512 $15*

D5520 $10*

D5611 $15*

D5612 $15*

D5621 $30*

D5622 $30*

D5630 $15*

D5640 $10*

D5650 $30*

D5660 $30*

D5670 $100*

D5671 $100*

D5710 $75*

D5711 $75*

D5720 $75*

D5721 $75*

D5730 $45*

D5731 $45*

D5740 $45*

D5741 $45*

D5750 $35*

D5751 $35*

D5760 $35*

D5761 $35*

D5810 $220*

D5811 $220*

D5820 $220*

D5821 $220*

D5850 $25

D5851 $25

DESCRIPTION

*Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit

*Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth *Periodontal maintenance

Additional Periodontal maintenance procedure Unscheduled dressing change (by someone other than treating dentist or their staff)

*Immediate denture - mandibular

*Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth)

*Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth)

*Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

*Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) *Immediate maxillary partial denture – resin base (including any conventional clasps, rests and teeth)

Gingival irrigation – per quadrant Unspecified periodontal procedure, by report

PROSTHODONTICS REMOVABLE

*Complete denture - maxillary

*Complete denture - mandibular

*Immediate denture - maxillary

*Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular

Adjust complete denture - maxillary

Adjust complete denture - mandibular

Adjust partial denture - maxillary

Adjust partial denture - mandibular

*Repair broken complete denture base, mandibular

*Immediate mandibular partial denture – resin base (including any conventional clasps, rests and teeth)

*Immediate maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

*Immediate mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)

*Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth)

*Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth)

*Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary

*Repair or replace broken retentive clasping materials – per tooth

*Replace broken teeth - per tooth

*Add tooth to existing partial denture

*Add clasp to existing partial denture - per tooth

*Replace all teeth and acrylic on cast metal framework (maxillary)

*Replace all teeth and acrylic on cast metal framework (mandibular)

*Repair broken complete denture base, maxillary

*Replace missing or broken teeth - complete denture (each tooth)

*Repair resin partial denture base, mandibular

*Repair resin partial denture base, maxillary

*Repair cast partial framework, mandibular

*Repair cast partial framework, maxillary

*Reline maxillary partial denture (direct)

*Reline mandibular partial denture (direct)

*Reline complete maxillary denture (indirect)

*Reline complete mandibular denture (indirect)

*Reline maxillary partial denture (indirect)

*Reline mandibular partial denture (indirect)

*Rebase complete maxillary denture

*Rebase complete mandibular denture

*Rebase maxillary partial denture

*Rebase mandibular partial denture

*Reline complete maxillary denture (direct)

*Reline complete mandibular denture (direct)

*Interim complete denture (maxillary)

*Interim complete denture (mandibular)

*Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary

*Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular

Tissue conditioning, maxillary

Tissue conditioning, mandibular

COPAY

OON

REIMBURSEMENT

D5862 $150

D5899 $0

D5982 $100*

D5987 $100*

D5988 $100*

D6010 $950

D6012 $950

D6056 $385

D6057 $495

D6058 $695

D6059 $695

D6060 $695

D6061 $695

D6062 $695

D6063 $695

D6064 $695

D6065 $695

D6066 $695

D6067 $695

D6068 $695

D6069 $695

D6070 $695

D6071 $695

D6072 $695

D6073 $695

D6074 $695

D6075 $695

D6076 $695

D6077 $695

D6080 $180

D6081 $36†

D6082 $695

D6083 $695

D6084 $695

D6085 $125

D6086 $695

D6087 $695

D6088 $695

D6090 $400

D6092 $45

D6093 $65

D6094 $695

D6095 $220

D6096 $500

D6097 $695

D6098 $695

D6099 $695

D6100 $700

D6110 $1200

D6111 $1200

D6112 $940

D6113 $940

D6114 $3800

D6115 $3800

D6116 $2200

DESCRIPTION

Precision attachment, by report

Unspecified removable prosthodontic procedure, by report

Surgical stent

Commissure splint

Surgical splint

*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 PROSTHETICS

*Surgical placement of implant body: endosteal implant

*Surgical placement of interim implant body for transitional prosthesis: endosteal implant

*Prefabricated abutment – includes modification and placement

*Custom fabricated abutment – includes placement

*Abutment supported porcelain/ceramic crown

*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 (predominantly 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 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 (predominantly base metal)

Provisional implant crown

*Implant supported crown - predominantly base alloys

*Implant supported crown - noble alloys

*Implant supported crown - titanium and titanium alloys

Repair implant supported prosthesis, by report

Re-cement or re-bond implant/abutment supported crown

*Implant supported retainer for cast metal fpd (titanium, titanium alloy, or high noble metal)

Implant maintenance procedures when prostheses are removed and reinserted, including cleansing of prostheses and abutments

Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure

*Implant supported crown - porcelain fused to predominantly base alloys

*Implant supported crown - porcelain fused to noble alloys

*Implant supported crown - porcelain fused to titanium and titanium alloys

*Implant supported retainer for FPD - porcelain fused to noble alloys

Implant removal, by report

*Implant /abutment supported removable denture for edentulous arch – maxillary

*Implant /abutment supported removable denture for edentulous arch – mandibular

*Implant /abutment supported removable denture for partially edentulous arch – maxillary

*Implant /abutment supported removable denture for partially edentulous arch – mandibular

Re-cement or re-bond implant/abutment supported fixed partial denture

*Abutment supported crown - (titanium)

Repair implant abutment, by report

Remove broken implant retaining screw

*Abutment supported crown - porcelain fused to titanium and titanium alloys

*Implant supported retainer - porcelain fused to predominantly base alloys

*Implant /abutment supported fixed denture for edentulous arch – maxillary

*Implant /abutment supported fixed denture for edentulous arch – mandibular

*Implant /abutment supported fixed denture for partially edentulous arch – maxillary

COPAY

OON

REIMBURSEMENT

D6117 $2200

D6118 $1760

D6119 $1760

D6120 $695

D6121 $695

D6122 $695

D6123 $695

D6190 $235

D6205 $695

D6210 $195*

D6211 $195*

D6212 $195*

D6214 $195*

D6240 $195*

D6241 $195*

D6242 $195*

D6243 $195*

D6245 $195*

D6250 $195*

D6251 $195*

D6252 $195*

D6253 $0

D6545 $180

D6548 $225*

D6600 $195*

D6601 $195*

D6602 $195*

D6603 $195*

D6604 $195*

D6605 $195*

D6606 $195*

D6607 $195*

D6608 $195*

D6609 $195*

D6610 $195*

D6611 $195*

D6612 $195*

D6613 $195*

D6614 $195*

D6615 $195*

D6624 $195*

D6634 $195*

D6710 $195*

D6720 $195*

D6721 $195*

D6722 $195*

D6740 $195*

D6750 $195*

D6751 $195*

D6752 $195*

D6753 $195*

D6780 $195*

D6781 $195*

D6782 $195*

D6783 $195*

D6784 $195*

*Implant/abutment supported interim fixed denture for edentulous arch – maxillary

*Implant supported retainer – porcelain fused to titanium and titanium alloys

*Implant supported retainer for metal FPD – predominantly base alloys

*Implant supported retainer for metal FPD – noble alloys

*Implant supported retainer for metal FPD – titanium and titanium alloys

Radiographic/surgical implant index, by report

DESCRIPTION

*Implant /abutment supported fixed denture for partially edentulous arch – mandibular

*Implant/abutment supported interim fixed denture for edentulous arch – mandibular

*Pontic - porcelain fused to high noble metal

*Pontic - porcelain fused to predominantly base metal

*Pontic - porcelain fused to noble metal

*Pontic - porcelain fused to titanium and titanium alloys

*Pontic - porcelain/ceramic

*Pontic - resin with high noble metal

PROSTHODONTICS FIXED

*Pontic - indirect resin based composite

*Pontic - cast high noble metal

*Pontic - cast predominantly base metal

*Pontic - cast noble metal

*Pontic - titanium

Retainer inlay - porcelain/ceramic, three or more surfaces

Retainer inlay - cast high noble metal, two surfaces

Retainer inlay - cast high noble metal, three or more surfaces

Retainer inlay - cast predominantly base metal, two surfaces

Retainer inlay - cast predominantly base metal, three or more surfaces

Retainer inlay - cast noble metal, two surfaces

*Pontic - resin with predominantly base metal

*Pontic - resin with noble metal

*Provisional pontic - further treatment or completion of diagnosis necessary prior to final impression

Retainer - cast metal for resin bonded fixed prosthesis

Retainer - porcelain/ceramic for resin bonded fixed prosthesis

Retainer inlay - porcelain/ceramic, two surfaces

Retainer onlay - cast predominantly base metal, three or more surfaces

Retainer onlay - cast noble metal, two surfaces

Retainer onlay - cast noble metal, three or more surfaces

Retainer inlay - titanium

Retainer onlay - titanium

*Retainer crown - indirect resin based composite

Retainer inlay - cast noble metal, three or more surfaces

Retainer onlay - porcelain/ceramic, two surfaces

Retainer onlay - porcelain/ceramic, three or more surfaces

Retainer onlay - cast high noble metal, two surfaces

Retainer onlay - cast high noble metal, three or more surfaces

Retainer onlay - cast predominantly base metal, two surfaces

*Retainer crown - porcelain fused to noble metal

*Retainer crown - porcelain fused to titanium and titanium alloys

*Retainer crown - 3/4 cast high noble metal

*Retainer crown - 3/4 cast predominantly base metal

*Retainer crown - 3/4 cast noble metal

*Retainer crown - 3/4 porcelain/ceramic

*Retainer crown - resin with high noble metal

*Retainer crown - resin with predominantly base metal

*Retainer crown - resin with noble metal

*Retainer crown - porcelain/ceramic

*Retainer crown - porcelain fused to high noble metal

*Retainer crown - porcelain fused to predominantly base metal

*Retainer crown ¾ - titanium and titanium alloys

COPAY

OON

REIMBURSEMENT

D6790 $195*

D6791 $195*

D6792 $195*

D6793 $125

D6794 $195*

D6930 $10

D6940 $125

D6950 $125

D6980 $80

D7111 $45

D7140 $10

D7210 $25

D7220 $40

D7230 $55

D7240 $63

D7241 $100

D7250 $25

D7251 $270

D7260 $160

D7261 $275

D7270 $50

D7272 $100

D7280 $125

D7282 $125

D7283 $80

D7285 $115

D7286 $60

D7287 $50

D7288 $25

D7291 $30

D7310 $20

D7311 $20

D7320 $50

D7321 $50

D7340 $370

D7350 $990

D7410 $25

D7411 $50

D7412 $55

D7450 $65

D7451 $95

D7471 $95

D7472 $95

D7473 $95

D7485 $95

D7510 $20

D7511 $20

D7520 $20

D7521 $20

D7910 $35

D7921 $125

D7950 $350

D7951 $800

D7952 $350

D7953 $100

*Retainer crown - titanium

Re-cement or re-bond fixed partial denture

Stress breaker

Precision attachment

Fixed partial denture repair necessitated by restorative material failure

ORAL SURGERY

DESCRIPTION

*Retainer crown - full cast high noble metal

*Retainer crown - full cast predominantly base metal

*Retainer crown - full cast noble metal

*Provisional retainer crown - further treatment or completion of diagnosis necessary prior to final impression

Removal of impacted tooth - completely bony, with unusual surgical complications

Removal of residual tooth roots (cutting procedure)

Coronectomy – intentional partial tooth removal

Oroantral fistula closure

Primary closure of a sinus perforation

Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth

Extraction, coronal remnants – primary tooth

Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

Removal of impacted tooth - soft tissue

Removal of impacted tooth - partially bony

Removal of impacted tooth - completely bony

Exfoliative cytological sample collection

Brush biopsy - transepithelial sample collection

Transseptal fiberotomy/supra crestal fiberotomy, by report

Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

Alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

Exposure of an unerupted tooth

Mobilization of erupted or malpositioned tooth to aid eruption

Placement of device to facilitate eruption of impacted tooth

Incisional biopsy of oral tissue-hard (bone, tooth)

Incisional biopsy of oral tissue-soft

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 lateral exostosis (maxilla or mandible)

Removal of torus palatinus

Removal of torus mandibularis

Reduction of osseous tuberosity

Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant

Vestibuloplasty - ridge extension (secondary epithelialization)

Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue)

Excision of benign lesion up to 1.25 cm

Excision of benign lesion greater than 1.25 cm

Excision of benign lesion, complicated

Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report

Sinus augmentation with bone or bone substitutes via a lateral open approach

Sinus augmentation via a vertical approach

Bone replacement graft for ridge preservation - per site

Incision and drainage of abscess - intraoral soft tissue

Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

Incision and drainage of abscess - extraoral soft tissue

Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

Suture of recent small wounds up to 5 cm

Collection and application of autologous blood concentrate product

COPAY

OON

REIMBURSEMENT

D7961 $50

D7962 $50

D7963 $50

D7970 $140

D7971 $102

D7972 $125

D8010 $1000

D8020 $1000

D8030 $1000

D8040 $1350

D8070 $1800

D8080 $1850

D8090 $1950

D8210 $103

D8220 $103

D8660 $35

D8670 $0

D8680 $300

D8681 $0

D8698 $0

D8699 $0

D8999 $250

D9110 $0

D9120 $0

D9210 $0

D9211 $0

D9212 $0

D9215 $0

D9222 $50

D9223 $50

D9230 $20

D9239 $65

D9243 $65

D9248 $15

D9310 $25

D9430 $0

D9440 $25

D9450 $0

D9610 $15

D9630 $15

D9910 $20

D9911 $0

D9930 $0

D9932 $0

D9933 $0

D9934 $0

D9935 $0

D9942 $40

D9943 $25

D9944 $250

D9945 $250

D9946 $250

D9950 $75

D9951 $25

D9952 $75

DESCRIPTION

Buccal / labial frenectomy (frenulectomy)

Limited orthodontic treatment of the primary dentition

Limited orthodontic treatment of the transitional dentition

Limited orthodontic treatment of the adolescent dentition

Limited orthodontic treatment of the adult dentition

Comprehensive orthodontic treatment of the transitional dentition

Comprehensive orthodontic treatment of the adolescent dentition

Lingual frenectomy (frenulectomy)

Frenuloplasty

Excision of hyperplastic tissue - per arch

Excision of pericoronal gingiva

Surgical reduction of fibrous tuberosity

ORTHODONTIC

Removable orthodontic retainer adjustment

Re-cement or re-bond fixed retainer – maxillary

Re-cement or re-bond fixed retainer – mandibular

Unspecified orthodontic procedure, by report

MISCELLANEOUS

Palliative (emergency) treatment of dental pain - minor procedure

Comprehensive orthodontic treatment of the adult dentition

*Removable appliance therapy

*Fixed appliance therapy

Pre-orthodontic treatment examination to monitor growth and development

Periodic orthodontic treatment visit

Orthodontic retention (removal of appliances, construction and placement of retainer(s))

Deep sedation/general anesthesia – each subsequent 15 minute increment

Inhalation of nitrous oxide/analgesia, anxiolysis

Intravenous moderate (conscious) sedation/analgesia- first 15 minutes

Intravenous moderate (conscious) sedation/analgesia – each subsequent 15 minute increment

Non-intravenous conscious sedation

Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician

Fixed partial denture sectioning

Local anesthesia not in conjunction with operative or surgical procedures

Regional block anesthesia

Trigeminal division block anesthesia

Local anesthesia in conjunction with operative or surgical procedures

Deep sedation/general anesthesia – first 15 minutes

Application of desensitizing resin for cervical and/or root surface, per tooth

Treatment of complications (post-surgical) - unusual circumstances, by report

Cleaning and inspection of removable complete denture, maxillary

Cleaning and inspection of removable complete denture, mandibular

Cleaning and inspection of removable partial denture, maxillary

Cleaning and inspection of removable partial denture, mandibular

Office visit for observation (during regularly scheduled hours) - no other services performed

Office visit - after regularly scheduled hours

Case presentation, detailed and extensive treatment planning

Therapeutic parenteral drug, single administration

Drugs or medicaments dispensed in the office for home use

*Application of desensitizing medicament

Occlusal adjustment - limited

Occlusal adjustment - complete

Repair and/or reline of occlusal guard

Occlusal guard adjustment

*Occlusal guard – hard appliance, full arch

*Occlusal guard – soft appliance, full arch

*Occlusal guard – hard appliance, partial arch

Occlusion analysis - mounted case

COPAY

OON

REIMBURSEMENT

D9972 $150

D9973 $30

D9975 $240

D9986 $25

D9991 $0

D9992 $0

D9993 $0

D9994 $0

D9995 $20

D9996 $20

D9997 $0

DESCRIPTION

External bleaching - per arch - performed in office

External bleaching - per tooth

External bleaching for home application, per arch; includes materials and fabrication of custom trays

Missed appointment

Dental case management – addressing appointment compliance barriers

Dental case management – care coordination

Dental case management – motivational interviewing

Dental case management – patient education to improve oral health literacy

Dental case management - patients with special health care needs

Teledentistry – synchronous; real-time encounter

Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review

EXCLUSIONS, LIMITATIONS, AND ADDITIONAL FEES

Specialty Services This Member Schedule of Benefits applies when listed dental services are performed by a participating General Dentist, unless otherwise authorized by Solstice.

Procedures not listed on the Schedule of Benefits that are performed by a participating General Dentist will be charged at the participating General Dentist’s usual and customary fee less 25%.

The Network General Dentist you select may not perform all procedures listed. The Co-payments shown apply to Network General Dentists.

You may receive specialty care from Orthodontist, Oral Surgeon, Endodontist, Periodontist, or Pediatric Dentist by self-referring to any participating specialist and receiving specialty care at the listed copayment or at a 25% reduction off of the provider's usual and customary fee.

Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions, or medications.

Treatment of malignancies, cysts, or neoplasms, without proof of medical necessity and prior Solstice approval.

Dental procedures initiated prior to the Member’s eligibility under this benefit plan or started after the Member’s termination from the plan.

Any dental procedure or treatment unable to be performed in the dental office due to the general health or physical limitations of the Member, including but not limited to, physical or emotional resistance, inability to visit the dental office, or allergy to commonly utilized local anesthetics.

Limitations and Additional Fees Any oral evaluation (excluding problem) is limited to One (1) time per consecutive six (6) months; Comprehensive exams can only be covered one (1) time per 36 months, if and only if patient is considered to be new or an established patient. All subsequent oral evaluations will be at a 25% reduction off the dentist’s usual and customary fee without a frequency limitation

Members seeking implant treatment should refer to their participating implantologist, a select Network of Participating Providers. Not all providers perform the implant procedures at the Co-payment listed on the Schedule of Benefits. Please refer to the provider listing at www.solsticebenefits.com under “Locate A Provider.”

Exclusions Services performed by a dentist or dental specialist, not contracted with Solstice without prior approval.

Any dental services or appliances which are determined to be not reasonable and/or necessary for maintaining or improving the Member’s dental health or experimental in nature.

Orthographic surgery or procedures and appliances for the treatment of myofunctional, myoskeletal or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits.

General anesthesia or IV sedation is available when listed on the Schedule of Benefits, medically necessary, and previously approved by Solstice.

New dentures include one (1) reline within the first six (6) months Replacement of crowns, implants, and fixed bridges or dentures is limited to one (1) time every consecutive five (5) years.

When crown, implant and/or bridgework exceed six (6) consecutive units, there will be an additional charge of $30.00 per unit.

Copayments marked by ‘*’ do not include the cost of material and laboratory fees. Additional cost to patient is as follows:

- High noble metal (precious) up to $145.00

- Titanium metal up to $120 (covered with proof of allergy to other metals)

- Noble metal (semi-precious) up to $120.00

- Predominantly base metal (non-precious) up to $55.00

- Crown laboratory fees up to $155.00

- Laboratory fees on dentures up to $225.00

- Porcelain laboratory fees for D2610-D2644, D2929, D2961, D2962, D6600, D6601, D6608, and D6609 up to $65.00

- Denture repair laboratory fees up to $50.00

- All ceramic and/or porcelain crown material fees up to $155.00 Copayments marked by “†” are not eligible at a specialist.

All bitewing X-rays are limited to one set in any twelve (12) consecutive month period.

The dental prophylaxis or periodontal maintenance procedure is limited to one (1) time in any consecutive six (6) month period. Any additional procedures will follow D1110 and D4910 Member copayments as listed in the Schedule of Benefits.

Fluoride treatment is limited to one (1) in any twelve (12) consecutive month period.

Sealants (D1351 or D1352) are limited to one (1) time per tooth in any three (3) consecutive year period. This is only allowed for unrestored permanent molar teeth for children under the age of 16.

Space maintainers and all adjustments are limited to children under the age of 16.

Harmful habit appliances are limited to one (1) time per person under the age of 16.

Member may choose Invisalign in place of traditional Orthodontic treatment, and would pay the sum of the listed member Ortho co-pay plus the difference in cost for the enhanced treatment.

Occlusal Guard(s) is limited to one (1) time in any consecutive thirty-six (36) months for the purposes of habitual grinding/Bruxism.

D0364-D0395 is limited to one (1) time per sixty (60) months, covered only in a dental setting and not in a radiographic imaging center.

Copayments marked by “^” are additional benefits utilized after the original limitation.

Either D0210, D0251, or D0330 are reimbursable one (1) time every five (5) consecutive years.

Copies of X-rays can be obtained for $2 per periapical image up to a maximum of $30. Panoramic X-ray can be obtained for a $15 fee.

D0274, D0277 or D0210 are payable only when other inclusive image have not been taken (paid) within the last six (6) months.

All denture adjustment fees are for dentures which were not fabricated at the present office; All denture adjustment for new dentures made within 12 months are at no fee to the member.

Emergency treatment is available for palliative treatment for the abatement of pain up to $100.00 per occurrence.

A broken appointment fee up to $20.00 may be charged by the dental office if 24-hour prior notice is not given.