Northern New England Benefit Trust is now Allegiant Care Same Benefits, Same Team, Same Care – Just a New Name!

To: Valued Members and Providers

From: Allegiant Care Member Services

Date: January 2018

RE: 2018 Dental Fee Schedule

Attached is the 2018 Dental Fee Schedule for all Allegiant Care members. Note: The “Plan Pays” amount on the fee schedule already has the percentages factored in. The member will be responsible for any balance due beyond what Allegiant Care pays. Allegiant Care does not contract with a network of dentists, so members may select a dentist of their choice. Please note a few important reminders to help expedite the process of dental claims/estimates:

• Allegiant Care’s Electronic Payer ID # is 38238, Group #: R40.

• Required documentation, including x-ray images, must be submitted on paper

o Periodontal work – full-mouth x-rays and charting

o Soft tissue grafts - a narrative statement and charting

o Bony impactions - a panorex x-ray

o Completed endodontic work – post-op periapical x-rays

o Prosthetics – a pre-op periapical x-ray, narrative statement for recommended crown; and x-ray of completed crown

o Adult orthodontic treatment - x-rays

• All wisdom teeth claims/estimates need to be submitted to Allegiant Care dental first (Codes: D7230, D7240, D7241). Once the claim is paid through the dental plan, we will forward the balance to CIGNA who pays as secondary.

If you have any questions, please call 1-800-258-9732 to speak with Amie at extension 233 or Ann at extension 229.

Code Procedure Description Plan Pays Code Procedure Description Plan Pays

EXAMINATIONS FILLINGS (cont.)

0120 periodic exam 49 2331 two surfaces 163

0150 initial exam 94 2332 three surfaces 198

0140 emergency exam 90 2335 four surfaces and incisors 248

0145 oral evaluation under 3 yrs. of age 78 2390 resin based composite crown 276

0160 problem focused 118 2391 one surface 148

9110 palliative treatment 135 2392 two surfaces 194

9310 consultation (per session) 123 2393 three surfaces 243

9311 consultation with medical health care professional 123 2394 four surfaces 278

X-RAYS AND LAB 2921 reattachment of tooth fragment 179

0210 full mouth X-rays 145 2930 stainless steel crown-primary tooth only 242

0220 intraoral X-ray first 32 2931 stainless steel crown-permanent tooth only 242

0230 intraoral X-ray each additional 26 2940 protective restoration/sedative filling 102

0240 occlusal X-rays 42 2951 pin retention (per tooth) 55

0270 bitewing-1 33 PERIODONTICS

0272 bitewing-2 51 0180 periodontal consultations 89

0273 bitewing-3 58 4210 gingivectomy per quadrant (4 or more teeth) 516

0274 bitewing-4 70 4211 gingivectomy (2 to 3 teeth) 258

0277 vertical bitewing 100 4212 gingivectomy (1 tooth) 170

0330 panorex X-ray 131 4220 subgingival curettage-per quadrant 175

0364 cone beam CT(< than 1 whole jaw) - by report 300 4230 crown exposure-per quadrant 501

0365 cone beam CT(1 full lower arch ) -by report 300 4231 crown exposure (1-3 teeth) 251

0366 cone beam CT(1 full upper arch) - by report 300 4240 gingival flap per quadrant (4 or more teeth) 600

0367 cone beam CT (view of both jaws) - by report 300 4241 gingival flap (1 tooth) 200

4242 gingival flap (2 to 3 teeth) 300

CLEANING AND FLOURIDE TREATMENTS 4260 osseous surgery-per quadrant 876

1110 cleaning-age 13 to adult 100 4261 osseous surgery (1 tooth) 292

1120 cleaning-child through age 12 78 4262 osseous surgery (2 to 3 teeth) 438

1206 topical fluoride varnish-through age 18 42 4263 bone graft-first site 443

1208 fluoride-child through age 18 42 4264 bone graft-each additional site 222

1351 sealants-child through age 18 58 4265 biologic materials/tissue regeneration 450

1352 resin-sealant/permanent tooth-through age 18 79 4266 tissue regeneration/resorbable 500

1353 sealant repair (per tooth/permanent) 52 4267 tissue regeneration/nonresorbable 508

SPACE MAINTAINERS (up to age 14) 4270 pedicle soft tissue graft-per report 800

1510 fixed unilateral 376 4273 connective tissue graft- per report 985

1515 fixed bilateral 530 4274 mesial/distall wedge procedure single tooth 554

1520 removable unilateral 460 4275 non-autogenous connective tissue graft 812

1525 removable bilateral 460 4276 combined connective tissue graft 837

1550 recementation (once per year) 61 4277 free soft tissue graft-per report 842

1575 distal shoe space maintainer - fixed unilateral 376 4278 free soft tissue graft (larger) per report 855

GUARDS (one type of guard once every 5 years) 4341 periodontal scaling/root planing-per quadrant 210

9941 athletic guard 261 4342 periodontal scaling /root planing (1 tooth) 70

9940 occlusal guard 484 4343 periodontal scaling /root planing (2 to 3 teeth) 105

9943 occlusal guard adjustment 50 4346 scaling/gingival inflammation/full mouth 100

4355 difficult prophylaxis/scaling 100

FILLINGS 4910 periodontal maintenance procedure 100

Amalgam – permanent or primary ENDODONTICS

2140 one surface 115 3110 pulp capping/remineralization 65

2150 two surfaces 145 3220 vital pulpotomy 155

2160 three surfaces 179 3221 pulpal debridement (primary & permanent) 174

2161 four surfaces or more 203 3230 pulpal therapy-anterior primary tooth 178

Composite Resin – permanent or primary 3240 pulpal therapy-posterior primary tooth 153

2330 one surface 131

2018 Dental Fee Schedule

BASIC CARE

DIAGNOSTIC

PREVENTIVE

BASIC CARE (cont.)

***Refer to Dental Benefit Limitations & Exclusions for further description of these covered services***

Revised January 2018

Allegiant Care 2018 Dental Fee Schedule Page 1 of 3EDI Payer ID: 38238, Group #: R40

(for electronic claim submission)

Allegiant Care

2018 Dental Fee Schedule

Code Procedure Description Plan Pays Code Procedure Description Plan Pays

ENDODONTICS (cont.) ORAL SURGERY (cont.)

Root Canal Therapy 7970 excision of hyperplastic tissue 397

3310 one root 716 7971 excision of pericoronal gingiva 196

3320 two roots 838 7979 non-surgical sialo lithotomy by report

3330 three roots 1,000 7980 surgical sialo lithotomy by report

3340 four roots 1,150 9222/

3351 apexification per visit 120 9223

3352 apexification/recalcification 120 9239/

3353 apexification final visit 120 9243

3357 pulpal regeneration completion of treatment 100

Apicoectomy CROWNS AND BRIDGES

3410 anterior 529 2510 metallic inlay-1 surface 330

3421 bicuspid 590 2520 metallic inlay-2 surfaces 381

3425 molar 663 2530 metallic inlay-3 or more surfaces 457

3426 each additional root 330 2543 metallic onlay-3 surfaces 377

3430 retrograde filling-per root 205 2544 metallic onlay-4 or more surfaces 441

3450 root resection 250 2610 porcelain/ceramic inlay-1 surface 359

3920 hemi section 203 2620 porcelain/ceramic inlay-2 surfaces 406

EXTRACTIONS 2630 porcelain/ceramic inlay-3 or more surfaces 426

7111 coronal remnants-primary tooth 100 2642 porcelain/ceramic onlay-2 surfaces 426

7140 single tooth 151 2643 porcelain/ceramic onlay-3 surfaces 569

7130 root removal-exposed root 117 2644 porcelain/ceramic onlay-4 or more surfaces 605

SURGICAL EXTRACTIONS 2650 inlay-composite/resin-1 surface 422

7210 erupted tooth 256 2651 inlay-composite/resin-2 surfaces 432

7220 soft tissue impaction 303 2652 inlay-composite/resin-3 or more surfaces 443

7230 partial bony impaction 365 2662 onlay-composite/resin-2 surfaces 432

7240 complete bony impaction 423 2663 onlay-composite/resin-3 surfaces 443

7241 complete bony impaction-difficult 439 2664 onlay-composite/resin-4 or more surfaces 508

7250 residual root recovery 259 2710 plastic crown (laboratory) 203

ORAL SURGERY 2740 porcelain crown 642

7260 oroantral fistula closure by report 2750 porcelain to high noble metal 633

7280 surgical exposure of ortho 440 2751 porcelain with nonprecious metal 535

7281 surgical exposure of unerupted tooth 440 2752 porcelain with semiprecious metal 591

7283 device to facilitate eruption of impacted tooth 173 2780 three-quarter high noble metal 633

7285 biopsy oral tissue-hard 290 2781 three-quarter predominantly base metal 472

7286 biopsy oral tissue-soft 307 2782 three-quarter cast noble metal 633

7288 brush biopsy 143 2783 three-quarter crown/porcelain 658

7295 autogenous grafting/harvest of bone 441 2790 gold crown - full cast 645

7296 corticotomy-1 to 3 tooth spaces, per quadrant by report 2791 nonprecious crown 498

7297 corticotomy-4 or more tooth spaces, per quadrant by report 2792 semiprecious crown 539

7310 alveoplasty (per quadrant w/extractions) 238 2794 titanium crown 580

7320 alveoplasty (per quadrant w/no extractions) 305 2810 three-quarter cast crown-metallic 540

7340 vestibuloplasty (per arch, uncomplicated) 216 2910 recement or re-bond inlay or onlay 59

7350 vestibuloplasty (per arch, w/ridge extension) 338 2920 recement or re-bond crown 62

7430 cystectomy 270 2932 prefabricated resin crown 154

7471 removal of exostosis 330 2950 crown build-up pin retained 155

7510 incision and drainage abscess-intraoral 218 2952 cast post and core, in addition to crown 223

7520 incision and drainage abscess-extraoral 300 2954 prefabricated post and core 182

7950 osseous or cartilage graft by report 2955 post removal 53

7951 sinus augmentation by report 2980 crown repair 130

7952 sinus augmentation vertical approach by report 2981 inlay repair 130

7953 bone replacement graft for implants 443 2982 onlay repair 130

7960 frenectomy 340 6210 high noble metal pontic 633

7963 frenuloplasty 254 6211 cast predominantly base pontic 535

BASIC CARE (cont.) BASIC CARE (cont.)

MAJOR CARE

***Refer to Dental Benefit Limitations & Exclusions for further description of these covered services***

general anesthesia - total benefit of all increments 500

IV sedation - total benefit of all increments 434

Revised January 2018 Page 2 of 3EDI Payer ID: 38238, Group #: R40

(for electronic claim submission)

Allegiant Care

2018 Dental Fee Schedule

Code Procedure Description Plan Pays Code Procedure Description Plan Pays

CROWNS AND BRIDGES (cont.) DENTURES(cont.)

6212 cast noble metal pontic 591 5520 replace tooth 87

6214 titanium pontic 580 5611 repair resin partial denture base, mandibular 100

6240 porcelain fused to high noble pontic 633 5612 repair resin partial denture base, maxillary 100

6241 porcelain to predominantly base pontic 535 5621 repair cast partial framework, mandibular 100

6242 porcelain to noble metal pontic 633 5622 repair cast partial framework, maxillary 100

6245 porcelain to ceramic pontic 642 5630 repair or replace broken clasps (per tooth) 127

6545 cast metal retainer 355 5640 broken tooth on partial (no other repairs) 89

6548 porcelain to ceramic retainer 355 5650 add tooth to partial 107

6549 resin retainer 355 5660 add clasp to existing partial (per tooth) 91

6740 porcelain to ceramic abutment 642 Rebase

6750 porcelain to gold abutment 633 5710 complete upper denture 228

6751 porcelain to nonprecious abutment 535 5711 complete lower denture 228

6752 porcelain to semiprecious abutment 591 5720 upper partial denture 228

6790 high noble full cast abutment 645 5721 lower partial denture 228

6791 predominantly base full cast abutment 498 Office Reline

6792 noble metal full cast abutment 645 5730 complete upper denture 193

6794 titanium abutment 580 5731 complete lower denture 193

6930 recement bridge 91 5740 upper partial denture 193

6980 bridge repair 178 5741 lower partial denture 193

IMPLANT CROWNS Laboratory Reline

6058 abutment supported porcelain/ceramic 642 5750 complete upper denture 217

6059 abutment supported porcelain/high noble 633 5751 complete lower denture 217

6060 abutment supported porcelain/base metal 535 5760 upper partial denture 213

6061 abutment supported porcelain/noble metal 633 5761 lower partial denture 213

6062 abutment supported high noble metal 645 Prosthetic Miscellaneous

6063 abutment supported cast metal 535 5850 tissue conditioning, maxillary 79

6064 abutment supported noble metal 645 5851 tissue conditioning, mandibular 79

6094 abutment supported titanium 580 5992 adjust prosthetic appliance 116

6065 implant supported porcelain/ceramic 642 5993 maintenance & cleaning of prosthesis 50

6066 implant supported porcelain/high noble metal 633 IMPLANT (Only for Plans DN0,DN3 & DN5)

6067 implant supported high noble metal 645

6092 recement implant crown 71

DENTURES

5110 complete upper/maxillary 650

5120 complete lower/mandibular 650 6010/

5130 immediate upper/maxillary 740 6011

5140 immediate lower/mandibular 740 6013 surgical placement mini Implant (per tooth) 500

5211 upper partial-acrylic base (includes clasps) 610 IMPLANT PROCEDURES (Only for Plans DN0,DN3 & DN5 )

5212 lower partial-acrylic base (includes clasps) 610 Part of the $1,000 prosthetic annual max DN0,DN5

5213 upper partial-cast metal framework 769 Part of the $1,500 all inclusive max DN3

5214 lower partial-cast metal framework 769 6110 implant/abutment complete remv-maxillary 1,000

5221 immediate upper/maxillary partial-resin base 564 6111 implant/abutment complete remv-mandibular 1,000

5222 immediate lower/mandibular partial-resin base 564 6112 implant/abutment partial remv-maxillary 500

5223 immediate upper/maxillary partial-metal frame 737 6113 implant/abutment partial remv-mandibular 500

5224 immediate lower/mandibular partial-metal frame 737 6114 implant/abutment complete fixed-maxillary 1,000

Adjustments 6115 implant/abutment complete fixed-mandibular 1,000

5410 complete upper denture 47 6116 implant/abutment partial fixed-maxillary 1,000

5411 complete lower denture 47 6117 implant/abutment partial fixed-mandibular 1,000

5421 upper partial 47 6055 implant connecting bar 305

5422 lower partial 47 6056 implant prefabricated abutment 311

Repairs 6057 implant custom abutment 362

5511 repair complete denture base, mandibular 100 6096 remove broken implant retaining screw 50

5512 repair complete denture base, maxillary 100 6100 implant removal by report

MAJOR CARE (cont.)

first and/or second stage of implant (per tooth) 1,000

MAJOR CARE (cont.)

Implant Lifetime maximum of $2,000 per

individual. Patient must be eligible for six (6)

consecutive months before Implant benefit can

be used.

***Refer to Dental Benefit Limitations & Exclusions for further description of these covered services***

Revised January 2018 Page 3 of 3EDI Payer ID: 38238, Group #: R40

(for electronic claim submission)