An Introduction to Core Dental & Vision Insurance

Exclusively from

CDI Overview v1.2

Benefit Highlights

• Routine Exams• Cleanings• Fluoride Treatment

Type 1 - Preventative Dental Care

• X-rays• Extractions• Fillings

Type 2 - Basic Dental Care

• Onlays• Crowns or Crown Repair• Root Canal

Type 3 - Major Dental Care*

*Please note-There is a 6 month waiting period for Major Dental Care unless you have had prior dental coverage in the last 6 months

Orthodontiafor dependent children

• Under the Platinum, Gold and Silver plans, orthodontic benefits are available for dependent children. Benefits are payable for orthodontic programs that are started before the dependent’s 17th birthday. Waiting periods may apply.

The Platinum, Gold and Silver plans provide a $1,000 lifetime maximum benefit per eligible dependent child, in addition to the plans annual maximum.

Core Dental Insurance (CDI) – Orthodontia Plan Allowances

Platinum Plan Gold Plan Silver Plan Value Plan

Coinsurance 50% 50% 50% No Ortho

Coverage for Adults No No No -

Lifetime Maximum (per person) $1,000 $1,000 $1,000 -

Waiting Period 12 months 12 months 12 months -

CDI Overview v1.2

CosmeticTeeth Whitening

• Professional teeth bleaching, also referred to as whitening, has become a popular cosmetic procedure. With this benefit, plan members can enjoy having a healthy, white smile that will boost self-confidence and add sparkle to their appearance.

Tooth bleaching pays a benefit for the following services up to the maximum covered expense:– Per arch bleaching (upper or lower) for ages 14 and over every 2 years– Single tooth bleaching– Internal bleaching to lighten a discolored tooth that has had root canal therapy

Dental Rewards®

• Is valuable feature that allows qualifying plan members to carryover part of their unused annual maximum. A member earns Dental Rewards® by submitting at least one claim for dental expenses incurred during the benefit year, while staying at or under the threshold amount for benefits received for that year. Members and their covered dependents may accumulate rewards up to the stated maximum carryover amount, and then use those rewards for any covered dental procedures subject to applicable coinsurance and plan provisions. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost. But he or she can begin earning rewards again the very next year. When a claim is submitted, your EOB will include the status of your Dental Rewards®. Or, you may call our Claim Customer Service unit to ask about the status of your Dental Rewards®.

All tlans

Threshold $500

Annual Carryover Amount $250

ttO .onus (Annual bonus if ttO provider is used for all claims) $100

aaximum wewards Accumulation $1,000

CDI Overview v1.2

Increase Annual Maximum with Dental Rewards®

Base Individual Annual Maximum Annual aaximum totential with Dental Rewards®tlatinum tlan - $2500 $3500

Dold tlan - $1500 $2500

Silver tlan - $1000 $2000

Value tlan - $1000 $2000

To be eligible for Dental Rewards®, file at least one claim in the given calendar year but not receive more than $500 of benefit. This allows you to carry-over $250/year into the next years annual maximum, for up-to 4 years. If a plan member doesn't submit a dental claim during a benefit year, all accumulated rewards are lost.

Vision CorrectionLASIK

• Provides coverage for LASIK and related procedures, including standard LASIK, Custom LASIK, LASIK with Wavefront Technology, CustomVue LASIK, LASIK with IntraLase technology and Photorefractive Keratectomy (PRK). Members earn a lifetime benefit per eye over time. The benefit amount increases throughout a four-year period, with the highest coverage provided at year four. Members earn benefits for each eye and may not combine benefits earned for each eye to pay for a covered procedure for a single eye. The LASIK Advantage benefit is available to members age 18 and older. There is no network tied to this coverage.

• There is a 12-month wait on LASIK benefits. After 12-months, a $125 benefit per eye is accrued. After 24-months, a $250 benefit per eye is accrued. One lifetime benefit allowable per eye.

Value, Silver, Gold & Platinum Plans

Lifetime Benefit Earned per Eye

After 12 months After 24 months

$125 benefit/eye $250 benefit/eye

CDI Overview v1.2

Vision & Hearing Benefits• Apply a portion of dental maximum benefit towards annual eye exams, lenses, frames and contact

lenses. Additional discounts are at no cost to plan members who use an EyeMed Access network at https://www.eyemedvisioncare.com/locator/locator.emvc?execution=e1s1

Vision Benefit: $100 each calendar year towards covered vision expenses. This benefit is taken from the annual dental benefit maximum.

• Covered Vision Expenses– Annual eye exams– Lenses: single, bifocal, trifocal, lenticular and progressive– Contact lenses including fit and follow up– Discounts are available to plan members who use an EyeMed Access network provider

• Hearing Wellness Benefit– Included - $75 exam per person per year.

• Greater Accessibility with over 235,000 network providers nationwide

• Experience the Value in Ameritas’wholly-owned provider network. The Ameritas network is never leased or rented, maintaining the value for Ameritas clients

• Save by using In-Network providers. - Network providers have agreed to charge significantly reduced fees for services. Save up to 40% through network providers or 25%, on average.

• No referrals necessary

• Higher benefit percentages when you see an Ameritas network provider

• Easily find providers near you with the Ameritas Provider Search at http://ameritas-dental.prismisp.com/

Access the In-Network and Save

Save up to 40% through network providers or 25%, on average.

CDI Overview v1.2

State Availability STATE Approved Credit

Cards ETF Check No $35

Enrollment Fee, Rates $5 less

tre-Appointment

Required AL Yes Yes Yes Yes AK Yes Yes Yes AZ Yes Yes Yes Yes Aw Yes Yes Yes Yes CA Yes Yes Yes CO Yes Yes Yes Yes No Fees CT Yes Yes Yes Yes DE Yes Yes Yes Yes DC Yes Yes Yes Yes FL DA Yes Yes Yes Yes HI Yes Yes Yes Yes ID Yes Yes Yes Yes IL Yes Yes Yes Yes IN Yes Yes Yes Yes IA Yes Yes Yes Yes KS Yes Yes Yes Yes tre-Appoint

KY Yes Yes Yes No Fees LA Yes Yes Yes Yes aE Yes Yes Yes Yes aD aA aI Yes Yes Yes No Fees aN Yes Yes Yes Yes aS Yes Yes Yes Yes aO Yes Yes Yes Yes aT Yes Yes Yes Yes tre-Appoint

NE Yes Yes Yes Yes NV Yes Yes Yes Yes NH Yes Yes Yes Yes NJ Yes Yes Yes Yes

Na Yes Yes Yes Yes NY NC Yes Yes Yes ND Yes Yes Yes Yes OH Yes Yes Yes Yes OK Yes Yes Yes Ow Yes Yes Yes Yes tA Yes Yes Yes Yes tre-Appoint

wI Yes Yes Yes Yes SC Yes Yes Yes Yes SD Yes Yes Yes Yes TN Yes Yes Yes No Fees TX Yes Yes Yes Yes UT Yes Yes Yes Yes VT Yes Yes Yes Yes VA WA Yes Yes Yes Yes WV Yes Yes Yes Yes WI Yes Yes Yes Yes WY Yes Yes Yes Yes

CDI Overview v1.2

Rates

aonthly wates Plan Level Platinum Gold Silver Value Individual $51.00 $41.00 $31.00 $21.00

Single & Dependents $122.75 $99.40 $75.82 $57.01 Married, No Dependents $97.00 $77.00 $57.00 $37.00

Family $168.75 $135.40 $101.82 $73.01

Quarterly wates Plan Level Platinum Gold Silver Value Individual $150.00 $120.00 $90.00 $60.00

Single & Dependents $365.25 $295.20 $224.46 $168.03 Married, No Dependents $288.00 $228.00 $168.00 $108.00

Family $503.25 $403.20 $302.46 $216.03

Semi-Annual wates Plan Level Platinum Gold Silver Value Individual $298.50 $238.50 $178.50 $118.50

Single & Dependents $729.00 $588.90 $447.42 $334.56 Married, No Dependents $574.50 $454.50 $334.50 $214.50

Family $1,005.00 $804.90 $603.42 $430.56

Annual wates Plan Level Platinum Gold Silver Value Individual $595.50 $475.50 $355.50 $235.50

Single & Dependents $1,456.50 $1,176.30 $893.34 $667.62 Married, No Dependents $1,147.50 $907.50 $667.50 $427.50

Family $2,008.50 $1,608.30 $1,205.34 $859.62

*In CO, aI, TN, KY, $5.00 per month premium discount applies to rates listed above!

*In CO, aI, TN, KY $35 application fee is waived!

CDI Overview v1.2

Important Disclosures

Waiting Periods There is a 6-month waiting period on ALL “Type 3 – Major” benefits. Orthodontia and LASIK benefits have a 12-month waiting period.

Creditable Coverage Waiver

The 6 month wait period for type 3 major services can be waived with proof of prior qualified dental insurance that has been canceled within 30 days prior to enrollment.

Deductible There is no deductible to meet and no year 1 benefit reductions!

Cleaning/Exam Notice! Plans have 1 insurance benefit and unlimited network discount benefits per 12 months on cleanings/exams

Networks Dental – Ameritas provider network Vision – EyeMed Access network provider

Billing Questions Billing – InsuranceTPA.com – 800-279-2290 Claims/Benefits Questions

Claims/Benefits– Ameritas – 800-487-5553

Application Fee $35.00 – charged in first month only in addition to first premium payment. Application Fee not charged in CO, KY, MI, TN.

10-day Review Each member has 10-days to review their policy. Written notice is needed to terminate their plan within 10-days from their effective date.

NO Credit Card States Credit cards are not accepted in AK, CA, OK and NC. However, ETF from a checking account is accepted.

Upgrade/Downgrade After 12 consecutive months on a plan, members are eligible for a plan upgrade. They are allowed 1 downgrade per year.

CDI Overview v1.2

Bonus Benefits! Orthodontia *not included on Value Plan

After a 12-month wait, there is a $1,000 lifetime benefit for each dependent child to be used towards orthodontia. Ortho services must be started before the child’s 17th birthday. This benefit is “in addition to” their annual maximum benefit. This benefit is subject to 50% coinsurance.

Cosmetic Whitening *not included on Value Plan

Cosmetic teeth whitening benefits are available for member over 14 years of age. These benefits vary by plan and are eligible every 2 years.

Dental Rewards® Dental Rewards® is a unique feature that allows members to roll a portion of their un-used annual benefit maximum into their next plan year. To access this benefit, the member must have submitted at least one claim during that year for dental services. A maximum lifetime carryover of $1,000 is allowed ($250/yr for 4 years).

LASIK Vision Correction After a 12-month wait, there is a lifetime benefit for LASIK vision correction available for members 18 years and older. After 12-months on the plan there is a $125 benefit per eye. After 24-months on the plan there is a $250 benefit per eye. This is a lifetime benefit meaning only one benefit per eye is allowed.

Vision Benefits $100 each calendar year towards covered vision expenses. This benefit is taken from the annual dental benefit maximum. Benefit can be used on/towards Exams, Frames, Lenses, contacts. Additional savings and discounts for members who use EyeMed Access network provider.

Hearing Benefits $75 per person per year towards a hearing exam. Not available in Washington.

CDI Overview v1.2

Maximum Covered Expense (MCE)

Maximum Covered Expense (MCE):  MCE is an easytounderstand benefit at a very affordable rate. The plan pays the amount of the expense, up to the MCE, and youpay the difference between that amount and the dentist's fee. As you can see, MCE increases/decreases based on the plan you select. Many times a single visit to thedentist will allow for multiple payouts of MCE. For example, if you visit the dentist for a preventive check up examination there could be separate MCE's payable for theexam, xrays, cleaning, etc...

You will receive additional outofpocket savings when you utilize an Ameritas PPO provider (in Texas, the Ameritas Dental Network). Ameritas PPO providers have agreedto charge discounted fees to member clients. The Ameritas PPO offers more than 170,000 provider access points nationwide. If there is no coverage for a particularprocedure you may still receive a discount through the PPO.

Example of PPO Savings

actual savings varies based on location and plan selected

Bob, who lives in the Chicago area (ZIP 60156), visits the dentist and gets an exam, cleaning, and xrays. The dentist discovers that Bob needs a filling and an extraction.Here is an example of PPO savings if Bob selects the GOLD or the PLATINUM plan:

Procedure/Procedure CodeDentist'saverage

charge in thearea

PPO Provider(MAC = Maximum Allowable

Charge)

Maximum Covered Expense(MCE)

Under the Gold Plan

Maximum Covered Expense(MCE)

Under the Platinum Plan

Comprehensive exam, D0150 $63 $38 $36 $46

Adult cleaning, D1110 $79 $52 $49 $63

Bitewing xrays, D0272 $38 $22 $21 $27

Filling (restorative amalgam),D2140 $117 $70 $51 $66

Complex extraction, D7230 $365 $226 $98 $133

 TOTAL       $662  $408 MAC*  $255 MCE  $335 MCE

 Under the GOLD plan, if Bob uses an Ameritas PPO dentist for services, his outofpocket expense is $153. If he uses an outofnetwork dentist, Bob will share more of the cost of his services, with his outofpocket expense at $407. Under the PLATINUM plan, with a PPO dentist, Bob's outofpocket expense is $97. If Bob uses an outofnetwork dentist, he will share more of the cost of his services, with his outofpocket expense at $327. 

Innetwork expenses vary by ZIP Code, out of network expenses vary depending on the amounts charged by nonnetwork dentists.  Without a plan, Bob's outofpocket expense would have been $662.

*PPO providers most common contracted fee"

Definitions:

Maximum Covered Expense (MCE):  MCE is an easytounderstand benefit at a very affordable rate.  The plan pays the amount of the expense, up to the MCE, for each covered procedure, and you pay the difference between that amount and the dentist's fee.  You will receive additional outofpocket savings when using an Ameritas PPO provider.

Maximum Allowable Charge (MAC):  The charges accepted by dentists who are Participating Providers.  The MAC is reviewed and updated periodically to reflect increasing Provider fees within the ZIP code area.  It is derived from the array of Provider charges within a particular ZIP code area.

Current Dental Terminology ©2011 American Dental Association.  All rights reserved.

Plan Benefits MCE

ProcedureCode

ProcedureName

ProcedureType

Platinum PlanAllowance

Gold PlanAllowance

Silver PlanAllowance

Value PlanAllowance

D0270 Bitewing ‐ Single Film 1 $15.00 $12.00 $9.00 $6.00

D0274 Bitewings ‐ Four Films 1 $42.00 $33.00 $25.00 $18.00

D0273 Bitewings ‐ Three Films 1 $32.00 $25.00 $19.00 $14.00

D0272 Bitewings ‐ Two Films 1 $27.00 $21.00 $16.00 $11.00

D0150 Comprehensive Oral Evaluation‐New Or Estab Patient 1 $46.00 $36.00 $27.00 $19.00

D0180 Comprehensive Periodontal Evaluation, New Or Estab 1 $46.00 $36.00 $27.00 $19.00

D8220 Fixed Appliance Therapy 1 $338.00 $263.00 $200.00 $141.00

D0145 Oral Evaluation For A Patient Under 3 Years Of Age 1 $23.00 $18.00 $14.00 $10.00

D0120 Periodic Oral Evaluation‐Established Patient 1 $30.00 $23.00 $18.00 $12.00

D1110 Prophylaxis ‐ Adult 1 $63.00 $49.00 $38.00 $27.00

D1120 Prophylaxis ‐ Child 1 $45.00 $35.00 $26.00 $19.00

D1550 Re‐Cementation Of Space Maintainer 1 $46.00 $36.00 $27.00 $19.00

D8210 Removable Appliance Therapy 1 $338.00 $263.00 $200.00 $141.00

D1555 Removal Of Fixed Space Maintainer 1 $63.00 $49.00 $38.00 $27.00

D1351 Sealant ‐ Per Tooth 1 $35.00 $27.00 $21.00 $15.00

D1515 Space Maintainer ‐ Fixed ‐ Bilateral 1 $367.00 $286.00 $218.00 $154.00

D1510 Space Maintainer ‐ Fixed ‐ Unilateral 1 $224.00 $174.00 $133.00 $94.00

D1525 Space Maintainer ‐ Removable ‐ Bilateral 1 $428.00 $333.00 $254.00 $179.00

D1520 Space Maintainer ‐ Removable ‐ Unilateral 1 $351.00 $273.00 $208.00 $147.00

D1204 Topical Application Of Fluoride ‐ Adult 1 $24.00 $19.00 $14.00 $10.00

D1203 Topical Application Of Fluoride ‐ Child 1 $24.00 $19.00 $14.00 $10.00

D1206 Topical Fluoride Varnish,Application For Caries 1 $24.00 $19.00 $14.00 $10.00

D0277 Vertical Bitewings ‐ 7 To 8 Films 1 $63.00 $49.00 $38.00 $27.00

D0473 Accession Of Tissue, Gross & Microscopic Exam 2 $91.00 $71.00 $42.00 $28.00

D0472 Accession Of Tissue, Gross Examination, Preparatio 2 $46.00 $36.00 $21.00 $14.00

D0474 Accession Of Tissue,Gross & Microscopic Exam, Prep 2 $91.00 $71.00 $42.00 $28.00

D7311 Alveoloplasty In Conj. With Extraction 2 $35.00 $26.00 $24.00 $19.00

D7321 Alveoloplasty Not In Conj. With Extraction 2 $44.00 $33.00 $30.00 $24.00

D7310 Alveoplasty In Conjunct With Ext‐4 + Tth, Per Quad 2 $69.00 $51.00 $47.00 $38.00

D7320 Alveoplasty Not In Conjunct W/Extr,4+ Tth Per Quad 2 $87.00 $65.00 $59.00 $48.00

D2161 Amalgam ‐ Four+ Surfaces ‐ Primary Or Permanent 2 $121.00 $94.00 $55.00 $37.00

D2140 Amalgam ‐ One Surface ‐ Primary Or Permanent 2 $66.00 $51.00 $30.00 $20.00

D2160 Amalgam ‐ Three Surfaces ‐ Primary Or Permanent 2 $101.00 $78.00 $46.00 $31.00

D2150 Amalgam ‐ Two Surfaces ‐ Primary Or Permanent 2 $84.00 $65.00 $38.00 $26.00

D7285 Biopsy Of Oral Tissue ‐ Hard ﴾Bone, Tooth﴿ 2 $298.00 $230.00 $136.00 $92.00

D7286 Biopsy Of Oral Tissue ‐ Soft 2 $161.00 $124.00 $73.00 $50.00

D7288 Brush Biopsy ‐ Transepithelial Sample Collection 2 $80.00 $62.00 $37.00 $25.00

D7983 Closure Of Salivary Fistula 2 $50.00 $37.00 $34.00 $27.00

D7912 Complicated Suture ‐ Greater Than 5 Cm 2 $40.00 $30.00 $27.00 $22.00

D7911 Complicated Suture ‐ Up To 5 Cm 2 $28.00 $21.00 $19.00 $15.00

D9310 Consultation ‐ Other Than Req Dentist Or Physician 2 $56.00 $43.00 $26.00 $17.00

D9221 Deep Sedation/General Anesthesia ‐ Each Add 15 Min 2 $39.00 $29.00 $26.00 $21.00

D9220 Deep Sedation/General Anesthesia‐First 30 Minutes 2 $119.00 $88.00 $81.00 $65.00

D7465 Destruction Of Lesion﴾S﴿ By Physical Or Chemical 2 $38.00 $28.00 $26.00 $21.00

D7441 Excision ‐ Malignant Tumor ‐ Greater Than 1.25 Cm 2 $124.00 $92.00 $84.00 $68.00

D7440 Excision ‐ Malignant Tumor ‐ Up To 1.25 Cm 2 $169.00 $126.00 $115.00 $93.00

D7411 Excision Of Benign Lesion Greater Than 1.25 Cm 2 $161.00 $119.00 $109.00 $88.00

D7410 Excision Of Benign Lesion Up To 1.25 Cm 2 $125.00 $93.00 $85.00 $69.00

D7412 Excision Of Benign Lesion, Complicated 2 $177.00 $131.00 $120.00 $97.00

D7414 Excision Of Malignant Lesion Greater Than 1.25 Cm 2 $124.00 $92.00 $84.00 $68.00

D7413 Excision Of Malignant Lesion Up To 1.25 Cm 2 $300.00 $232.00 $137.00 $93.00

D7415 Excision Of Malignant Lesion, Complicated 2 $136.00 $101.00 $92.00 $75.00

D7970 Excision Or Hyperplastic Tissue ‐ Per Arch 2 $104.00 $77.00 $70.00 $57.00

D7287 Exfoliative Cytological Sample Collection 2 $80.00 $62.00 $37.00 $25.00

D7111 Extraction, Coronal Remnants ‐ Deciduous Tooth 2 $74.00 $57.00 $34.00 $23.00

D7140 Extraction, Erupted Tooth Or Exposed Root 2 $74.00 $57.00 $34.00 $23.00

D0260 Extraoral ‐ Each Additional Film 2 $20.00 $15.00 $9.00 $6.00

D0250 Extraoral ‐ First Film 2 $25.00 $20.00 $12.00 $8.00

D2940 Fillings ‐ Sedative 2 $48.00 $37.00 $22.00 $15.00

D7960 Frenulectomy ‐ Separate Procedure ﴾Ectomy/Otomy﴿ 2 $135.00 $100.00 $91.00 $74.00

D7963 Frenuloplasty 2 $168.00 $125.00 $114.00 $92.00

D4355 Full Mouth Debridement For Perio Evaluation 2 $81.00 $63.00 $37.00 $25.00

D2410 Gold Foil ‐ One Surface 2 $66.00 $51.00 $30.00 $20.00

D2430 Gold Foil ‐ Three Surfaces 2 $101.00 $78.00 $46.00 $31.00

D2420 Gold Foil ‐ Two Surfaces 2 $84.00 $65.00 $38.00 $26.00

D7520 Incision And Drainage Of Abscess ‐ Extraoral Soft 2 $64.00 $48.00 $44.00 $35.00

D7510 Incision And Drainage Of Abscess ‐ Intraoral Soft 2 $56.00 $41.00 $38.00 $31.00

D0210 Intraoral ‐ Complete Series ﴾Including Bitewings﴿ 2 $78.00 $60.00 $36.00 $24.00

D0240 Intraoral ‐ Occlusal Film 2 $20.00 $15.00 $9.00 $6.00

D0230 Intraoral ‐ Periapical Each Additional Film 2 $11.00 $9.00 $5.00 $3.00

D0220 Intraoral ‐ Periapical First Film 2 $14.00 $11.00 $7.00 $4.00

D9242 Intravenous Sedation/Analgesia ‐ Each Add 15 Min 2 $19.00 $14.00 $13.00 $11.00

D9241 Intravenous Sedation/Analgesia ‐ First 30 Minutes 2 $79.00 $58.00 $53.00 $43.00

D0140 Limited Oral Evaluation ‐ Problem Focused 2 $39.00 $30.00 $18.00 $12.00

D7560 Maxillary Sinusotomy For Removal Of Tooth Fragment 2 $186.00 $138.00 $126.00 $102.00

D7282 Mobilization Of Erupted Or Malpositioned Tooth‐Aid 2 $132.00 $98.00 $89.00 $72.00

D9952 Occlusal Adjustment ‐ Complete 2 $265.00 $205.00 $121.00 $82.00

D9951 Occlusal Adjustment ‐ Limited 2 $53.00 $41.00 $24.00 $16.00

D9440 Office Visit ‐ After Regularly Scheduled Hours 2 $68.00 $53.00 $31.00 $21.00

D9430 Office Visit ‐ During Regular Hours‐No Other Serv 2 $39.00 $30.00 $18.00 $12.00

D7260 Oroantral Fistula Closure 2 $196.00 $145.00 $133.00 $107.00

D9110 Palliative ﴾Emergency﴿ Treatment ‐ Minor Procedure 2 $55.00 $43.00 $25.00 $17.00

D0330 Panoramic Film 2 $63.00 $48.00 $29.00 $19.00

D7550 Partial Ostectomy/Sequestrectomy For Removal 2 $141.00 $105.00 $96.00 $78.00

D4910 Periodontal Maintenance 2 $84.00 $65.00 $38.00 $26.00

D7283 Placement Of Device To Facilitate Eruption Of 2 $55.00 $41.00 $37.00 $30.00

D7261 Primary Closure Of A Sinus Perforation 2 $196.00 $145.00 $133.00 $107.00

D7490 Radical Resection Of Maxilla Or Mandible 2 $169.00 $126.00 $115.00 $93.00

D0170 Re‐Evaluation ‐ Limited, Problem Focused 2 $39.00 $30.00 $18.00 $12.00

D0170 Re‐Evaluation ‐ Limited, Problem Focused 2 $39.00 $30.00 $18.00 $12.00

D2915 Recement Cast Or Prefabricated Post And Core 2 $26.00 $20.00 $12.00 $8.00

D2920 Recement Crown 2 $52.00 $40.00 $24.00 $16.00

D6930 Recement Fixed Partial Denture 2 $72.00 $55.00 $33.00 $22.00

D6092 Recement Implant/Abutment Supported Crown 2 $52.00 $40.00 $24.00 $16.00

D6093 Recement Implant/Abutment Supported Fix Part Dent 2 $52.00 $40.00 $24.00 $16.00

D2910 Recement Inlay, Onlay, Or Partial Coverage Restora 2 $53.00 $41.00 $24.00 $16.00

D5731 Reline Complete Mandibular Denture ﴾Chairside﴿ 2 $153.00 $118.00 $70.00 $47.00

D5751 Reline Complete Mandibular Denture ﴾Laboratory﴿ 2 $224.00 $173.00 $102.00 $69.00

D5730 Reline Complete Maxillary Denture ﴾Chairside﴿ 2 $154.00 $119.00 $70.00 $48.00

D5750 Reline Complete Maxillary Denture ﴾Laboratory﴿ 2 $229.00 $177.00 $104.00 $71.00

D5741 Reline Mandibular Partial Denture ﴾Chairside﴿ 2 $139.00 $107.00 $63.00 $43.00

D5761 Reline Mandibular Partial Denture ﴾Laboratory﴿ 2 $230.00 $178.00 $105.00 $71.00

D5740 Reline Maxillary Partial Denture ﴾Chairside﴿ 2 $138.00 $106.00 $63.00 $43.00

D5760 Reline Maxillary Partial Denture ﴾Laboratory﴿ 2 $229.00 $177.00 $104.00 $71.00

D7530 Removal Of Foreign Body From Mucosa, Skin,Alveolar 2 $51.00 $38.00 $35.00 $28.00

D7240 Removal Of Impacted Tooth ‐ Completely Bony 2 $155.00 $115.00 $105.00 $85.00

D7230 Removal Of Impacted Tooth ‐ Partially Bony 2 $133.00 $98.00 $90.00 $73.00

D7241 Removal Of Impacted Tooth‐Completely Bony,W/Compli 2 $177.00 $131.00 $120.00 $97.00

D7471 Removal Of Lateral Exostosis ﴾Maxilla Or Mandible﴿ 2 $112.00 $83.00 $76.00 $61.00

D7473 Removal Of Toris Mandibularis 2 $112.00 $83.00 $76.00 $61.00

D7472 Removal Of Torus Palatinus 2 $112.00 $83.00 $76.00 $61.00

D7472 Removal Of Torus Palatinus 2 $112.00 $83.00 $76.00 $61.00

D7540 Remove Reaction Producing Foreign Body ‐ Muscu‐Skl 2 $141.00 $105.00 $96.00 $78.00

D7460 Remv Of Benign Nonodontogenic Cyst/Tumor < 1.25 Cm 2 $125.00 $93.00 $85.00 $69.00

D7461 Remv Of Benign Nonodontogenic Cyst/Tumor > 1.25 Cm 2 $161.00 $119.00 $109.00 $88.00

D7450 Remv Of Benign Odontogenic Cyst Or Tumor < 1.25 Cm 2 $125.00 $93.00 $85.00 $69.00

D7451 Remv Of Benign Odontogenic Cyst Or Tumor > 1.25 Cm 2 $161.00 $119.00 $109.00 $88.00

D5510 Repair Broken Complete Denture Base 2 $84.00 $65.00 $38.00 $26.00

D5620 Repair Cast Framework 2 $98.00 $76.00 $45.00 $30.00

D5630 Repair Or Replace Broken Clasp 2 $102.00 $79.00 $47.00 $32.00

D5610 Repair Resin Denture Base 2 $83.00 $64.00 $38.00 $26.00

D5640 Replace Broken Teeth ‐ Per Tooth 2 $74.00 $57.00 $34.00 $23.00

D5520 Replace Missing Or Broken Teeth ‐ Complete Denture 2 $69.00 $54.00 $32.00 $21.00

D2335 Resin‐Based Comp‐ 4+ Surfaces Or Incisal, Anterior 2 $140.00 $108.00 $64.00 $43.00

D2330 Resin‐Based Composite ‐ One Surface, Anterior 2 $80.00 $62.00 $37.00 $25.00

D2391 Resin‐Based Composite ‐ One Surface, Posterior 2 $88.00 $68.00 $40.00 $27.00

D2332 Resin‐Based Composite ‐ Three Surfaces, Anterior 2 $127.00 $98.00 $58.00 $39.00

D2393 Resin‐Based Composite ‐ Three Surfaces, Posterior 2 $140.00 $108.00 $64.00 $43.00

D2331 Resin‐Based Composite ‐ Two Surfaces, Anterior 2 $101.00 $78.00 $46.00 $31.00

D2392 Resin‐Based Composite ‐ Two Surfaces, Posterior 2 $111.00 $86.00 $51.00 $34.00

D2390 Resin‐Based Composite Crown,Anterior 2 $171.00 $132.00 $78.00 $53.00

D2394 Resin‐Based Composite‐Four Or More Surf, Posterior 2 $154.00 $119.00 $70.00 $48.00

D7980 Sialolithotomy 2 $155.00 $115.00 $105.00 $85.00

D7280 Surgical Access Of An Unerupted Tooth 2 $184.00 $136.00 $124.00 $101.00

D7972 Surgical Reduction Of Fibrous Tuberosity 2 $165.00 $122.00 $112.00 $90.00

D7485 Surgical Reduction Of Osseous Tuberosity 2 $182.00 $135.00 $123.00 $100.00

D7250 Surgical Removal Of Residual Tooth Roots﴾Cut Proc﴿ 2 $83.00 $62.00 $56.00 $46.00

D7910 Suture Of Recent Small Wounds Up To 5 Cm 2 $25.00 $18.00 $17.00 $14.00

D7270 Tooth Reimplantation And/Or Stabilization 2 $118.00 $88.00 $80.00 $65.00

D7272 Tooth Transplantation 2 $118.00 $88.00 $80.00 $65.00

D9930 Treatment Of Complications ﴾Post‐Surgical﴿ 2 $42.00 $32.00 $19.00 $13.00

D7350 Vestibuloplasty ‐ Ridge Extension ‐ Complicated 2 $314.00 $233.00 $213.00 $172.00

D7340 Vestibuloplasty ‐ Ridge Extension ‐ Uncomplicated 2 $126.00 $94.00 $86.00 $69.00

D7210 Surgical Removal Of Erupted Tooth Requiring Elevat 2 $44.00

D6194 Abut Retainer Crown For Fpd ‐ ﴾Titanium﴿ 3 $372.00 $276.00 $252.00 $0.00

D6060 Abut Supported Porc Fused To Metal Crn﴾Base Metal﴿ 3 $372.00 $276.00 $252.00 $0.00

D6059 Abut Supported Porc Fused To Metal Crn﴾High Noble﴿ 3 $372.00 $276.00 $252.00 $0.00

D6061 Abut Supported Porc Fused To Metal Crn﴾Noble Metl﴿ 3 $341.00 $253.00 $231.00 $0.00

D6063 Abutment Supported Cast Metal Crown ﴾Base Metal﴿ 3 $372.00 $276.00 $252.00 $0.00

D6062 Abutment Supported Cast Metal Crown ﴾High Noble﴿ 3 $372.00 $276.00 $252.00 $0.00

D6064 Abutment Supported Cast Metal Crown ﴾Noble Metal﴿ 3 $403.00 $299.00 $273.00 $0.00

D6094 Abutment Supported Crown ‐ ﴾Titanium﴿ 3 $372.00 $276.00 $252.00 $0.00

D6058 Abutment Supported Porcelain/Ceramic Crown 3 $341.00 $253.00 $231.00 $0.00

D6072 Abutment Supported Retainer For Cast Metal Fpd 3 $372.00 $276.00 $252.00 $0.00

D6073 Abutment Supported Retainer For Cast Metal Fpd 3 $372.00 $276.00 $252.00 $0.00

D6074 Abutment Supported Retainer For Cast Metal Fpd 3 $403.00 $299.00 $273.00 $0.00

D6069 Abutment Supported Retainer For Porc Fusd To M Fpd 3 $372.00 $276.00 $252.00 $0.00

D6070 Abutment Supported Retainer For Porc Fusd To M Fpd 3 $372.00 $276.00 $252.00 $0.00

D6071 Abutment Supported Retainer For Porc Fusd To M Fpd 3 $341.00 $253.00 $231.00 $0.00

D6068 Abutment Supported Retainer For Porc/Ceramic Fpd 3 $341.00 $253.00 $231.00 $0.00

D5660 Add Clasp To Existing Partial Denture 3 $61.00 $46.00 $42.00 $0.00

D5650 Add Tooth To Existing Partial Denture 3 $53.00 $39.00 $36.00 $0.00

D5411 Adjust Complete Denture ‐ Mandibular 3 $22.00 $16.00 $15.00 $0.00

D5410 Adjust Complete Denture ‐ Maxillary 3 $23.00 $17.00 $16.00 $0.00

D5422 Adjust Partial Denture ‐ Mandibular 3 $23.00 $17.00 $16.00 $0.00

D5421 Adjust Partial Denture ‐ Maxillary 3 $24.00 $18.00 $16.00 $0.00

D3353 Apexification/Recalcification ‐ Final Visit 3 $163.00 $121.00 $110.00 $0.00

D3351 Apexification/Recalcification ‐ Initial Visit 3 $82.00 $61.00 $56.00 $0.00

D3352 Apexification/Recalcification‐Interim Medication 3 $56.00 $41.00 $38.00 $0.00

D3410 Apicoectomy/Periradicular Surgery ‐ Anterior 3 $236.00 $175.00 $160.00 $0.00

D3421 Apicoectomy/Periradicular Surgery ‐ Bicuspid 3 $272.00 $202.00 $184.00 $0.00

D3425 Apicoectomy/Periradicular Surgery ‐ Molar 3 $295.00 $219.00 $200.00 $0.00

D3426 Apicoectomy/Periradicular Surgery‐Each Addn'L Root 3 $105.00 $78.00 $71.00 $0.00

D4265 Biologic Materials To Aid In Soft & Osseous Regen 3 $61.00 $46.00 $42.00 $0.00

D4264 Bone Replacement Graft‐Each Addl Site In Quadrant 3 $92.00 $69.00 $63.00 $0.00

D4263 Bone Replacement Graft‐First Site In Quadrant 3 $123.00 $91.00 $83.00 $0.00

D4249 Clinical Crown Lengthening, Hard Tissue 3 $226.00 $168.00 $153.00 $0.00

D4276 Combined Connective Tissue And Dbl Pedicle Graft 3 $342.00 $254.00 $232.00 $0.00

D5120 Complete Denture ‐ Mandibular 3 $396.00 $294.00 $268.00 $0.00

D5110 Complete Denture ‐ Maxillary 3 $409.00 $303.00 $277.00 $0.00

D6973 Core Build Up For Retainer, Including Any Pins 3 $79.00 $59.00 $54.00 $0.00

D2950 Core Build‐Up, Including Any Pins 3 $79.00 $59.00 $54.00 $0.00

D2780 Crown ‐ 3/4 Cast High Noble Metal 3 $365.00 $271.00 $247.00 $0.00

D6780 Crown ‐ 3/4 Cast High Noble Metal 3 $403.00 $299.00 $273.00 $0.00

D6782 Crown ‐ 3/4 Cast Noble Metal 3 $341.00 $253.00 $231.00 $0.00

D2782 Crown ‐ 3/4 Cast Noble Metal 3 $332.00 $246.00 $225.00 $0.00

D2781 Crown ‐ 3/4 Cast Predominantly Base Metal 3 $317.00 $236.00 $215.00 $0.00

D6781 Crown ‐ 3/4 Cast Predominantly Base Metal 3 $372.00 $276.00 $252.00 $0.00

D6783 Crown ‐ 3/4 Porcelain/Ceramic 3 $341.00 $253.00 $231.00 $0.00

D2783 Crown ‐ 3/4 Porcelain/Ceramic 3 $395.00 $293.00 $268.00 $0.00

D2712 Crown ‐ 3/4 Resin‐Based Composite ﴾Indirect﴿ 3 $355.00 $264.00 $241.00 $0.00

D6790 Crown ‐ Full Cast High Noble Metal 3 $372.00 $276.00 $252.00 $0.00

D6792 Crown ‐ Full Cast Noble Metal 3 $341.00 $253.00 $231.00 $0.00

D6791 Crown ‐ Full Cast Predominantly Base Metal 3 $372.00 $276.00 $252.00 $0.00

D2790 Crown ‐ Gold ‐ Full Cast 3 $365.00 $271.00 $247.00 $0.00

D6710 Crown ‐ Indirect Resin Based Composite 3 $307.00 $228.00 $208.00 $0.00

D2791 Crown ‐ Nonprecious Metal ‐ Full Cast 3 $317.00 $236.00 $215.00 $0.00

D6750 Crown ‐ Porcelain Fused To High Noble Metal 3 $403.00 $299.00 $273.00 $0.00

D6752 Crown ‐ Porcelain Fused To Noble Metal 3 $341.00 $253.00 $231.00 $0.00

D2750 Crown ‐ Porcelain With Gold 3 $384.00 $285.00 $260.00 $0.00

D2751 Crown ‐ Porcelain With Nonprecious Metal 3 $329.00 $244.00 $223.00 $0.00

D2752 Crown ‐ Porcelain With Semiprecious Metal 3 $353.00 $262.00 $239.00 $0.00

D6740 Crown ‐ Porcelain/Ceramic 3 $341.00 $253.00 $231.00 $0.00

D2740 Crown ‐ Porcelain/Ceramic Substrate 3 $395.00 $293.00 $268.00 $0.00

D2720 Crown ‐ Resin With Gold 3 $366.00 $271.00 $248.00 $0.00

D6720 Crown ‐ Resin With High Noble Metal 3 $372.00 $276.00 $252.00 $0.00

D6722 Crown ‐ Resin With Noble Metal 3 $310.00 $230.00 $210.00 $0.00

D2721 Crown ‐ Resin With Nonprecious Metal 3 $279.00 $207.00 $189.00 $0.00

D6721 Crown ‐ Resin With Predominantly Base Metal 3 $193.00 $143.00 $131.00 $0.00

D2722 Crown ‐ Resin With Semiprecious Metal 3 $342.00 $254.00 $232.00 $0.00

D2710 Crown ‐ Resin‐Based Composite ﴾Indirect﴿ 3 $143.00 $106.00 $97.00 $0.00

D2792 Crown ‐ Semiprecious Metal ‐ Full Cast 3 $332.00 $246.00 $225.00 $0.00

D2794 Crown ‐ Titanium 3 $365.00 $271.00 $247.00 $0.00

D6794 Crown ‐ Titanium 3 $372.00 $276.00 $252.00 $0.00

D2980 Crown Repair, By Report 3 $64.00 $47.00 $43.00 $0.00

D6751 Crown‐Porcelain Fused To Predominantly Base Metal 3 $372.00 $276.00 $252.00 $0.00

D4381 Delivery Of Antimicrobial Agents Into Tissue 3 $56.00 $42.00 $38.00 $0.00

D4274 Distal Or Proximal Wedge Procedure 3 $165.00 $122.00 $112.00 $0.00

D3310 Endodontic Therapy, Anterior Tooth 3 $229.00 $170.00 $155.00 $0.00

D3320 Endodontic Therapy, Bicuspid Tooth 3 $270.00 $201.00 $183.00 $0.00

D3330 Endodontic Therapy, Molar 3 $354.00 $263.00 $240.00 $0.00

D9972 External Bleaching ‐ Per Arch 3 $60.00 $44.00 $40.00 $0.00

D9973 External Bleaching ‐ Per Tooth 3 $37.00 $28.00 $25.00 $0.00

D6980 Fixed Partial Denture Repair, By Report 3 $71.00 $53.00 $48.00 $0.00

D9120 Fixed Partial Denture Sectioning 3 $71.00 $53.00 $48.00 $0.00

D4271 Free Soft Tissue Graft Procedure ﴾Incl Donor Site﴿ 3 $293.00 $218.00 $199.00 $0.00

D4241 Gingival Flap Proc,Incl Root Planing‐1 To 3 Teeth 3 $103.00 $76.00 $70.00 $0.00

D4240 Gingival Flap Proc,Incl Root Planing‐4 Or More Tth 3 $205.00 $152.00 $139.00 $0.00

D4211 Gingivectomy Or Gingivoplasty ‐ 1 To 3 Teeth 3 $75.00 $56.00 $51.00 $0.00

D4210 Gingivectomy Or Gingivoplasty ‐ 4 Or More Teeth 3 $149.00 $111.00 $101.00 $0.00

D3920 Hemisection‐Incl Root Removal Not Root Canal 3 $130.00 $96.00 $88.00 $0.00

D5140 Immediate Denture ‐ Mandibular 3 $428.00 $318.00 $290.00 $0.00

D5130 Immediate Denture ‐ Maxillary 3 $443.00 $328.00 $300.00 $0.00

D6067 Implant Supported Metal Crown 3 $372.00 $276.00 $252.00 $0.00

D6066 Implant Supported Porcelain Fused To Metal Crown 3 $372.00 $276.00 $252.00 $0.00

D6065 Implant Supported Porcelain/Ceramic Crown 3 $341.00 $253.00 $231.00 $0.00

D6077 Implant Supported Retainer For Cast Metal Fpd 3 $372.00 $276.00 $252.00 $0.00

D6075 Implant Supported Retainer For Ceramic Fpd 3 $341.00 $253.00 $231.00 $0.00

D6076 Implant Supported Retainer For Por Fusd To M Fpd 3 $372.00 $276.00 $252.00 $0.00

D6078 Implant/Abutment Supported Fixed Denture For Comp 3 $409.00 $303.00 $277.00 $0.00

D6079 Implant/Abutment Supported Fixed Denture For Parti 3 $474.00 $351.00 $321.00 $0.00

D6053 Implant/Abutment Supported Removable Dtr‐Edentulou 3 $409.00 $303.00 $277.00 $0.00

D6054 Implant/Abutment Supported Removable Ptr‐Edentulou 3 $474.00 $351.00 $321.00 $0.00

D3332 Incomplete Endo Therapy; Inop, Unrest Or Fract Tth 3 $135.00 $100.00 $92.00 $0.00

D6603 Inlay ‐ Cast High Noble Metal, Three Or More Surf 3 $300.00 $223.00 $203.00 $0.00

D6602 Inlay ‐ Cast High Noble Metal, Two Surfaces 3 $273.00 $202.00 $185.00 $0.00

D6607 Inlay ‐ Cast Noble Metal ‐ Three Or More Surfaces 3 $273.00 $202.00 $185.00 $0.00

D6606 Inlay ‐ Cast Noble Metal ‐ Two Surfaces 3 $248.00 $184.00 $168.00 $0.00

D6604 Inlay ‐ Cast Predominantly Base Metal, 2 Surfaces 3 $236.00 $175.00 $160.00 $0.00

D2510 Inlay ‐ Metallic ‐ One Surface 3 $253.00 $188.00 $171.00 $0.00

D2530 Inlay ‐ Metallic ‐ Three Or More Surfaces 3 $324.00 $241.00 $220.00 $0.00

D2520 Inlay ‐ Metallic ‐ Two Surfaces 3 $301.00 $224.00 $204.00 $0.00

D2610 Inlay ‐ Porcelain/Ceramic One Surface 3 $279.00 $207.00 $189.00 $0.00

D2630 Inlay ‐ Porcelain/Ceramic Three Or More Surfaces 3 $332.00 $247.00 $225.00 $0.00

D2620 Inlay ‐ Porcelain/Ceramic Two Surfaces 3 $303.00 $225.00 $205.00 $0.00

D6601 Inlay ‐ Porcelain/Ceramic, Three Or More Surfaces 3 $334.00 $247.00 $226.00 $0.00

D6600 Inlay ‐ Porcelain/Ceramic, Two Surfaces 3 $303.00 $225.00 $205.00 $0.00

D2652 Inlay ‐ Resin‐Based Composite 3 + Surfaces 3 $296.00 $219.00 $200.00 $0.00

D2650 Inlay ‐ Resin‐Based Composite One Surface 3 $290.00 $215.00 $196.00 $0.00

D2651 Inlay ‐ Resin‐Based Composite Two Surfaces 3 $286.00 $212.00 $194.00 $0.00

D6624 Inlay ‐ Titanium 3 $300.00 $223.00 $203.00 $0.00

D6605 Inlay‐Cast Predominantly Base Metal,3 Or More Surf 3 $259.00 $192.00 $176.00 $0.00

D5811 Interim Complete Denture ﴾Mandibular﴿ 3 $190.00 $141.00 $129.00 $0.00

D5810 Interim Complete Denture ﴾Maxillary﴿ 3 $180.00 $134.00 $122.00 $0.00

D5821 Interim Partial Denture ﴾Mandibular﴿ 3 $167.00 $124.00 $113.00 $0.00

D5820 Interim Partial Denture ﴾Maxillary﴿ 3 $159.00 $118.00 $108.00 $0.00

D5820 Interim Partial Denture ﴾Maxillary﴿ 3 $159.00 $118.00 $108.00 $0.00

D9974 Internal Bleaching ‐ Per Tooth 3 $45.00 $33.00 $30.00 $0.00

D5226 Mandibular Partial Denture ‐ Flexible Base 3 $340.00 $253.00 $231.00 $0.00

D5212 Mandibular Partial Denture ‐ Resin Base 3 $340.00 $253.00 $231.00 $0.00

D5214 Mandibular Partial Denture‐Cast Metal W/Resin Base 3 $474.00 $351.00 $321.00 $0.00

D5225 Maxillary Partial Denture ‐ Flexible Base 3 $294.00 $218.00 $199.00 $0.00

D5211 Maxillary Partial Denture ‐ Resin Base 3 $294.00 $218.00 $199.00 $0.00

D5213 Maxillary Partial Denture‐Cast Metal W/Resin Base 3 $474.00 $351.00 $321.00 $0.00

D6611 Onlay ‐ Cast High Noble Metal, Three Or More Surf 3 $330.00 $245.00 $223.00 $0.00

D6610 Onlay ‐ Cast High Noble Metal, Two Surfaces 3 $300.00 $223.00 $203.00 $0.00

D6615 Onlay ‐ Cast Noble Metal ‐ Three Or More Surfaces 3 $300.00 $223.00 $203.00 $0.00

D6614 Onlay ‐ Cast Noble Metal ‐ Two Surfaces 3 $273.00 $202.00 $185.00 $0.00

D6612 Onlay ‐ Cast Predominantly Base Metal,2 Surfaces 3 $259.00 $192.00 $176.00 $0.00

D6613 Onlay ‐ Cast Predominantly Base Metal,3 Or More 3 $285.00 $212.00 $193.00 $0.00

D2542 Onlay ‐ Metallic ‐ Two Surfaces 3 $328.00 $243.00 $222.00 $0.00

D2544 Onlay ‐ Metallic, Four Or More Surfaces 3 $381.00 $282.00 $258.00 $0.00

D2543 Onlay ‐ Metallic, Three Surfaces 3 $366.00 $271.00 $248.00 $0.00

D2644 Onlay ‐ Porcelain/Ceramic, Four Or More Surfaces 3 $378.00 $281.00 $256.00 $0.00

D6609 Onlay ‐ Porcelain/Ceramic, Three Or More Surfaces 3 $361.00 $268.00 $244.00 $0.00

D2643 Onlay ‐ Porcelain/Ceramic, Three Surfaces 3 $367.00 $272.00 $249.00 $0.00

D2642 Onlay ‐ Porcelain/Ceramic, Two Surfaces 3 $328.00 $243.00 $222.00 $0.00

D6608 Onlay ‐ Porcelain/Ceramic, Two Surfaces 3 $328.00 $243.00 $222.00 $0.00

D2664 Onlay ‐ Resin‐Based Composite 4 + Surfaces 3 $337.00 $250.00 $228.00 $0.00

D2663 Onlay ‐ Resin‐Based Composite Three Surfaces 3 $317.00 $235.00 $215.00 $0.00

D2662 Onlay ‐ Resin‐Based Composite Two Surfaces 3 $308.00 $228.00 $208.00 $0.00

D6634 Onlay ‐ Titanium 3 $330.00 $245.00 $223.00 $0.00

D4260 Osseous Surg﴾Incl Flap Entry & Clos﴿‐4 Or More Tth 3 $376.00 $279.00 $255.00 $0.00

D4261 Osseous Surgery﴾Incl Flap Entry & Clos﴿‐1 To 3 Tth 3 $188.00 $140.00 $128.00 $0.00

D5860 Overdenture ‐ Complete, By Report 3 $409.00 $303.00 $277.00 $0.00

D5861 Overdenture ‐ Partial, By Report 3 $474.00 $351.00 $321.00 $0.00

D4270 Pedicle Soft Tissue Graft Procedure 3 $277.00 $206.00 $188.00 $0.00

D4342 Periodontal Scaling And Root Planing, 1 To 3 Teeth 3 $38.00 $29.00 $26.00 $0.00

D4341 Periodontal Scaling And Root Planing‐4 Or More Tth 3 $77.00 $57.00 $52.00 $0.00

D6210 Pontic ‐ Cast High Noble Metal 3 $372.00 $276.00 $252.00 $0.00

D6212 Pontic ‐ Cast Noble Metal 3 $403.00 $299.00 $273.00 $0.00

D6211 Pontic ‐ Cast Predominantly Base Metal 3 $372.00 $276.00 $252.00 $0.00

D6205 Pontic ‐ Indirect Resin Based Composite 3 $307.00 $228.00 $208.00 $0.00

D6240 Pontic ‐ Porcelain Fused To High Noble Metal 3 $372.00 $276.00 $252.00 $0.00

D6242 Pontic ‐ Porcelain Fused To Noble Metal 3 $341.00 $253.00 $231.00 $0.00

D6245 Pontic ‐ Porcelain/Ceramic 3 $341.00 $253.00 $231.00 $0.00

D6250 Pontic ‐ Resin With High Noble Metal 3 $372.00 $276.00 $252.00 $0.00

D6252 Pontic ‐ Resin With Noble Metal 3 $403.00 $299.00 $273.00 $0.00

D6251 Pontic ‐ Resin With Predominantly Base Metal 3 $341.00 $253.00 $231.00 $0.00

D6214 Pontic ‐ Titanium 3 $372.00 $276.00 $252.00 $0.00

D6241 Pontic‐Porcelain Fused To Predominantly Base Metal 3 $372.00 $276.00 $252.00 $0.00

D6970 Post & Core In Addition To Fixed Partial Dent Ret 3 $112.00 $83.00 $76.00 $0.00

D2952 Post And Core In Addition To Crown, Ind Fabricated 3 $126.00 $94.00 $86.00 $0.00

D6972 Prefabricated Post & Core In Add To Fixed Partial 3 $112.00 $83.00 $76.00 $0.00

D2954 Prefabricated Post And Core In Addition To Crown 3 $105.00 $78.00 $71.00 $0.00

D3221 Pulpal Debridement, Primary And Permanent Teeth 3 $50.00 $37.00 $34.00 $0.00

D3230 Pulpal Therapy ‐ Anterior, Primary Tooth 3 $67.00 $50.00 $45.00 $0.00

D3240 Pulpal Therapy ‐ Posterior, Primary Tooth 3 $58.00 $43.00 $39.00 $0.00

D5711 Rebase Complete Mandibular Denture 3 $157.00 $117.00 $107.00 $0.00

D5711 Rebase Complete Mandibular Denture 3 $157.00 $117.00 $107.00 $0.00

D5710 Rebase Complete Maxillary Denture 3 $149.00 $110.00 $101.00 $0.00

D5721 Rebase Mandibular Partial Denture 3 $150.00 $111.00 $102.00 $0.00

D5720 Rebase Maxillary Partial Denture 3 $142.00 $105.00 $96.00 $0.00

D5281 Removable Unilateral Partial Denture‐1 Piece Cast 3 $254.00 $188.00 $172.00 $0.00

D5671 Repl All Tth & Acrylic On Cast Metal Framewrk‐Mand 3 $340.00 $253.00 $231.00 $0.00

D5670 Replace All Tth & Acrylic On Cast Metal Frmwrk‐Max 3 $294.00 $218.00 $199.00 $0.00

D6548 Retainer ‐ Porcelain/Ceramic For Resin Bonded Fixe 3 $124.00 $92.00 $84.00 $0.00

D6545 Retainer‐Cast Metal For Resin Bonded Fixed Prosthe 3 $124.00 $92.00 $84.00 $0.00

D3346 Retreatment Of Prev Root Canal Therapy‐Anterior 3 $286.00 $212.00 $194.00 $0.00

D3347 Retreatment Of Prev Root Canal Therapy‐Bicuspid 3 $329.00 $244.00 $223.00 $0.00

D3348 Retreatment Of Prev Root Canal Therapy‐Molar 3 $409.00 $303.00 $277.00 $0.00

D3430 Retrograde Filling‐Per Root 3 $64.00 $48.00 $44.00 $0.00

D3450 Root Amputation‐Per Root 3 $153.00 $114.00 $104.00 $0.00

D4275 Soft Tissue Allograft 3 $293.00 $218.00 $199.00 $0.00

D4273 Subepithelial Connective Tissue Graft Procedures 3 $342.00 $254.00 $232.00 $0.00

D3220 Therapeutic Pulpotomy﴾Excluding Final Restoration﴿ 3 $50.00 $37.00 $34.00 $0.00

D5851 Tissue Conditioning, Mandibular 3 $45.00 $33.00 $30.00 $0.00

D5850 Tissue Conditioning, Maxillary 3 $42.00 $31.00 $28.00 $0.00

D7220 Removal Of Impacted Tooth ‐ Soft Tissue 3 $100.00 $74.00 $68.00 $55.00

D7210 Surgical Removal Of Erupted Tooth Requiring Elevat 3 $80.00 $59.00 $54.00

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