Dental Coverage Details
The below details for dental coverage do NOT apply to all plans. Only plans designated with embedded dental coverage offer both pediatric and adult dental coverage. 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 Client Services (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 CODE | DESCRIPTION | SERVICE LIMITS | MEMBER COST SHARE | ALLOWED AMOUNT | |
|---|---|---|---|---|---|
| D0120 | PERIODIC ORAL EVALUATION EST PT | 2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $65.91 | Preventive Dental Care |
| D0150 | COMP ORAL EVALUATION - NEW/EST PT | 2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $116.00 | Preventive Dental Care |
| D0140 | LTD ORAL EVALUATION - PROBLEM FOCUS | 2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $110.00 | Preventive Dental Care |
| D0145 | ORL EVAL PT<3 YR CNSL PRIM CAREGIVR | 2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $105.64 | Preventive Dental Care |
| D0160 | DTL&EXT ORAL EVAL - PROB FOCUS RPT | 2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $234.75 | Preventive Dental Care |
| D0170 | RE-EVALUATION - LTD PROBLEM FOCUSED | 2 per year (Any combination of Periodic, Comprehesive or Limited Oral Evaluations) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $81.26 | Preventive Dental Care |
| D0180 | COMP PERIODONTAL EVAL - NEW/EST PT | 2 per year | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $130.01 | Preventive Dental Care |
| D0210 | INTRAORAL-CMPL SER RADIOGRAPH IMAGS | 1 per 3 years | First 2 - No Cost Share Any Subsquent Within The 3 Calendar Year Period - Non-Covered | $185.00 | Preventive Dental Care |
| D0270 | BITEWING - SINGLE RADIOGRAPHC IMAGE | 2 per year (Any Bitewing Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $38.00 | Preventive Dental Care |
| D0272 | BITEWINGS - TWO RADIOGRAPHIC IMAGES | 2 per year (Any Bitewing Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $61.00 | Preventive Dental Care |
| D0273 | BITEWINGS-THREE RADIOGRAPHIC IMAGES | 2 per year (Any Bitewing Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $74.00 | Preventive Dental Care |
| D0274 | BITEWINGS - FOUR RADIOGRAPHC IMAGES | 2 per year (Any Bitewing Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $85.00 | Preventive Dental Care |
| D0277 | VERT BITEWNGS - 7-8 RADIOGRAPH IMAG | 2 per year (Any Bitewing Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $92.13 | Preventive Dental Care |
| D0330 | PANORAMIC RADIOGRAPHIC IMAGE | 1 per 5 years | First - No Cost Share Any Subsquent Within The 5 Calendar Year Period - Non-Covered | $167.03 | Preventive Dental Care |
| D1110 | PROPHYLAXIS - ADULT | 2 per year (Any Prophlyaxis Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $120.99 | Preventive Dental Care |
| D1120 | PROPHYLAXIS - CHILD | 2 per year (Any Prophlyaxis Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $80.36 | Preventive Dental Care |
| D1206 | TOPICAL APPLICATN FLUORIDE VARNISH | 2 per year - Pediatric Only (Any Varnish Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $76.74 | Preventive Dental Care |
| D1208 | TOPICAL APPLICATION OF FLUORIDE | 2 per year - Pediatric Only (Any Varnish Combination) | First 2 - No Cost Share Any Subsequent Within The Calendar Year - Non-Covered | $61.40 | Preventive Dental Care |
| D1351 | SEALANT - PER TOOTH | 1 per tooth per 3 years - Pediatric Only | First Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered | $73.13 | Preventive Dental Care |
| D1352 | PREV RSN REST MOD HIGH CARIES RISK | 1 per tooth per 3 years - Pediatric Only | First Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered | $218.50 | Preventive Dental Care |
| D2940 | PROTECTIVE RESTORATION | 1 per tooth per 3 years - Pediatric Only | First Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered | $361.15 | Preventive Dental Care |
| D2990 | RESIN FILL OF TOOH SURFACE | 1 per tooth per 3 years - Pediatric Only | First Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered | $101.12 | Preventive Dental Care |
| D1353 | SEALANT REPAIR - PER TOOTH | 1 per tooth per 3 years - Pediatric Only | First Tooth - No Cost share. Any Subsequent Within The 3 Year Calendar Year Period - Non-Covered | $51.47 | Preventive Dental Care |
| D1510 | SPACE MNTNR - FIXED UNI - PER QUAD | 1 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 | $450.54 | Preventive Dental Care |
| D1516 | SPACE MAINTAIN-FIXED-BILAT MAXIL | 1 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 | $648.27 | Preventive Dental Care |
| D1517 | SPACE MAINTAIN-FIXED BILAT MANDIB | 1 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 | $645.56 | Preventive Dental Care |
| D1520 | SPACE MNTNR - REMOV UNI - PER QUAD | 1 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 | $442.32 | Preventive Dental Care |
| D1526 | SPACE MAINTAIN- REMOVE-BILAT, MAXIL | 1 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 | $684.38 | Preventive Dental Care |
| D1527 | SPACE MNTAIN- REMOVE- BILAT, MANDIB | 1 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 | $684.38 | Preventive Dental Care |
| D1575 | DIST SHOE SPC MNTNR - FIX UNI-QUAD | 1 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 | $500.20 | Preventive Dental Care |
| D1551 | RE-CEM/RE-BOND BIL SPACE MNTNR-MAX | 1 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 | $100.22 | Preventive Dental Care |
| D1552 | RE-CEM/RE-BOND BIL SPC MNTNR - MAND | 1 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 | $99.32 | Preventive Dental Care |
| D1553 | RE-CEM/RE-BOND UNI SPACE MNTNR-QUAD | 1 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 | $99.32 | Preventive Dental Care |
| D1556 | REMV FIX UNI SPACE MNTNR - PER QUAD | Removal 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. | $82.16 | Preventive Dental Care | |
| D1557 | REMOVAL FIXED BIL SPACE MNTNR - MAX | Removal 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. | $82.16 | Preventive Dental Care | |
| D1558 | REMOVAL FIX BIL SPACE MNTNR - MAND | Removal 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. | $83.97 | Preventive Dental Care | |
| D0171 | RE-EVALUATION-POST-OP OFFICE VISIT | Include In Surgical Procedure Global | $57.83 | Basic & Restorative Services | |
| D0220 | IO-PERIAPICAL 1ST RADIOGRAPHC IMAGE | As Needed For Diagnosis | Member Cost Share | $37.02 | Basic & Restorative Services |
| D0230 | IO-PERIAPICAL EA ADD RADIOGRPH IMAG | As Needed For Diagnosis | Member Cost Share | $34.31 | Basic & Restorative Services |
| D0240 | INTRAORAL-OCCLUSAL RADIOGRAPH IMAGE | As Needed For Diagnosis | Member Cost Share | $52.37 | Basic & Restorative Services |
| D0250 | EXTRA-ORAL - 2D PROJECTION X-RAY | As Needed For Diagnosis | Member Cost Share | $70.42 | Basic & Restorative Services |
| D0251 | EXTRA-ORAL POSTERIOR DENTAL X-RAY | As Needed For Diagnosis | Member Cost Share | $50.06 | Basic & Restorative Services |
| D0460 | PULP VITALITY TESTS | As Needed For Diagnosis | Member Cost Share | $57.78 | Basic & Restorative Services |
| D2140 | AMALGAM-ONE SURFACE PRIMARY/PERM | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $156.20 | Basic & Restorative Services |
| D2150 | AMALGAM-TWO SURFACES PRIMARY/PERM | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $213.08 | Basic & Restorative Services |
| D2160 | AMALGAM-3 SURFACES PRIMARY/PERM | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $254.61 | Basic & Restorative Services |
| D2161 | AMALGAM-FOUR/MORE SURF PRIM/PERM | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $292.53 | Basic & Restorative Services |
| D2330 | RESIN-BASED COMPOSITE ONE SURF ANT | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $219.40 | Basic & Restorative Services |
| D2331 | RESIN-BASED COMPOSITE 2 SURFACE ANT | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $283.50 | Basic & Restorative Services |
| D2332 | RESIN-BASED COMPOSITE 3 SURFACE ANT | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $337.68 | Basic & Restorative Services |
| D2335 | RESIN COMP 4/> SURF INCISAL ANGLE | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $393.66 | Basic & Restorative Services |
| D2391 | RESIN COMPOS - 1 SURFACE POSTERIOR | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $237.00 | Basic & Restorative Services |
| D2392 | RESIN COMPOS - 2 SURFACES POSTERIOR | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $310.00 | Basic & Restorative Services |
| D2393 | RESIN COMPOS - 3 SURFACES POSTERIOR | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $385.00 | Basic & Restorative Services |
| D2394 | RESIN COMPOS - 4/MORE SURFACES POST | 1 Per Tooth Surface Per 2 Years | Member Cost Share | $490.26 | Basic & Restorative Services |
| D9110 | PALLIATVE TX DENTAL PAIN-MINOR PROC | Service 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 | $160.00 | Basic & Restorative Services |
| D2921 | REATTCH TOOTH FRAG INCISL EDGE/CUSP | Service 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 | $303.37 | Basic & Restorative Services |
| D9610 | TX PARENTRAL DRUG 1 ADMINISTRATION | Service 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 | $87.58 | Basic & Restorative Services |
| D9612 | TX PARENTERAL RX 2/> ADMIN DIFF MED | Service 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 | $101.80 | Basic & Restorative Services |
| D9310 | CNSLT DX DENT/PHY NOT REQ DENT/PHY | Member Cost Share | $170.47 | Basic & Restorative Services | |
| D9311 | CONSULTATION W/MED HEALTH CARE PROF | Member Cost Share | $176.91 | Basic & Restorative Services | |
| D9440 | OV-AFTER REGULARLY SCHEDULED HOURS | Member Cost Share | $183.28 | Basic & Restorative Services | |
| D9930 | TX COMPS - UNUSUL CIRCUMSTANCES RPT | Member Cost Share | $94.45 | Basic & Restorative Services | |
| D3110 | PULP CAP - DIRECT | Member Cost Share | $110.15 | Basic & Restorative Services | |
| D3120 | PULP CAP - INDIRECT | Member Cost Share | $87.58 | Basic & Restorative Services | |
| D2951 | PIN RETN - PER TOOTH ADDITION REST | 1 Per Tooth Per 5 Years | Member Cost Share | $74.94 | Major & Complex Services |
| D2915 | RECEMENT CAST/PREFAB POST & CORE | 1 Per Tooth Per 5 Years | Member Cost Share | $105.58 | Major & Complex Services |
| D2950 | CORE BUILDUP INCL PINS WHEN REQUIRE | 1 Per Tooth Per 5 Years | Member Cost Share | $357.54 | Major & Complex Services |
| D2952 | POST & CORE ADD CROWN INDIRECT FAB | 1 Per Tooth Per 5 Years | Member Cost Share | $1,136.73 | Major & Complex Services |
| D2953 | EA ADD INDIRECT FAB POST SAME TOOTH | 1 Per Tooth Per 5 Years | Member Cost Share | $230.06 | Major & Complex Services |
| D2954 | PREFABR POST&CORE ADDITION CROWN | 1 Per Tooth Per 5 Years | Member Cost Share | $406.30 | Major & Complex Services |
| D2955 | POST REMOVAL | 1 Per Tooth Per 5 Years | Member Cost Share | $353.93 | Major & Complex Services |
| D2957 | EA ADD PREFABR POST - SAME TOOTH | 1 Per Tooth Per 5 Years | Member Cost Share | $228.43 | Major & Complex Services |
| D3220 | TX PULPOT-CORONL DENTNOCEMENTL JUNC | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $225.72 | Major & Complex Services |
| D3221 | PULPAL DEBRID PRIMARY&PERM TEETH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $247.39 | Major & Complex Services |
| D3222 | PART PULPOTMY APEXOGNEIS PERM TOOTH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $367.47 | Major & Complex Services |
| D3230 | PULPAL THERAPY - ANT PRIMARY TOOTH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $241.07 | Major & Complex Services |
| D3240 | PULPAL THERAPY - POST PRIMARY TOOTH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $297.05 | Major & Complex Services |
| D3310 | ENDODONTIC THERAPY ANTERIOR TOOTH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $956.15 | Major & Complex Services |
| D3320 | ENDODONTIC THERAPY PREMOLAR TOOTH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,171.04 | Major & Complex Services |
| D3330 | ENDODONTIC THERAPY MOLAR TOOTH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,475.31 | Major & Complex Services |
| D3331 | TX RC OBSTRUCTION; NON-SURG ACCESS | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $373.79 | Major & Complex Services |
| D3332 | INCMPL ENDO TX;INOP UNRSTR/FX TOOTH | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $549.23 | Major & Complex Services |
| D3333 | INTRL ROOT REPAIR PERFORATION DEFEC | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $324.13 | Major & Complex Services |
| D3346 | RETX PREVIOUS RC THERAPY - ANTERIOR | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $38,525.00 | Major & Complex Services |
| D3347 | RETREATMENT PREVIOUS RC TX-PREMOLAR | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,474.40 | Major & Complex Services |
| D3348 | RETX PREVIOUS RC THERAPY - MOLAR | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,852.71 | Major & Complex Services |
| D3351 | APEX/RECALCIFICATION INITIAL VISIT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $584.16 | Major & Complex Services |
| D3352 | APEX/RECALCIFICATN INTRM MED REPLAC | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $260.03 | Major & Complex Services |
| D3353 | APEXIFICAT/RECALCIFICAT-FINAL VISIT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,153.88 | Major & Complex Services |
| D3355 | PULPAL REGENERATION - INITIAL VISIT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $584.16 | Major & Complex Services |
| D3356 | PULPAL REGENERATION - MED REPLACMNT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $259.13 | Major & Complex Services |
| D3357 | PULPAL REGENERATION - COMPLETION TX | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $930.87 | Major & Complex Services |
| D3410 | APICOECTOMY - ANTERIOR | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,173.74 | Major & Complex Services |
| D3421 | APICOECTOMY - PREMOLAR | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,296.54 | Major & Complex Services |
| D3425 | APICOECTOMY - MOLAR FIRST ROOT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,472.60 | Major & Complex Services |
| D3426 | APICOECTOMY | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $486.65 | Major & Complex Services |
| D3430 | RETROGRADE FILLING - PER ROOT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $371.99 | Major & Complex Services |
| D3920 | HEMISECTION NOT INCL RC THERAPY | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $790.02 | Major & Complex Services |
| D3950 | CANAL PREP&FIT PREFORMED DOWEL/POST | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $260.03 | Major & Complex Services |
| D3450 | ROOT AMPUTATION - PER ROOT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $789.12 | Major & Complex Services |
| D3471 | SURG REPR OF ROOT RESORPTION - ANT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,032.89 | Major & Complex Services |
| D3472 | SURG REPR OF ROOT RESORPTION - PM | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,032.89 | Major & Complex Services |
| D3473 | SURG REPR OF ROOT RESORPTN - MOLAR | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,032.89 | Major & Complex Services |
| D3501 | SURG EXP RS NO APCECTMY/REPR RR-ANT | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,032.89 | Major & Complex Services |
| D3502 | SURG EXP RS NO APCECTOMY/REPR RR-PM | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,032.89 | Major & Complex Services |
| D3503 | SUR EXP RS NO APICOECT/RPR RR - MOL | 1 Per Tooth/root Per lifetime (Any Root Cancel Treatment Combination Limit) | Member Cost Share | $1,032.89 | Major & Complex Services |
| D3428 | BONE GRAFT PERIRADICULR SURG 1 SITE | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $777.65 | Major & Complex Services |
| D3429 | BONE GRAFT PERIRADICULR SURG EA ADD | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $736.26 | Major & Complex Services |
| D4263 | BN REPL GR-RET NAT TT-1ST SITE QUAD | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $714.18 | Major & Complex Services |
| D4264 | BRG-RET NAT TOOTH-EA ADD SITE QUAD | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $697.02 | Major & Complex Services |
| D6103 | BONE GRAFT REPAIR PERI-IMPL DEFECT | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $690.70 | Major & Complex Services |
| D6104 | BONE GRAFT TIME IMPLANT PLACEMENT | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $510.13 | Major & Complex Services |
| D7949 | LEFORT II/LEFORT III - W/BONE GRAFT | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $2,109.89 | Major & Complex Services |
| D7953 | BONE REPLCMT GRAFT RIDGE PRES -SITE | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Bone Graft Surgery Combine Limit) | Member Cost Share | $517.35 | Major & Complex Services |
| D4210 | GINGIVECT/PLSTY 4/>CNTIG TEETH QUAD | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Ginivectomy/Gingivoplasty Combination Limit) | Member Cost Share | $1,124.09 | Major & Complex Services |
| D4211 | GINGIVECT/PLSTY 1-3CNTIG TEETH QUAD | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Ginivectomy/Gingivoplasty Combination Limit) | Member Cost Share | $604.93 | Major & Complex Services |
| D4212 | GING/GINGIVOPLASTY RES PROC-TOOTH | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Ginivectomy/Gingivoplasty Combination Limit) | Member Cost Share | $386.43 | Major & Complex Services |
| D4240 | GINGL FLP 4/>CNTIG/TOOTH BOUND QUAD | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Gingival Flap Procedure Combination Limit) | Member Cost Share | $1,503.30 | Major & Complex Services |
| D4241 | GINGL FLP 1-3 CNTIG/TOOTH BND QUAD | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Gingival Flap Procedure Combination Limit) | Member Cost Share | $915.52 | Major & Complex Services |
| D4245 | APICALLY POSITIONED FLAP | 1 per Single Tooth (or multiple teeth within the same quadrant) per 3 Years (Any Gingival Flap Procedure Combination Limit) | Member Cost Share | $1,089.78 | Major & Complex Services |
| D4249 | CLIN CROWN LEN - HARD TISSUE | 1 per Quadrant per 3 Years | Member Cost Share | $1,543.02 | Major & Complex Services |
| D4260 | OSSEOUS SURG 4/> CNTIG TEETH QUAD | 1 per Quadrant per 3 Years | Member Cost Share | $2,363.74 | Major & Complex Services |
| D4261 | OSSEOUS SURG 1-3 CNTIG TEETH QUAD | 1 per Quadrant per 3 Years | Member Cost Share | $1,358.83 | Major & Complex Services |
| D4268 | SURGICAL REVISION PROC PER TOOTH | 1 per Quadrant per 3 Years | Member Cost Share | $457.38 | Major & Complex Services |
| D4274 | MESIAL/DISTAL WEDGE PROC 1 TOOTH | 1 per Quadrant per 3 Years | Member Cost Share | $1,245.97 | Major & Complex Services |
| D4270 | PEDICLE SOFT TISSUE GRAFT PROCEDURE | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $1,682.07 | Major & Complex Services |
| D4273 | AUTOGEN CONNECTIVE TISS GRAFT PROC | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $1,862.64 | Major & Complex Services |
| D4275 | NON-AUTOGENOUS CONNECTIVE TISS GRFT | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $1,837.36 | Major & Complex Services |
| D4276 | COMB CNCTIV TISS&PED GRFT PER TOOTH | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $1,102.31 | Major & Complex Services |
| D4277 | FREE SFT TSS GFT 1ST T/EDNTULOUS T | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $36,929.00 | Major & Complex Services |
| D4278 | FREE ST GFT EA CNTG T/EDNT T SAME S | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $1,020.25 | Major & Complex Services |
| D4283 | AUTOGEN CONNECTIVE TISS GRAFT PROC | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $939.00 | Major & Complex Services |
| D4285 | NON-AUTOGEN CNCT TISSUE GRAFT PROC | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $943.51 | Major & Complex Services |
| D4266 | GUID TISS REGEN-RESORB BARRIER-SITE | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $650.98 | Major & Complex Services |
| D4267 | GUID TISS REGEN-NONRESORB BARRIER | 1 Per Tooth Per Year - Not to Exceed 2 Per Year (Any Tissue Graft Procedure Combination Limit) | Member Cost Share | $778.28 | Major & Complex Services |
| D4341 | PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUAD | Peds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 Years | Member Cost Share | $449.63 | Major & Complex Services |
| D4342 | PRDONTAL SCAL&ROOT PLAN 1-3 TEETH | Peds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 Years | Member Cost Share | $333.16 | Major & Complex Services |
| D4346 | SCALING PRES GEN MOD/SEV GING INF | Peds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 Years | Member Cost Share | $210.37 | Major & Complex Services |
| D6080 | IMPL MAINT PROC REMV REINSRT CLEAN | Peds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 Years | Member Cost Share | $295.24 | Major & Complex Services |
| D6081 | SCAL&DEB INF/MUCST 1 IMPL NO F EN&C | Peds: 1 Per Quadrant Per 2 Years Adults: 1 Per Quadrant Per 3 Years | Member Cost Share | $124.84 | Major & Complex Services |
| D4355 | FM DEBR ENBL COMP OR E&DX SUBQ VST | 1 Per Lifetime | Member Cost Share | $232.04 | Major & Complex Services |
| D4910 | PERIODONTAL MAINTENANCE | Peds: 4 Per Year Adults: 2 Per Year | Member Cost Share | $206.76 | Major & Complex Services |
| D5850 | TISSUE CONDITIONING MAXILLARY | 1 Per 2 Years | Member Cost Share | $235.65 | Major & Complex Services |
| D5851 | TISSUE CONDITIONING MANDIBULAR | 1 Per 2 Years | Member Cost Share | $235.65 | Major & Complex Services |
| D6010 | SURG PLCMT IMPL BODY: ENDOSTEAL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,756.49 | Major & Complex Services |
| D6012 | SURG PLCMT INTERIM IMPL PROS: ENDOS | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,812.05 | Major & Complex Services |
| D6013 | SURGICAL PLACEMENT OF MINI IMPLANT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,789.00 | Major & Complex Services |
| D6040 | SURG PLACEMENT: EPOSTEAL IMPLANT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $6,092.39 | Major & Complex Services |
| D6050 | SURG PLACEMENT: TRANSOSTEAL IMPLANT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $10,313.60 | Major & Complex Services |
| D6051 | INTERIM IMPLANT ABUTMENT PLACEMENT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $652.78 | Major & Complex Services |
| D6055 | CONNECTING BAR IMPLANT/ABUT SUPPORT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,465.42 | Major & Complex Services |
| D6056 | PREFAB ABUTMENT-INCL MOD & PLCMNT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $783.70 | Major & Complex Services |
| D6057 | CUSTOM FAB ABUTMENT-INCL PLACEMENT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $904.69 | Major & Complex Services |
| D6058 | ABUT SUPP PORCELN/CERAMIC CROWN | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,895.15 | Major & Complex Services |
| D6059 | ABUT PORCLN TO MTL CRWN HI NOBL MTL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,473.50 | Major & Complex Services |
| D6060 | ABUT PORCLN TO METL CROWN BASE METL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,330.27 | Major & Complex Services |
| D6061 | ABUT PORCLN TO MTL CROWN NOBLE MTL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,586.36 | Major & Complex Services |
| D6062 | ABUT SUPP CAST MTL CRWN HI NOBL MTL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,844.58 | Major & Complex Services |
| D6063 | ABUT SUPP CAST METL CROWN BASE METL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,321.13 | Major & Complex Services |
| D6064 | ABUT SUPP CAST METL CROWN NOBL METL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,306.97 | Major & Complex Services |
| D6065 | IMPLANT SUPP PORCELN/CERAMIC CROWN | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,282.48 | Major & Complex Services |
| D6066 | IMPL SUPP CR-PORCELN FU HI NBL ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,156.98 | Major & Complex Services |
| D6067 | IMPLANT SUPP CROWN-HI NOBLE ALLOYS | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,188.58 | Major & Complex Services |
| D6068 | ABUT SUPP RETAIN PORCELN/CERAM FPD | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,437.38 | Major & Complex Services |
| D6069 | ABUT RETN PORCLN MTL FPD HI NOBL MT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,908.69 | Major & Complex Services |
| D6070 | ABUT RETN PORCLN METL FPD BASE METL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,803.05 | Major & Complex Services |
| D6071 | ABUT SUPP RETN PORCLN FUSD METL FPD | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,552.05 | Major & Complex Services |
| D6072 | ABUT SUPP RETAIN CAST METAL FPD | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,512.32 | Major & Complex Services |
| D6073 | ABUT RETN CAST METL FPD BASE METL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,379.21 | Major & Complex Services |
| D6074 | ABUT RETN CAST METL FPD NOBL METL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,360.74 | Major & Complex Services |
| D6075 | IMPLANT SUPP RETAIN CERAMIC FPD | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,240.05 | Major & Complex Services |
| D6076 | IMPL SUP RET FPD-PRCLN F HI NBL ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,174.14 | Major & Complex Services |
| D6077 | IMPL SUPP RET METAL FPD-HI NBL ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,115.45 | Major & Complex Services |
| D6082 | IMPL SUP CR-PRCLN FU PREDM BASE ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,515.77 | Major & Complex Services |
| D6083 | IMPLANT SUPP CRWN - PORCELN FU NBL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,950.22 | Major & Complex Services |
| D6084 | IMPLANT SUPPORTED CROWN - PORCELN F | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $33,225.00 | Major & Complex Services |
| D6086 | IMPLANT SUPP CRWN - PREDOM BASE ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,285.17 | Major & Complex Services |
| D6087 | IMPLANT SUPP CROWN - NOBLE ALLOYS | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $33,325.00 | Major & Complex Services |
| D6088 | IMPLANT SUPP CROWN - TI & TI ALLOYS | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,930.36 | Major & Complex Services |
| D6090 | REPAIR IMPL SUPP PROSTH BY REPORT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $190.17 | Major & Complex Services |
| D6091 | REPL RP ATT IMPL/ABUT S PROS PER | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $463.18 | Major & Complex Services |
| D6092 | RECEMENT IMPL/ABUT SUPPORTED CROWN | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $148.98 | Major & Complex Services |
| D6093 | RECEMENT IMPL/ABUT FIX PART DENTURE | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $224.82 | Major & Complex Services |
| D6094 | ABUTMENT SUPP CROWN - TI & TI ALLOY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,046.74 | Major & Complex Services |
| D6095 | REPAIR IMPLANT ABUTMENT BY REPORT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $266.12 | Major & Complex Services |
| D6096 | REMOVE BROKEN IMPL RETAINING SCREW | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $467.69 | Major & Complex Services |
| D6097 | ABUT SUPP CR-PORCELN FU TI & TI ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,442.28 | Major & Complex Services |
| D6098 | IMPL SUPP RETN - PORC FU PDMT B ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,141.94 | Major & Complex Services |
| D6099 | IMPL SUP RTN FPD-PORCELN FU NBL ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,950.22 | Major & Complex Services |
| D6100 | SURGICAL REMOVAL OF IMPLANT BODY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $754.81 | Major & Complex Services |
| D6101 | DEBR PRIIMPL DEF CLN EXPSD IMPL FLP | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $915.52 | Major & Complex Services |
| D6102 | DEBR&OSS CNTR PRIIMPL DEF;CLN SURF | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,353.42 | Major & Complex Services |
| D6110 | IMPL/ABUT SUPP RMV D EDENT ARCH-MAX | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,512.72 | Major & Complex Services |
| D6111 | IMPL/ABUT SUPP RMV D EDENT ARCH-MND | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,512.72 | Major & Complex Services |
| D6112 | IMPL/ABUT SUP RMV D PR EDNT ARCH-MX | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,581.33 | Major & Complex Services |
| D6113 | IMPL/ABUT SP RMV D PR EDNT ARCH-MND | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $2,576.82 | Major & Complex Services |
| D6114 | IMPL/ABUT SP FIXED D EDENT ARCH-MAX | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $8,801.27 | Major & Complex Services |
| D6115 | IMPL/ABUT SUP FIXD D EDENT ARCH-MND | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $8,859.06 | Major & Complex Services |
| D6116 | IMPL/ABUT SUP F D PR EDENT ARCH-MAX | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $4,323.89 | Major & Complex Services |
| D6117 | IMPL/ABUT SP FIXD D PR EDENT ARCH-M | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $4,323.89 | Major & Complex Services |
| D6118 | IMP/ABUT SPTD INT D EDENT ARCH-M | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,788.63 | Major & Complex Services |
| D6119 | IMPL/ABUT SPT INT F D EDNT ARCH-MAX | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,788.63 | Major & Complex Services |
| D6120 | IMPL SUP RET PRCLN FU TIT & TIT ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,565.38 | Major & Complex Services |
| D6121 | IMPL SUP RET MTL FPD PREDM BASE ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,950.22 | Major & Complex Services |
| D6122 | IMPL SUP RET METAL FPD - NOBLE AL | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,452.59 | Major & Complex Services |
| D6123 | IMPL SUP RET MTL FPD TIT & TIT ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,930.36 | Major & Complex Services |
| D6190 | RADIOGRAPHIC/SURG IMPLANT INDX RPT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $587.77 | Major & Complex Services |
| D6191 | SEMI-PRECISION ABUTMENT - PLACEMENT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,394.05 | Major & Complex Services |
| D6192 | SEMI-PRECISION ATTACHMENT - PLCMT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,394.05 | Major & Complex Services |
| D6194 | ABUT SUP RET CRWN FPD TIT & TIT ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,399.46 | Major & Complex Services |
| D6195 | ABUT SUP RET-PRCLN FU TIT & TIT ALY | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $1,439.19 | Major & Complex Services |
| D6198 | REMOVE INTERIM IMPLANT COMPONENT | Peds: 1 Per Tooth Per 5 years Adults: 1 Per Tooth Per 7 years | Member Cost Share | $68.34 | Major & Complex Services |
| D2510 | INLAY - METALLIC - ONE SURFACE | Peds: 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 | $905.59 | Major & Complex Services |
| D2520 | INLAY - METALLIC - TWO SURFACES | Peds: 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 | $1,181.87 | Major & Complex Services |
| D2530 | INLAY - METALLIC - 3/MORE SURFACES | Peds: 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 | $1,184.58 | Major & Complex Services |
| D2542 | ONLAY - METALLIC - TWO SURFACES | Peds: 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 | $1,164.72 | Major & Complex Services |
| D2543 | ONLAY METALLIC THREE SURFACES | Peds: 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 | $1,245.97 | Major & Complex Services |
| D2544 | ONLAY METALLIC FOUR OR MORE SURF | Peds: 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 | $1,326.33 | Major & Complex Services |
| D2610 | INLAY - PORCELN/CERAMIC - 1 SURFACE | Peds: 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 | $935.38 | Major & Complex Services |
| D2620 | INLAY - PORCELN/CERAMIC - 2 SURF | Peds: 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 | $1,232.43 | Major & Complex Services |
| D2630 | INLAY - PORCELN/CERAM - 3/MORE SURF | Peds: 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 | $1,259.52 | Major & Complex Services |
| D2642 | ONLAY - PORCELN/CERAMIC - 2 SURF | Peds: 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 | $1,184.58 | Major & Complex Services |
| D2643 | ONLAY - PORCELN/CERAMIC - 3 SURF | Peds: 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 | $1,204.44 | Major & Complex Services |
| D2644 | ONLAY - PORCELN/CERAM - 4/MORE SURF | Peds: 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 | $1,352.51 | Major & Complex Services |
| D2650 | INLAY RESIN COMPOSITE ONE SURFACE | Peds: 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 | $842.39 | Major & Complex Services |
| D2651 | INLAY RESIN COMPOSITE TWO SURFACES | Peds: 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 | $880.31 | Major & Complex Services |
| D2652 | INLAY RESIN COMPOSITE 3/> SURFACES | Peds: 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 | $939.00 | Major & Complex Services |
| D2662 | ONLAY-RSN COMPOS COMPOS/RSN-2 SURF | Peds: 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 | $874.89 | Major & Complex Services |
| D2663 | ONLAY-RSN COMPOS COMPOS/RSN-3 SURF | Peds: 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 | $943.51 | Major & Complex Services |
| D2664 | ONLAY RESIN COMPOSITE 4/> SURFACES | Peds: 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 | $1,000.39 | Major & Complex Services |
| D2910 | RECEMENT INLAY ONLAY/PART COV REST | Peds: 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 | $138.14 | Major & Complex Services |
| D2390 | RESIN COMPOS CROWN ANTERIOR | Peds: 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 | $469.50 | Major & Complex Services |
| D2710 | CROWN - RESIN-BASED COMPOSITE | Peds: 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 | $542.63 | Major & Complex Services |
| D2712 | CROWN - 3/4 RESIN-BASED COMPOSITE | Peds: 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 | $616.04 | Major & Complex Services |
| D2720 | CROWN - RESIN WITH HIGH NOBLE METAL | Peds: 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 | $1,226.37 | Major & Complex Services |
| D2721 | CROWN - RESIN PREDOM BASE METAL | Peds: 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 | $1,155.12 | Major & Complex Services |
| D2722 | CROWN - RESIN WITH NOBLE METAL | Peds: 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 | $1,182.20 | Major & Complex Services |
| D2740 | CROWN - PORCELAIN/CERAMIC | Peds: 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 | $1,505.10 | Major & Complex Services |
| D2750 | CROWN - PORCELN FUSED HI NOBLE METL | Peds: 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 | $1,542.12 | Major & Complex Services |
| D2751 | CROWN-PORCELN FUSD PREDOM BASE METL | Peds: 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 | $1,110.99 | Major & Complex Services |
| D2752 | CROWN - PORCELAIN FUSED NOBLE METAL | Peds: 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 | $1,621.57 | Major & Complex Services |
| D2753 | CROWN - PORCLN FUSD TO TIT & TIT ALY | Peds: 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 | $1,154.67 | Major & Complex Services |
| D2780 | CROWN - 3/4 CAST HIGH NOBLE METAL | Peds: 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 | $1,441.00 | Major & Complex Services |
| D2781 | CROWN - 3/4 CAST PREDOM BASE METL | Peds: 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 | $1,088.83 | Major & Complex Services |
| D2782 | CROWN - 3/4 CAST NOBLE METAL | Peds: 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 | $1,574.62 | Major & Complex Services |
| D2783 | CROWN - 3/4 PORCELAIN/CERAMIC | Peds: 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 | $1,351.61 | Major & Complex Services |
| D2790 | CROWN - FULL CAST HIGH NOBLE METAL | Peds: 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 | $1,530.38 | Major & Complex Services |
| D2791 | CROWN - FULL CAST PREDOM BASE METL | Peds: 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 | $1,086.28 | Major & Complex Services |
| D2792 | CROWN - FULL CAST NOBLE METAL | Peds: 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 | $1,139.47 | Major & Complex Services |
| D2794 | CROWN - TITANIUM AND TITANIUM ALY | Peds: 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 | $1,201.43 | Major & Complex Services |
| D2920 | RECEMENT CROWN | Peds: 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 | $140.85 | Major & Complex Services |
| D2928 | PREFAB PORC/CER CROWN - PERM TOOTH | Peds: 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 | $421.52 | Major & Complex Services |
| D2929 | PREFAB PORC/CERAMC CROWN-PRIM TOOTH | Peds: 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 | $496.58 | Major & Complex Services |
| D2930 | PRFABR STAINLESS STEEL CROWN-PRIM | Peds: 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 | $383.72 | Major & Complex Services |
| D2931 | PRFABR STAINLESS STEEL CROWN-PERM | Peds: 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 | $460.47 | Major & Complex Services |
| D2932 | PREFABRICATED RESIN CROWN | Peds: 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 | $409.91 | Major & Complex Services |
| D2933 | PRFABR STNLSS STEEL CROWN RSN WNDOW | Peds: 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 | $386.72 | Major & Complex Services |
| D2934 | PREFB ESTHET COAT STNLSS STEEL CRWN | Peds: 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 | $506.52 | Major & Complex Services |
| D2960 | LABIAL VENEER - DIRECT | Peds: 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 | $920.03 | Major & Complex Services |
| D2961 | LABIAL VENEER RESIN LAM - INDIRECT | Peds: 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 | $1,087.07 | Major & Complex Services |
| D2962 | LABIAL VNR PORCELAIN LAM - INDIRECT | Peds: 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 | $1,671.23 | Major & Complex Services |
| D2971 | ADD PRC CSTMZ CR UND XST PRT D FRWK | Peds: 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 | $139.35 | Major & Complex Services |
| D2980 | CROWN REPR NEC RESTORATV MATL FAIL | Peds: 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 | $257.32 | Major & Complex Services |
| D5110 | COMPLETE DENTURE - MAXILLARY | Peds: 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 | $2,798.93 | Major & Complex Services |
| D5120 | COMPLETE DENTURE - MANDIBULAR | Peds: 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 | $2,792.61 | Major & Complex Services |
| D5130 | IMMEDIATE DENTURE - MAXILLARY | Peds: 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 | $2,814.28 | Major & Complex Services |
| D5140 | IMMEDIATE DENTURE - MANDIBULAR | Peds: 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 | $2,792.61 | Major & Complex Services |
| D5211 | MAXILLARY PARTIAL DENTUR RESIN BASE | Peds: 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 | $1,712.00 | Major & Complex Services |
| D5212 | MANDIB PARTIAL DENTURE RESIN BASE | Peds: 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 | $32,825.00 | Major & Complex Services |
| D5213 | MAX PRTL DENTURE- CAST METAL FW | Peds: 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 | $2,830.53 | Major & Complex Services |
| D5214 | MAND PRTL DENTURE - CAST METAL FW | Peds: 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 | $2,830.53 | Major & Complex Services |
| D5221 | IMMED MAX PRTL DENTURE - RESIN BASE | Peds: 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 | $1,154.21 | Major & Complex Services |
| D5222 | IMMED MAND PRTL DENTURE - RESN BASE | Peds: 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 | $1,274.77 | Major & Complex Services |
| D5223 | IMMED MAX PRTL D - CAST METAL FW | Peds: 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 | $1,633.69 | Major & Complex Services |
| D5224 | IMMED MAND PRTL D - CAST MTL FW | Peds: 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 | $1,668.91 | Major & Complex Services |
| D5225 | MAXILLARY PART DENTURE - FLEX BASE | Peds: 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 | $1,675.75 | Major & Complex Services |
| D5226 | MANDIBULAR PART DENTURE - FLEX BASE | Peds: 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 | $1,675.75 | Major & Complex Services |
| D5282 | REMV UNI PRT D - 1 PC CAST METL MAX | Peds: 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 | $878.50 | Major & Complex Services |
| D5283 | REMV UNI PRT D - 1 PC C METL MAND | Peds: 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 | $878.50 | Major & Complex Services |
| D5284 | REMV UNI PD-1 PECE FLEX BS-PER QUAD | Peds: 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 | $876.70 | Major & Complex Services |
| D5286 | REMV UNI PD - 1 PECE RESIN-PER QUAD | Peds: 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 | $800.86 | Major & Complex Services |
| D5410 | ADJUST COMPLETE DENTURE - MAXILLARY | Peds: 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 | $139.00 | Major & Complex Services |
| D5411 | ADJUST COMPLETE DENTUR - MANDIBULAR | Peds: 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 | $139.00 | Major & Complex Services |
| D5421 | ADJUST PARTIAL DENTURE - MAXILLARY | Peds: 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 | $139.00 | Major & Complex Services |
| D5422 | ADJUST PARTIAL DENTURE - MANDIBULAR | Peds: 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 | $139.00 | Major & Complex Services |
| D5863 | OVERDENTURE - COMPLETE MAXILLARY | Peds: 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 | $2,818.79 | Major & Complex Services |
| D5864 | OVERDENTURE - PARTIAL MAXILLARY | Peds: 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 | $2,818.79 | Major & Complex Services |
| D5865 | OVERDENTURE - COMPLETE MANDIBULAR | Peds: 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 | $2,882.90 | Major & Complex Services |
| D5866 | OVERDENTURE - PARTIAL MANDIBULAR | Peds: 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 | $2,818.79 | Major & Complex Services |
| D6205 | PONTIC INDIRECT RESIN BASED COMPOS | Peds: 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 | $818.01 | Major & Complex Services |
| D6210 | PONTIC - CAST HIGH NOBLE METAL | Peds: 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 | $1,505.10 | Major & Complex Services |
| D6211 | PONTIC - CAST PREDOM BASE METAL | Peds: 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 | $1,060.25 | Major & Complex Services |
| D6212 | PONTIC - CAST NOBLE METAL | Peds: 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 | $1,117.16 | Major & Complex Services |
| D6214 | PONTIC - TITANIUM & TITANIUM ALLOYS | Peds: 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 | $1,094.33 | Major & Complex Services |
| D6240 | PONTIC-PORCELN FUSED HI NOBLE METL | Peds: 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 | $1,498.78 | Major & Complex Services |
| D6241 | PONTIC-PORCLN FUSD PREDOM BASE METL | Peds: 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 | $1,470.79 | Major & Complex Services |
| D6242 | PONTIC - PORCELN FUSED NOBLE METAL | Peds: 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 | $1,417.52 | Major & Complex Services |
| D6243 | PONTIC - PORCELN FU TIT & TIT ALY | Peds: 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 | $1,332.65 | Major & Complex Services |
| D6245 | PONTIC - PORCELAIN/CERAMIC | Peds: 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 | $1,533.09 | Major & Complex Services |
| D6250 | PONTIC - RESIN W/HIGH NOBLE METAL | Peds: 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 | $1,145.09 | Major & Complex Services |
| D6251 | PONTIC RESIN W/PREDOM BASE METAL | Peds: 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 | $1,055.93 | Major & Complex Services |
| D6252 | PONTIC RESIN W/NOBLE METAL | Peds: 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 | $1,107.96 | Major & Complex Services |
| D6253 | INTRM PONTC-TX/CMPL DX NEC B4 F IMP | Peds: 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 | $405.30 | Major & Complex Services |
| D6545 | RETN-CAST METL RSN BOND FIX PROSTH | Peds: 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 | $899.27 | Major & Complex Services |
| D6548 | RETN-PORCELN/CERAM RSN BOND PROSTH | Peds: 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 | $1,007.61 | Major & Complex Services |
| D6549 | RETAINER - RESIN BONDED FIXED PROS | Peds: 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 | $367.47 | Major & Complex Services |
| D6601 | RETAINER INLAY-PORC/CERAM 3/MOR SRF | Peds: 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 | $786.61 | Major & Complex Services |
| D6602 | RET INLAY-CAST HI NOBLE METL 2 SURF | Peds: 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 | $911.20 | Major & Complex Services |
| D6603 | RET INLA-CST HI NOBL MTL 3/MORE SRF | Peds: 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 | $877.14 | Major & Complex Services |
| D6604 | RET INLAY-CAST PDMT BASE METL 2 SRF | Peds: 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 | $646.67 | Major & Complex Services |
| D6605 | RET INLA-CST PDMT BSE MTL 3/MOR SRF | Peds: 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 | $853.20 | Major & Complex Services |
| D6606 | RETAIN INLAY-CAST NOBLE METL 2 SURF | Peds: 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 | $755.62 | Major & Complex Services |
| D6607 | RET INLAY-CAST NOBLE METL 3/MRE SRF | Peds: 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 | $850.77 | Major & Complex Services |
| D6608 | RETAINER ONLAY-PORCELN/CERAM 2 SURF | Peds: 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 | $1,008.19 | Major & Complex Services |
| D6609 | RETAINR ONLAY-PORC/CERAM 3/MORE SRF | Peds: 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 | $1,080.97 | Major & Complex Services |
| D6610 | RET ONLAY-CAST HI NOBLE METL 2 SURF | Peds: 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 | $839.39 | Major & Complex Services |
| D6611 | RET ON-CST HI NOBLE METL 3/MORE SRF | Peds: 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 | $1,138.20 | Major & Complex Services |
| D6612 | ONLAY-CAST PREDOM BASE METL 2 SURF | Peds: 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 | $1,032.48 | Major & Complex Services |
| D6613 | RET ON-CST PDMT BSE METL 3/MORE SRF | Peds: 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 | $1,072.54 | Major & Complex Services |
| D6614 | RET ONLAY-CAST NOBLE METAL 2 SURF | Peds: 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 | $1,020.11 | Major & Complex Services |
| D6615 | RET ONLAY-CST NOBLE METL 3/MORE SRF | Peds: 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 | $1,044.51 | Major & Complex Services |
| D6624 | RETAINER INLAY - TITANIUM | Peds: 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 | $962.46 | Major & Complex Services |
| D6634 | RETAINER ONLAY - TITANIUM | Peds: 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 | $1,005.47 | Major & Complex Services |
| D6710 | RET CROWN-INDIR RESIN BASED COMPOS | Peds: 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 | $864.94 | Major & Complex Services |
| D6720 | RETAINER CROWN-RESIN HI NOBLE METAL | Peds: 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 | $1,044.78 | Major & Complex Services |
| D6721 | RETAINER CROWN-RESIN PDMT BASE METL | Peds: 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 | $1,061.67 | Major & Complex Services |
| D6722 | RETAINER CROWN-RESIN W/NOBLE METAL | Peds: 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 | $1,071.86 | Major & Complex Services |
| D6740 | RETAINER CROWN - PORCELAIN/CERAMIC | Peds: 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 | $1,538.51 | Major & Complex Services |
| D6750 | RET CROWN-PORC FUSED HI NOBLE METL | Peds: 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 | $1,561.08 | Major & Complex Services |
| D6751 | RET CROWN-PORC FUSED PDMT BASE METL | Peds: 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 | $1,101.11 | Major & Complex Services |
| D6752 | RETNR CRWN-PORCELN FUSD NOBLE METAL | Peds: 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 | $1,450.93 | Major & Complex Services |
| D6753 | RET CRWN - PORCELN FU TIT & TIT ALY | Peds: 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 | $1,444.61 | Major & Complex Services |
| D6780 | RETNER CROWN-3/4 CAST HI NOBLE METL | Peds: 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 | $1,205.63 | Major & Complex Services |
| D6781 | RETNR CRWN-3/4 CAST PDMT BASE METAL | Peds: 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 | $971.30 | Major & Complex Services |
| D6782 | RETAINER CROWN-3/4 CAST NOBLE METAL | Peds: 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 | $947.36 | Major & Complex Services |
| D6783 | RETAINER CROWN-3/4 PORCELAIN/CERAMC | Peds: 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 | $1,049.03 | Major & Complex Services |
| D6784 | RETAINER CROWN 3/4 - TI & TI ALLOYS | Peds: 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 | $1,141.81 | Major & Complex Services |
| D6790 | RETNR CRWN-FULL CAST HI NOBLE METAL | Peds: 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 | $1,505.10 | Major & Complex Services |
| D6791 | RETNR CRWN-FULL CAST PDMT BASE METL | Peds: 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 | $1,074.37 | Major & Complex Services |
| D6792 | RETAINER CROWN-FULL CAST NOBLE METL | Peds: 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 | $1,118.18 | Major & Complex Services |
| D6793 | INTRM RET CR-TX/CMPL DX B4 FNL IMP | Peds: 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 | $332.63 | Major & Complex Services |
| D6794 | RETAINER CROWN - TI & TI ALLOYS | Peds: 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 | $1,293.09 | Major & Complex Services |
| D6920 | CONNECTOR BAR | Peds: 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 | $409.91 | Major & Complex Services |
| D9120 | FIXED PARTIAL DENTURE SECTIONING | Peds: 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 | $235.65 | Major & Complex Services |
| D5511 | REPAIR BKN CMPL DENTURE BASE MAND | 2 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 | $281.70 | Major & Complex Services |
| D5512 | REPAIR BKN CMPL DENTURE BASE MAX | 2 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 | $281.70 | Major & Complex Services |
| D5520 | REPL MISS/BROKEN TEETH-CMPL DENTUR | 2 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 | $242.87 | Major & Complex Services |
| D5611 | REPAIR RESIN PRTL DENTURE BASE MAND | 2 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 | $281.70 | Major & Complex Services |
| D5612 | REPAIR RESIN PRTL DENTURE BASE MAX | 2 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 | $281.70 | Major & Complex Services |
| D5621 | REPAIR CAST PARTIAL FRAMEWORK MAND | 2 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 | $356.64 | Major & Complex Services |
| D5622 | REPAIR CAST PARTIAL FRAMEWORK MAX | 2 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 | $356.64 | Major & Complex Services |
| D5630 | REPR/REPLCE BROKEN CLASP-PER TOOTH | 2 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 | $335.87 | Major & Complex Services |
| D5640 | REPLACE BROKEN TEETH - PER TOOTH | 2 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 | $247.39 | Major & Complex Services |
| D5650 | ADD TOOTH EXISTING PARTIAL DENTURE | 2 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 | $325.94 | Major & Complex Services |
| D5660 | ADD CLASP XST PRT DENTURE-PER TOOTH | 2 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 | $395.46 | Major & Complex Services |
| D5670 | REPL ALL TEETH&ACRYLC FRMEWRK MAX | 2 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 | $815.30 | Major & Complex Services |
| D5671 | REPL ALL TEETH&ACRYLC FRMEWRK MAND | 2 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 | $775.57 | Major & Complex Services |
| D6980 | FXD PRT DNTR REPR NEC RSTRTV MTL FL | 2 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 | $369.28 | Major & Complex Services |
| D5710 | REBASE COMPLETE MAXILLARY DENTURE | 1 Per 2 Years | Member Cost Share | $957.05 | Major & Complex Services |
| D5711 | REBASE COMPLETE MANDIBULAR DENTURE | 1 Per 2 Years | Member Cost Share | $957.05 | Major & Complex Services |
| D5720 | REBASE MAXILLARY PARTIAL DENTURE | 1 Per 2 Years | Member Cost Share | $702.44 | Major & Complex Services |
| D5721 | REBASE MANDIBULAR PARTIAL DENTURE | 1 Per 2 Years | Member Cost Share | $702.44 | Major & Complex Services |
| D5730 | RELINE COMPL MAXILLARY DENTURE DIR | 1 Per 2 Years | Member Cost Share | $525.48 | Major & Complex Services |
| D5731 | RELINE COMPL MANDIBULAR DENTURE DIR | 1 Per 2 Years | Member Cost Share | $525.48 | Major & Complex Services |
| D5740 | RELINE MAXILLARY PART DENTURE DIR | 1 Per 2 Years | Member Cost Share | $455.05 | Major & Complex Services |
| D5741 | RELINE MANDIBULAR PART DENTURE DIR | 1 Per 2 Years | Member Cost Share | $455.05 | Major & Complex Services |
| D5750 | RELINE COMPL MAXILLARY DENTUR INDIR | 1 Per 2 Years | Member Cost Share | $795.44 | Major & Complex Services |
| D5751 | RELINE CMPL MANDIBULAR DENTUR INDIR | 1 Per 2 Years | Member Cost Share | $795.44 | Major & Complex Services |
| D5760 | RELINE MAXILLARY PART DENTURE INDIR | 1 Per 2 Years | Member Cost Share | $710.57 | Major & Complex Services |
| D5761 | RELINE MANDIBULAR PART DENTUR INDIR | 1 Per 2 Years | Member Cost Share | $710.57 | Major & Complex Services |
| D6930 | RECEMENT FIXED PARTIAL DENTURE | 1 Per 5 Years | Member Cost Share | $201.34 | Major & Complex Services |
| D7210 | EXTN ERU TT RQR REMV BONE &/SECT TT | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $381.92 | Oral Surgery Services |
| D7310 | ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $474.01 | Oral Surgery Services |
| D7311 | ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETH | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $390.04 | Oral Surgery Services |
| D7320 | ALVEOLOPLASTY NO EXT 4/> TEETH/SPAC | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $689.80 | Oral Surgery Services |
| D7321 | ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETH | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $548.95 | Oral Surgery Services |
| D7340 | VESTIBULOPLASTY RIDGE EXT SEC EPITH | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $3,388.51 | Oral Surgery Services |
| D7350 | VESTBULPLSTY RIDGE EXT SFT TISS GFT | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $5,260.17 | Oral Surgery Services |
| D7471 | REMOVAL OF LATERAL EXOSTOSIS | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $1,454.54 | Oral Surgery Services |
| D7485 | REDUCTION OF OSSEOUS TUBEROSITY | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $1,402.17 | Oral Surgery Services |
| D7510 | I&D ABSCESS-INTRAORAL SOFT TISS | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $479.00 | Oral Surgery Services |
| D7511 | I & D ABSC INTRAORAL SOFT TISS COMP | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $1,692.90 | Oral Surgery Services |
| D7520 | I&D ABSC EXTRAORAL SOFT TISS | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $406.08 | Oral Surgery Services |
| D7521 | I & D ABSC XTRAORAL SOFT TISS COMP | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $2,144.34 | Oral Surgery Services |
| D7910 | SUTURE RECENT SMALL WOUNDS UP 5 CM | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $862.25 | Oral Surgery Services |
| D7971 | EXCISION OF PERICORONAL GINGIVA | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $267.25 | Oral Surgery Services |
| D7972 | SURGICAL RDUC FIBROUS TUBEROSITY | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $984.14 | Oral Surgery Services |
| D7111 | EXTRACT CORONAL RMNNTS-PRIM TOOTH | Member Cost Share | $164.32 | Oral Surgery Services | |
| D7140 | EXTRAC ERUPTED TOOTH/EXPOSED ROOT | Member Cost Share | $223.00 | Oral Surgery Services | |
| D7250 | REMOVAL OF RESIDUAL TOOTH ROOTS | 1 Per 6 Years (Any Surgical Extraction Combination Limit) | Member Cost Share | $384.63 | Oral Surgery Services |
| D0340 | 2D CEPHALOMET X-RAY-ACQN MSR&ANALY | Only as Dentally Necessary | Member Cost Share | $167.03 | Orthodontic Care Services |
| D0470 | DIAGNOSTIC CASTS | Only as Dentally Necessary | Member Cost Share | $124.60 | Orthodontic Care Services |
| D8010 | LTD ORTHODONT TX PRIMARY DENTITION | Only as Dentally Necessary | Member Cost Share | $3,160.25 | Orthodontic Care Services |
| D8020 | LTD ORTHODONT TX TRNSITIONL DENTITN | Only as Dentally Necessary | Member Cost Share | $3,390.56 | Orthodontic Care Services |
| D8030 | LTD ORTHODONTIC TX ADOLES DENTITION | Only as Dentally Necessary | Member Cost Share | $2,341.92 | Orthodontic Care Services |
| D8040 | LTD ORTHODONTIC TX ADULT DENTITION | Only as Dentally Necessary | Member Cost Share | $4,285.07 | Orthodontic Care Services |
| D8070 | COMP ORTHODONT TX TRNSITNL DENTITN | Only as Dentally Necessary | Member Cost Share | $6,722.08 | Orthodontic Care Services |
| D8080 | COMP ORTHODONT TX ADOLES DENTITION | Only as Dentally Necessary | Member Cost Share | $6,809.19 | Orthodontic Care Services |
| D8090 | COMP ORTHODONTIC TX ADULT DENTITION | Only as Dentally Necessary | Member Cost Share | $6,782.50 | Orthodontic Care Services |
| D8210 | REMOVABLE APPLIANCE THERAPY | Only as Dentally Necessary | Member Cost Share | $851.92 | Orthodontic Care Services |
| D8220 | FIXED APPLIANCE THERAPY | Only as Dentally Necessary | Member Cost Share | $921.54 | Orthodontic Care Services |
| D8660 | PREORTHODONTIC TREATMENT VISIT | Only as Dentally Necessary | Member Cost Share | $269.59 | Orthodontic Care Services |
| D8670 | PERIODIC ORTHODONTIC TX VISIT | Only as Dentally Necessary | Member Cost Share | $436.44 | Orthodontic Care Services |
| D8680 | ORTHODONTIC RETENTION | Only as Dentally Necessary | Member Cost Share | $593.71 | Orthodontic Care Services |
| D8698 | RE-CEMENT/RE-BOND FIX RETAIN - MAX | Only as Dentally Necessary | Member Cost Share | $154.39 | Orthodontic Care Services |
| D8699 | RE-CEMENT/RE-BOND FIX RETAIN - MAND | Only as Dentally Necessary | Member Cost Share | $154.39 | Orthodontic Care Services |