Current Dental Terminology © 2010 American Dental Association. All rights reserved. CA 1136CA Base 09 (10/08)

Concordia Plus Schedule of Benefits

Plan CA 936

CLINICAL ORAL EVALUATIONSD0120 Periodic oral evaluation - established patient 0D0140 Limited oral evaluation - problem focused 0 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver 0D0150 Comprehensive oral evaluation - new or established patient 0D0160 Detailed and extensive oral evaluation - problem focused, by report 0D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) 0D0180 Comprehensive periodontal evaluation - new or established patient 0

RADIOGRAPHS/DIAGNOSTIC IMAGING(including interpretation)

D0210 Intraoral - complete series (including bitewings) 0D0220 Intraoral-periapicalfirstfilm 0D0230 Intraoral-periapicaleachadditionalfilm 0D0240 Intraoral-occlusalfilm 0D0250 Extraoral-firstfilm 0D0260 Extraoral-eachadditionalfilm 0D0270 Bitewing-singlefilm 0D0272 Bitewings-twofilms 0D0273 Bitewings-threefilms 0D0274 Bitewings-fourfilms 0D0277 Verticalbitewings-7to8films 0D0330 Panoramicfilm 0D0340 Cephalometricfilm 0D0350 Oral/facial photographic images 0

TESTS AND EXAMINATIONSD0415 Collection of microorganisms for culture and sensitivity 0D0416 Viral culture 0D0417 Collection and preparation of saliva sample for laboratory diagnostic testing 25D0418 Analysis of saliva sample 25D0421 Genetic test for susceptibility to oral disease 0D0425 Caries susceptibility tests 0D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures 0

D0460 Pulp vitality tests 0D0470 Diagnostic casts 0

ORAL PATHOLOGY LABORATORYD0472 Accession of tissue, gross examination, preparation and transmission of written report 30D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report 50D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmision of written report 70D0502 Other oral pathology procedures, by report 0

DENTAL PROPHYLAXISD1110 Prophylaxis - adult 0 D1120 Prophylaxis - child 0

TOPICAL FLUORIDE TREATMENT(office procedure)

D1203 Topicalapplicationoffluoride-child 0D1204 Topicalapplicationoffluoride-adult 0D1206 Topicalfluoridevarnish;therapeuticapplication for moderate to high risk patients 0

OTHER PREVENTIVE SERVICESD1310 Nutritional counseling for control of dental disease 0D1320 Tobacco counseling for the control and prevention of oral disease 0D1330 Oral hygiene instructions 0D1351 Sealant - per tooth 0

SPACE MAINTENANCE (passive appliances)

D1510 Spacemaintainer-fixed-unilateral 40D1515 Spacemaintainer-fixed-bilateral 64D1520 Space maintainer - removable - unilateral 60D1525 Space maintainer - removable - bilateral 65D1550 Re-cementation of space maintainer 0 D1555 Removaloffixedspacemaintainer 15

AMALGAM RESTORATIONS (including polishing)

D2140 Amalgam - one surface, primary or permanent 0D2150 Amalgam - two surfaces, primary or permanent 0D2160 Amalgam - three surfaces, primary or permanent 0

IMPORTANT INFORMATION ABOUT YOUR PLAN

ADA ADA MemberCODE DESCRIPTION Pays $

 ThisScheduleofBenefitsprovidesalistingofprocedurescoveredbyYourPlan.ForproceduresthatrequireaCopayment,theamounttobepaidisshowninthecolumntitled“MemberPays$.”YoupaytheseCopaymentstothedentalofficeatthetimeofservice.

 YoumustselectaUnitedConcordiaPrimaryDentalOffice(PDO)toreceiveCoveredServices.YourPDOwillperformthebelowproceduresorreferYoutoaSpecialtyCareDentistforfurthercare.TreatmentbyanOutofNetworkDentistisnotcovered,exceptasdescribedintheEvidenceofCoverage.

 OnlyprocedureslistedonthisScheduleofBenefitsareCoveredServices.Forservicesnotlisted(notcovered),Youareresponsibleforthefullfeechargedbythedentist.ProcedurecodesandmemberCopaymentsmaybeupdatedtomeetAmericanDentalAssociation(ADA)CurrentDentalTerminology(CDT)inaccordancewithnationalstandards.

 In-NetworkDentistswillchargeanadditional$125fortheuseofprecious(highnoble)orsemiprecious(noble)metal.  ForacompletedescriptionofYourPlan,pleaserefertotheEvidenceofCoverageandtheExclusionsandLimitationsinadditiontothisScheduleofBenefits.

 IfYouhaveanyquestionsaboutYourUnitedConcordiaDentalPlan,pleasecallOurCustomerServiceDepartmenttollfreeat 1-866-357-3304 or access Our Website at www.unitedconcordia.com.

ADA ADA MemberCODE DESCRIPTION Pays $

Concordia Plus Schedule of Benefits Plan CA 1136

Current Dental Terminology © 2010 American Dental Association. All rights reserved. CA 1136CA Base 09 (10/08)

D2161 Amalgam - four or more surfaces, primary or permanent 0

RESIN-BASED COMPOSITE RESTORATIONS - DIRECTD2330 Resin-based composite - one surface, anterior 15D2331 Resin-based composite - two surfaces, anterior 18D2332 Resin-based composite - three surfaces, anterior 21D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) 27D2390 Resin-based composite crown, anterior 27D2391 Resin-based composite - one surface, posterior 85D2392 Resin-based composite - two surfaces, posterior 109D2393 Resin-based composite - three surfaces, posterior 133D2394 Resin-based composite - four or more surfaces, posterior 140

INLAY/ONLAY RESTORATIONSD2510 Inlay - metallic - one surface 62D2520 Inlay - metallic - two surfaces 135D2530 Inlay - metallic - three or more surfaces 150D2542 Onlay - metallic - two surfaces 160D2543 Onlay - metallic - three surfaces 160D2544 Onlay - metallic - four or more surfaces 165

CROWNS - SINGLE RESTORATIONS ONLYD2710 Crown - resin-based composite (indirect) 69D2712 Crown - 3/4 resin-based composite (indirect) 69D2720 Crown - resin with high noble metal 175D2721 Crown - resin with predominantly base metal 175D2722 Crown - resin with noble metal 175D2740 Crown - porcelain/ceramic substrate 200 D2750 Crown - porcelain fused to high noble metal 175D2751 Crown - porcelain fused to predominantly base metal 175 D2752 Crown - porcelain fused to noble metal 175D2780 Crown - 3/4 cast high noble metal 175D2781 Crown - 3/4 cast predominantly base metal 175D2782 Crown - 3/4 cast noble metal 175D2783 Crown - 3/4 porcelain/ceramic 200D2790 Crown - full cast high noble metal 175D2791 Crown - full cast predominantly base metal 175 D2792 Crown - full cast noble metal 175D2794 Crown - titanium 175 D2799 Provisional crown 0

OTHER RESTORATIVE SERVICESD2910 Recement inlay, onlay, or partial coverage restoration 0D2915 Recement cast or prefabricated post and core 10D2920 Recement crown 10D2930 Prefabricated stainless steel crown - primary tooth 35D2931 Prefabricated stainless steel crown - permanent tooth 40D2932 Prefabricated resin crown 55D2933 Prefabricated stainless steel crown with resin window 55D2934 Prefabricated esthetic coated stainless steel crown - primary tooth 55D2940 Protective restoration 0D2950 Core buildup, including any pins 40D2951 Pin retention - per tooth, in addition to restoration 0D2952 Post and core in addition to crown, indirectly fabricated 60

D2953 Each additional indirectly fabricated post - same tooth 10D2954 Prefabricated post and core in addition to crown 40D2955 Post removal (not in conjunction with endodontic therapy) 0D2957 Each additional prefrabricated post - same tooth 10D2970 Temporary crown (fractured tooth) 44D2971 Additional procedures to construct new crown under existing partial denture framework 25D2980 Crown repair, by report 10

PULP CAPPINGD3110 Pulpcap-direct(excludingfinalrestoration) 0D3120 Pulpcap-indirect(excludingfinalrestoration) 0

PULPOTOMYD3220 Therapeuticpulpotomy(excludingfinalrestoration)18D3221 Pulpal debridement, primary and permanent teeth 18D3222 Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development 18

ENDODONTIC THERAPY ON PRIMARY TEETHD3230 Pulpaltherapy(resorbablefilling)-anterior, primarytooth(excludingfinalrestoration) 19D3240 Pulpaltherapy(resorbablefilling)-posterior, primarytooth(excludingfinalrestoration) 23

ENDODONTIC THERAPY(including treatment plan, clinical procedures

and follow-up care)D3310 Endodontic therapy, anterior tooth (excluding finalrestoration) 55D3320 Endodontic therapy, bicuspid tooth (excluding finalrestoration) 70D3330 Endodontictherapy,molar(excludingfinal restoration) 110

ENDODONTIC RETREATMENT D3346 Retreatment of previous root canal therapy - anterior 75D3347 Retreatment of previous root canal therapy - bicuspid 80D3348 Retreatment of previous root canal therapy - molar 115

APEXIFICATION/RECALCIFICATION PROCEDURES D3351 Apexification/recalcification/pulpalregeneration- initialvisit(apicalclosure/calcificrepairof perforations, root resorption, pulp space disinfection,

etc.) 125D3352 Apexification/recalcification/pulpalregeneration- interim medication replacement (apical closure/ calcificrepairofperforations,rootresorption,pulp spacedisinfection,etc.) 85D3353 Apexification/recalcification-finalvisit(includes completed root canal therapy - apical closure/ calcificrepairofperforations,rootresorption,etc.) 100D3354 Pulpal regeneration – (completion of regenerative treatment in an immature permanent tooth with a necroticpulp);doesnotincludefinalrestoration 85

APICOECTOMY/PERIRADICULAR SERVICESD3410 Apicoectomy/periradicular surgery - anterior 75D3421 Apicoectomy/periradicular surgery - bicuspid (firstroot) 75D3425 Apicoectomy/periradicular surgery - molar (firstroot) 75

ADA ADA MemberCODE DESCRIPTION Pays $

ADA ADA MemberCODE DESCRIPTION Pays $

Current Dental Terminology © 2010 American Dental Association. All rights reserved. CA 1136CA Base 09 (10/08)

D3426 Apicoectomy/periradicular surgery (each additional root) 40D3430 Retrogradefilling-perroot 0D3450 Root amputation - per root 0

OTHER ENDODONTIC PROCEDURESD3910 Surgical procedure for isolation of tooth with rubber dam 0D3920 Hemisection (including any root removal), not including root canal therapy 35D3950 Canalpreparationandfittingofpreformed dowel or post 0

SURGICAL SERVICES (including usual postoperative care)

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant 40D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant 20D4240 Gingivalflapprocedure,includingrootplaning- four or more contiguous teeth or tooth bounded spacesperquadrant 45D4241 Gingivalflapprocedure,includingrootplaning- one to three contiguous teeth or tooth bounded spacesperquadrant 18D4245 Apicallypositionedflap 55D4249 Clinical crown lengthening - hard tissue 60D4260 Osseoussurgery(includingflapentryand closure) - four or more contiguous teeth or toothboundedspacesperquadrant 75D4261 Osseoussurgery(includingflapentryand closure) - one to three contiguous teeth or toothboundedspacesperquadrant 30D4263 Bonereplacementgraft-firstsiteinquadrant 120D4264 Bone replacement graft - each additional site inquadrant 92D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) 45

NON-SURGICAL PERIODONTAL SERVICESD4341 Periodontal scaling and root planing - four or moreteethperquadrant 30D4342 Periodontal scaling and root planing - one to threeteethperquadrant 8D4355 Fullmouthdebridementtoenablecomprehensive evaluation and diagnosis 0D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, per report 43

OTHER PERIODONTAL SERVICESD4910 Periodontal maintenance 30D4920 Unscheduleddressingchange(bysomeoneother than treating dentist) 19

COMPLETE DENTURES (including routine post-delivery care)

D5110 Complete denture - maxillary 175D5120 Complete denture - mandibular 175D5130 Immediate denture - maxillary 200D5140 Immediate denture - mandibular 200

PARTIAL DENTURES (including routine post-delivery care)

D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) 110D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) 110D5213 Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 175D5214 Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) 175D5225 Maxillarypartialdenture-flexiblebase(including any clasps, rests and teeth) 201D5226 Mandibularpartialdenture-flexiblebase (including any clasps, rests and teeth) 201D5281 Removable unilateral partial denture - one piece cast metal (including clasps and teeth) 125

ADJUSTMENTS TO DENTURESD5410 Adjust complete denture - maxillary 10D5411 Adjust complete denture - mandibular 10D5421 Adjust partial denture - maxillary 10D5422 Adjust partial denture - mandibular 10

REPAIRS TO COMPLETE DENTURESD5510 Repair broken complete denture base 15D5520 Replace missing or broken teeth - complete denture (each tooth) 15

REPAIRS TO PARTIAL DENTURESD5610 Repair resin denture base 15D5620 Repair cast framework 15D5630 Repair or replace broken clasp 15D5640 Replace broken teeth - per tooth 15D5650 Add tooth to existing partial denture 15D5660 Add clasp to existing partial denture 15D5670 Replace all teeth and acrylic on cast metal framework (maxillary) 114D5671 Replace all teeth and acrylic on cast metal framework (mandibular) 114

DENTURE REBASE PROCEDURESD5710 Rebase complete maxillary denture 15 D5711 Rebase complete mandibular denture 15D5720 Rebase maxillary partial denture 20D5721 Rebase mandibular partial denture 20

DENTURE RELINE PROCEDURESD5730 Reline complete maxillary denture (chairside) 25D5731 Reline complete mandibular denture (chairside) 25D5740 Reline maxillary partial denture (chairside) 25D5741 Reline mandibular partial denture (chairside) 25D5750 Reline complete maxillary denture (laboratory) 35D5751 Reline complete mandibular denture (laboratory) 35D5760 Reline maxillary partial denture (laboratory) 35D5761 Reline mandibular partial denture (laboratory) 35D5810 Interim complete denture - maxillary 200D5811 Interim complete denture - mandibular 200D5820 Interim partial denture - maxillary 90D5821 Interim partial denture - mandibular 90

OTHER REMOVABLE PROSTHETIC SERVICESD5850 Tissue conditioning, maxillary 17D5851 Tissue conditioning, mandibular 17

ADA ADA MemberCODE DESCRIPTION Pays $

ADA ADA MemberCODE DESCRIPTION Pays $

Current Dental Terminology © 2010 American Dental Association. All rights reserved. CA 1136CA Base 09 (10/08)

FIXED PARTIAL DENTURE PONTICS D6205 Pontic - indirect resin based composite 200D6210 Pontic - cast high noble metal 175D6211 Pontic - cast predominantly base metal 175D6212 Pontic - cast noble metal 175D6214 Pontic - titanium 175 D6240 Pontic - porcelain fused to high noble metal 175D6241 Pontic - porcelain fused to predominantly base metal 175D6242 Pontic - porcelain fused to noble metal 175D6245 Pontic - porcelain/ceramic 200D6250 Pontic - resin with high noble metal 175D6251 Pontic - resin with predominantly base metal 175D6252 Pontic - resin with noble metal 175

FIXED PARTIAL DENTURE RETAINERS - INLAYS/ONLAYS D6545 Retainer-castmetalforresinbondedfixed prosthesis 138D6548 Retainer - porcelain/ceramic for resin bonded fixedprosthesis 207D6602 Inlay - cast high noble metal, two surfaces 135D6603 Inlay - cast high noble metal, three or more surfaces 150D6604 Inlay - cast predominantly base metal, two surfaces 135D6605 Inlay - cast predominantly base metal, three or more surfaces 150D6606 Inlay - cast noble metal, two surfaces 135D6607 Inlay - cast noble metal, three or more surfaces 150D6610 Onlay - cast high noble metal, two surfaces 160D6611 Onlay - cast high noble metal, three or more surfaces 160D6612 Onlay - cast predominantly base metal, two surfaces 160D6613 Onlay - cast predominantly base metal, three or more surfaces 160D6614 Onlay - cast noble metal, two surfaces 160D6615 Onlay - cast noble metal, three or more surfaces 160D6624 Inlay - titanium 150D6634 Onlay - titanium 165

FIXED PARTIAL DENTURE RETAINERS - CROWNSD6710 Crown - indirect resin based composite 200D6720 Crown - resin with high noble metal 175D6721 Crown - resin with predominantly base metal 175D6722 Crown - resin with noble metal 175D6740 Crown - porcelain/ceramic 200 D6750 Crown - porcelain fused to high noble metal 175D6751 Crown - porcelain fused to predominantly base metal 175D6752 Crown - porcelain fused to noble metal 175D6780 Crown - 3/4 cast high noble metal 175D6781 Crown - 3/4 cast predominantly base metal 175D6782 Crown - 3/4 cast noble metal 175D6783 Crown - 3/4 porcelain/ceramic 200D6790 Crown - full cast high noble metal 175D6791 Crown - full cast predominantly base metal 175D6792 Crown - full cast noble metal 175D6794 Crown - titanium 175

OTHER FIXED PARTIAL DENTURE SERVICESD6930 Recementfixedpartialdenture 0D6940 Stress breaker 125D6950 Precision attachment 188D6970 Postandcoreinadditiontofixedpartial

denture retainer, indirectly fabricated 60D6972 Prefabricatedpostandcoreinadditiontofixed partial denture retainer 40D6973 Core build up for retainer, including any pins 40D6976 Each additional indirectly fabricated post - same tooth 10D6977 Each additional prefabricated post - same tooth 10D6980 Fixedpartialdenturerepair,byreport 10

EXTRACTIONS(includes local anesthesia, suturing, if needed, and

routine postoperative care)D7111 Extraction, coronal remnants - deciduous tooth 4D7140 Extraction, erupted tooth or exposed root

(elevation and/or forceps removal) 10SURGICAL EXTRACTIONS

(includes local anesthesia, suturing, if needed, and routine postoperative care)

D7210 Surgicalremovaloferuptedtoothrequiringremoval of bone and/or sectioning of tooth, and including elevationofmucoperiostealflapifindicated 20D7220 Removal of impacted tooth - soft tissue 25D7230 Removal of impacted tooth - partially bony 30D7240 Removal of impacted tooth - completely bony 40D7241 Removal of impacted tooth - completely bony, with unusual surgical complications 50D7250 Surgical removal of residual tooth roots

(cutting procedure) 20D7251 Coronectomy – intentional partial tooth removal 40

OTHER SURGICAL PROCEDURESD7280 Surgical access of an unerupted tooth 24D7283 Placement of device to facilitate eruption of impacted tooth 6D7285 Biopsy of oral tissue - hard (bone, tooth) 55D7286 Biopsy of oral tissue - soft 55D7288 Brush biopsy - transepithelial sample collection 45

ALVEOLOPLASTY (surgical preparation of ridge for dentures)

D7310 Alveoloplasty in conjunction with extractions - fourormoreteethortoothspaces,perquadrant 15D7311 Alveoloplasty in conjunction with extractions - onetothreeteethortoothspaces,perquadrant 10D7320 Alveoloplasty not in conjunction with extractions - fourormoreteethortoothspaces,perquadrant 25D7321 Alveoloplasty not in conjunction with extractions - onetothreeteethortoothspaces,perquadrant 10

SURGICAL EXCISION OF INTRA-OSSEOUS LESIONSD7450 Removal of benign odontogenic cyst or tumor - lesiondiameterupto1.25cm 50D7451 Removal of benign odontogenic cyst or tumor - lesiondiametergreaterthan1.25cm 185

EXCISION OF BONE TISSUED7471 Removal of lateral exostosis (maxilla or mandible) 140D7472 Removal of torus palatinus 140

ADA ADA MemberCODE DESCRIPTION Pays $

ADA ADA MemberCODE DESCRIPTION Pays $

Current Dental Terminology © 2010 American Dental Association. All rights reserved. CA 1136CA Base 09 (10/08)

D7473 Removal of torus mandibularis 140D7485 Surgical reduction of osseous tuberosity 225

SURGICAL INCISIOND7510 Incision and drainage of abscess - intraoral soft tissue 25D7511 Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) 60D7520 Incision and drainage of abscess - extraoral soft tissue 50D7521 Incision and drainage of abscess – extraoral soft tissue – complicated (includes drainage of multiple fascial spaces) 80

REPAIR OF TRAUMATIC WOUNDSD7910 Suture of recent small wounds up to 5 cm 50

OTHER REPAIR PROCEDURESD7960 Frenulectomy–alsoknownasfrenectomyor frenotomy - separate procedure not incidental to another procedure 30D7963 Frenuloplasty 15D7970 Excision of hyperplastic tissue - per arch 66D7971 Excision of pericoronal gingiva 30

LIMITED ORTHODONTIC TREATMENTD8010 Limited orthodontic treatment of the primary dentition 1,500D8020 Limited orthodontic treatment of the transitional dentition 1,500D8030 Limited orthodontic treatment of the adolescent dentition 1,500D8040 Limited orthodontic treatment of the adult dentition 1,500

INTERCEPTIVE ORTHODONTIC TREATMENTD8050 Interceptive orthodontic treatment of the primary dentition 1,500D8060 Interceptive orthodontic treatment of the transitional dentition 1,500

COMPREHENSIVE ORTHODONTIC TREATMENT D8070 Comprehensive orthodontic treatment of the transitional dentition 1,500D8080 Comprehensive orthodontic treatment of the adolescent dentition 1,500D8090 Comprehensive orthodontic treatment of the adult dentition 2,000

MINOR TREATMENT TO CONTROL HARMFUL HABITS D8210 Removable appliance therapy 750D8220 Fixedappliancetherapy 750

OTHER ORTHODONTIC SERVICESD8660 Pre-orthodontic treatment visit 40D8670 Periodic orthodontic treatment visit (as part of contract) 0D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) 240 Orthodontic records fee 265

UNCLASSIFIED TREATMENTD9110 Palliative (emergency) treatment of dental pain - minor procedure 15D9120 Fixedpartialdenturesectioning 50

ANESTHESIAD9210 Local anesthesia not in conjunction with operative or surgical procedures 0

ADA ADA MemberCODE DESCRIPTION Pays $

ADA ADA MemberCODE DESCRIPTION Pays $

D9211 Regional block anesthesia 0D9212 Trigeminal division block anesthesia 0D9215 Local anesthesia in conjunction with operative or surgical procedures 0D9220Deepsedation/generalanesthesia-first30 minutes 160D9221 Deep sedation/general anesthesia - each additional 15 minutes 68D9241 Intravenous conscious sedation/analgesia - first30minutes 170D9242 Intravenous conscious sedation/analgesia - each additional 15 minutes 42

PROFESSIONAL CONSULTATIOND9310 Consultation - diagnostic service provided by dentistorphysicianotherthanrequestingdentist or physician 0

PROFESSIONAL VISITSD9430 Officevisitforobservation(duringregularly scheduled hours) - no other services performed 0D9440Officevisit,afterregularlyscheduledhours 40D9450 Case presentation, detailed and extensive treatment planning 0

MISCELLANEOUS SERVICESD9940 Occlusal guard, by report 170D9942 Repair and/or reline of occlusal guard 55D9951 Occlusal adjustment - limited 10D9952 Occlusal adjusment - complete 40 Broken appointment per 30 minutes

(without 24-hour notice) 20BLEACHING

D9972 External bleaching - per arch 160FOOTNOTES

PleasereportundercodeD8999“Unspecifiedorthodonticprocedure,byreport”.Recordsincludealldiagnosticpro-cedures,suchascephalometricfilms,fullmouthx-rays,models,andtreatmentplans.

PleasereportundercodeD9999“Unspecifiedadjunctiveprocedure,byreport.”

Charges for the use of precious (high noble) or semiprecious (noble) metal are not included in the copay-mentforcrowns,bridges,pontics,inlaysandonlays.Thedecision to use these materials is a cooperative effort between the provider and the patient, based on the pro-fessionaladviceoftheprovider.Providersareexpectedto charge no more than an additional $125 for these materials.