Memorial Hermann Advantage HMO

2020 Dental Fee Schedule

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SCHEDULE A

Description of Benefits and Copayments

The Benefits shown below are performed as deemed appropriate by the attendingContract Dentist subject to the limitations and exclusions of the Program. Pleaserefer to Schedules B, C, D and E for further clarification of Benefits. Enrollees shoulddiscuss all treatment options with their Contract Dentist prior to services beingrendered.

Text that appears in italics below is specifically intended to clarify the deliveryof Benefits under this Program and is not to be interpreted as Current DentalTerminology ("CDT"), CDT-2019 procedure codes, descriptors or nomenclature thatare under copyright by the American Dental Association ("ADA"). The ADA mayperiodically change CDT codes or definitions. Such updated codes, descriptors andnomenclature may be used to describe these covered procedures in compliance withfederal legislation.

CODE DESCRIPTIONENROLLEE

PAYS

D0100-D0999 I. DIAGNOSTIC

GP means General Practitioner.

SP means Specialty Care Practitioner.D0120 Periodic oral evaluation - established patient ........................................ No CostD0140 Limited oral evaluation - problem focused (GP) ................................... No CostD0140 Limited oral evaluation - problem focused (SP) ................................... $20.00D0145 Oral evaluation for a patient under three years of age and

counseling with primary caregiver .......................................................... No CostD0150 Comprehensive oral evaluation - new or established patient (GP) ..... No CostD0150 Comprehensive oral evaluation - new or established patient (SP) ..... $20.00D0160 Detailed and extensive oral evaluation - problem focused, by report

(GP) ............................................................................................................... No CostD0160 Detailed and extensive oral evaluation - problem focused, by report

(SP) ................................................................................................................ $20.00D0170 Re-evaluation - limited, problem focused (established patient; not

post-operative visit) ................................................................................... No CostD0171 Re-evaluation - post-operative office visit ............................................. $5.00D0180 Comprehensive periodontal evaluation - new or established patient

(GP) ............................................................................................................... No CostD0180 Comprehensive periodontal evaluation - new or established patient

(SP) ................................................................................................................ $20.00D0190 Screening of a patient ............................................................................... No CostD0191 Assessment of a patient ............................................................................ No CostD0210 Intraoral - complete series of radiographic images .............................. No CostD0220 Intraoral - periapical first radiographic image ....................................... No CostD0230 Intraoral - periapical each additional radiographic image ................... No CostD0240 Intraoral - occlusal radiographic image .................................................. No CostD0270 Bitewing - single radiographic image ..................................................... No CostD0272 Bitewings - two radiographic images ..................................................... No CostD0273 Bitewings - three radiographic images ................................................... No Cost

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D0274 Bitewings - four radiographic images ..................................................... No CostD0277 Vertical bitewings - 7 to 8 radiographic images .................................... No CostD0330 Panoramic radiographic image ................................................................. No CostD0460 Pulp vitality tests ........................................................................................ No CostD0470 Diagnostic casts .......................................................................................... No CostD0601 Caries risk assessment and documentation, with a finding of low

risk - 1 every 3 years .................................................................................. No CostD0602 Caries risk assessment and documentation, with a finding of

moderate risk - 1 every 3 years ................................................................ No CostD0603 Caries risk assessment and documentation, with a finding of high

risk - 1 every 3 years .................................................................................. No CostD0999 Unspecified diagnostic procedure, by report - includes office visit,

per visit (in addition to other services) .................................................. No Cost

D1000-D1999 II. PREVENTIVED1110 Prophylaxis cleaning - adult - 1 D1110, D1120 or D4346 per 6 month

period 2 ......................................................................................................... No CostD1120 Prophylaxis cleaning - child - 1 D1110, D1120 or D4346 per 6 month

period 2 ......................................................................................................... No CostD1206 Topical application of fluoride varnish - child to age 19; 1 D1206 or

D1208 per 6 month period 2 ..................................................................... No CostD1208 Topical application of fluoride - excluding varnish - child to age 19; 1

D1206 or D1208 per 6 month period 2 .................................................... No CostD1330 Oral hygiene instructions .......................................................................... No CostD1351 Sealant - per tooth - limited to permanent molars through age 15 ..... $10.00D1352 Preventive resin restoration in a moderate to high caries risk patient

- permanent tooth - limited to permanent molars through age 15 ..... $10.00D1353 Sealant repair - per tooth - limited to permanent molars through

age 15 ............................................................................................................ $10.00D1354 Interim caries arresting medicament application - per tooth - child

to age 19; 1 per 6 month period ............................................................... No CostD1510 Space maintainer - fixed - unilateral ....................................................... $55.00D1516 Space maintainer - fixed - bilateral, maxillary ........................................ $55.00D1517 Space maintainer - fixed - bilateral, mandibular .................................... $55.00D1520 Space maintainer - removable - unilateral .............................................. $55.00D1526 Space maintainer - removable - bilateral, maxillary .............................. $55.00D1527 Space maintainer - removable - bilateral, mandibular .......................... $55.00D1550 Re-cement or re-bond space maintainer ................................................ $10.00D1555 Removal of fixed space maintainer ......................................................... $10.00D1575 Distal shoe space maintainer - fixed - unilateral - child to age 9 ........ $55.00

D2000-D2999 III. RESTORATIVE

- Includes indirect pulp capping, bases, liners and acid etch procedures.D2140 Amalgam - one surface, primary or permanent .................................... $20.00D2150 Amalgam - two surfaces, primary or permanent .................................. $22.00D2160 Amalgam - three surfaces, primary or permanent ................................ $24.00D2161 Amalgam - four or more surfaces, primary or permanent ................... $26.00D2330 Resin-based composite - one surface, anterior ..................................... $21.00D2331 Resin-based composite - two surfaces, anterior ................................... $26.00D2332 Resin-based composite - three surfaces, anterior ................................. $30.00D2335 Resin-based composite - four or more surfaces or involving incisal

angle (anterior) ........................................................................................... $35.00D2390 Resin-based composite crown, anterior ................................................. $50.00

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D2391 Resin-based composite - one surface, posterior ................................... OptionalD2392 Resin-based composite - two surfaces, posterior ................................. OptionalD2393 Resin-based composite - three surfaces, posterior ............................... OptionalD2394 Resin-based composite - four or more surfaces, posterior .................. OptionalD2410 Gold foil - one surface ............................................................................... OptionalD2420 Gold foil - two surfaces ............................................................................. OptionalD2430 Gold foil - three surfaces .......................................................................... OptionalD2510 Inlay - metallic - one surface 4 ................................................................. $180.00D2520 Inlay - metallic - two surfaces 4 ............................................................... $190.00D2530 Inlay - metallic - three or more surfaces 4 .............................................. $200.00D2542 Onlay - metallic - two surfaces 4 ............................................................. $196.00D2543 Onlay - metallic - three surfaces 4 ........................................................... $206.00D2544 Onlay - metallic - four or more surfaces 4 .............................................. $212.00D2610 Inlay - porcelain/ceramic - one surface .................................................. OptionalD2620 Inlay - porcelain/ceramic - two surfaces ................................................. OptionalD2630 Inlay - porcelain/ceramic - three or more surfaces ............................... OptionalD2642 Onlay - porcelain/ceramic - two surfaces ............................................... OptionalD2643 Onlay - porcelain/ceramic - three surfaces ............................................ OptionalD2644 Onlay - porcelain/ceramic - four or more surfaces ............................... OptionalD2650 Inlay - resin-based composite - one surface .......................................... OptionalD2651 Inlay - resin-based composite - two surfaces ........................................ OptionalD2652 Inlay - resin-based composite - three or more surfaces ....................... OptionalD2662 Onlay - resin-based composite - two surfaces ...................................... OptionalD2663 Onlay - resin-based composite - three surfaces .................................... OptionalD2664 Onlay - resin-based composite - four or more surfaces ....................... OptionalD2710 Crown - resin-based composite (indirect) 3 ........................................... $120.00D2720 Crown - resin with high noble metal 3, 4 .................................................. $225.00D2721 Crown - resin with predominantly base metal 3 .................................... $225.00D2722 Crown - resin with noble metal 3 ............................................................. $225.00D2740 Crown - porcelain/ceramic 3 ..................................................................... $225.00D2750 Crown - porcelain fused to high noble metal 3, 4 ................................... $225.00D2751 Crown - porcelain fused to predominantly base metal 3 ...................... $225.00D2752 Crown - porcelain fused to noble metal 3 .............................................. $225.00D2780 Crown - 3/4 cast high noble metal 4 ....................................................... $225.00D2781 Crown - 3/4 cast predominantly base metal ......................................... $225.00D2782 Crown - 3/4 cast noble metal .................................................................. $225.00D2783 Crown - 3/4 porcelain/ceramic 3 .............................................................. $225.00D2790 Crown - full cast high noble metal 4 ....................................................... $225.00D2791 Crown - full cast predominantly base metal .......................................... $225.00D2792 Crown - full cast noble metal ................................................................... $225.00D2794 Crown - titanium 4 ...................................................................................... $225.00D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage

restoration .................................................................................................... $10.00D2915 Re-cement or re-bond indirectly fabricated or prefabricated post

and core ....................................................................................................... $10.00D2920 Re-cement or re-bond crown ................................................................... $10.00D2921 Reattachment of tooth fragment, incisal edge or cusp (anterior) ...... $35.00D2929 Prefabricated porcelain/ceramic crown - primary tooth - anterior ..... OptionalD2930 Prefabricated stainless steel crown - primary tooth ............................. $55.00D2931 Prefabricated stainless steel crown - permanent tooth ........................ $55.00

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D2932 Prefabricated resin crown - anterior primary tooth .............................. $55.00D2933 Prefabricated stainless steel crown with resin window - anterior

primary tooth ............................................................................................... OptionalD2940 Protective restoration ................................................................................. $16.00D2941 Interim therapeutic restoration - primary dentition .............................. $16.00D2949 Restorative foundation for an indirect restoration ................................ $20.00D2950 Core buildup, including any pins when required ................................... $20.00D2951 Pin retention - per tooth, in addition to restoration ............................. $20.00D2952 Post and core in addition to crown, indirectly fabricated 4 ................. $20.00D2953 Each additional indirectly fabricated post - same tooth 4 ................... $20.00D2954 Prefabricated post and core in addition to crown ................................ $20.00D2957 Each additional prefabricated post - same tooth ................................. $20.00D2971 Additional procedures to construct new crown under existing

partial denture framework ........................................................................ $45.00D2980 Crown repair necessitated by restorative material failure .................... $25+labD2981 Inlay repair necessitated by restorative material failure ....................... $25+labD2982 Onlay repair necessitated by restorative material failure ..................... $25+labD2983 Veneer repair necessitated by restorative material failure ................... $25+labD2990 Resin infiltration of incipient smooth surface lesions - limited to

permanent molars through age 15 ........................................................... $10.00

D3000-D3999 IV. ENDODONTICSD3110 Pulp cap - direct (excluding final restoration) ....................................... No CostD3120 Pulp cap - indirect (excluding final restoration) .................................... No CostD3220 Therapeutic pulpotomy (excluding final restoration) - removal of

pulp coronal to the dentinocemental junction and application ofmedicament ................................................................................................. $16.00

D3221 Pulpal debridement, primary and permanent teeth ............................. $15.00D3222 Partial pulpotomy for apexogenesis - permanent tooth with

incomplete root development .................................................................. $16.00D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth

(excluding final restoration) ...................................................................... $16.00D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth

(excluding final restoration) ...................................................................... $16.00D3310 Root canal - endodontic therapy, anterior tooth (excluding final

restoration) ................................................................................................... $60.00D3320 Root canal - endodontic therapy, premolar tooth (excluding final

restoration) ................................................................................................... $120.00D3330 Root canal - endodontic therapy, molar tooth (excluding final

restoration) ................................................................................................... $180.00D3331 Treatment of root canal obstruction; non-surgical access ................... $60.00D3332 Incomplete endodontic therapy; inoperable, unrestorable or

fractured tooth ............................................................................................ $60.00D3346 Retreatment of previous root canal therapy - anterior ........................ $72.00D3347 Retreatment of previous root canal therapy - premolar ...................... $144.00D3348 Retreatment of previous root canal therapy - molar ............................ $215.00D3410 Apicoectomy - anterior ............................................................................. $100.00D3421 Apicoectomy - premolar (first root) ....................................................... $100.00D3425 Apicoectomy - molar (first root) ............................................................. $100.00D3426 Apicoectomy (each additional root) ....................................................... $50.00D3427 Periradicular surgery without apicoectomy ........................................... $100.00D3430 Retrograde filling - per root ..................................................................... $50.00

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D4000-D4999 V. PERIODONTICS

- Includes preoperative and postoperative evaluations and treatment under a localanesthetic.D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or

tooth bounded spaces per quadrant ...................................................... $175.00D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or

tooth bounded spaces per quadrant ...................................................... $175.00D4212 Gingivectomy or gingivoplasty to allow access for restorative

procedure, per tooth .................................................................................. $175.00D4240 Gingival flap procedure, including root planing - four or more

contiguous teeth or tooth bounded spaces per quadrant ................... $150.00D4241 Gingival flap procedure, including root planing - one to three

contiguous teeth or tooth bounded spaces per quadrant ................... $150.00D4245 Apically positioned flap ............................................................................. $150.00D4249 Clinical crown lengthening - hard tissue ................................................ $175.00D4260 Osseous surgery (including elevation of a full thickness flap and

closure) - four or more contiguous teeth or tooth bounded spacesper quadrant ................................................................................................ $300.00

D4261 Osseous surgery (including elevation of a full thickness flap andclosure) - one to three contiguous teeth or tooth bounded spacesper quadrant ................................................................................................ $300.00

D4341 Periodontal scaling and root planing - four or more teeth perquadrant ....................................................................................................... $45.00

D4342 Periodontal scaling and root planing - one to three teeth perquadrant ....................................................................................................... $45.00

D4346 Scaling in presence of generalized moderate or severe gingivalinflammation - full mouth, after oral evaluation - 1 D1110, D1120 orD4346 per 6 month period ....................................................................... No Cost

D4355 Full mouth debridement to enable a comprehensive oral evaluationand diagnosis on a subsequent visit ....................................................... $45.00

D4910 Periodontal maintenance ........................................................................... $36.00D4921 Gingival irrigation - per quadrant ............................................................ No Cost

D5000-D5899 VI. PROSTHODONTICS (removable)D5110 Complete denture - maxillary 5 ................................................................ $250.00D5120 Complete denture - mandibular 5 ............................................................ $250.00D5130 Immediate denture - maxillary 5 ............................................................... $325.00D5140 Immediate denture - mandibular 5 ........................................................... $325.00D5211 Maxillary partial denture - resin base (including retentive/clasping

materials, rests, and teeth) 5 ..................................................................... $270.00D5212 Mandibular partial denture - resin base (including retentive/clasping

materials, rests, and teeth) 5 ..................................................................... $270.00D5213 Maxillary partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth) 5 .............. $295.00D5214 Mandibular partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth) 5 $295.00D5221 Immediate maxillary partial denture - resin base (including any

conventional clasps, rests and teeth) ...................................................... $270.00D5222 Immediate mandibular partial denture - resin base (including any

conventional clasps, rests and teeth) ...................................................... $270.00D5223 Immediate maxillary partial denture - cast metal framework with

resin denture bases (including any conventional clasps, rests andteeth) ............................................................................................................. $295.00

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D5224 Immediate mandibular partial denture - cast metal framework withresin denture bases (including any conventional clasps, rests andteeth) ............................................................................................................. $295.00

D5225 Maxillary partial denture - flexible base (including any clasps, restsand teeth) 5 .................................................................................................. Optional

D5226 Mandibular partial denture - flexible base (including any clasps,rests and teeth) 5 ........................................................................................ Optional

D5282 Removable unilateral partial denture - one piece cast metal(including clasps and teeth), maxillary ................................................... $270.00

D5283 Removable unilateral partial denture - one piece cast metal(including clasps and teeth), mandibular ............................................... $270.00

D5410 Adjust complete denture - maxillary ....................................................... $10.00D5411 Adjust complete denture - mandibular ................................................... $10.00D5421 Adjust partial denture - maxillary ............................................................ $10.00D5422 Adjust partial denture - mandibular ........................................................ $10.00D5511 Repair broken complete denture base, mandibular .............................. $25.00D5512 Repair broken complete denture base, maxillary .................................. $25.00D5520 Replace missing or broken teeth - complete denture (each tooth) .... $10.00D5611 Repair resin partial denture base, mandibular ....................................... $25.00D5612 Repair resin partial denture base, maxillary ........................................... $25.00D5621 Repair cast partial framework, mandibular ............................................ $25.00D5622 Repair cast partial framework, maxillary ................................................ $25.00D5630 Repair or replace broken retentive/clasping materials - per tooth ..... $25.00D5640 Replace broken teeth - per tooth ............................................................ $10.00D5650 Add tooth to existing partial denture ..................................................... $10.00D5660 Add clasp to existing partial denture - per tooth ................................. $10.00D5670 Replace all teeth and acrylic on cast metal framework (maxillary) .... $165.00D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $165.00D5710 Rebase complete maxillary denture ........................................................ $50.00D5711 Rebase complete mandibular denture .................................................... $50.00D5720 Rebase maxillary partial denture ............................................................. $50.00D5721 Rebase mandibular partial denture ......................................................... $50.00D5730 Reline complete maxillary denture (chairside) ...................................... $30.00D5731 Reline complete mandibular denture (chairside) .................................. $30.00D5740 Reline maxillary partial denture (chairside) ........................................... $30.00D5741 Reline mandibular partial denture (chairside) ........................................ $30.00D5750 Reline complete maxillary denture (laboratory) .................................... $50.00D5751 Reline complete mandibular denture (laboratory) ................................ $50.00D5760 Reline maxillary partial denture (laboratory) ......................................... $50.00D5761 Reline mandibular partial denture (laboratory) ..................................... $50.00D5820 Interim partial denture (maxillary) ........................................................... No CostD5821 Interim partial denture (mandibular) ....................................................... No CostD5850 Tissue conditioning, maxillary ................................................................... $25.00D5851 Tissue conditioning, mandibular ............................................................... $25.00D5863 Overdenture - complete maxillary ........................................................... OptionalD5864 Overdenture - partial maxillary ................................................................ OptionalD5865 Overdenture - complete mandibular ....................................................... OptionalD5866 Overdenture - partial mandibular ............................................................ Optional

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D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered

D6000-D6199 VIII. IMPLANT SERVICES - Not Covered

D6200-D6999 IX. PROSTHODONTICS, fixed (each retainer and each ponticconstitutes a unit in a fixed partial denture [bridge])

D6210 Pontic - cast high noble metal 4 .............................................................. $225.00D6211 Pontic - cast predominantly base metal ................................................. $225.00D6212 Pontic - cast noble metal .......................................................................... $225.00D6240 Pontic - porcelain fused to high noble metal 3, 4 ................................... $225.00D6241 Pontic - porcelain fused to predominantly base metal 3 ...................... $225.00D6242 Pontic - porcelain fused to noble metal 3 ............................................... $225.00D6250 Pontic - resin with high noble metal 3, 4 .................................................. $225.00D6251 Pontic - resin with predominantly base metal 3 .................................... $225.00D6252 Pontic - resin with noble metal 3 ............................................................. $225.00D6545 Retainer - cast metal for resin bonded fixed prosthesis ...................... OptionalD6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis ......... OptionalD6549 Retainer - for resin bonded fixed prosthesis .......................................... OptionalD6600 Retainer inlay - porcelain/ceramic, two surfaces ................................... OptionalD6601 Retainer inlay - porcelain/ceramic, three or more surfaces ................. OptionalD6602 Retainer inlay - cast high noble metal, two surfaces 4 .......................... $200.00D6603 Retainer inlay - cast high noble metal, three or more surfaces 4 ......... $200.00D6604 Retainer inlay - cast predominantly base metal, two surfaces ............ $180.00D6605 Retainer inlay - cast predominantly base metal, three or more

surfaces ......................................................................................................... $190.00D6606 Retainer inlay - cast noble metal, two surfaces ..................................... $190.00D6607 Retainer inlay - cast noble metal, three or more surfaces ................... $200.00D6608 Retainer onlay - porcelain/ceramic, two surfaces ................................. OptionalD6609 Retainer onlay - porcelain/ceramic, three or more surfaces ................ OptionalD6610 Retainer onlay - cast high noble metal, two surfaces 4 ........................ $206.00D6611 Retainer onlay - cast high noble metal, three or more surfaces 4 ....... $212.00D6612 Retainer onlay - cast predominantly base metal, two surfaces ........... $196.00D6613 Retainer onlay - cast predominantly base metal, three or more

surfaces ......................................................................................................... $202.00D6614 Retainer onlay - cast noble metal, two surfaces ................................... $206.00D6615 Retainer onlay - cast noble metal, three or more surfaces .................. $212.00D6720 Retainer crown - resin with high noble metal 3, 4 ................................... $225.00D6721 Retainer crown - resin with predominantly base metal 3 ..................... $225.00D6722 Retainer crown - resin with noble metal 3 .............................................. $225.00D6750 Retainer crown - porcelain fused to high noble metal 3, 4 .................... $225.00D6751 Retainer crown - porcelain fused to predominantly base metal 3 ....... $225.00D6752 Retainer crown - porcelain fused to noble metal 3 ............................... $225.00D6780 Retainer crown - 3/4 cast high noble metal 4 ........................................ $225.00D6781 Retainer crown - 3/4 cast predominantly base metal .......................... $225.00D6782 Retainer crown - 3/4 cast noble metal ................................................... $225.00D6790 Retainer crown - full cast high noble metal 4 ........................................ $225.00D6791 Retainer crown - full cast predominantly base metal ........................... $225.00

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D6792 Retainer crown - full cast noble metal .................................................... $225.00D6930 Re-cement or re-bond fixed partial denture .......................................... $15.00D6940 Stress breaker .............................................................................................. $35.00

D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY

- Includes preoperative and postoperative evaluations and treatment under a localanesthetic.D7111 Extraction, coronal remnants - primary tooth ....................................... $18.00D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps

removal) ........................................................................................................ $18.00D7210 Extraction, erupted tooth requiring removal of bone and/or

sectioning of tooth, and including elevation of mucoperiosteal flapif indicated ................................................................................................... $30.00

D7220 Removal of impacted tooth - soft tissue ................................................ $50.00D7230 Removal of impacted tooth - partially bony .......................................... $75.00D7240 Removal of impacted tooth - completely bony ..................................... $100.00D7241 Removal of impacted tooth - completely bony, with unusual surgical

complications ............................................................................................... $100.00D7250 Removal of residual tooth roots (cutting procedure) ........................... No CostD7251 Coronectomy - intentional partial tooth removal .................................. $100.00D7286 Incisional biopsy of oral tissue-soft ......................................................... $25.00D7310 Alveoloplasty in conjunction with extractions - four or more teeth

or tooth spaces, per quadrant ................................................................. $65.00D7311 Alveoloplasty in conjunction with extractions - one to three teeth or

tooth spaces, per quadrant ....................................................................... $65.00D7320 Alveoloplasty not in conjunction with extractions - four or more

teeth or tooth spaces, per quadrant ....................................................... $85.00D7321 Alveoloplasty not in conjunction with extractions - one to three

teeth or tooth spaces, per quadrant ....................................................... $85.00D7471 Removal of lateral exostosis (maxilla or mandible) ............................... $65.00D7472 Removal of torus palatinus ....................................................................... $65.00D7473 Removal of torus mandibularis ................................................................ $65.00D7510 Incision and drainage of abscess - intraoral soft tissue ........................ No CostD7960 Frenulectomy - also known as frenectomy or frenotomy - separate

procedure not incidental to another procedure .................................... $50.00

D8000-D8999 XI. ORTHODONTICS

Pre and post orthodontic records include:The benefit for pre-treatment records and diagnostic servicesincludes: ........................................................................................................ $200.00

D0210 Intraoral - complete series of radiographic imagesD0322 Tomographic surveyD0330 Panoramic radiographic imageD0340 2D cephalometric radiographic image - acquisition, measurement

and analysisD0350 2D oral/facial photographic images obtained intraorally or

extraorallyD0351 3D photographic imageD0470 Diagnostic casts

The benefit for post-treatment records includes: ................................. $70.00D0210 Intraoral - complete series of radiographic imagesD0470 Diagnostic casts

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D8020 Limited orthodontic treatment of the transitional dentition 1 ..............$1,950.00D8030 Limited orthodontic treatment of the adolescent dentition 1 ..............$1,950.00D8040 Limited orthodontic treatment of the adult dentition 1 ........................ $2,150.00D8070 Comprehensive orthodontic treatment of the transitional dentition 1 $1,950.00D8080 Comprehensive orthodontic treatment of the adolescent dentition 1 $1,950.00D8090 Comprehensive orthodontic treatment of the adult dentition 1 .......... $2,150.00D8660 Pre-orthodontic treatment examination to monitor growth and

development (applied to treatment fee if patient proceeds withtreatment) .................................................................................................... $25.00

D8670 Periodic orthodontic treatment visit - Inclusive of treatment fee ....... No CostD8680 Orthodontic retention (removal of appliances, construction and

placement of retainer(s)) 1 ........................................................................ No CostD8681 Removable orthodontic retainer adjustment ......................................... No Cost

D9000-D9999 XII. ADJUNCTIVE GENERAL SERVICESD9110 Palliative (emergency) treatment of dental pain - minor procedure .. $15.00D9211 Regional block anesthesia ......................................................................... No CostD9212 Trigeminal division block anesthesia ....................................................... No CostD9215 Local anesthesia in conjunction with operative or surgical

procedures ................................................................................................... No CostD9219 Evaluation for moderate sedation, deep sedation or general

anesthesia ..................................................................................................... No CostD9310 Consultation - diagnostic service provided by dentist or physician

other than requesting dentist or physician ............................................ $25.00D9311 Consultation with medical health care professional ............................. No CostD9430 Office visit for observation (during regularly scheduled hours) - no

other services performed .......................................................................... $5.00D9440 Office visit - after regularly scheduled hours ........................................ $20.00D9450 Case presentation, detailed and extensive treatment planning .......... No CostD9932 Cleaning and inspection of removable complete denture, maxillary .. No CostD9933 Cleaning and inspection of removable complete denture,

mandibular ................................................................................................... No CostD9934 Cleaning and inspection of removable partial denture, maxillary ....... No CostD9935 Cleaning and inspection of removable partial denture, mandibular ... No CostD9986 Missed appointment - without 24 hour notice - per 15 minutes of

appointment time ....................................................................................... $10.00D9987 Canceled appointment - without 24 hour notice - per 15 minutes of

appointment time ....................................................................................... $10.00D9990 Certified translation or sign-language services - per visit ................... No CostD9991 Dental case management - addressing appointment compliance

barriers .......................................................................................................... No CostD9992 Dental case management - care coordination ....................................... No CostD9995 Teledentistry - synchronous; real-time encounter ................................. No CostD9996 Teledentistry - asynchronous; information stored and forwarded to

dentist for subsequent review .................................................................. No Cost

Optional is defined as any alternative procedure presented by the Contract Dentistthat satisfies the same dental need as a covered procedure, is chosen by the Enrollee,and is subject to the limitations and exclusions of the Program. The applicable chargeto the Enrollee is the difference between the Contract Dentist's "filed fee" for theOptional procedure and the "filed fee" for the covered procedure, plus any applicableCopayment for the covered procedure. Optional treatment does not apply when

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alternative choices are Benefits. "Filed fees" mean the Contract Dentist's fees on filewith Alpha. Questions regarding this Program should be directed to the CustomerService department at 800-422-4234.

If services for a listed procedure are performed by the assigned Contract Dentist, theEnrollee pays the specified Copayment. Listed procedures which require a Dentist toprovide Specialized Services, and are referred by the assigned Contract Dentist, mustbe authorized by Alpha. The Enrollee pays the Copayment specified for such services.

The Contract Dentist will provide Emergency Dental Services for covered procedureswhenever possible. If an Enrollee requires Emergency Dental Services and is unable toaccess care from the Contract Dentist, then Alpha shall reimburse the Enrollee for thecost of such Emergency Dental Services which exceeds the Copayment. EmergencyDental Services shall be limited to listed procedures, and as described in code D9110above: (Palliative (emergency) treatment of dental pain). Any further treatment ofthe cause of such Emergency Dental Services must be obtained from the ContractDentist. All services are subject to the limitations and exclusions of the Program. Non-network Dentists will be paid at the usual and customary or an agreed upon rate.

FOOTNOTES

1 Services include initial examination, diagnosis, consultation, initial banding, 24months of active treatment, debanding, and the retention phase of treatment.The retention phase includes the initial construction, placement and adjustmentsto retainers and office visits for a maximum of 24 months. For treatment plansextending beyond 24 months of active treatment, the Enrollee will be subject to amonthly office visit fee, not to exceed $75.00 per month.

2 Frequency limitations do not apply when services are needed more frequentlydue to medical necessity as determined by the Contract Dentist.

3 Porcelain on molars is considered optional treatment.

4 Base or noble metal is the Benefit if the Contract Dentist determines that it willrestore the form and function of the tooth. High noble metal (precious), if electedby the Enrollee for a crown, bridge, indirectly fabricated post and core, inlay oronlay, will be charged to the Enrollee at the additional laboratory cost of the highnoble metal. An additional laboratory charge also applies to a titanium crown.

5 Includes any adjustments for six months.

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SCHEDULE B

Limitations of Benefits

* Frequency limitations do not apply when services are needed more frequently dueto medical necessity as determined by the Contract Dentist.

1. Prophylaxis is limited to one treatment each six month* period (includesperiodontal maintenance).

2. Full maxillary and/or mandibular dentures including immediate dentures are notto exceed one each in any five-year period from initial placement.

3. Partial dentures are not to be replaced within any five year period from initialplacement, unless necessary due to natural tooth loss where the addition orreplacement of teeth to the existing partial is not feasible.

4. Crowns and fixed partial dentures (bridges) are not to be replaced within any fiveyear period from initial placement.

5. Denture relines are limited to one per denture during any 12 consecutive months.

6. Periodontal treatments (scaling and root planing) are limited to four quadrantsduring any 12 consecutive months.

7. Full mouth debridement (gross scale) is limited to one treatment in any 12consecutive month period.

8. Bitewing x-rays are limited to not more than one series of four films in any sixmonth* period.

9. A full mouth x-ray series (including any combination of periapicals or bitewingswith a panoramic film) or a series of seven or more vertical bitewings is limited toone series every 24 months*.

10. Replacement of prosthetic appliances (bridges, partial or full dentures) shall beconsidered only if the existing appliance is no longer functional or cannot bemade functional by repair or adjustment and meets the five year limitation forreplacement.

11. Coverage is limited to the Benefit customarily provided. Enrollee must pay thedifference in cost between the Contract Dentist's usual fees for the coveredBenefit and the Optional or more expensive treatment plus any applicableCopayment.

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12. Services that are more expensive than the treatment usually provided underaccepted dental practice standards or include the use of specialized techniquesinstead of standard procedures, such as a crown where filling would restorea tooth or an implant in place of a fixed bridge or partial denture to restore amissing tooth, are considered Optional treatment.

13. Composite resin restorations to restore decay or missing tooth structure thatextend beyond the enamel layer are limited to anterior teeth (cuspid to cuspid)and facial surfaces of maxillary bicuspids.

14. A fixed partial denture (bridge) is limited to the replacement of permanentanterior teeth provided it is not in connection with a partial denture on the samearch, or duplicates an existing, non-functional bridge and it meets the five yearlimitation for replacement.

15. Stayplates, in conjunction with fixed or removable appliances, are limited to thereplacement of extracted anterior teeth for adults during a healing period or inchildren 16 years and under for missing anterior teeth.

16. Benefits provided by a pediatric Dentist are limited to children through ageseven following an attempt by the assigned Contract Dentist to treat the childand upon Authorization by Alpha, less applicable Copayments. Exceptionsfor medical conditions, regardless of age limitation, will be considered on anindividual basis.

17. Porcelain crowns and porcelain fused to metal crowns on all molars is consideredOptional treatment.

18. Fixed bridges used to replace missing posterior teeth are considered Optionalwhen the abutment teeth are dentally sound and would be crowned only for thepurpose of supporting a pontic. A fixed bridge used under these circumstancesis considered Optional dental treatment. The Enrollee must pay the difference incost between the Contract Dentist's "filed fees" for the covered procedure andOptional treatment, plus any Copayment for the covered procedure.

19. Benefits for dental expenses incurred in connection with any dental ororthodontic procedure started before the Enrollee's eligibility with this Programare limited as follows:

Upon request of a newly covered Enrollee, Alpha will provide Benefits for thecompletion of covered services begun prior to the time his or her coveragebecame effective. Alpha will not provide coverage for incomplete services thatare not otherwise Benefits under the terms and conditions of the Contract.Enrollees may request completion of treatment in progress by calling theCustomer Service department at 800 422-4234 during normal business hours,or by sending a written request to Alpha.

Whenever possible, an Enrollee should complete treatment in progress with theDentist who initiated the service. If such Dentist is an out-of-network Dentist,that Dentist must agree to the same terms and conditions that apply to an in-

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network Dentist in order for Alpha to provide Benefits. Copayments and othercost sharing components will apply. Benefits may be adjusted so that the totalpaid by the Enrollee and/or coverage provided by all plans is not more than100% of total Allowable Expenses (as defined in the Coordination of Benefitssection of the Contract).

Should the Enrollee be unable to complete treatment with the Dentist whoinitiated the service, Alpha will make reasonable and appropriate arrangementsfor completion of such treatment by a Contract Dentist.

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SCHEDULE C

Exclusions of Benefits

1. General anesthesia, IV sedation, and nitrous oxide and the services of a specialanesthesiologist.

2. Dental procedures performed for purely cosmetic purposes.

3. Dental conditions arising out of and due to Enrollee's employment for whichWorkers' Compensation is payable. Services which are provided to the Enrolleeby state government or agency thereof, or are provided without cost to theEnrollee by any municipality, county or other subdivision.

4. Treatment required by reason of war, declared or undeclared.

5. All related fees for admission, use, or stays in a hospital, out-patient surgerycenter, extended care facility, or other similar care facility.

6. Treatment of fractures, dislocations and subluxations of the mandible or maxilla.This includes any surgical treatment to correct facial mal-alignments of TMJabnormalities.

7. Loss or theft of fixed and removable prosthetics (crowns, bridges, full or partialdentures).

8. Dental expenses incurred in connection with any dental procedures started aftertermination of eligibility for coverage.

9. Any service that is not specifically listed in Schedule A, Description of Benefitsand Copayments.

10. Correcting congenital or developmental malformations, including replacement ofcongenitally missing teeth, unless restoration is needed to restore normal bodilyfunction (unless mandated by state law).

11. Cysts and malignancies.

12. Prescription drugs.

13. Cases in which, in the professional judgment of the attending Dentist, asatisfactory result cannot be obtained or where the prognosis is poor or guarded.

14. Dental services received from any dental facility other than the assigned dentalfacility, unless expressly authorized by Alpha or as cited under Emergency DentalServices. To obtain Authorization, the Enrollee should call the Customer Servicedepartment at 800-422-4234.

15. Prophylactic removal of impactions (asymptomatic, nonpathological).

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16. "Consultations" for noncovered procedures.

17. Implant placement or removal of appliances placed on or services associatedwith implants, including but not limited to prophylaxis and periodontaltreatment.

18. Placement of a crown where there is sufficient tooth structure to retain astandard filling.

19. Restorations placed due to cosmetics, abrasions, attrition, erosion, restoring oraltering vertical dimension, congenital or developmental malformation of teeth.

20. Appliances or restorations necessary to increase vertical dimension, replaceor stabilize tooth structure loss by attrition, realignment of teeth, periodontalsplinting, gnathologic recordings, equilibration or treatment of disturbances ofthe temporomandibular joint (TMJ).

21. Extensive treatment plans involving 10 or more crowns or units of fixedbridgework (major mouth reconstruction).

22. Precious metal for removable appliances, precision abutments for partials orbridges (overlays, implants, and appliances associated therewith), personalizationand characterization.

23. Any part of a preventive or soft tissue management program, which is not alisted covered service on Schedule A, Description of Benefits and Copayments.

24. Treatment or appliances that are provided by a Dentist whose practicespecializes in prosthodontic services;

25. Cosmetic care as a result of orthodontic treatment.

26. Extractions solely for the purpose of orthodontics.

27. Charges by the Contract Dentist for broken or missed appointments not reportedwithin 24 hours.

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SCHEDULE D

Orthodontic Limitations

The Program provides coverage for orthodontic treatment plans provided throughContract Orthodontists. The cost to the Enrollee for the treatment plan is listed inSchedule A, Description of Benefits and Copayments subject to the following:

1. Orthodontic treatment must be provided by a Contract Orthodontist.

2. Benefits cover 24 months of active orthodontic treatment and include theinitial examination, diagnosis, consultation, initial banding, de-banding andthe retention phase of treatment. The retention phase includes the initialconstruction, placement and adjustments to retainers and office visits for amaximum of 24 months.

3. For treatment plans extending beyond 24 months of active treatment, theEnrollee will be subject to a monthly office visit fee not to exceed $75.00 permonth.

4. Should an Enrollee's coverage be canceled or terminated for any reason, and atthe time of cancellation or termination be receiving any orthodontic treatment,the Enrollee will be solely responsible for payment for treatment provided aftercancellation or termination. In this event the Enrollee's obligation shall be basedon the Contract Orthodontist's usual fee at the beginning of treatment. TheContract Orthodontist will prorate the amount over the number of months tocompletion of the treatment. The Enrollee will make payments based on anarrangement with the Contract Orthodontist.

5. If treatment is not required or the Enrollee chooses not to start treatmentafter the diagnosis and consultation have been completed by the ContractOrthodontist, the Enrollee will be charged a consultation fee of $25.00 inaddition to diagnostic record fees.

6. Three recementations or replacements of a bracket/band on the same toothor a total of five rebracketings/rebandings on different teeth during thecovered course of treatment are Benefits. If any additional recementations orreplacements of brackets/bands are performed, the Enrollee is responsible forthe cost at the Contract Orthodontist's usual fee.

7. The Copayment is payable to the Contract Orthodontist who initiates bandingin a course of orthodontic treatment. If, after banding has been initiated, theEnrollee changes to another Contract Orthodontist to continue orthodontictreatment, (i) the Enrollee will not be entitled to a refund of any amountspreviously paid, and (ii) the Enrollee will be responsible for all payments, upto and including the full Copayment, that are required by the new ContractOrthodontist for completion of the orthodontic treatment.

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SCHEDULE E

Orthodontic Exclusions

1. Lost, stolen or broken orthodontic appliances, functional appliances, headgear,retainers and expansion appliances.

2. Retreatment of orthodontic cases.

3. Changes in treatment necessitated by accident of any kind, and/or lack ofEnrollee cooperation.

4. Surgical procedures incidental to orthodontic treatment.

5. Myofunctional therapy.

6. Surgical procedures related to cleft palate, micrognathia or macrognathia.

7. Treatment related to temporomandibular joint disturbances.

8. Supplemental appliances not routinely utilized in typical comprehensiveorthodontics, including, but not limited to: palatal expander, habit controlappliance, pendulum, quad helix or herbst.

9. Active treatment that extends more than 24 months from the point of bandingdentition will be subject to an office visit charge not to exceed $75.00 permonth.

10. Cosmetic care as a result of orthodontic treatment.

11. Phase I orthodontics is an exclusion as well as activator appliances and minortreatment for tooth guidance and/or arch expansion. Phase I is defined as earlytreatment including interceptive orthodontia prior to the development of latemixed dentition.

12. Extractions solely for the purpose of orthodontics.

13. Patient initiated transfer after bands have been placed.

14. Composite or ceramic brackets, lingual adaptation of orthodontic bands andother specialized or cosmetic alternatives to standard fixed and removableorthodontic appliances.

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H7115_PDDntlFee_C IA 10/10/2019

Memorial Hermann Advantage HMO is provided by Memorial Hermann Health Plan, Inc., a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal.

Memorial Hermann Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 855.645.8448 (TTY 711).