Dental Coverage Details

The below details for dental coverage do not apply to all plans.  All SoloCare plans include pediatric dental benefits for children up to the age of 19.  Some SoloCare plans include embedded dental coverage for adults.  To confirm your patient’s plan includes dental coverage, please refer to the Member’s ID card or Summary of Benefits and Coverage. You may also call Customer Service (800-811-4793) to verify patient eligibility for dental services.

Note:  Network Participation is not required.  Please visit the Certificate of Coverage for additional details.

Note:  Adult Dental Coverage is subject to a $1,000 Benefit Max per plan year.

Note:  Dental Services do not require Prior Authorization.

DENTAL CODEDESCRIPTIONSERVICE LIMITSMEMBER COST SHAREALLOWED AMOUNT
D0120PERIODIC ORAL EVALUATION EST PT2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$65.91Preventive Dental Care
D0150COMP ORAL EVALUATION - NEW/EST PT2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$116.00Preventive Dental Care
D0140LTD ORAL EVALUATION - PROBLEM FOCUS2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$110.00Preventive Dental Care
D0145ORL EVAL PT<3 YR CNSL PRIM CAREGIVR2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$105.64Preventive Dental Care
D0160DTL&EXT ORAL EVAL - PROB FOCUS RPT2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$234.75Preventive Dental Care
D0170RE-EVALUATION - LTD PROBLEM FOCUSED2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$81.26Preventive Dental Care
D0180COMP PERIODONTAL EVAL - NEW/EST PT2 per yearFirst 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$130.01Preventive Dental Care
D0210INTRAORAL-CMPL SER RADIOGRAPH IMAGS1 per 3 yearsFirst 2 - No Cost Share Any Subsquent Within The 3 Calendar Year Period - Non-Covered$185.00Preventive Dental Care
D0270BITEWING - SINGLE RADIOGRAPHC IMAGE2 per year (Any Bitewing Combination)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$38.00Preventive Dental Care
D0272BITEWINGS - TWO RADIOGRAPHIC IMAGES2 per year (Any Bitewing Combination)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$61.00Preventive Dental Care
D0273BITEWINGS-THREE RADIOGRAPHIC IMAGES2 per year (Any Bitewing Combination)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$74.00Preventive Dental Care
D0274BITEWINGS - FOUR RADIOGRAPHC IMAGES2 per year (Any Bitewing Combination)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$85.00Preventive Dental Care
D0277VERT BITEWNGS - 7-8 RADIOGRAPH IMAG2 per year (Any Bitewing Combination)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$92.13Preventive Dental Care
D0330PANORAMIC RADIOGRAPHIC IMAGE1 per 5 yearsFirst - No Cost Share Any Subsquent Within The 5 Calendar Year Period - Non-Covered$167.03Preventive Dental Care
D1110PROPHYLAXIS - ADULT2 per year (Any Prophlyaxis Combination) First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$120.99Preventive Dental Care
D1120PROPHYLAXIS - CHILD2 per year (Any Prophlyaxis Combination) First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$80.36Preventive Dental Care
D1206TOPICAL APPLICATN FLUORIDE VARNISH2 per year - Pediatric Only (Any Varnish Combination)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$76.74Preventive Dental Care
D1208TOPICAL APPLICATION OF FLUORIDE2 per year - Pediatric Only (Any Varnish Combination)First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered$61.40Preventive Dental Care
D1351SEALANT - PER TOOTH1 per tooth per 3 years - Pediatric OnlyFirst Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered$73.13Preventive Dental Care
D1352PREV RSN REST MOD HIGH CARIES RISK1 per tooth per 3 years - Pediatric OnlyFirst Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered$218.50Preventive Dental Care
D2940PROTECTIVE RESTORATION1 per tooth per 3 years - Pediatric OnlyFirst Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered$361.15Preventive Dental Care
D2990RESIN FILL OF TOOH SURFACE1 per tooth per 3 years - Pediatric OnlyFirst Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered$101.12Preventive Dental Care
D1353SEALANT REPAIR - PER TOOTH1 per tooth per 3 years - Pediatric OnlyFirst Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered$51.47Preventive Dental Care
D1510SPACE MNTNR - FIXED UNI - PER QUAD1 Per tooth per Lifetime (Any Initial Placement Combination)First Space Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$450.54Preventive Dental Care
D1516SPACE MAINTAIN-FIXED-BILAT MAXIL1 Per tooth per Lifetime (Any Initial Placement Combination)First Space Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$648.27Preventive Dental Care
D1517SPACE MAINTAIN-FIXED BILAT MANDIB1 Per tooth per Lifetime (Any Initial Placement Combination)First Space Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$645.56Preventive Dental Care
D1520SPACE MNTNR - REMOV UNI - PER QUAD1 Per tooth per Lifetime (Any Initial Placement Combination)First Space Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$442.32Preventive Dental Care
D1526SPACE MAINTAIN- REMOVE-BILAT, MAXIL1 Per tooth per Lifetime (Any Initial Placement Combination)First Space Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$684.38Preventive Dental Care
D1527SPACE MNTAIN- REMOVE- BILAT, MANDIB1 Per tooth per Lifetime (Any Initial Placement Combination)First Space Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$684.38Preventive Dental Care
D1575DIST SHOE SPC MNTNR - FIX UNI-QUAD1 Per tooth per Lifetime (Any Initial Placement Combination)First Space Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$500.20Preventive Dental Care
D1551RE-CEM/RE-BOND BIL SPACE MNTNR-MAX1 Per tooth per Lifetime (Any Re-cement Combination)First Re-cement Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$100.22Preventive Dental Care
D1552RE-CEM/RE-BOND BIL SPC MNTNR - MAND1 Per tooth per Lifetime (Any Re-cement Combination)First Re-cement Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$99.32Preventive Dental Care
D1553RE-CEM/RE-BOND UNI SPACE MNTNR-QUAD1 Per tooth per Lifetime (Any Re-cement Combination)First Re-cement Maintainer Per Tooth - No Cost Share Any subsequent for that same tooth during a member's lifetime - Non-Covered$99.32Preventive Dental Care
D1556REMV FIX UNI SPACE MNTNR - PER QUADRemoval of Space Maintainers is only covered if NOT preformed by the provider who placed them or a provider in the same practice. When preformed by the same physician/practice, it is considered part of the placement.$82.16Preventive Dental Care
D1557REMOVAL FIXED BIL SPACE MNTNR - MAXRemoval of Space Maintainers is only covered if NOT preformed by the provider who placed them or a provider in the same practice. When preformed by the same physician/practice, it is considered part of the placement.$82.16Preventive Dental Care
D1558REMOVAL FIX BIL SPACE MNTNR - MANDRemoval of Space Maintainers is only covered if NOT preformed by the provider who placed them or a provider in the same practice. When preformed by the same physician/practice, it is considered part of the placement.$83.97Preventive Dental Care
D0171RE-EVALUATION-POST-OP OFFICE VISITInclude In Surgical Procedure Global$57.83Basic & Restorative Services
D0220IO-PERIAPICAL 1ST RADIOGRAPHC IMAGEAs Needed For DiagnosisMember Cost Share$37.02Basic & Restorative Services
D0230IO-PERIAPICAL EA ADD RADIOGRPH IMAGAs Needed For DiagnosisMember Cost Share$34.31Basic & Restorative Services
D0240INTRAORAL-OCCLUSAL RADIOGRAPH IMAGEAs Needed For DiagnosisMember Cost Share$52.37Basic & Restorative Services
D0250EXTRA-ORAL - 2D PROJECTION X-RAYAs Needed For DiagnosisMember Cost Share$70.42Basic & Restorative Services
D0251EXTRA-ORAL POSTERIOR DENTAL X-RAYAs Needed For DiagnosisMember Cost Share$50.06Basic & Restorative Services
D0460PULP VITALITY TESTSAs Needed For DiagnosisMember Cost Share$57.78Basic & Restorative Services
D2140AMALGAM-ONE SURFACE PRIMARY/PERM1 Per Tooth Surface Per 2 YearsMember Cost Share$156.20Basic & Restorative Services
D2150AMALGAM-TWO SURFACES PRIMARY/PERM1 Per Tooth Surface Per 2 YearsMember Cost Share$213.08Basic & Restorative Services
D2160AMALGAM-3 SURFACES PRIMARY/PERM1 Per Tooth Surface Per 2 YearsMember Cost Share$254.61Basic & Restorative Services
D2161AMALGAM-FOUR/MORE SURF PRIM/PERM1 Per Tooth Surface Per 2 YearsMember Cost Share$292.53Basic & Restorative Services
D2330RESIN-BASED COMPOSITE ONE SURF ANT1 Per Tooth Surface Per 2 YearsMember Cost Share$219.40Basic & Restorative Services
D2331RESIN-BASED COMPOSITE 2 SURFACE ANT1 Per Tooth Surface Per 2 YearsMember Cost Share$283.50Basic & Restorative Services
D2332RESIN-BASED COMPOSITE 3 SURFACE ANT1 Per Tooth Surface Per 2 YearsMember Cost Share$337.68Basic & Restorative Services
D2335RESIN COMP 4/> SURF INCISAL ANGLE1 Per Tooth Surface Per 2 YearsMember Cost Share$393.66Basic & Restorative Services
D2391RESIN COMPOS - 1 SURFACE POSTERIOR1 Per Tooth Surface Per 2 YearsMember Cost Share$237.00Basic & Restorative Services
D2392RESIN COMPOS - 2 SURFACES POSTERIOR1 Per Tooth Surface Per 2 YearsMember Cost Share$310.00Basic & Restorative Services
D2393RESIN COMPOS - 3 SURFACES POSTERIOR1 Per Tooth Surface Per 2 YearsMember Cost Share$385.00Basic & Restorative Services
D2394RESIN COMPOS - 4/MORE SURFACES POST1 Per Tooth Surface Per 2 YearsMember Cost Share$490.26Basic & Restorative Services
D9110PALLIATVE TX DENTAL PAIN-MINOR PROCService covered for infection or temporary pain relief only if no other services outside of the exam and x-rays were performed on the same date of service.Member Cost Share$160.00Basic & Restorative Services
D2921REATTCH TOOTH FRAG INCISL EDGE/CUSPService covered for infection or temporary pain relief only if no other services outside of the exam and x-rays were performed on the same date of service.Member Cost Share$303.37Basic & Restorative Services
D9610TX PARENTRAL DRUG 1 ADMINISTRATIONService covered for infection or temporary pain relief only if no other services outside of the exam and x-rays were performed on the same date of service.Member Cost Share$87.58Basic & Restorative Services
D9612TX PARENTERAL RX 2/> ADMIN DIFF MEDService covered for infection or temporary pain relief only if no other services outside of the exam and x-rays were performed on the same date of service.Member Cost Share$101.80Basic & Restorative Services
D9310CNSLT DX DENT/PHY NOT REQ DENT/PHYMember Cost Share$170.47Basic & Restorative Services
D9311CONSULTATION W/MED HEALTH CARE PROFMember Cost Share$176.91Basic & Restorative Services
D9440OV-AFTER REGULARLY SCHEDULED HOURSMember Cost Share$183.28Basic & Restorative Services
D9930TX COMPS - UNUSUL CIRCUMSTANCES RPTMember Cost Share$94.45Basic & Restorative Services
D3110PULP CAP - DIRECTMember Cost Share$110.15Basic & Restorative Services
D3120PULP CAP - INDIRECTMember Cost Share$87.58Basic & Restorative Services
D2951PIN RETN - PER TOOTH ADDITION REST1 Per Tooth Per 5 YearsMember Cost Share$74.94Major & Complex Services
D2915RECEMENT CAST/PREFAB POST & CORE1 Per Tooth Per 5 YearsMember Cost Share$105.58Major & Complex Services
D2950CORE BUILDUP INCL PINS WHEN REQUIRE1 Per Tooth Per 5 YearsMember Cost Share$357.54Major & Complex Services
D2952POST & CORE ADD CROWN INDIRECT FAB1 Per Tooth Per 5 YearsMember Cost Share$1,136.73Major & Complex Services
D2953EA ADD INDIRECT FAB POST SAME TOOTH1 Per Tooth Per 5 YearsMember Cost Share$230.06Major & Complex Services
D2954PREFABR POST&CORE ADDITION CROWN1 Per Tooth Per 5 YearsMember Cost Share$406.30Major & Complex Services
D2955POST REMOVAL1 Per Tooth Per 5 YearsMember Cost Share$353.93Major & Complex Services
D2957EA ADD PREFABR POST - SAME TOOTH1 Per Tooth Per 5 YearsMember Cost Share$228.43Major & Complex Services
D3220TX PULPOT-CORONL DENTNOCEMENTL JUNC1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$225.72Major & Complex Services
D3221PULPAL DEBRID PRIMARY&PERM TEETH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$247.39Major & Complex Services
D3222PART PULPOTMY APEXOGNEIS PERM TOOTH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$367.47Major & Complex Services
D3230PULPAL THERAPY - ANT PRIMARY TOOTH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$241.07Major & Complex Services
D3240PULPAL THERAPY - POST PRIMARY TOOTH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$297.05Major & Complex Services
D3310ENDODONTIC THERAPY ANTERIOR TOOTH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$956.15Major & Complex Services
D3320ENDODONTIC THERAPY PREMOLAR TOOTH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,171.04Major & Complex Services
D3330ENDODONTIC THERAPY MOLAR TOOTH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,475.31Major & Complex Services
D3331TX RC OBSTRUCTION; NON-SURG ACCESS1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$373.79Major & Complex Services
D3332INCMPL ENDO TX;INOP UNRSTR/FX TOOTH1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$549.23Major & Complex Services
D3333INTRL ROOT REPAIR PERFORATION DEFEC1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$324.13Major & Complex Services
D3346RETX PREVIOUS RC THERAPY - ANTERIOR1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$38,525.00Major & Complex Services
D3347RETREATMENT PREVIOUS RC TX-PREMOLAR1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,474.40Major & Complex Services
D3348RETX PREVIOUS RC THERAPY - MOLAR1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,852.71Major & Complex Services
D3351APEX/RECALCIFICATION INITIAL VISIT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$584.16Major & Complex Services
D3352APEX/RECALCIFICATN INTRM MED REPLAC1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$260.03Major & Complex Services
D3353APEXIFICAT/RECALCIFICAT-FINAL VISIT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,153.88Major & Complex Services
D3355PULPAL REGENERATION - INITIAL VISIT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$584.16Major & Complex Services
D3356PULPAL REGENERATION - MED REPLACMNT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$259.13Major & Complex Services
D3357PULPAL REGENERATION - COMPLETION TX1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$930.87Major & Complex Services
D3410APICOECTOMY - ANTERIOR1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,173.74Major & Complex Services
D3421APICOECTOMY - PREMOLAR1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,296.54Major & Complex Services
D3425APICOECTOMY - MOLAR FIRST ROOT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,472.60Major & Complex Services
D3426APICOECTOMY1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$486.65Major & Complex Services
D3430RETROGRADE FILLING - PER ROOT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$371.99Major & Complex Services
D3920HEMISECTION NOT INCL RC THERAPY1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$790.02Major & Complex Services
D3950CANAL PREP&FIT PREFORMED DOWEL/POST1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$260.03Major & Complex Services
D3450ROOT AMPUTATION - PER ROOT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$789.12Major & Complex Services
D3471SURG REPR OF ROOT RESORPTION - ANT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,032.89Major & Complex Services
D3472SURG REPR OF ROOT RESORPTION - PM1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,032.89Major & Complex Services
D3473SURG REPR OF ROOT RESORPTN - MOLAR1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,032.89Major & Complex Services
D3501SURG EXP RS NO APCECTMY/REPR RR-ANT1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,032.89Major & Complex Services
D3502SURG EXP RS NO APCECTOMY/REPR RR-PM1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,032.89Major & Complex Services
D3503SUR EXP RS NO APICOECT/RPR RR - MOL1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit)Member Cost Share$1,032.89Major & Complex Services
D3428BONE GRAFT PERIRADICULR SURG 1 SITE1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$777.65Major & Complex Services
D3429BONE GRAFT PERIRADICULR SURG EA ADD1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$736.26Major & Complex Services
D4263BN REPL GR-RET NAT TT-1ST SITE QUAD1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$714.18Major & Complex Services
D4264BRG-RET NAT TOOTH-EA ADD SITE QUAD1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$697.02Major & Complex Services
D6103BONE GRAFT REPAIR PERI-IMPL DEFECT1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$690.70Major & Complex Services
D6104BONE GRAFT TIME IMPLANT PLACEMENT1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$510.13Major & Complex Services
D7949LEFORT II/LEFORT III - W/BONE GRAFT1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$2,109.89Major & Complex Services
D7953BONE REPLCMT GRAFT RIDGE PRES -SITE1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit)Member Cost Share$517.35Major & Complex Services
D4210GINGIVECT/PLSTY 4/>CNTIG TEETH QUAD1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Ginivectomy/Gingivoplasty Combination Limit)Member Cost Share$1,124.09Major & Complex Services
D4211GINGIVECT/PLSTY 1-3CNTIG TEETH QUAD1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Ginivectomy/Gingivoplasty Combination Limit)Member Cost Share$604.93Major & Complex Services
D4212GING/GINGIVOPLASTY RES PROC-TOOTH1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Ginivectomy/Gingivoplasty Combination Limit)Member Cost Share$386.43Major & Complex Services
D4240GINGL FLP 4/>CNTIG/TOOTH BOUND QUAD1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Gingival Flap Procedure Combination Limit)Member Cost Share$1,503.30Major & Complex Services
D4241GINGL FLP 1-3 CNTIG/TOOTH BND QUAD1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Gingival Flap Procedure Combination Limit)Member Cost Share$915.52Major & Complex Services
D4245APICALLY POSITIONED FLAP1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Gingival Flap Procedure Combination Limit)Member Cost Share$1,089.78Major & Complex Services
D4249CLIN CROWN LEN - HARD TISSUE1 per Quadrant per 3 Years Member Cost Share$1,543.02Major & Complex Services
D4260OSSEOUS SURG 4/> CNTIG TEETH QUAD1 per Quadrant per 3 Years Member Cost Share$2,363.74Major & Complex Services
D4261OSSEOUS SURG 1-3 CNTIG TEETH QUAD1 per Quadrant per 3 Years Member Cost Share$1,358.83Major & Complex Services
D4268SURGICAL REVISION PROC PER TOOTH1 per Quadrant per 3 Years Member Cost Share$457.38Major & Complex Services
D4274MESIAL/DISTAL WEDGE PROC 1 TOOTH1 per Quadrant per 3 Years Member Cost Share$1,245.97Major & Complex Services
D4270PEDICLE SOFT TISSUE GRAFT PROCEDURE1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$1,682.07Major & Complex Services
D4273AUTOGEN CONNECTIVE TISS GRAFT PROC1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$1,862.64Major & Complex Services
D4275NON-AUTOGENOUS CONNECTIVE TISS GRFT1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$1,837.36Major & Complex Services
D4276COMB CNCTIV TISS&PED GRFT PER TOOTH1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$1,102.31Major & Complex Services
D4277FREE SFT TSS GFT 1ST T/EDNTULOUS T1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$36,929.00Major & Complex Services
D4278FREE ST GFT EA CNTG T/EDNT T SAME S1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$1,020.25Major & Complex Services
D4283AUTOGEN CONNECTIVE TISS GRAFT PROC1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$939.00Major & Complex Services
D4285NON-AUTOGEN CNCT TISSUE GRAFT PROC1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$943.51Major & Complex Services
D4266GUID TISS REGEN-RESORB BARRIER-SITE1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$650.98Major & Complex Services
D4267GUID TISS REGEN-NONRESORB BARRIER1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit)Member Cost Share$778.28Major & Complex Services
D4341PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUADPeds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 YearsMember Cost Share$449.63Major & Complex Services
D4342PRDONTAL SCAL&ROOT PLAN 1-3 TEETHPeds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 YearsMember Cost Share$333.16Major & Complex Services
D4346SCALING PRES GEN MOD/SEV GING INFPeds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 YearsMember Cost Share$210.37Major & Complex Services
D6080IMPL MAINT PROC REMV REINSRT CLEANPeds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 YearsMember Cost Share$295.24Major & Complex Services
D6081SCAL&DEB INF/MUCST 1 IMPL NO F EN&CPeds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 YearsMember Cost Share$124.84Major & Complex Services
D4355FM DEBR ENBL COMP OR E&DX SUBQ VST1 Per LifetimeMember Cost Share$232.04Major & Complex Services
D4910PERIODONTAL MAINTENANCEPeds: 4 Per Year Adults: 2 Per YearMember Cost Share$206.76Major & Complex Services
D5850TISSUE CONDITIONING MAXILLARY1 Per 2 YearsMember Cost Share$235.65Major & Complex Services
D5851TISSUE CONDITIONING MANDIBULAR1 Per 2 YearsMember Cost Share$235.65Major & Complex Services
D6010SURG PLCMT IMPL BODY: ENDOSTEALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,756.49Major & Complex Services
D6012SURG PLCMT INTERIM IMPL PROS: ENDOSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,812.05Major & Complex Services
D6013SURGICAL PLACEMENT OF MINI IMPLANTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,789.00Major & Complex Services
D6040SURG PLACEMENT: EPOSTEAL IMPLANTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$6,092.39Major & Complex Services
D6050SURG PLACEMENT: TRANSOSTEAL IMPLANTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$10,313.60Major & Complex Services
D6051INTERIM IMPLANT ABUTMENT PLACEMENTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$652.78Major & Complex Services
D6055CONNECTING BAR IMPLANT/ABUT SUPPORTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,465.42Major & Complex Services
D6056PREFAB ABUTMENT-INCL MOD & PLCMNTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$783.70Major & Complex Services
D6057CUSTOM FAB ABUTMENT-INCL PLACEMENTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$904.69Major & Complex Services
D6058ABUT SUPP PORCELN/CERAMIC CROWNPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,895.15Major & Complex Services
D6059ABUT PORCLN TO MTL CRWN HI NOBL MTLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,473.50Major & Complex Services
D6060ABUT PORCLN TO METL CROWN BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,330.27Major & Complex Services
D6061ABUT PORCLN TO MTL CROWN NOBLE MTLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,586.36Major & Complex Services
D6062ABUT SUPP CAST MTL CRWN HI NOBL MTLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,844.58Major & Complex Services
D6063ABUT SUPP CAST METL CROWN BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,321.13Major & Complex Services
D6064ABUT SUPP CAST METL CROWN NOBL METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,306.97Major & Complex Services
D6065IMPLANT SUPP PORCELN/CERAMIC CROWNPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,282.48Major & Complex Services
D6066IMPL SUPP CR-PORCELN FU HI NBL ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,156.98Major & Complex Services
D6067IMPLANT SUPP CROWN-HI NOBLE ALLOYSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,188.58Major & Complex Services
D6068ABUT SUPP RETAIN PORCELN/CERAM FPDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,437.38Major & Complex Services
D6069ABUT RETN PORCLN MTL FPD HI NOBL MTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,908.69Major & Complex Services
D6070ABUT RETN PORCLN METL FPD BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,803.05Major & Complex Services
D6071ABUT SUPP RETN PORCLN FUSD METL FPDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,552.05Major & Complex Services
D6072ABUT SUPP RETAIN CAST METAL FPDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,512.32Major & Complex Services
D6073ABUT RETN CAST METL FPD BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,379.21Major & Complex Services
D6074ABUT RETN CAST METL FPD NOBL METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,360.74Major & Complex Services
D6075IMPLANT SUPP RETAIN CERAMIC FPDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,240.05Major & Complex Services
D6076IMPL SUP RET FPD-PRCLN F HI NBL ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,174.14Major & Complex Services
D6077IMPL SUPP RET METAL FPD-HI NBL ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,115.45Major & Complex Services
D6082IMPL SUP CR-PRCLN FU PREDM BASE ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,515.77Major & Complex Services
D6083IMPLANT SUPP CRWN - PORCELN FU NBLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,950.22Major & Complex Services
D6084IMPLANT SUPPORTED CROWN - PORCELN FPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$33,225.00Major & Complex Services
D6086IMPLANT SUPP CRWN - PREDOM BASE ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,285.17Major & Complex Services
D6087IMPLANT SUPP CROWN - NOBLE ALLOYSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$33,325.00Major & Complex Services
D6088IMPLANT SUPP CROWN - TI & TI ALLOYSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,930.36Major & Complex Services
D6090REPAIR IMPL SUPP PROSTH BY REPORTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$190.17Major & Complex Services
D6091REPL RP ATT IMPL/ABUT S PROS PERPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$463.18Major & Complex Services
D6092RECEMENT IMPL/ABUT SUPPORTED CROWNPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$148.98Major & Complex Services
D6093RECEMENT IMPL/ABUT FIX PART DENTUREPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$224.82Major & Complex Services
D6094ABUTMENT SUPP CROWN - TI & TI ALLOYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,046.74Major & Complex Services
D6095REPAIR IMPLANT ABUTMENT BY REPORTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$266.12Major & Complex Services
D6096REMOVE BROKEN IMPL RETAINING SCREWPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$467.69Major & Complex Services
D6097ABUT SUPP CR-PORCELN FU TI & TI ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,442.28Major & Complex Services
D6098IMPL SUPP RETN - PORC FU PDMT B ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,141.94Major & Complex Services
D6099IMPL SUP RTN FPD-PORCELN FU NBL ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,950.22Major & Complex Services
D6100SURGICAL REMOVAL OF IMPLANT BODYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$754.81Major & Complex Services
D6101DEBR PRIIMPL DEF CLN EXPSD IMPL FLPPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$915.52Major & Complex Services
D6102DEBR&OSS CNTR PRIIMPL DEF;CLN SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,353.42Major & Complex Services
D6110IMPL/ABUT SUPP RMV D EDENT ARCH-MAXPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,512.72Major & Complex Services
D6111IMPL/ABUT SUPP RMV D EDENT ARCH-MNDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,512.72Major & Complex Services
D6112IMPL/ABUT SUP RMV D PR EDNT ARCH-MXPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,581.33Major & Complex Services
D6113IMPL/ABUT SP RMV D PR EDNT ARCH-MNDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$2,576.82Major & Complex Services
D6114IMPL/ABUT SP FIXED D EDENT ARCH-MAXPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$8,801.27Major & Complex Services
D6115IMPL/ABUT SUP FIXD D EDENT ARCH-MNDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$8,859.06Major & Complex Services
D6116IMPL/ABUT SUP F D PR EDENT ARCH-MAXPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$4,323.89Major & Complex Services
D6117IMPL/ABUT SP FIXD D PR EDENT ARCH-MPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$4,323.89Major & Complex Services
D6118IMP/ABUT SPTD INT D EDENT ARCH-MPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,788.63Major & Complex Services
D6119IMPL/ABUT SPT INT F D EDNT ARCH-MAXPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,788.63Major & Complex Services
D6120IMPL SUP RET PRCLN FU TIT & TIT ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,565.38Major & Complex Services
D6121IMPL SUP RET MTL FPD PREDM BASE ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,950.22Major & Complex Services
D6122IMPL SUP RET METAL FPD - NOBLE ALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,452.59Major & Complex Services
D6123IMPL SUP RET MTL FPD TIT & TIT ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,930.36Major & Complex Services
D6190RADIOGRAPHIC/SURG IMPLANT INDX RPTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$587.77Major & Complex Services
D6191SEMI-PRECISION ABUTMENT - PLACEMENTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,394.05Major & Complex Services
D6192SEMI-PRECISION ATTACHMENT - PLCMTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,394.05Major & Complex Services
D6194ABUT SUP RET CRWN FPD TIT & TIT ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,399.46Major & Complex Services
D6195ABUT SUP RET-PRCLN FU TIT & TIT ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$1,439.19Major & Complex Services
D6198REMOVE INTERIM IMPLANT COMPONENTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 yearsMember Cost Share$68.34Major & Complex Services
D2510INLAY - METALLIC - ONE SURFACEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$905.59Major & Complex Services
D2520INLAY - METALLIC - TWO SURFACESPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,181.87Major & Complex Services
D2530INLAY - METALLIC - 3/MORE SURFACESPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,184.58Major & Complex Services
D2542ONLAY - METALLIC - TWO SURFACESPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,164.72Major & Complex Services
D2543ONLAY METALLIC THREE SURFACESPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,245.97Major & Complex Services
D2544ONLAY METALLIC FOUR OR MORE SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,326.33Major & Complex Services
D2610INLAY - PORCELN/CERAMIC - 1 SURFACEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$935.38Major & Complex Services
D2620INLAY - PORCELN/CERAMIC - 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,232.43Major & Complex Services
D2630INLAY - PORCELN/CERAM - 3/MORE SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,259.52Major & Complex Services
D2642ONLAY - PORCELN/CERAMIC - 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,184.58Major & Complex Services
D2643ONLAY - PORCELN/CERAMIC - 3 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,204.44Major & Complex Services
D2644ONLAY - PORCELN/CERAM - 4/MORE SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,352.51Major & Complex Services
D2650INLAY RESIN COMPOSITE ONE SURFACEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$842.39Major & Complex Services
D2651INLAY RESIN COMPOSITE TWO SURFACESPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$880.31Major & Complex Services
D2652INLAY RESIN COMPOSITE 3/> SURFACESPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$939.00Major & Complex Services
D2662ONLAY-RSN COMPOS COMPOS/RSN-2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$874.89Major & Complex Services
D2663ONLAY-RSN COMPOS COMPOS/RSN-3 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$943.51Major & Complex Services
D2664ONLAY RESIN COMPOSITE 4/> SURFACESPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$1,000.39Major & Complex Services
D2910RECEMENT INLAY ONLAY/PART COV RESTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth,the limit will be applied.Member Cost Share$138.14Major & Complex Services
D2390RESIN COMPOS CROWN ANTERIORPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$469.50Major & Complex Services
D2710CROWN - RESIN-BASED COMPOSITEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$542.63Major & Complex Services
D2712CROWN - 3/4 RESIN-BASED COMPOSITEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$616.04Major & Complex Services
D2720CROWN - RESIN WITH HIGH NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,226.37Major & Complex Services
D2721CROWN - RESIN PREDOM BASE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,155.12Major & Complex Services
D2722CROWN - RESIN WITH NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,182.20Major & Complex Services
D2740CROWN - PORCELAIN/CERAMICPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,505.10Major & Complex Services
D2750CROWN - PORCELN FUSED HI NOBLE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,542.12Major & Complex Services
D2751CROWN-PORCELN FUSD PREDOM BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,110.99Major & Complex Services
D2752CROWN - PORCELAIN FUSED NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,621.57Major & Complex Services
D2753CROWN - PORCLN FUSD TO TIT & TIT ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,154.67Major & Complex Services
D2780CROWN - 3/4 CAST HIGH NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,441.00Major & Complex Services
D2781CROWN - 3/4 CAST PREDOM BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,088.83Major & Complex Services
D2782CROWN - 3/4 CAST NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,574.62Major & Complex Services
D2783CROWN - 3/4 PORCELAIN/CERAMICPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,351.61Major & Complex Services
D2790CROWN - FULL CAST HIGH NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,530.38Major & Complex Services
D2791CROWN - FULL CAST PREDOM BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,086.28Major & Complex Services
D2792CROWN - FULL CAST NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,139.47Major & Complex Services
D2794CROWN - TITANIUM AND TITANIUM ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,201.43Major & Complex Services
D2920RECEMENT CROWNPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$140.85Major & Complex Services
D2928PREFAB PORC/CER CROWN - PERM TOOTHPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$421.52Major & Complex Services
D2929PREFAB PORC/CERAMC CROWN-PRIM TOOTHPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$496.58Major & Complex Services
D2930PRFABR STAINLESS STEEL CROWN-PRIMPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$383.72Major & Complex Services
D2931PRFABR STAINLESS STEEL CROWN-PERMPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$460.47Major & Complex Services
D2932PREFABRICATED RESIN CROWNPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$409.91Major & Complex Services
D2933PRFABR STNLSS STEEL CROWN RSN WNDOWPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$386.72Major & Complex Services
D2934PREFB ESTHET COAT STNLSS STEEL CRWNPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$506.52Major & Complex Services
D2960LABIAL VENEER - DIRECTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$920.03Major & Complex Services
D2961LABIAL VENEER RESIN LAM - INDIRECTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,087.07Major & Complex Services
D2962LABIAL VNR PORCELAIN LAM - INDIRECTPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,671.23Major & Complex Services
D2971ADD PRC CSTMZ CR UND XST PRT D FRWKPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$139.35Major & Complex Services
D2980CROWN REPR NEC RESTORATV MATL FAILPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$257.32Major & Complex Services
D5110COMPLETE DENTURE - MAXILLARYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,798.93Major & Complex Services
D5120COMPLETE DENTURE - MANDIBULARPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,792.61Major & Complex Services
D5130IMMEDIATE DENTURE - MAXILLARYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,814.28Major & Complex Services
D5140IMMEDIATE DENTURE - MANDIBULARPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,792.61Major & Complex Services
D5211MAXILLARY PARTIAL DENTUR RESIN BASEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,712.00Major & Complex Services
D5212MANDIB PARTIAL DENTURE RESIN BASEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$32,825.00Major & Complex Services
D5213MAX PRTL DENTURE- CAST METAL FWPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,830.53Major & Complex Services
D5214MAND PRTL DENTURE - CAST METAL FWPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,830.53Major & Complex Services
D5221IMMED MAX PRTL DENTURE - RESIN BASEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,154.21Major & Complex Services
D5222IMMED MAND PRTL DENTURE - RESN BASEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,274.77Major & Complex Services
D5223IMMED MAX PRTL D - CAST METAL FWPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,633.69Major & Complex Services
D5224IMMED MAND PRTL D - CAST MTL FWPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,668.91Major & Complex Services
D5225MAXILLARY PART DENTURE - FLEX BASEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,675.75Major & Complex Services
D5226MANDIBULAR PART DENTURE - FLEX BASEPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,675.75Major & Complex Services
D5282REMV UNI PRT D - 1 PC CAST METL MAXPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$878.50Major & Complex Services
D5283REMV UNI PRT D - 1 PC C METL MANDPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$878.50Major & Complex Services
D5284REMV UNI PD-1 PECE FLEX BS-PER QUADPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$876.70Major & Complex Services
D5286REMV UNI PD - 1 PECE RESIN-PER QUADPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$800.86Major & Complex Services
D5410ADJUST COMPLETE DENTURE - MAXILLARYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$139.00Major & Complex Services
D5411ADJUST COMPLETE DENTUR - MANDIBULARPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$139.00Major & Complex Services
D5421ADJUST PARTIAL DENTURE - MAXILLARYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$139.00Major & Complex Services
D5422ADJUST PARTIAL DENTURE - MANDIBULARPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$139.00Major & Complex Services
D5863OVERDENTURE - COMPLETE MAXILLARYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,818.79Major & Complex Services
D5864OVERDENTURE - PARTIAL MAXILLARYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,818.79Major & Complex Services
D5865OVERDENTURE - COMPLETE MANDIBULARPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,882.90Major & Complex Services
D5866OVERDENTURE - PARTIAL MANDIBULARPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$2,818.79Major & Complex Services
D6205PONTIC INDIRECT RESIN BASED COMPOSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$818.01Major & Complex Services
D6210PONTIC - CAST HIGH NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,505.10Major & Complex Services
D6211PONTIC - CAST PREDOM BASE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,060.25Major & Complex Services
D6212PONTIC - CAST NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,117.16Major & Complex Services
D6214PONTIC - TITANIUM & TITANIUM ALLOYSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,094.33Major & Complex Services
D6240PONTIC-PORCELN FUSED HI NOBLE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,498.78Major & Complex Services
D6241PONTIC-PORCLN FUSD PREDOM BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,470.79Major & Complex Services
D6242PONTIC - PORCELN FUSED NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,417.52Major & Complex Services
D6243PONTIC - PORCELN FU TIT & TIT ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,332.65Major & Complex Services
D6245PONTIC - PORCELAIN/CERAMICPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,533.09Major & Complex Services
D6250PONTIC - RESIN W/HIGH NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,145.09Major & Complex Services
D6251PONTIC RESIN W/PREDOM BASE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,055.93Major & Complex Services
D6252PONTIC RESIN W/NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,107.96Major & Complex Services
D6253INTRM PONTC-TX/CMPL DX NEC B4 F IMPPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$405.30Major & Complex Services
D6545RETN-CAST METL RSN BOND FIX PROSTHPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$899.27Major & Complex Services
D6548RETN-PORCELN/CERAM RSN BOND PROSTHPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,007.61Major & Complex Services
D6549RETAINER - RESIN BONDED FIXED PROSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$367.47Major & Complex Services
D6601RETAINER INLAY-PORC/CERAM 3/MOR SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$786.61Major & Complex Services
D6602RET INLAY-CAST HI NOBLE METL 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$911.20Major & Complex Services
D6603RET INLA-CST HI NOBL MTL 3/MORE SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$877.14Major & Complex Services
D6604RET INLAY-CAST PDMT BASE METL 2 SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$646.67Major & Complex Services
D6605RET INLA-CST PDMT BSE MTL 3/MOR SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$853.20Major & Complex Services
D6606RETAIN INLAY-CAST NOBLE METL 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$755.62Major & Complex Services
D6607RET INLAY-CAST NOBLE METL 3/MRE SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$850.77Major & Complex Services
D6608RETAINER ONLAY-PORCELN/CERAM 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,008.19Major & Complex Services
D6609RETAINR ONLAY-PORC/CERAM 3/MORE SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,080.97Major & Complex Services
D6610RET ONLAY-CAST HI NOBLE METL 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$839.39Major & Complex Services
D6611RET ON-CST HI NOBLE METL 3/MORE SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,138.20Major & Complex Services
D6612ONLAY-CAST PREDOM BASE METL 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,032.48Major & Complex Services
D6613RET ON-CST PDMT BSE METL 3/MORE SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,072.54Major & Complex Services
D6614RET ONLAY-CAST NOBLE METAL 2 SURFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,020.11Major & Complex Services
D6615RET ONLAY-CST NOBLE METL 3/MORE SRFPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,044.51Major & Complex Services
D6624RETAINER INLAY - TITANIUMPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$962.46Major & Complex Services
D6634RETAINER ONLAY - TITANIUMPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,005.47Major & Complex Services
D6710RET CROWN-INDIR RESIN BASED COMPOSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$864.94Major & Complex Services
D6720RETAINER CROWN-RESIN HI NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,044.78Major & Complex Services
D6721RETAINER CROWN-RESIN PDMT BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,061.67Major & Complex Services
D6722RETAINER CROWN-RESIN W/NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,071.86Major & Complex Services
D6740RETAINER CROWN - PORCELAIN/CERAMICPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,538.51Major & Complex Services
D6750RET CROWN-PORC FUSED HI NOBLE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,561.08Major & Complex Services
D6751RET CROWN-PORC FUSED PDMT BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,101.11Major & Complex Services
D6752RETNR CRWN-PORCELN FUSD NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,450.93Major & Complex Services
D6753RET CRWN - PORCELN FU TIT & TIT ALYPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,444.61Major & Complex Services
D6780RETNER CROWN-3/4 CAST HI NOBLE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,205.63Major & Complex Services
D6781RETNR CRWN-3/4 CAST PDMT BASE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$971.30Major & Complex Services
D6782RETAINER CROWN-3/4 CAST NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$947.36Major & Complex Services
D6783RETAINER CROWN-3/4 PORCELAIN/CERAMCPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,049.03Major & Complex Services
D6784RETAINER CROWN 3/4 - TI & TI ALLOYSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,141.81Major & Complex Services
D6790RETNR CRWN-FULL CAST HI NOBLE METALPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,505.10Major & Complex Services
D6791RETNR CRWN-FULL CAST PDMT BASE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,074.37Major & Complex Services
D6792RETAINER CROWN-FULL CAST NOBLE METLPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,118.18Major & Complex Services
D6793INTRM RET CR-TX/CMPL DX B4 FNL IMPPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$332.63Major & Complex Services
D6794RETAINER CROWN - TI & TI ALLOYSPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$1,293.09Major & Complex Services
D6920CONNECTOR BARPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$409.91Major & Complex Services
D9120FIXED PARTIAL DENTURE SECTIONINGPeds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years Combination Limit - Inlays/Onlays/Crowns/Pontics/Veneers/Bridges or Dentures - If any of these services are preformed on a tooth, the limit will be applied.Member Cost Share$235.65Major & Complex Services
D5511REPAIR BKN CMPL DENTURE BASE MAND2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$281.70Major & Complex Services
D5512REPAIR BKN CMPL DENTURE BASE MAX2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$281.70Major & Complex Services
D5520REPL MISS/BROKEN TEETH-CMPL DENTUR2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$242.87Major & Complex Services
D5611REPAIR RESIN PRTL DENTURE BASE MAND2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$281.70Major & Complex Services
D5612REPAIR RESIN PRTL DENTURE BASE MAX2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$281.70Major & Complex Services
D5621REPAIR CAST PARTIAL FRAMEWORK MAND2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$356.64Major & Complex Services
D5622REPAIR CAST PARTIAL FRAMEWORK MAX2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$356.64Major & Complex Services
D5630REPR/REPLCE BROKEN CLASP-PER TOOTH2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$335.87Major & Complex Services
D5640REPLACE BROKEN TEETH - PER TOOTH2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$247.39Major & Complex Services
D5650ADD TOOTH EXISTING PARTIAL DENTURE2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$325.94Major & Complex Services
D5660ADD CLASP XST PRT DENTURE-PER TOOTH2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$395.46Major & Complex Services
D5670REPL ALL TEETH&ACRYLC FRMEWRK MAX2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$815.30Major & Complex Services
D5671REPL ALL TEETH&ACRYLC FRMEWRK MAND2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$775.57Major & Complex Services
D6980FXD PRT DNTR REPR NEC RSTRTV MTL FL2 Per 2 Years For Permanent Appliances Six (6) months must have passed since initial placement and the narrative from the treating Dentist supports the procedure.Member Cost Share$369.28Major & Complex Services
D5710REBASE COMPLETE MAXILLARY DENTURE1 Per 2 YearsMember Cost Share$957.05Major & Complex Services
D5711REBASE COMPLETE MANDIBULAR DENTURE1 Per 2 YearsMember Cost Share$957.05Major & Complex Services
D5720REBASE MAXILLARY PARTIAL DENTURE1 Per 2 YearsMember Cost Share$702.44Major & Complex Services
D5721REBASE MANDIBULAR PARTIAL DENTURE1 Per 2 YearsMember Cost Share$702.44Major & Complex Services
D5730RELINE COMPL MAXILLARY DENTURE DIR1 Per 2 YearsMember Cost Share$525.48Major & Complex Services
D5731RELINE COMPL MANDIBULAR DENTURE DIR1 Per 2 YearsMember Cost Share$525.48Major & Complex Services
D5740RELINE MAXILLARY PART DENTURE DIR1 Per 2 YearsMember Cost Share$455.05Major & Complex Services
D5741RELINE MANDIBULAR PART DENTURE DIR1 Per 2 YearsMember Cost Share$455.05Major & Complex Services
D5750RELINE COMPL MAXILLARY DENTUR INDIR1 Per 2 YearsMember Cost Share$795.44Major & Complex Services
D5751RELINE CMPL MANDIBULAR DENTUR INDIR1 Per 2 YearsMember Cost Share$795.44Major & Complex Services
D5760RELINE MAXILLARY PART DENTURE INDIR1 Per 2 YearsMember Cost Share$710.57Major & Complex Services
D5761RELINE MANDIBULAR PART DENTUR INDIR1 Per 2 YearsMember Cost Share$710.57Major & Complex Services
D6930RECEMENT FIXED PARTIAL DENTURE1 Per 5 YearsMember Cost Share$201.34Major & Complex Services
D7210EXTN ERU TT RQR REMV BONE &/SECT TT1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$381.92Oral Surgery Services
D7310ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$474.01Oral Surgery Services
D7311ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETH1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$390.04Oral Surgery Services
D7320ALVEOLOPLASTY NO EXT 4/> TEETH/SPAC1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$689.80Oral Surgery Services
D7321ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETH1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$548.95Oral Surgery Services
D7340VESTIBULOPLASTY RIDGE EXT SEC EPITH1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$3,388.51Oral Surgery Services
D7350VESTBULPLSTY RIDGE EXT SFT TISS GFT1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$5,260.17Oral Surgery Services
D7471REMOVAL OF LATERAL EXOSTOSIS1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$1,454.54Oral Surgery Services
D7485REDUCTION OF OSSEOUS TUBEROSITY1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$1,402.17Oral Surgery Services
D7510I&D ABSCESS-INTRAORAL SOFT TISS1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$479.00Oral Surgery Services
D7511I & D ABSC INTRAORAL SOFT TISS COMP1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$1,692.90Oral Surgery Services
D7520I&D ABSC EXTRAORAL SOFT TISS1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$406.08Oral Surgery Services
D7521I & D ABSC XTRAORAL SOFT TISS COMP1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$2,144.34Oral Surgery Services
D7910SUTURE RECENT SMALL WOUNDS UP 5 CM1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$862.25Oral Surgery Services
D7971EXCISION OF PERICORONAL GINGIVA1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$267.25Oral Surgery Services
D7972SURGICAL RDUC FIBROUS TUBEROSITY1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$984.14Oral Surgery Services
D7111EXTRACT CORONAL RMNNTS-PRIM TOOTHMember Cost Share$164.32Oral Surgery Services
D7140EXTRAC ERUPTED TOOTH/EXPOSED ROOTMember Cost Share$223.00Oral Surgery Services
D7250REMOVAL OF RESIDUAL TOOTH ROOTS1 Per 6 Years (Any Surgical Extraction Combination Limit)Member Cost Share$384.63Oral Surgery Services
D03402D CEPHALOMET X-RAY-ACQN MSR&ANALYOnly as Dentally NecessaryMember Cost Share$167.03Orthodontic Care Services
D0470DIAGNOSTIC CASTSOnly as Dentally NecessaryMember Cost Share$124.60Orthodontic Care Services
D8010LTD ORTHODONT TX PRIMARY DENTITIONOnly as Dentally NecessaryMember Cost Share$3,160.25Orthodontic Care Services
D8020LTD ORTHODONT TX TRNSITIONL DENTITNOnly as Dentally NecessaryMember Cost Share$3,390.56Orthodontic Care Services
D8030LTD ORTHODONTIC TX ADOLES DENTITIONOnly as Dentally NecessaryMember Cost Share$2,341.92Orthodontic Care Services
D8040LTD ORTHODONTIC TX ADULT DENTITIONOnly as Dentally NecessaryMember Cost Share$4,285.07Orthodontic Care Services
D8070COMP ORTHODONT TX TRNSITNL DENTITNOnly as Dentally NecessaryMember Cost Share$6,722.08Orthodontic Care Services
D8080COMP ORTHODONT TX ADOLES DENTITIONOnly as Dentally NecessaryMember Cost Share$6,809.19Orthodontic Care Services
D8090COMP ORTHODONTIC TX ADULT DENTITIONOnly as Dentally NecessaryMember Cost Share$6,782.50Orthodontic Care Services
D8210REMOVABLE APPLIANCE THERAPYOnly as Dentally NecessaryMember Cost Share$851.92Orthodontic Care Services
D8220FIXED APPLIANCE THERAPYOnly as Dentally NecessaryMember Cost Share$921.54Orthodontic Care Services
D8660PREORTHODONTIC TREATMENT VISITOnly as Dentally NecessaryMember Cost Share$269.59Orthodontic Care Services
D8670PERIODIC ORTHODONTIC TX VISITOnly as Dentally NecessaryMember Cost Share$436.44Orthodontic Care Services
D8680ORTHODONTIC RETENTIONOnly as Dentally NecessaryMember Cost Share$593.71Orthodontic Care Services
D8698RE-CEMENT/RE-BOND FIX RETAIN - MAXOnly as Dentally NecessaryMember Cost Share$154.39Orthodontic Care Services
D8699RE-CEMENT/RE-BOND FIX RETAIN - MANDOnly as Dentally NecessaryMember Cost Share$154.39Orthodontic Care Services