2019 SCHEDULE OF DENTAL PROCEDURES AND ALLOWABLE …

2019 SCHEDULE OF DENTAL PROCEDURES AND ALLOWABLE CHARGES FOR THE STATE DENTAL PLAN

PLEASE NOTE THAT THE ALLOWABLE DOLLAR CHARGE IS SET BY THE STATE AND MAY NOT REFLECT THE TOTAL CHARGE FOR THE PARTICULAR SERVICE BY YOUR DENTIST. YOU ARE RESPONSIBLE FOR PAYMENT OF ANY DIFFERENCE BETWEEN THE AMOUNT COVERED BY THE STATE AS AN EMPLOYEE, OR A COVERED DEPENDENT, AND THE DENTIST'S CHARGE. YOU SHOULD DISCUSS FEES WITH YOUR DENTIST PRIOR TO TREATMENT.

THE MAXIMUM ALLOWABLE CHARGE FOR ANY DENTAL PROCEDURE NOT SPECIFIED IN THIS SCHEDULE WILL BE DETERMINED BY THE PLAN ADMINISTRATOR THROUGH ITS MEDICAL STAFF AND/OR DENTAL CONSULTANTS BASED ON COMPARABLE OR SIMILAR SERVICES, UNLESS SUCH PROCEDURE IS SPECIFICALLY EXCLUDED IN THIS SCHEDULE OR BY OTHER TERMS AND CONDITIONS OF COVERAGE.

"NC" INDICATES NON COVERED.

PROCEDURE CODE

CLASS I. DIAGNOSTIC AND PREVENTIVE (Payable @ 100% of State Allowance)

ORAL EXAMINATIONS:

D0120 D0140 D0145 D0150 D0160 D0170 D0171 D0180 D0190 D0191

PERIODIC ORAL EVALUATION LIMITED ORAL EVALUATION-PROBLEM FOCUSED ORAL EVALUATION PATIENT UNDER 3 COMPREHENSIVE ORAL EVALUATION 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 SCREENING OF NEW PATIENT TO DETERMINE THE NEED TO SEE A DENTIST FOR DIAGNOSIS ASSESSMENT OF A PATIENT TO IDENTIFY THE NEED FOR A REFERRAL

ALLOWANCE

$18.20 $20.40 $19.30 $19.30 $19.30 $18.20

NC $19.30

NC $11.85

D0210 D0220 D0230 D0240 D0250 D0251 D0270 D0272 D0273 D0274 D0277 D0290 D0310 D0320 D0321 D0322 D0330 D0340 D0350 D0351

RADIOGRAPHS: NO BENEFITS ARE PAYABLE FOR ANY CHARGES FOR BITEWING X-RAYS MORE THAN TWICE DURING ANY BENEFIT YEAR OR MORE THAN ONE SERIES OF FULL-MOUTH X-RAYS OR ONE PANORAMIC FILM IN ANY 36-MONTH PERIOD, UNLESS A SPECIAL NEED FOR THESE SERVICES AT MORE FREQUENT INTERVALS IS DOCUMENTED BY THE DENTIST AND DEEMED NECESSARY BY THE PLAN ADMINISTRATOR.

RADIOGRAPHIC IMAGES- INTRAORAL - COMPLETE SERIES RADIOGRAPHIC IMAGE- INTRAORAL- PERIAPICAL-FIRST RADIOGRAPHIC IMAGE RADIOGRAPHIC IMAGE- INTRAORAL- PERIAPICAL- EACH ADDITIONAL RADIOGRAPHIC IMAGE INTRAORAL- OCCLUSAL RADIOGRAPHIC IMAGE EXTRA-ORAL - 2D PROJECTION RADIOGRAPHIC IMAGES CREATED USING A STATIONARY RADIATION SOURCE, AND DETECTOR EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE BITEWING - SINGLE RADIOGRAPHIC IMAGE BITEWINGS - TWO RADIOGRAPHIC IMAGES BITEWINGS - THREE RADIOGRAPHIC IMAGES BITEWINGS - FOUR RADIOGRAPHIC IMAGES VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES POSTERIOR-ANTERIOR OR LATERAL SKULL AND FACIAL BONE SURVEY RADIOGRAPHIC IMAGES SIALOGRAPHY TEMPOROMANDIBULAR JOINT ARTHROGRAM, INCLUDING INJECTION OTHER TEMPOROMANDIBULAR JOINT RADIOGRAPHIC IMAGES TOMOGRAPHIC SURVEY PANORAMIC RADIOGRAPHIC IMAGE 2D CEPHALOMETRIC RADIOGRAPHIC IMAGE- ACQUISITION, MEASUREMENT AND ANALYSIS ORAL/FACIAL PHOTOGRAPHIC IMAGE OBTAINED INTRAORALLY OR EXTRAORALLY 3D PHOTOGRAPHIC IMAGE

$49.30 $8.40 $6.20 $16.70 $7.30 $7.30 $12.00 $14.50 $16.90 $19.30 $36.00 $33.70

NC NC NC NC $42.10 NC NC NC

1

D0364 D0365 D0366 D0367 D0368 D0369 D0370 D0371

D0380 D0381 D0382 D0383 D0384 D0385 D0386

D0391 D0393 D0394 D0395

D0411 D0412 D0415 D0416 D0417 D0418 D0422 D0423 D0425 D0431 D0460 D0470 D0472 D0473 D0474 D0475 D0476 D0477 D0478 D0479 D0480 D0481 D0482 D0483 D0484 D0485 D0486 D0502 D0601 D0602

CONE BEAM CT CAPTURE AND INTERPRETATION WITH LIMITED FIELD OF VIEW- LESS THAN ONE WHOLE JAW CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW- MANDIBLE CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW- MAXILLA CONE BEAM CT CAPTURE AND INTERPRETATION WITH FIELD OF VIEW OF BOTH JAWS CONE BEAM CT CAPTURE AND INTERPRETATION FOR TMJ SERIES MAXILLOFACIAL MRI CAPTURE AND INTERPRETATION MAXILLOFACIAL UNTRASOUND CAPTURE AND INTERPRETATION SIALOENDOSCOPY- CAPTURE AND INTERPRETATION

IMAGE CAPTURE ONLY:

CONE BEAM CT IMAGE CAPTURE WITH LIMITED FIELD OF VIEW- LESS THAN ONE WHOLE JAW CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW- MANDIBLE CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW- MAXILLA CONE BEAM CT IMAGE CAPTURE WITH FIELD OF VIEW OF BOTH JAWS CONE BEAM CT IMAGE CAPTURE FOR TMJ SERIES MAXILLOFACIAL MRI IMAGE CAPTURE MAXILLOFACIAL UNTRASOUND IMAGE CAPTURE

INTERPRETATION AND REPORT ONLY

INTERPRETATION OF DIAGNOSTIC IMAGE, INCLUDING REPORT 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

TEST AND LABORATORY EXAMINATIONS:

HbA1c IN OFFICE POINT OF SERVICE TESTING BLOOD GLUCOSE LEVEL TEST - IN OFFICE USING A GLUCOSE METER COLLECTION OF MICROORGANISMS FOR CULTURE AND SENSITIVITY VIRAL CULTURE COLLECTION AND PREPARATION OF SALIVA SAMPLE FOR LABORATORY DIAGNOSTIC TESTING ANALYSIS OF SALIVA SAMPLE COLLECTION AND PREPARATION OF GENETIC SAMPLE MATERIAL FOR LABORATORY ANALYSIS AND REPORT GENETIC TEST FOR SUSCEPTIBILITY TO DISEASES- SPECIMEN ANALYSIS CARIES SUSCEPTIBILITY TESTS ADJUNCTIVE PRE-DIAGNOSTIC TEST THAT AIDS IN DETECTION OF MUCOSAL ABNORMALITIES PULP VITALITY TESTS DIAGNOSTIC CASTS (NC ON A ROUTINE BASIS- BENEFITS ARE PAYABLE ONLY ONCE IN A FIVE YEAR PERIOD.) ACCESSION OF TISSUE- GROSS EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT ACCESSION OF TISSUE- GROSS EXAMINATION ACCESSION OF TISSUE- GROSS AND MICROSCOPIC EXAMINATION DECALCIFICATION PROCEDURE SPECIAL STAINS FOR MICROORGANISMS SPECIAL STAINS, NOT FOR MICROORGANISMS IMMUNOHISTOCHEMICAL STAINS TISSUE IN-SITU HYBRIDIZATION, INCLUDING INTERPRETATION ACCESSION OF EXFOLIATIVECYTOLOGIC SMEARS ELECTRON MICROSCOPY- DIAGNOSTIC DIRECT IMMUNOFLUORESCENCE INDIRECT IMMUNOFLUORESCENCE CONSULTATION ON SLIDES PREPARED ELSEWHERE CONSULTATION, INCLUDING PREPARATION OF SLIDES FROM BIOPSY MATERIAL SUPPLIED FROM REFERRING SOURCE ACCESSION OF TRANSEPITHELIAL CYTOLOGIC SAMPLE, MICROSCOPIC EXAMINATION, PREPARATION AND TRANSMISSION OF WRITTEN REPORT OTHER ORAL PATHOLOGY PROCEDURES CARIES RISK ASSESSMENT AND DOCUMENTATION, WITH A FINDING OF LOW RISK CARIES RISK ASSESSMENT AND DOCUMENTATION, WITH A FINDING OF MODERATE RISK

2

NC NC NC NC NC NC NC NC

NC NC NC NC NC NC NC

NC NC NC NC

NC NC NC NC NC NC NC NC NC NC $16.70 $37.30 NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC

D0603 CARIES RISK ASSESSMENT AND DOCUMENTATION, WITH A FINDING OF HIGH RISK

NC

3

D0999

D1110 D1120

D1206 D1208

D1310 D1320 D1330 D1351 D1352 D1353 D1354

D1510 D1516 D1517 D1520 D1526 D1527 D1550 D1555 D1575

D1999 D9110

D9310

D4910

D9910 D9911

UNSPECIFIED DIAGNOSTIC PROCEDURE, BY REPORT

DENTAL PROPHYLAXIS: (NO MORE THAN TWO PROCEDURES IN ANY BENEFIT YEAR.)

PROPHYLAXIS - ADULT PROPHYLAXIS - CHILD

TOPICAL APPLICATION OF FLUORIDE: NO BENEFITS ARE PAYABLE FOR MORE THAN ANY COMBINATION OF TWO APPLICATIONS OF STANNOUS FLUORIDE OR ACID FLUORIDE PHOSPHATE DURING ANY BENEFIT YEAR.

TOPICAL APPILCATION OF FLUORIDE VARNISH TOPICAL APPLICATION OF FLUORIDE

OTHER PREVENTIVE SERVICES:

NUTRITIONAL COUNSELING FOR THE CONTROL OF DENTAL DISEASE TOBACCO COUNSELING ORAL HYGIENE INSTRUCTION SEALANT - TOPICAL APPLICATION OF SEALANTS PER TOOTH, FOR UNRESTORED, RECENTLY ERUPTED PERMANENT MOLARS FOR PATIENTS THROUGH AGE 15. ONE TREATMENT EVERY THREE YEARS PER TOOTH PREVENTIVE RESIN RESTORATION IN A MODERATE TO HIGH CARIES RISK PATIENT- PERMANENT TOOTH SEALANT REPAIR- PER TOOTH INTERIM CARIES ARRESTING MEDICAMENT APPLICATION

BY REPORT

$30.10 $27.60

$13.10 $13.10

NC NC NC $19.30 $26.60 $15.44 NC

SPACE MAINTAINERS (CHILD):

SPACE MAINTAINER - FIXED- UNILATERAL SPACE MAINTAINER - FIXED - BILATERAL, MAXILLARY SPACE MAINTAINER - FIXED - BILATERAL, MANDIBULAR SPACE MAINTAINER - REMOVABLE- UNILATERAL SPACE MAINTAINER - REMOVABLE- BILATERAL, MAXILLARY SPACE MAINTAINER - REMOVABLE - BILATERAL, MANDIBULAR RECEMENTATION OF SPACE MAINTAINER REMOVAL OF FIXED SPACE MAINTAINER- PERFORMED BY A DENTIST WHO DID NOT ORIGINALLY PLACE THE APPLIANCE DISTAL SHOE SPACE MAINTAINER - FIXED - UNILATERAL

UNCLASSIFIED TREATMENT:

UNSPECIFIED PREVENTIVE PROCEDURE, BY REPORT PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN- MINOR PROCEDURES

PROFESSIONAL CONSULTATION:

CONSULTATION (DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN REQUESTING DENTIST OR PHYSICIAN)

PERIODONTAL MAINTENANCE (ONLY ALLOWED WITH HISTORY OF PERIODONTAL THERAPY):

PERIODONTAL MAINTENANCE PROCEDURE

MISCELLANEOUS SERVICES:

APPLICATION OF DESENSITIZING MEDICAMENTS (NO MORE THAN TWO PROCEDURES PER QUADRANT IN ANY BENEFIT YEAR)- NARRATIVE REQUIRED APPLICATION OF DESENSITIZING RESIN- PER TOOTH

$127.50 $192.30 $192.30 $69.60 $174.40 $174.40 $33.70 $25.50 $127.50

BY REPORT $21.70

$24.00

$45.70

$15.60 NC

4

D2140 D2150 D2160 D2161 D2951

D2330 D2331 D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2410 D2420 D2430 D2940 D2951

D2921 D2941 D2949

D3110 D3120

D3220 D3221 D3222

CLASS II. BASIC DENTAL SERVICES (PAYABLE AT 80% OF THE STATE ALLOWANCE AFTER THE BENEFIT YEAR DEDUCTIBLE)

NO BENEFITS ARE PAYABLE FOR TEMPORARY PROCEDURES WHICH ARE CONSIDERED PART OF A MORE DEFINITIVE TREATMENT.

AMALGAM RESTORATIONS (INCLUDING ALL ADHESIVES, BONDING AGENTS, BASES, LINERS AND PULP CAPS):

AMALGAM - ONE SURFACE, PERMANENT AMALGAM - TWO SURFACES, PERMANENT AMALGAM - THREE SURFACES, PERMANENT AMALGAM - FOUR OR MORE SURFACES, PERMANENT PIN RETENTION - PER TOOTH, IN ADDITION TO RESTORATION

COMPOSITE RESTORATIONS (INCLUDING ALL ADHESIVES, BONDING AGENTS, BASES, LINERS AND PULP CAPS):

RESIN - ONE SURFACE, ANTERIOR RESIN - TWO SURFACES, ANTERIOR RESIN - THREE SURFACES, ANTERIOR RESIN-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) RESIN-BASED COMPOSITE CROWN, ANTERIOR RESIN-BASED COMPOSITE - ONE SURFACE, POSTERIOR (ALTERNATE PROCEDURE RULE APPLIES- ALLOWANCE IS THE SAME AS D2140) RESIN-BASED COMPOSITE - TWO SURFACES, POSTERIOR (ALTERNATE PROCEDURE RULE APPLIES- ALLOWANCE IS THE SAME AS D2150) RESIN-BASED COMPOSITE - THREE SURFACES, POSTERIOR (ALTERNATE PROCEDURE RULE APPLIES- ALLOWANCE IS THE SAME AS D2160) RESIN-BASED COMPOSITE - FOUR OR MORE SURFACES, POSTERIOR (ALTERNATE PROCEDURE RULE APPLIES- ALLOWANCE IS THE SAME AS D2161) GOLD FOIL-ONE SURFACE GOLD FOIL-TWO SURFACE GOLD FOIL-THREE SURFACE PROTECTIVE RESTORATION PIN RETENTION- PER TOOTH, IN ADDITION TO RESTORATION

OTHER RESTORATIVE SERVICES:

REATTACHMENT OF TOOTH FRAGMENT, INCISAL EDGE OR CUSP INTERIM THERAPEUTIC RESTORATION- PRIMARY DENTITION RESTORATIVE FOUNDATION FOR AN INDIRECT RESTORATION

ENDODONTICS:

PULP CAPPING:

PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION) PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION)

PULPOTOMY:

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 DEVELOPMMENT

$33.90 $44.80 $54.60 $68.80 $14.20

$39.30 $53.60 $65.60 $72.10 $192.50

NC NC NC NC NC NC NC $37.40 $14.20

NC NC NC

NC NC

$42.60 $42.60 $42.60

5

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