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Managed Dental Guard 06/06/2005

Plan Schedules Patient Charges MDG CODE Covered Services 6NYM

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Appointments and Diagnostic Services 0120/0140/0150 Oral evaluation 0 0999 Office visit during regular hours participating general dentist only 5 9999 Broken appointment (without 24 hours notice) 25 Radiographs 0210 Intraoral complete series (including bitewings) 0 0220/0230/0240 Intraoral periapical or occlusal single film 0 0270/0272/0274 Bitewings 0 0330 Panoramic film 0 0460/0470 Pulp vitality test / Diagnostic casts 0 Preventive and Space Maintenance 1110/1120 Prophylaxis 0 1201/1203 Topical application of fluoride (may include prophylaxis) child 0 1310 Nutritional counseling for control of dental disease 0 1330 Oral hygiene instruction 0 1351 Sealant per tooth 0 1510 Space maintainer fixed unilateral 0 1515 Space maintainer fixed bilateral 0 1550 Recementation of space maintainer 0 Restorative 2140 Amalgam one surface permanent 0 2150 Amalgam two surfaces permanent 0 2160 Amalgam three surfaces permanent 0 2161 Amalgam four or more surfaces permanent 0 2330 Resin/composite one surface, anterior 0 2331 Resin/composite two surfaces, anterior 0 2332 Resin/composite three surfaces, anterior 0 2335 Resin/composite four or more surfaces or incisal angle, anterior 0 2390 Resin based composite crown, anterior 105 2391 Resin based composite 1 surface posterior 60 2392 Resin based composite 2 surface posterior 80 2393 Resin based composite 3 surface posterior 95 2394 Resin based composite 4 or more surface, posterior 105 Crown, Bridge and Other Cast Restorations 2510 Inlay metallic one surface** 224 2520/6520 Inlay metallic two surfaces** 256 2530/6530 Inlay metallic three surfaces** 296 2543/6543 Onlay metallic three surfaces** 304 2544/6544 Onlay metallic four or more surfaces** 316 2740 Crown porcelain/ceramic substrate 316 2750-2752 Crown porcelain fused to metal** 316 2780-2782 Crown cast metallic** 316 2790-2792 Crown full cast metal** 316 2794 Crown titanium** 316 6210-6212 Pontic cast metal** 308 6240-6242 Pontic porcelain fused to metal** 308 6602 Retainer inlay metallic 2 surface ** 256 6603 Retainer inlay metallic 3 or more surface ** 296 6610 Retainer onlay, metallic, two surface ** 304 6611 Retainer onlay, metallic, four or more surface** 316 6624 Inlay titanium** 256 6634/6794 Onlay titanium / Crown titanium** 316 6750-6752 Crown abutment porcelain fused to metal** 316 6780 Crown cast high noble metal** 316 6790-6792 Crown abutment full cast metal** 316 6999 Multiple crown and bridge unit treatment plan per unit 125 Other Restorative Services 2910/2920 Recement inlay, crown, bridge 36 2915 Recement cast or prefabricated post 36 2930/2931 Prefabricated stainless steel crown 88 2932 Prefabricated resin crown 108 2940 Sedative filling 0 2950/6973 Core buildup, including any pins 80 2951 Pin retention per tooth, in addition to restoration 18 2952/6970 Cast post and core 124 2954/6972 Prefabricated post and core 100 2960 Labial veneer (laminate) chairside 295 2971 Additional procedure, new crown under existing partial denture 100 6930 Recement fixed partial denture 36 Endodontics 3110/3120 Pulp cap (excl rest) 0 3220 Therapeutic pulpotomy (excl rest) 0 3310 Root canal anterior (excl final rest) 0 3320 Root canal bicuspid (excl final rest) 0 Covered Services are subject to exclusions, limitations and Plan provisions as described in Members Plan booklet and the Manual (including the Quality Management retrospective review). Other codes may be used to describe Covered Services. These plans have been filed with the applicable state regulatory agencies and are pending approval. If high noble metal is used, there will be an additional patient charge for the actual cost of the high noble metal. The Member will be responsible for the Office Visit Fee when the Plan Schedule suffix listed on the Eligibility Report is an M. Guardian will be responsible for the Office Visit Fee when the Plan Schedule suffix listed on the Eligibility Report is a G. V.05151 NY

Managed Dental Guard 06/06/2005


Plan Schedules Patient Charges MDG CODE 3330 3346 3347 3348 3410 3421 3425 3426 3430 4210 4211 4240 4241 4249 4260 4261 4270 4271 4341 4342 4355 4910 4920 9951 5110/5120 5130/5140 5211 5212 5213/5214 5225/5226 5410/11/21/22 5510 5520/5640 5610 5630 5650 5660 5710/11/20/21 5730/31/40/41 5750/51/60/61 5820/5821 5850/5851 7111/7140 7210 7220 7230 7240 7241 7250 7270 7280 7285 7286 7310 7311 7320 7321 7450 7451 7471 7510 7960 7963 9110 9215 9310 9430 9440 Covered Services Root canal molar (excl final rest) Root canal retreatment anterior Root canal retreatment bicuspid Root canal retreatment molar Apicoectomy/periradicular surgery anterior Apicoectomy/periradicular surgery bicuspid first root Apicoectomy/periradicular surgery molar first root Apicoectomy/periradicular surgery each additional root Retrograde filling per root Periodontics Gingivectomy or gingivoplasty per quadrant Gingivectomy or gingivoplasty per tooth Gingival flap procedure including root planing per quadrant Gingival flap procedure including root planing, 1-3 teeth Crown lengthening hard tissue Osseous surgery including flap entry, closure per quadrant five to eight teeth Osseous surgery including flap entry, closure per quadrant one to four teeth Pedicle soft tissue graft procedure Free soft tissue graft procedure (including donor site surgery) Periodontal scaling/root planing per quadrant Periodontal scaling/root planing 1-3 teeth per quad Full mouth debridement to enable evaluation and diagnosis Periodontal maintenance procedures (following active therapy) Unscheduled dressing change (other than by treating dentist) Occlusal adjustment limited per visit Prosthodontics (Removable) Complete denture (including routine post delivery care) Immediate denture (including routine post delivery care) Upper partial denture, resin base, including clasps, rests, teeth Lower partial denture, resin base, including clasps, rests, teeth Cast metal framework with resin base including clasps, rests, teeth Maxillary or mandibular partial denture flexible base Repairs and Adjustments Denture adjustments Repair broken base, complete denture Replace missing or broken teeth per tooth Repair resin saddle or base Repair or replace clasp Add tooth to existing partial Add clasp to existing partial Rebase denture Reline denture (chairside) Reline denture (laboratory) Interim partial denture (stayplate) Tissue conditioning Oral Surgery Extraction coronal remnants, deciduous tooth / erupted tooth or exposed root Surgical removal of erupted tooth Removal of impacted tooth soft tissue Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony, with unusual surgical complications Surgical removal of residual tooth roots (cutting procedure) Tooth reimplantation and/or stabilization of accidentally evulsed tooth Surgical exposure of impacted or unerupted tooth for orthodontic reasons Biopsy of oral tissue hard Biopsy of oral tissue soft Alveoplasty in conjunction with extractions per quadrant Alveoplasty in conjunction w/ext, 1-3 teeth or teeth spaces Alveoplasty not in conjunction with extractions per quadrant Alveoplasty w/o ext., 1-3 teeth or teeth spaces Removal of odontogenic cyst/tumor, up to 1.25cm. Removal of odontogenic cyst/tumor, over 1.25cm. Removal of lateral exostosis maxilla or mandible Incision and drainage of intraoral abscess Frenulectomy (separate procedure) Frenuloplasty Miscellaneous Services Palliative (emergency) treatment per visit Local anesthesia Consultation (by dentist other than practitioner providing treatment) Office visit for observation, no other service Office visit, after regularly scheduled hours 6NYM 270 375 425 525 240 270 320 116 72 200 60 240 144 280 380 230 350 363 0 0 0 0 38 40 362 394 305 354 400 460 20 40 36 44 56 52 64 160 88 120 140 36 0 0 0 140 160 200 90 225 250 125 88 125 65 150 105 388 625 475 0 250 400 15 0 0 0 50

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Covered Services are subject to exclusions, limitations and Plan provisions as described in Members Plan booklet and the Manual (including the Quality Management retrospective review). Other codes may be used to describe Covered Services. These plans have been filed with the applicable state regulatory agencies and are pending approval. If high noble metal is used, there will be an additional patient charge for the actual cost of the high noble metal. The Member will be responsible for the Office Visit Fee when the Plan Schedule suffix listed on the Eligibility Report is an M. Guardian will be responsible for the Office Visit Fee when the Plan Schedule suffix listed on the Eligibility Report is a G. V.05151 NY