Inlay/Onlay Restorations - Covered only when needed due to decay.
Inlay-metallic - one surface
Inlay-metallic - two surfaces
Inlay-metallic - three or more surfaces
Onlay-metallic - three surfaces
Onlay-metallic - four or more surfaces
Inlay-porcelain/ceramic - one surface
Inlay-porcelain/ceramic - two surfaces
Inlay-porcelain/ceramic - three or more surfaces
Onlay - porcelain/ceramic - two surfaces
Onlay - porcelain/ceramic - three surfaces
Onlay - porcelain/ceramic - four or more surfaces
Inlay - resin-based composite - one surface
Inlay - resin-based composite - two surfaces
Inlay - resin-based composite - three or more surfaces
Onlay - resin-based composite - two surfaces
Onlay - resin-based composite - three surfaces
Onlay - resin-based composite - four or more surfaces
Crowns-Single Restorations Only - Covered only when needed due to decay
Crown - resin-based composite (indirect)
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown - porcelain/ceramic substrate
Crown - porcelain fused to high noble metal
Crown - porcelain fused to a predominantly base metal
Crown - porcelain fused to noble metal
Crown - full cast high noble metal
Crown - full cast predominantly base metal
Crown - full cast noble metal
Recement crown
Prefabricated stainless steel crown - primary tooth
Prefabricated stainless steel crown - permanent tooth (available to children under age 19 only)
Prefabricated resin crown (available to children under age 19 only)
Prefabricated stainless steel crown with resin window (available to children under age 19 only)
Core build-up, including any pins when required
Pin retention - per tooth, in addition to restoration
Post and core in addition to the crown, indirectly fabricated
Prefabricated post and core in addition to a crown
Post removal
Crown repair necessitated by restorative material failure
Endodontic. Endodontic surgical procedures include any local anesthesia and routine post-operative visits.
Endodontic Therapy for Primary Teeth - including necessary X-rays and cultures but, excluding final restoration, and limited to use on primary teeth only.
Pulp cap - direct (excluding final restoration)
Pulp cap - indirect (excluding final restoration)
Therapeutic pulpotomy (excluding final restoration)
Pulpal therapy (restorable filling) - anterior primary
Pulpal therapy (restorable filling) - posterior primary
Endodontic Therapy - Including necessary X-rays and cultures but, excluding final restoration and limited to use on permanent teeth only.
Endodontic therapy, anterior (excluding final restoration)
Endodontic therapy, bicuspid (excluding final restoration)
Endodontic therapy, molar (excluding final restoration)
Retreatment of previous root canal-anterior
Retreatment of previous root canal-bicuspid
Retreatment of previous root canal-molar
Apexification / Recalcification
Apexification/recalcification - initial visit
Apexification/recalcification - interim medication replacement
Apexification/recalcification - final visit
Apicoectomy / Periradicular Services
Apicoectomy - anterior
Apicoectomy - bicuspid (first root)
Apicoectomy - molar (first root)
Apicoectomy (each additional root)
Retrograde filling - per root
Root amputation - per root
Endodontic endosseous implant
Intentional re-implantation (including necessary splinting)
Other Endodontic Procedures
Hemisection, including any root removal but not including root canal therapy
PERIODONTIC. Periodontal surgical procedures include any local anesthesia and routine post-operative visits.
Surgical Periodontal Services
Gingivectomy or gingivoplasty - four or more teeth/quadrant
Gingivectomy or gingivoplasty - one to three teeth/quadrant
Gingival flap including root planning - four or more teeth/quadrant
Clinical crown lengthening - hard tissue
Osseous surgery - four or more teeth/quadrant
Bone replacement graft - first site in quadrant
Bone replacement graft - each additional site in quadrant
Guided tissue regeneration - resorbable barrier
Guided tissue regeneration - not a resorbable barrier
Pedicle soft tissue graft procedure
Subepithelial connective tissue graft, per tooth
Distal or proximal wedge procedure
Free soft tissue graft procedure, including donor site surgery, first tooth or edentulous tooth position in graft
Non-Surgical Periodontal Services Service
Provisional splinting - intracoronal
Provisional splinting - extracoronal
**Periodontal scaling & root planning four or more teeth, per quadrant
**Periodontal scaling & root planning one to three teeth, per quadrant
Full mouth debridement
Localized delivery of antimicrobial agents, per tooth
Periodontal maintenance
**Payment requires presence of periodontal disease as confirmed by both x-rays and pocket depth summaries of each tooth involved.
Prosthodontic, (Removable)
REMOVABLE PROSTHODONTICS (PARTIAL AND COMPLETE DENTURES) - Fees for both partial and complete dentures and relining include adjustments within 6 months after installation. Relines are not covered until more than 6 months after installation. Adjustments are not covered as separate procedures until more than 6 months after installation. Precision attachments, overdentures, specialized techniques, and characterizations are considered optional and the additional expense for these shall be borne by the patient. All partials include conventional clasps, rests, and teeth.
Complete Dentures
Complete dentures - maxillary
Complete dentures - mandibular
Immediate denture - maxillary
Immediate denture - mandibular
Partial Dentures
Maxillary partial denture - resin base
Mandibular partial denture - resin base
Maxillary partial denture - metal framework / resin base
Mandibular partial denture - metal framework / resin base
Removable unilateral partial denture - one-piece cast metal
Adjustments to Dentures
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
Repairs to Complete Dentures
Repair broken complete denture base
Replace missing or broken tooth on denture
Repairs to Partial Dentures
Repair resin denture base
Repair cast framework
Repair or replace broke clasp
Replace broken tooth - per tooth
Add tooth to existing partial denture
Add clasp to existing partial denture
Denture Rebase Procedures
Rebase complete maxillary denture
Rebase complete mandibular denture
Rebase maxillary partial denture
Rebase mandibular partial denture
Denture Reline Procedures
Reline complete maxillary denture (chair side)
Reline complete mandibular denture (chair side)
Reline maxillary partial denture (chair side)
Reline mandibular partial denture (chair side)
Reline complete maxillary denture (lab)
Reline complete mandibular denture (lab)
Reline maxillary partial denture (lab)
Reline mandibular partial denture(lab)
Other Removable Prosthetic Services
** Overdenture - complete maxillary
** Overdenture - partial maxillary
** Overdenture - complete mandibular
** Overdenture - partial mandibular
Fixed Partial Denture Pontics
Pontic - cast high noble metal
Pontic - cast predominantly base metal
Pontic - cast noble metal
Pontic - porcelain fused to high noble metal
Pontic - porcelain fused to predominantly base metal
Pontic - porcelain fused to noble metal
Pontic - porcelain / ceramic
Pontic - resin with high noble metal
Pontic - resin with predominantly base metal
Pontic - resin with noble metal
Fixed Partial Denture Retainers - Inlays/Onlays
Retainer - cast metal for resin bonded fixed prosthesis
Crown - resin with high noble metal
Crown - resin with predominantly base metal
Crown - resin with noble metal
Crown – porcelain/ceramic
Crown - Porcelain fused to high noble metal
Crown - Porcelain fused to a predominantly base metal
Fixed Partial Denture Retainers - Crowns
Crown - porcelain fused to noble metal
Crown - 3/4 cast high noble metal
Crown - full cast high noble metal
Crown - full cast predominantly base metal
Crown - full cast noble metal
Other Fixed Partial Denture Retainers Services
Re-cement or re-bond fixed partial denture
Stress breaker
Fixed partial denture repair
Implant Services
Implant Services are not covered unless the Participating Employer elects the optional implant coverage (as shown in the schedule of benefits) and pays the required premium. Services related to the surgical placement of a dental implant are limited to one per year with replacement of a surgical implant frequency limitation of one every 10 years. Prosthesis over implant replacement is limited to every 5 years if unserviceable and cannot be repaired.
Surgical Services
Surgical placement of implant body: endosteal implant
Surgical placement: eposteal implant
Surgical placement: transosteal implant
Single Crowns, Abutment Supported
Abutment supported porcelain/ceramic crown
Abutment supported porcelain fused to metal crown (high noble metal)
Abutment supported porcelain fused to metal crown (predominantly base metal)
Abutment supported porcelain fused to metal crown (noble metal)
Abutment supported cast metal crown (high noble metal)
Abutment supported cast metal crown (predominantly base metal)
Abutment supported cast metal crown (noble metal)
Implant-supported porcelain/ceramic
Implant-supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal)
Implant-supported metal crown (titanium, titanium alloy, high noble metal)
Fixed Partial Denture Retainer, Abutment Supported
Abutment supported retainer for porcelain/ceramic FPD
Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
Abutment supported retainer for porcelain fused to metal FPD (noble metal)
Abutment supported retainer for cast metal fad (high noble metal)
Abutment supported retainer for cast metal fad (predominantly base metal)
Abutment supported retainer for cast metal fad (noble metal)
Fixed Partial Denture Retainer, Implant Supported
Implant supported retainer for ceramic FPD
Implant supported retainer for porcelain fused to metal fad (titanium, titanium alloy, or high noble metal)
Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal)
Other Implant Services
Abutment supported crown – (titanium)
Implant removal, by report
Abutment supported retainer crown for fad (titanium)
Fixed Partial Denture Pontics
Indirect resin-based composite
Cast high noble
Cast predominately base metal
Cast noble metal
Titanium
Porcelain fused to high noble metal
Porcelain fused to a predominately base metal
Porcelain fused to noble metal
Porcelain/ceramic
Inlays / Onlays
Porcelain/ceramic, two surfaces
Porcelain/ceramic, three or four surfaces
Cast high noble metal, two surfaces
Cast high noble metal, three or four surfaces
Cast predominately base metal. two surfaces
Cast predominately base metal, three or more surfaces
Cast noble metal, two surfaces
Cast noble metal, three or more surfaces
Titanium
Oral and Maxillofacial Surgery. Including any local anesthesia and routine post-operative visits.
Surgical Extractions
Surgical removal of erupted tooth
Removal of impacted tooth-soft tissue
Removal of impacted tooth-partial bony
Removal of impacted tooth-completely bony
Removal of impacted tooth-completely bony - complications
Surgical removal of residual roots
Other Surgical Procedures
Tooth re-implantation and / or stabilization
Tooth transplantation
Surgical access of an un-erupted tooth
Mobilization of erupted or malpositioned tooth to aid eruption
Incisional biopsy of oral tissue – hard
Incisional biopsy of oral tissue- soft
Surgical repositioning of teeth
Transseptal fiberotomy
Alveoloplasty - Surgical Preparation of Ridge
Alveoloplasty in conjunction with extractions / four-plus, per quad
Alveoloplasty not in conjunction with extractions / four plus, per quad
Vestibuloplasty
Vestibuloplasty - ridge extension (secondaryepithelialization)
Vestibuloplasty - ridge extension (including soft tissue grafts
Surgical Excision of Soft Tissue Lesions
Radical excision of lesion up to 1.25 cm
Excision of malignant tumor up to 1.25 cm
Excision of malignant tumor greater than 1.25 cm
Surgical Excision of Intra-Osseous Lesions
Removal of odontogenic cyst/tumor up to 1.25 cm
Removal of odontogenic cyst/tumor greater than 1.25 cm
Removal of nonodontogenic cyst/tumor up to 1.25 cm
Removal of nonodontogenic cyst/tumor greater than 1.25 cm
Destruction of lesion(s) by physical or chemical method
Surgical Incision
Incision and drainage of abscess, intraoral soft tissue
Incision and drainage of abscess, extraoral soft tissue
Other Repair Procedures
Frenulectomy
Excision of hyperplastic tissue- per arch
Excision of percoronal gingival
Anesthesia. When administered by the dentist in the dentist’s office and is only covered when a cutting procedure is being performed at that time.
Deep sedation/general anesthesia - each 15-minute increment
Intravenous conscious sedation – each 15 minutes increment