Common use of Preventive Clause in Contracts

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period No Charge D1120 Prophylaxis - child limited to once in a 6-month period No Charge D1206 Topical fluoride varnish limited to once in a 6-month period No Charge D1208 Topical application of fluoride excluding varnish limited to once in a 6-month period No Charge D1310 Nutritional counseling for control of dental disease No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use No Charge D1330 Oral hygiene instructions No Charge D1351 Sealant - per tooth limited to first, second and third permanent molars that occupy the second molar position No Charge D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent molars that occupy the second molar position No Charge D1353 Sealant repair - per tooth No Charge D1354 Interim caries arresting medicament application - per tooth No Charge D1355 Caries preventive medicament application - per tooth No Charge D1510 Space maintainer - fixed - unilateral limited to once per quadrant No Charge D1516 Space maintainer - fixed - bilateral, maxillary No Charge D1517 Space maintainer - fixed - bilateral, mandibular No Charge D1520 Space maintainer - removable - unilateral limited to once per quadrant No Charge D1526 Space maintainer - removable - bilateral, maxillary No Charge D1527 Space maintainer - removable - bilateral, mandibular No Charge D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge D1556 Removal of fixed unilateral space maintainer - per quadrant No Charge D1557 Removal of fixed bilateral space maintainer - maxillary No Charge D1558 Removal of fixed bilateral space maintainer - mandibular No Charge D1575 Distal shoe space maintainer - fixed - unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular den

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period No Charge D1120 Prophylaxis - child limited to once in a 6-month period No Charge D1206 Topical fluoride varnish limited to once in a 6-month period No Charge D1208 Topical application of fluoride excluding varnish limited to once in a 6-month period No Charge D1310 Nutritional counseling for control of dental disease No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use No Charge D1330 Oral hygiene instructions No Charge D1351 Sealant - per tooth limited to first, second and third permanent molars that occupy the second molar position No Charge D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent molars that occupy the second molar position No Charge D1353 Sealant repair - per tooth No Charge D1354 Interim caries arresting medicament application - per tooth No Charge D1355 Caries preventive medicament application - per tooth No Charge D1510 Space maintainer - fixed - unilateral limited to once per quadrant No Charge D1516 Space maintainer - fixed - bilateral, maxillary No Charge D1517 Space maintainer - fixed - bilateral, mandibular No Charge D1520 Space maintainer - removable - unilateral limited to once per quadrant No Charge D1526 Space maintainer - removable - bilateral, maxillary No Charge D1527 Space maintainer - removable - bilateral, mandibular No Charge D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge Platinum 90 Ambetter PPO AI-AN D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge D1556 Removal of fixed unilateral space maintainer - per quadrant No Charge D1557 Removal of fixed bilateral space maintainer - maxillary No Charge D1558 Removal of fixed bilateral space maintainer - mandibular No Charge D1575 Distal shoe space maintainer - fixed - unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% Platinum 90 Ambetter PPO AI-AN D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% Platinum 90 Ambetter PPO AI-AN D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% Platinum 90 Ambetter PPO AI-AN D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% Platinum 90 Ambetter PPO AI-AN D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% Platinum 90 Ambetter PPO AI-AN D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% Platinum 90 Ambetter PPO AI-AN D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% Platinum 90 Ambetter PPO AI-AN D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% Platinum 90 Ambetter PPO AI-AN D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular den

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period No Charge $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1120 Prophylaxis - child limited to once in a 6-month period No Charge $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish limited to once in a 6-month period No Charge $10 1 of (D1206, D1208) per 6 months D1208 Topical application of fluoride - excluding varnish limited to once in a 6-month period No Charge D1310 Nutritional counseling for control $10 1 of dental disease No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral(D1206, behavioral, and systemic health effects associated with high-risk substance use No Charge D1330 Oral hygiene instructions No Charge D1208) per 6 months D1351 Sealant - per tooth limited to first, second and third permanent $20 Permanent molars that occupy the second molar position No Charge without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent $20 Permanent molars that occupy the second molar position No Charge D1353 Sealant repair - without restorations or decay; 1 per tooth No Charge 36 months D1354 Interim caries arresting medicament application - per tooth No Charge D1355 Caries preventive medicament application - $10 1 per tooth No Charge 6 months D1510 Space maintainer - fixed fixed, unilateral - unilateral limited to once per quadrant No Charge $150 D1516 Space maintainer - fixed - bilateral, maxillary No Charge $225 D1517 Space maintainer - fixed - bilateral, mandibular No Charge $225 D1520 Space maintainer - removable removable, unilateral - unilateral limited to once per quadrant No Charge $150 D1526 Space maintainer - removable - bilateral, maxillary No Charge $225 D1527 Space maintainer - removable - bilateral, mandibular No Charge $225 D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge $30 D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge $30 D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge $30 D1556 Removal of fixed unilateral space maintainer - maintainer- per quadrant No Charge $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary No Charge $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No Charge $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed - fixed, unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces $150 1 per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap lifetime; Age 8 and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; under Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular denPediatric Enrollees

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period No Charge $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1120 Prophylaxis - child limited to once in a 6-month period No Charge $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish limited to once in a 6-month period No Charge $10 1 of (D1206, D1208) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1208 Topical application of fluoride - excluding varnish limited to once in a 6-month period No Charge D1310 Nutritional counseling for control $10 1 of dental disease No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral(D1206, behavioral, and systemic health effects associated with high-risk substance use No Charge D1330 Oral hygiene instructions No Charge D1208) per 6 months D1351 Sealant - per tooth limited to first, second and third permanent $20 Permanent molars that occupy the second molar position No Charge without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent $20 Permanent molars that occupy the second molar position No Charge D1353 Sealant repair - without restorations or decay; 1 per tooth No Charge 36 months D1354 Interim caries arresting medicament application - per tooth No Charge D1355 Caries preventive medicament application - $10 1 per tooth No Charge 6 months D1510 Space maintainer - fixed fixed, unilateral - unilateral limited to once per quadrant No Charge $150 D1516 Space maintainer - fixed - bilateral, maxillary No Charge $225 D1517 Space maintainer - fixed - bilateral, mandibular No Charge $225 D1520 Space maintainer - removable removable, unilateral - unilateral limited to once per quadrant No Charge $150 D1526 Space maintainer - removable - bilateral, maxillary No Charge $225 D1527 Space maintainer - removable - bilateral, mandibular No Charge $225 D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge $30 D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge $30 D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge $30 D1556 Removal of fixed unilateral space maintainer - maintainer- per quadrant No Charge $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary No Charge $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No Charge $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed - fixed, unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces $150 1 per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap lifetime; Age 8 and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular denunder

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period No Charge cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1120 Prophylaxis - child limited to once in a 6-month period No Charge cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish limited to once in a 6-month period No Charge cost 1 of (D1206, D1208) per 6 months D1208 Topical application of fluoride - excluding varnish limited to once in a 6-month period No Charge D1310 Nutritional counseling for control cost 1 of dental disease No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral(D1206, behavioral, and systemic health effects associated with high-risk substance use No Charge D1330 Oral hygiene instructions No Charge D1208) per 6 months D1351 Sealant - per tooth limited to first, second and third permanent No cost Permanent molars that occupy the second molar position No Charge without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent No cost Permanent molars that occupy the second molar position No Charge D1353 Sealant repair - without restorations or decay; 1 per tooth No Charge 36months D1354 Interim caries arresting medicament application - application- per tooth No Charge D1355 Caries preventive medicament application - cost 1 per tooth No Charge 6 months D1510 Space maintainer - fixed fixed, unilateral - unilateral limited to once per quadrant No Charge cost D1516 Space maintainer - fixed - bilateral, maxillary No Charge cost D1517 Space maintainer - fixed - bilateral, mandibular No Charge cost D1520 Space maintainer - removable removable, unilateral - unilateral limited to once per quadrant No Charge cost D1526 Space maintainer - removable - bilateral, maxillary No Charge cost Code Description Pediatric Enrollee Cost Share Clarification/Limitations for Pediatric Enrollees D1527 Space maintainer - removable - bilateral, mandibular No Charge cost D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge cost D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge cost D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge cost D1556 Removal of fixed unilateral space maintainer - per quadrant No Charge cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary No Charge cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No Charge cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed - fixed, unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces cost 1 per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap lifetime; Age 8 and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular denunder

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period $15 No Charge cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months 1 per 6 months D1120 Prophylaxis - child limited to once in $15 Not a 6-month period No Charge benefit Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish limited to once in a 6-month period $10 No Charge Cost 1 of (D1206, D1208)per 6 months 1 of (D1206 or D1208)per 6 months D1208 Topical application of fluoride - excluding varnish limited to once in a 6-month period $10 No Charge Cost 1 of (D1206, D1208)per 6 months 1 of (D1206 or D1208)per 6 months D1310 Nutritional counseling for control of dental disease Not a benefit No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use No Charge Cost D1330 Oral hygiene instructions Not a benefit No Charge Cost D1351 Sealant - per tooth limited to first, second and third permanent $20 Not a benefit Permanent molars that occupy the second molar position No Charge without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent $20 Not a benefit Permanent molars that occupy the second molar position No Charge D1353 Sealant repair - without restorations or decay; 1 per tooth No Charge 36 months D1354 Interim caries arresting medicament application - per tooth $10 No Charge D1355 Caries preventive medicament application - Cost 1 per tooth No Charge 6 months D1510 Space maintainer - fixed fixed, unilateral - unilateral limited to once per quadrant No Charge $150 Not a benefit D1516 Space maintainer - fixed - bilateral, maxillary No Charge $225 Not a benefit D1517 Space maintainer - fixed - bilateral, mandibular No Charge $225 Not a benefit D1520 Space maintainer - removable removable, unilateral - unilateral limited to once per quadrant No Charge $150 Not a benefit D1526 Space maintainer - removable - bilateral, maxillary No Charge $225 Not a benefit Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1527 Space maintainer - removable - bilateral, mandibular No Charge $225 Not a benefit D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge $30 Not a benefit D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge $30 Not a benefit D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge $30 Not a benefit D1556 Removal of fixed unilateral space maintainer - per quadrant No Charge $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treatingdentist/ dental office D1557 Removal of fixed bilateral space maintainer - maxillary No Charge $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treatingdentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No Charge $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than theoriginal treating dentist/dental office D1575 Distal shoe space maintainer - fixed - fixed, unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. $150 Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces 1 per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap lifetime; Age 8 and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular denunder

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period No Charge cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1120 Prophylaxis - child limited to once in a 6-month period No Charge cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish limited to once in a 6-month period No Charge cost 1 of (D1206, D1208) per 6 months D1208 Topical application of fluoride - excluding varnish limited to once in a 6-month period No Charge D1310 Nutritional counseling for control cost 1 of dental disease No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral(D1206, behavioral, and systemic health effects associated with high-risk substance use No Charge D1330 Oral hygiene instructions No Charge D1208) per 6 months D1351 Sealant - per tooth limited to first, second and third permanent No cost Permanent molars that occupy the second molar position No Charge without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent No cost Permanent molars that occupy the second molar position No Charge D1353 Sealant repair - without restorations or decay; 1 per tooth No Charge 36 months D1354 Interim caries arresting medicament application - application- per tooth No Charge D1355 Caries preventive medicament application - cost 1 per tooth No Charge 6 months D1510 Space maintainer - fixed fixed, unilateral - unilateral limited to once per quadrant No Charge cost D1516 Space maintainer - fixed - bilateral, maxillary No Charge cost D1517 Space maintainer - fixed - bilateral, mandibular No Charge cost D1520 Space maintainer - removable removable, unilateral - unilateral limited to once per quadrant No Charge cost D1526 Space maintainer - removable - bilateral, maxillary No Charge cost D1527 Space maintainer - removable - bilateral, mandibular No Charge cost D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge cost D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge cost D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge cost Code Description Pediatric Enrollee Cost Share Clarification/Limitations for Pediatric Enrollees D1556 Removal of fixed unilateral space maintainer - per quadrant No Charge cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary No Charge cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No Charge cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed - fixed, unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces cost 1 per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap lifetime; Age 8 and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular denunder

Preventive. D1110 Prophylaxis - adult limited to once in a 12-month period $15 No Charge cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months 1 per 6 months D1120 Prophylaxis - child limited to once in $15 Not a 6-month period No Charge benefit Cleaning; 1 of (D1110, D1120, D4346) per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1206 Topical application of fluoride varnish limited to once in a 6-month period $10 No Charge Cost 1 of (D1206, D1208)per 6 months 1 of (D1206 or D1208)per 6 months D1208 Topical application of fluoride - excluding varnish limited to once in a 6-month period $10 No Charge Cost 1 of (D1206, D1208)per 6 months 1 of (D1206 or D1208)per 6 months D1310 Nutritional counseling for control of dental disease Not a benefit No Charge D1320 Tobacco counseling for the control and prevention of oral disease No Charge D1321 Counseling for the control and prevention of adverse oral, behavioral, and systemic health effects associated with high-risk substance use No Charge Cost D1330 Oral hygiene instructions Not a benefit No Charge Cost D1351 Sealant - per tooth limited to first, second and third permanent $20 Not a benefit Permanent molars that occupy the second molar position No Charge without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth limited to first, second and third permanent $20 Not a benefit Permanent molars that occupy the second molar position No Charge D1353 Sealant repair - without restorations or decay; 1 per tooth No Charge 36 months D1354 Interim caries arresting medicament application - pertooth $10 No Cost 1 per tooth No Charge D1355 Caries preventive medicament application - per tooth No Charge 6 months D1510 Space maintainer - fixed fixed, unilateral - unilateral limited to once per quadrant No Charge $150 Not a benefit D1516 Space maintainer - fixed - bilateral, maxillary No Charge $225 Not a benefit D1517 Space maintainer - fixed - bilateral, mandibular No Charge $225 Not a benefit D1520 Space maintainer - removable removable, unilateral - unilateral limited to once per quadrant No Charge $150 Not a benefit D1526 Space maintainer - removable - bilateral, maxillary No Charge $225 Not a benefit D1527 Space maintainer - removable - bilateral, mandibular No Charge $225 Not a benefit D1551 Re-cement or re-bond bilateral space maintainer - maxillary No Charge $30 Not a benefit D1552 Re-cement or re-bond bilateral space maintainer - mandibular No Charge $30 Not a benefit D1553 Re-cement or re-bond unilateral space maintainer - per quadrant No Charge $30 Not a benefit D1556 Removal of fixed unilateral space maintainer - per quadrant No Charge $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treatingdentist/ dental office Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1557 Removal of fixed bilateral space maintainer - maxillary No Charge $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treatingdentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular No Charge $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than theoriginal treating dentist/dental office D1575 Distal shoe space maintainer - fixed - fixed, unilateral - per quadrant No Charge D2140 Amalgam - one surface, primary limited to once in a 12-month period 20% D2140 Amalgam - one surface, permanent limited to once in a 36-month period 20% D2150 Amalgam - two surfaces, primary limited to once in a 12-month period 20% D2150 Amalgam - two surfaces, permanent limited to once in a 36-month period 20% D2160 Amalgam - three surfaces, primary limited to once in a 12-month period 20% D2160 Amalgam - three surfaces, permanent limited to once in a 36-month period 20% D2161 Amalgam - four or more surfaces, primary limited to once in a 12-month period 20% D2161 Amalgam - four or more surfaces, permanent limited to once in a 36-month period 20% D2330 Resin-based composite - one surface, anterior, primary limited to once in a 12-month period 20% D2330 Resin-based composite - one surface, anterior, permanent limited to once in a 36-month period 20% D2331 Resin-based composite - two surfaces, anterior primary limited to once in a 12-12month period 20% D2331 Resin-based composite - two surfaces, anterior permanent limited to once in a 36-month period 20% D2332 Resin-based composite - three surfaces, anterior primary limited to once in a 12-month period 20% D2332 Resin-based composite - three surfaces, anterior permanent limited to once in a 36-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) primary limited to once in a 12-month period 20% D2335 Resin-based composite - four or more surfaces (anterior) permanent limited to once in a 36-month period 20% D2390 Resin-based composite crown, anterior, primary limited to once in a 12-month period 20% D2390 Resin-based composite crown, anterior, permanent limited to once in a 36-month period 20% D2391 Resin-based composite - one surface, posterior primary limited to once in a 12-month period 20% D2391 Resin-based composite - one surface, posterior permanent limited to once in a 36-month period 20% D2392 Resin-based composite - two surfaces, posterior; primary limited to once in a 12-month period 20% D2392 Resin-based composite - two surfaces, posterior; permanent limited to once in a 36-month period 20% D2393 Resin-based composite - three surfaces, posterior; primary limited to once in a 12-month period 20% D2393 Resin-based composite - three surfaces, posterior; permanent limited to once in a 36-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; primary limited to once in a 12-month period 20% D2394 Resin-based composite - four or more surfaces, posterior; permanent limited to once in a 36-month period 20% D2710 Crown - Resin-based composite (indirect) limited to once in a 5-year period 20% D2712 Crown - ¾ resin-based composite (indirect) limited to once in a 5-year period 20% D2721 Crown - Resin with predominantly base metal limited to once in a 5-year period 20% D2740 Crown - porcelain/ceramic limited to once in a 5-year period 20% D2751 Crown - porcelain fused to predominantly base metal limited to once in a 5-year period 20% D2781 Crown - ¾ cast predominantly base metal limited to once in a 5-year period 20% D2783 Crown - ¾ porcelain/ceramic limited to once in a 5-year period 20% D2791 Crown - full cast predominantly base metal limited to once in a 5-year period 20% D2910 Recement or re-bond inlay, onlay, veneer or partial coverage restoration limited to once in a 12-month period 20% D2915 Recement or re-bond indirectly fabricated or prefabricated post and core 20% D2920 Recement or re-bond crown 20% D2921 Reattachment of tooth fragment, incisal edge, or cusp 20% D2928 Prefabricated porcelain/ceramic crown - permanent tooth 20% D2929 Prefabricated porcelain/ceramic crown - primary tooth limited to once in a 12-month period 20% D2930 Prefabricated stainless steel crown - primary tooth limited to once in a 12-month period 20% D2931 Prefabricated stainless steel crown - permanent tooth limited to once in a 36-month period 20% D2932 Prefabricated Resin Crown, primary limited to once in a 12-month period 20% D2932 Prefabricated Resin Crown, permanent limited to once in a 36-month period 20% D2933 Prefabricated Stainless steel crown with resin window, primary limited to one in a 12-month period 20% D2933 Prefabricated Stainless steel crown with resin window, permanent limited to once in a 36-month period 20% D2940 Protective restoration limited to once per tooth in a 12- month period 20% D2941 Interim therapeutic restoration - primary dentition 20% D2949 Restorative foundation for an indirect restoration 20% D2950 Core buildup, including any pins when required 20% D2951 Pin retention - per tooth, in addition to restoration 20% D2952 Post and core in addition to crown, indirectly fabricated limited to once per tooth regardless of number of posts placed 20% D2953 Each additional indirectly fabricated post - same tooth 20% D2954 Prefabricated post and core in addition to crown limited to once per tooth regardless of number of posts placed 20% D2955 Post removal 20% D2957 Each additional prefabricated post - same tooth 20% D2971 Additional procedures to customize a crown to fit under an existing partial dental framework 20% D2976 Band stabilization – per tooth 20% D2980 Crown repair necessitated by restorative material failure, by report. Limited to laboratory processed crowns on permanent teeth. $150 Not a benefit within 12 months of initial crown placement or previous repair for the same provider. 20% D2989 Excavation of a tooth resulting in the determination of non- restorability 20% D2991 Application of hydroxyapatite regeneration medicament – per tooth No Charge D2999 Unspecified restorative procedure, by report 20% D3110 Pulp cap - direct (excluding final restoration) 50% D3120 Pulp cap - indirect (excluding final restoration) 50% D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament limited to once per primary tooth 50% D3221 Pupal debridement primary and permanent teeth 50% D3222 Partial Pulpotomy for apexogenesis, permanent tooth with incomplete root development limited to once per permanent tooth 50% D3230 Pulpal therapy (resorbable filing) - anterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3240 Pulpal therapy (resorbable filing) - posterior, primary tooth (excluding final restoration) limited to once per primary tooth 50% D3310 Endodontic (Root canal) therapy, Anterior (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3320 Endodontic (Root canal) therapy, premolar (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3330 Endodontic (Root canal) therapy, Molar tooth (excluding final restoration) limited to once per tooth for initial root canal therapy treatment 50% D3331 Treatment of root canal obstruction; nonsurgical access 50% D3333 Internal root repair of perforation defects 50% D3346 Retreatment of previous root canal therapy - anterior 50% D3347 Retreatment of previous root canal therapy - premolar 50% D3348 Retreatment of previous root canal therapy - molar 50% D3351 Apexification/recalcification - initial visit (apical closure/calcific repair of perforations, root resorption, etc.) limited to once per permanent tooth 50% D3352 Apexification/recalcification - interim medication replacement only following D3351. Limited to once per permanent tooth 50% D3410 Apicoectomy - anterior 50% D3421 Apicoectomy - premolar (first root) 50% D3425 Apicoectomy - molar (first root) 50% D3426 Apicoectomy (each additional root) 50% D3428 Bone graft in conjunction with periradicular surgery - per tooth, single site 50% D3429 Bone graft in conjunction with periradicular surgery - each additional contiguous tooth in the same surgical site 50% D3430 Retrograde filling - per root 50% D3431 Biologic materials to aid in soft and osseous tissue regeneration, in conjunction with periradicular surgery 50% D3471 Surgical repair of root resorption - anterior 50% D3472 Surgical repair of root resorption - premolar 50% D3473 Surgical repair of root resorption - molar 50% D3910 Surgical procedure for isolation of tooth with rubber dam 50% D3999 Unspecified endodontic procedure, by report 50% D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces 1 per quadrant - once per quadrant every 36 months 50% D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4249 Clinical crown lengthening - hard tissue 50% D4260 Osseous surgery (including elevation of a full thickness flap lifetime; Age 8 and closure) - four or more contiguous teeth or tooth spaces per quadrant - once per quadrant every 36 months 50% D4261 Osseous surgery (including elevation of a full thickness flap and closure) - one to three contiguous teeth or tooth bounded spaces per quadrant - once per quadrant every 36 months 50% D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site 50% D4341 Periodontal scaling and root planing - four or more teeth per quadrant - once per quadrant every 24 months 50% D4342 Periodontal scaling and root planing - one to three teeth per quadrant - once per quadrant every 24 months 50% D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation 50% D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit 50% D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth 50% D4910 Periodontal maintenance limited to once in a calendar quarter 20% D4920 Unscheduled dressing change (by someone other than treating dentist). Once per Member per provider; for Members age 13 or older only; must be performed within 30 days of the date of service of gingivectomy or gingivoplasty (D4210 and D4211) and osseous surgery (D4260 and D4261). 50% D4999 Unspecified periodontal procedure, by report 50% D5110 Complete denture - maxillary limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5120 Complete denture - mandibular limited to once in a 5-year period from a previous complete, immediate or overdenture- complete denture 50% D5130 Immediate denture - maxillary 50% D5140 Immediate denture - mandibular 50% D5211 Maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5212 Mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) limited to once in a 5-year period 50% D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) 50% D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) 50% D5410 Adjust complete denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5411 Adjust complete denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5421 Adjust partial denture - maxillary limited to once per date of service; twice in a 12-month period 50% D5422 Adjust partial denture - mandibular limited to once per date of service; twice in a 12-month period 50% D5511 Repair broken complete denture base, mandibular 50% D5512 Repair broken complete denture base, maxillary 50% D5520 Replace missing or broken teeth - complete denture (each tooth) limited to a maximum of four, per arch, per date of service; twice per arch in a 12-month period 50% D5611 Repair resin denture base, mandibular 50% D5612 Repair resin denture base, maxillary 50% D5621 Repair cast framework, mandibular 50% D5622 Repair cast framework, maxillary 50% D5630 Repair or replace broken retentive/clasping materials- per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5640 Replace broken teeth - per tooth - limited to maximum of four, per arch, per date of service; twice per arch in a 12- month period 50% D5650 Add tooth to existing partial denture limited to a maximum of three, per date of service; once per tooth 50% D5660 Add clasp to existing partial denture - per tooth - limited to a maximum of three, per date of service; twice per arch in a 12-month period 50% D5730 Reline complete maxillary denture (chairside) limited to once in a 12-month period 50% D5731 Reline complete mandibular denture (chairside) limited to once in a 12-month period 50% D5740 Reline maxillary partial denture (chairside) limited to once in a 12-month period 50% D5741 Reline mandibular partial denture (chairside) limited to once in a 12-month period 50% D5750 Reline complete maxillary denture (laboratory) limited to once in a 12-month period 50% D5751 Reline complete mandibular denture (laboratory) limited to once in a 12-month period 50% D5760 Reline maxillary partial denture (laboratory) limited to once in a 12-month period 50% D5761 Reline mandibular partial denture (laboratory) limited to once in a 12-month period 50% D5850 Tissue conditioning, maxillary limited to twice per prosthesis in a 36-month period 50% D5851 Tissue conditioning, mandibular maxillary limited to twice per prosthesis in a 36-month period. Not a benefit: a. same date of service as reline complete mandibular denture (chairside) (D5731), reline mandibular partial denture (chairside) (D5741), reline complete mandibular denunder