Dear Domestic SMU Students,

On behalf of the Student Health Center, welcome to SMU!

For the 2020-2021 Academic Year, SMU has partnered with Academic HealthPlans, Inc. and Aetna to

provide high-quality health insurance coverage for our students and their dependents. The University’s

Student Health Insurance Plan (SHIP) provides coverage for accidents and sicknesses, hospitalizations,

emergency room, wellness and other services. Your deductible will be waived for treatment at the

Student Health Center. The plan also provides travel assistance services for medical evacuations and

repatriation. To learn more, please visit smu.myahpcare.com and select “Benefits.”

SMU requires all Domestic students, both undergraduate and graduate, taking nine (9) or more credit

hours to have health insurance through either an individual/family plan or the University offered plan.

SMU’s mandatory policy requires those students with the enrollment status mentioned to provide

documentation of current insurance coverage or to enroll in the Student Health Insurance Plan (SHIP) by

the deadline date each term. Students will do so, after they have enrolled for classes, by selecting the

‘Student Health Insurance’ tile in the ‘Student Center’ component of My.SMU.edu. Select “Mandatory

Health Insurance” and enter your Date of Birth and Social Security Number. Select the Enroll button to

enroll in the plan, or the Waive button to complete a waiver form (Documentation must be done in

My.SMU.edu to be considered for a waiver. Any other documentation will not be accepted. (i.e.

providing documentation on a Health History form, by fax, etc.)) You should enroll in the Plan after you

have selected your classes and before the waiver deadline.

For domestic students maintaining their own private coverage the student must waive SHIP coverage in

order to avoid automatic enrollment into SHIP.

• Semi-annual premium charge of $1,628 applied to the student’s University account

• The deadline for Fall 2020 is August 07, 2020.

No reversals of premiums or changes to insurance can be made after the deadline each semester.

For more information and instructions on how to WAIVE or ELECT coverage please visit

smu.edu/healthinsurance.

The Student Health Center files claims for the Student Health Insurance Plan only. Students who have

other insurance will be provided an itemized receipt upon request at the time of service so that they

may file the visit with their insurance company on their own. This receipt is adequate to file with

insurance companies for reimbursement.

Health insurance is separate from the student health center fees and is paid for independently.

If you have any questions, please contact the Insurance Office at the Student Health Center at

studenthealthinsurance@smu.edu.

Student Health Insurance Plan

EligibilityAll domestic students taking nine (9) or more credit hours are required to maintain health insurance as a condition of enrollment. A domestic student may waive out of the policy by documenting current, comparable U.S. insurance coverage in the Student Center component of MY.SMU.EDU before the deadline each semester. Domestic students not waiving are required to enroll in the Student Health Insurance Plan. To complete the waiver or elect coverage, go to the Student Center component of MY.SMU.EDU. If you choose not to elect coverage, or do not waive coverage, by the waiver deadline, the premium will be charged to your SMU student account. No changes will be made to a student’s SMU account after August 7, 2020 for Fall 2020 or December 7, 2021 for Spring 2021. For more detailed information, please visit smu.edu/healthinsurance.

All domestic students taking between four (4) and eight (8) credit hours are eligible to enroll on a voluntary basis during the open enrollment period each semester and have their premiums billed to their SMU Student Accounts. Students taking eight (8) hours or less will not be automatically enrolled.

Eligible dependents of those enrolled in the plan may participate in the plan on a voluntary basis.

Please view the complete brochure online at smu.myahpcare.com for full details of participation in the plan.

Southern Methodist University 2020-2021Domestic Students

Additional Benefits• Access to a 24-hour nurse line• Coverage when traveling • Academic Emergency Services

2020SMU-DOFAHP-OF(20) Aetna-SMU

Please note: The new insurance carrier for the 2020-2021 school year is Aetna.

This flyer is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits and programs and does not constitute a contract. Covered Medical Expenses are subject to plan maximums, limitations, and exclusions as described in the Policy. The PPO network is Aetna PPO.

Student Health Center: There is no copayment for routine office visits. The Deductible is waived, covered expenses will be payable at 80% for insured students. Adult immunizations covered at the SHC include TB skin test, MMR#1, MMR#2, Tdap, Td and meningitis.

At SMU SHC: Prescriptions are payable at 100% after a $15 Copayment for each Generic Drug and $40 Copayment for each Brand Name Drug.

BENEFIT MAXIMUMS & DEDUCTIBLES

Benefit Maximum Unlimited

Individual Deductible Network Provider: $400 per Insured Person, per Policy Year Non-Network Provider: $1,200 per Insured Person, per Policy Year

Family Deductible Network Provider: $1,200 for all Insureds in a Family, per Policy Year Non-Network Provider: $3,600 for all Insureds in a Family, per Policy Year

Individual Out-of-Pocket Network Provider: $7,900 per Insured Person, per Policy Year Non-Network Provider: $10,000 per Insured Person, per Policy Year

Family Out-of-Pocket Network Provider: $12,700 for all Insureds in a Family, per Policy Year Non-Network Provider: $37,500 for all Insureds in a Family, per Policy Year

BENEFIT CATEGORYNetwork Provider Non-Network Provider

Payments are based on the Negotiated Charge

Payments are based on theRecognized Charge

Hospital Room and Board Expense 80% per admission 60% per admission

Inpatient/Outpatient Surgery 80% 60%

Physician and specialist services 100% after a $30 Copayment per visit(deductible waived)

60% per visit(deductible applies)

Diagnostic Testing 80% per visit 60% per visit

Emergency Services Expense(deductible waived) 80% after a $250 Copayment per visit 80% after a $250 Copayment per visit

Prescription Drugs

At pharmacies contracting with Aetna100% after a

$25 Copayment per Preferred Generic Drug

$50 Copayment per Preferred Brand-Name Drug

$75 Copayment per Non-Preferred Brand-Name Drug

$75 Copayment per Specialty Drug

60% after a $25 Copayment per Preferred

Generic Drug$50 Copayment per Preferred

Brand-Name Drug$75 Copayment per Non-Preferred

Brand-Name Drug$75 Copayment per Specialty Drug

Preventive ServicesFor more information, please visit healthcare.gov/preventive-care-benefits/

100% per visit(deductible waived) 60% per visit

2020-2021 PREMIUM COSTS AND COVERAGE PERIODS

Coverage Periods Fall08/01/2020 through 12/31/2020

Spring/Summer01/01/2021 through 07/31/2021

Open Enrollment 04/13/2020 through 08/07/20 11/01/2020 through 12/07/2020

Waiver Deadline 08/07/2020 12/07/2020

Student $ 1,628.00 $ 1,628.00

Spouse $ 1,628.00 $ 1,628.00

Each Child, 2x Max1 $ 1,628.00 $ 1,628.00

To view all enrollment and coverage periods available, please visit smu.myahpcare.com.

These rates include an administrative fee.1Coverage for two or more children is calculated at the child rate times two (2).

Student Health Insurance PlanSouthern Methodist University - Domestic 2020-2021

Please note: The new insurance carrier for the 2020-2021 school year is Aetna.

All About Your Dental CoverageSouthern Methodist University Student Health PlanThis Delta Dental PPO™ table of allowance plan offers reliable coverage for a low annual premium. You can visit any dentist to receive coverage.

With a table of allowance plan, you’ll know in advance how much is covered. Each procedure has an “allowance,” or set amount that Delta Dental will pay (if no deductibles or maximums apply). If your dentist charges over the allowance, you will be responsible for the remaining amount. To save the most, visit a Delta Dental PPO dentist. These dentists have agreed to reduced fees.

deltadentalins.com/enrollees

Stay in network to saveTo keep your out-of-pocket costs low, choose a Delta Dental PPO

dentist. These dentists have agreed to reduced fees. If you can’t find a PPO dentist, a Delta Dental Premier dentist is your next best bet. Go to deltadentalins.com to find a PPO or Premier dentist in your area.

Create an online accountAccess claims and benefits detail at the touch of a button. Go to

deltadentalins.com to register for an online account.

Skip the ID cardWhen you visit the dentist, you don’t need to carry a dental plan

ID card. Just tell the dental office you’re covered by Delta Dental Insurance Company and provide your name, student ID number and date of birth.

Go mobileLog in to your online account from your smartphone. Or, download the Delta

Dental mobile app from the App Store or Google Play. You can pull up an ID card, view claims and see your benefits details.

Request an estimatePlanning an expensive procedure? Ask your dental office for a pre-treatment

estimate, and Delta Dental will send you and your dentist an estimate of your out-of-pocket costs.

How to make the most of your dental plan

Got questions? Visit smu.myahpcare.com/enrollment or call Delta Dental’s Customer Service at 800-521-2651.

Delta Dental PPO is underwritten by Delta Dental Insurance Company in TX. Copyright © 2020 Delta Dental. All rights reserved. TOA_SMU (rev. 7/20)

Effective date: August 1, 2020

Coverage ends: July 31, 2021

Enrollment period: July 17, 2020 – September 30, 2020

Deductible per plan year: $50 per person, $150 per familyWaived for diagnostic and preventive services

Maximum per plan year: $1,200

Benefits: See the table of allowances for a complete list of covered procedures and allowances.

Your Plan DetailsTable of allowances: How much Delta Dental pays for each procedureTo find out how much your plan pays for a covered service, browse the following list. You are responsible for the amount not covered by your plan. Procedures are organized by type.

ProcedureCode

Description Fee

Diagnostic ServicesD0120 Periodic oral evaluation – established patient $14.00D0140 Limited oral evaluation – problem focused $26.00D0150 Comprehensive oral evaluation – new or established patient $25.00D0160 Detailed and extensive oral evaluation – problem focused, by report $35.00D0170 Re-evaluation – limited, problem focused (established patient; not post-operative

visit)$35.00

D0180 Comprehensive periodontal evaluation – new or established patient $26.00D0190 Screening of a patient $10.00D0191 Assessment of a patient $10.00D0210 Intraoral – complete series of radiographic images $52.00D0220 Intraoral – periapical first radiographic image $9.00D0230 Intraoral – periapical each additional radiographic image $8.00D0240 Intraoral – occlusal radiographic image $13.00D0250 Extra-oral – 2D projection radiographic image created using a stationary radiation

source, and detector$22.00

D0270 Bitewing – single radiographic image $9.00D0272 Bitewings – two radiographic images $15.00D0274 Bitewings – four radiographic images $22.00D0277 Vertical bitewings – 7 to 8 radiographic images $19.00D0330 Panoramic radiographic image $42.00D0419 Assessment of salivary flow by measurement $2.00D0460 Pulp vitality tests $17.00D0601 Caries risk assessment and documentation, with a finding of low risk $3.00D0602 Caries risk assessment and documentation, with a finding of moderate risk $3.00D0603 Caries risk assessment and documentation, with a finding of high risk $3.00

Preventive ServicesD1110 Prophylaxis – adult $36.00D1120 Prophylaxis – child $26.00D1208 Topical application of fluoride – excluding varnish $11.00D1351 Sealant – per tooth $22.00D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent

tooth$26.00

D1354 Interim caries arresting medicament application – per tooth $28.00D1510 Space maintainer – fixed, unilateral – per quadrant $100.00D1516 Space maintainer – fixed – bilateral, maxillary $172.00

ProcedureCode

Description Fee

D1517 Space maintainer – fixed – bilateral, mandibular $172.00D1520 Space maintainer – removable, unilateral – per quadrant $62.00D1526 Space maintainer – removable – bilateral, maxillary $182.00D1527 Space maintainer – removable – bilateral, mandibular $182.00D1551 Re-cement or re-bond bilateral space maintainer – maxillary $21.00D1552 Re-cement or re-bond bilateral space maintainer – mandibular $21.00D1553 Re-cement or re-bond unilateral space maintainer – per quadrant $21.00D1575 Distal shoe space maintainer - fixed, unilateral – per quadrant $100.00

Restorative ServicesD2140 Amalgam – one surface, primary or permanent $35.00D2150 Amalgam – two surfaces, primary or permanent $47.00D2160 Amalgam – three surfaces, primary or permanent $59.00D2161 Amalgam – four or more surfaces, primary or permanent $64.00D2330 Resin-based composite – one surface, anterior $43.00D2331 Resin-based composite – two surfaces, anterior $54.00D2332 Resin-based composite – three surfaces, anterior $68.00D2335 Resin-based composite – four or more surfaces or involving incisal angle

(anterior)$78.00

D2390 Resin-based composite crown, anterior $86.00D2391 Resin-based composite – one surface, posterior $44.00D2392 Resin-based composite – two surfaces, posterior $62.00D2393 Resin-based composite – three surfaces, posterior $77.00D2394 Resin-based composite – four or more surfaces, posterior $86.00D2510 Inlay – metallic – one surface $105.00D2520 Inlay – metallic – two surfaces $194.00D2530 Inlay – metallic – three or more surfaces $182.00D2542 Onlay – metallic – two surfaces $110.00D2543 Onlay – metallic – three surfaces $122.00D2544 Onlay – metallic – four or more surfaces $127.00D2610 Inlay – porcelain/ceramic – one surface $108.00D2620 Inlay – porcelain/ceramic – two surfaces $217.00D2630 Inlay – porcelain/ceramic – three or more surfaces $210.00D2642 Onlay – porcelain/ceramic – two surfaces $96.00D2643 Onlay – porcelain/ceramic – three surfaces $118.00D2644 Onlay – porcelain/ceramic – four or more surfaces $141.00D2650 Inlay – resin-based composite – one surface $102.00D2651 Inlay – resin-based composite – two surfaces $94.00D2652 Inlay – resin-based composite – three or more surfaces $118.00D2662 Onlay – resin-based composite – two surfaces $120.00D2663 Onlay – resin-based composite – three surfaces $124.00D2664 Onlay – resin-based composite – four or more surfaces $129.00D2710 Crown – resin-based composite (indirect) $68.00D2720 Crown – resin with high noble metal $144.00D2721 Crown – resin with predominantly base metal $110.00D2722 Crown – resin with noble metal $169.00D2740 Crown – porcelain/ceramic substrate $227.00D2750 Crown – porcelain fused to high noble metal $220.00D2751 Crown – porcelain fused to predominantly base metal $209.00D2752 Crown – porcelain fused to noble metal $211.00D2753 Crown – porcelain fused to titanium and titanium alloys $220.00D2780 Crown – ¾ cast high noble metal $226.00D2781 Crown – ¾ cast predominantly base metal $195.00D2782 Crown – ¾ cast noble metal $197.00

ProcedureCode

Description Fee

D2783 Crown – ¾ porcelain/ceramic $227.00D2790 Crown – full cast high noble metal $219.00D2791 Crown – full cast predominantly base metal $189.00D2792 Crown – full cast noble metal $190.00D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration $17.00D2920 Re-cement or re-bond crown $15.00D2921 Reattachment of tooth fragment, incisal edge or cusp $58.00D2930 Prefabricated stainless steel crown – primary tooth $47.00D2931 Prefabricated stainless steel crown – permanent tooth $54.00D2932 Prefabricated resin crown $46.00D2933 Prefabricated stainless steel crown with resin window $70.00D2940 Protective restoration $17.00D2941 Interim therapeutic restoration – primary dentition $17.00D2950 Core buildup, including any pins when required $41.00D2951 Pin retention – per tooth, in addition to restoration $10.00D2952 Post and core in addition to crown, indirectly fabricated $74.00D2953 Each additional indirectly fabricated post – same tooth $74.00D2954 Prefabricated post and core in addition to crown $62.00D2955 Post removal $55.00D2957 Each additional prefabricated post – same tooth $62.00D2960 Labial veneer (resin laminate) – chairside $69.00D2961 Labial veneer (resin laminate) – laboratory $149.00D2962 Labial veneer (porcelain laminate) – laboratory $190.00D2980 Crown repair necessitated by restorative material failure $46.00D2981 Inlay repair necessitated by restorative material failure $46.00D2982 Onlay repair necessitated by restorative material failure $46.00D2983 Veneer repair necessitated by restorative material failure $46.00

EndodonticsD3220 Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the

dentinocemental junction and application of medicament$26.00

D3221 Pulpal debridement, primary and permanent teeth $12.00D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final

restoration)$37.00

D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration)

$35.00

D3310 Endodontic therapy, anterior tooth (excluding final restoration) $123.00D3320 Endodontic therapy, premolar tooth (excluding final restoration) $150.00D3330 Endodontic therapy, molar tooth (excluding final restoration) $188.00D3331 Treatment of root canal obstruction; non-surgical access $12.00D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $12.00D3333 Internal root repair of perforation defects $12.00D3346 Retreatment of previous root canal therapy – anterior $125.00D3347 Retreatment of previous root canal therapy – premolar $167.00D3348 Retreatment of previous root canal therapy – molar $216.00D3410 Apicoectomy – anterior $99.00D3421 Apicoectomy – premolar (first root) $158.00D3425 Apicoectomy – molar (first root) $142.00D3426 Apicoectomy (each additional root) $36.00D3427 Periradicular surgery without apicoectomy $39.00D3430 Retrograde filling – per root $39.00D3450 Root amputation – per root $108.00D3920 Hemisection (including any root removal), not including root canal therapy $41.00

ProcedureCode

Description Fee

PeriodonticsD4210 Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded

spaces per quadrant$54.00

D4211 Gingivectomy or gingivoplasty – one to three contiguous teeth or tooth bounded spaces per quadrant

$33.00

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth $33.00

D4240 Gingival flap procedure, including root planing – four or more contiguous teeth or tooth bounded spaces per quadrant

$94.00

D4241 Gingival flap procedure, including root planing – one to three contiguous teeth or tooth bounded spaces per quadrant

$94.00

D4245 Apically positioned flap $111.00D4249 Clinical crown lengthening – hard tissue $127.00D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or

more contiguous teeth or tooth bounded spaces per quadrant$230.00

D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant

$230.00

D4263 Bone replacement graft – retained natural tooth – first site in quadrant $78.00D4264 Bone replacement graft – retained natural tooth – each additional site in quadrant $90.00D4265 Biologic materials to aid in soft and osseous tissue regeneration $121.00D4266 Guided tissue regeneration – resorbable barrier, per site $121.00D4267 Guided tissue regeneration – nonresorbable barrier, per site (includes membrane

removal)$129.00

D4270 Pedicle soft tissue graft procedure $209.00D4273 Autogenous connective tissue graft procedure (including donor and recipient

surgical sites) first tooth, implant, or edentulous tooth position in graft $256.00

D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)

$150.00

D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft

$197.00

D4276 Combined connective tissue and double pedicle graft, per tooth $256.00D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first

tooth, implant, or edentulous tooth position in graft$197.00

D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant, or edentulous tooth position in same graft site

$147.00

D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

$154.00

D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site

$118.00

D4341 Periodontal scaling and root planing – four or more teeth per quadrant $44.00D4342 Periodontal scaling and root planing – one to three teeth per quadrant $44.00D4346 Scaling in presence of generalized moderate or severe gingival inflammation – full

mouth, after oral evaluation$36.00

D4355 Full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit

$31.00

D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth

$33.00

D4910 Periodontal maintenance $24.00D4920 Unscheduled dressing change (by someone other than treating dentist or their

staff)$6.00

ProcedureCode

Description Fee

Prosthodontics (Removeable)D5110 Complete denture – maxillary $253.00D5120 Complete denture – mandibular $261.00D5130 Immediate denture – maxillary $285.00D5140 Immediate denture – mandibular $285.00D5211 Maxillary partial denture – resin base (including retentive/clasping materials, rests,

and teeth)$213.00

D5212 Mandibular partial denture – resin base (including retentive/clasping materials, rests, and teeth)

$230.00

D5213 Maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

$317.00

D5214 Mandibular partial denture – cast metal framework with resin denture bases (includingretentive/clasping materials, rests and teeth)

$312.00

D5221 Immediate maxillary partial denture – resin base (including retentive/clasping materials, rests and teeth)

$256.00

D5222 Immediate mandibular partial denture – resin base (including retentive/clasping materials, rests and teeth)

$276.00

D5223 Immediate maxillary partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

$381.00

D5224 Immediate mandibular partial denture – cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

$375.00

D5282 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary

$160.00

D5283 Removable unilateral partial denture – one piece cast metal (including clasps and teeth), mandibular

$160.00

D5284 Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant

$144.00

D5286 Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant

$144.00

D5410 Adjust complete denture – maxillary $12.00D5411 Adjust complete denture – mandibular $10.00D5421 Adjust partial denture – maxillary $14.00D5422 Adjust partial denture – mandibular $11.00D5511 Repair broken complete denture base, mandibular $24.00D5512 Repair broken complete denture base, maxillary $24.00D5520 Replace missing or broken teeth – complete denture (each tooth) $23.00D5611 Repair resin partial denture base, mandibular $25.00D5612 Repair resin partial denture base, maxillary $25.00D5621 Repair cast partial framework, mandibular $34.00D5622 Repair cast partial framework, maxillary $34.00D5630 Repair or replace broken retentive clasping materials – per tooth $36.00D5640 Replace broken teeth – per tooth $21.00D5650 Add tooth to existing partial denture $31.00D5660 Add clasp to existing partial denture – per tooth $37.00D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $101.00D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $112.00D5710 Rebase complete maxillary denture $83.00D5711 Rebase complete mandibular denture $102.00D5720 Rebase maxillary partial denture $101.00D5721 Rebase mandibular partial denture $112.00D5730 Reline complete maxillary denture (chairside) $51.00D5731 Reline complete mandibular denture (chairside) $43.00

ProcedureCode

Description Fee

D5740 Reline maxillary partial denture (chairside) $42.00D5741 Reline mandibular partial denture (chairside) $47.00D5750 Reline complete maxillary denture (laboratory) $80.00D5751 Reline complete mandibular denture (laboratory) $78.00D5760 Reline maxillary partial denture (laboratory) $70.00D5761 Reline mandibular partial denture (laboratory) $73.00D5820 Interim partial denture (maxillary) $87.00D5821 Interim partial denture (mandibular) $111.00D5850 Tissue conditioning, maxillary $39.00D5851 Tissue conditioning, mandibular $24.00D5863 Overdenture – complete maxillary $253.00D5864 Overdenture – partial maxillary $317.00D5865 Overdenture – complete mandibular $261.00D5866 Overdenture – partial mandibular $312.00D5875 Modification of removable prosthesis following implant surgery $34.00

Implant services and fixed prosthodonticsD6010 Surgical placement of implant body: endosteal implant $583.00D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal

implant$583.00

D6013 Surgical placement of mini implant $292.00D6040 Surgical placement: eposteal implant $1,089.00D6050 Surgical placement: transosteal implant $1,100.00D6055 Connecting bar – implant supported or abutment supported $507.00D6056 Prefabricated abutment – includes modification and placement $139.00D6057 Custom fabricated abutment – includes placement $189.00D6058 Abutment supported porcelain/ceramic crown $325.00D6059 Abutment supported porcelain fused to metal crown (high noble metal) $332.00D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) $306.00D6061 Abutment supported porcelain fused to metal crown (noble metal) $306.00D6062 Abutment supported cast metal crown (high noble metal) $327.00D6063 Abutment supported cast metal crown (predominantly base metal) $287.00D6064 Abutment supported cast metal crown (noble metal) $279.00D6065 Implant supported porcelain/ceramic crown $340.00D6066 Implant supported crown – porcelain fused to high noble alloys $332.00D6067 Implant supported crown – high noble alloys $327.00D6068 Abutment supported retainer for porcelain/ceramic FPD $340.00D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) $332.00D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base

metal)$306.00

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) $306.00D6072 Abutment supported retainer for cast metal FPD (high noble metal) $327.00D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) $287.00D6074 Abutment supported retainer for cast metal FPD (noble metal) $279.00D6075 Implant supported retainer for ceramic FPD $340.00D6076 Implant supported retainer for FPD – porcelain fused to high noble alloys $332.00D6077 Implant supported retainer for metal FPD – high noble alloys $327.00D6080 Implant maintenance procedures when prostheses are removed and reinserted,

including cleansing of prostheses and abutments$48.00

D6081 Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure

$44.00

D6082 Implant supported crown – porcelain fused to predominantly base alloys $306.00D6083 Implant supported crown – porcelain fused to noble alloys $306.00D6084 Implant supported crown – porcelain fused to titanium and titanium alloys $309.00

ProcedureCode

Description Fee

D6086 Implant supported crown – predominantly base alloys $287.00D6087 Implant supported crown – noble alloys $279.00D6088 Implant supported crown – titanium and titanium alloys $309.00D6090 Repair implant supported prosthesis, by report $84.00D6091 Replacement of semi-precision or precision attachment (male or female

component) of implant/abutment supported prosthesis, per attachment$54.00

D6092 Re-cement or re-bond implant/abutment supported crown $31.00D6093 Re-cement or re-bond implant/abutment supported fixed partial denture $46.00D6094 Abutment supported crown – titanium and titanium alloys $309.00D6095 Repair implant abutment, by report $95.00D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys $309.00D6098 Implant supported retainer – porcelain fused to predominantly base alloys $306.00D6099 Implant supported retainer for FPD – porcelain fused to noble alloys $306.00D6100 Implant removal, by report $124.00D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and

surface cleaning of the exposed implant surfaces, including flap entry and closure$94.00

D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure

$230.00

D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure $78.00

D6104 Bone graft at time of implant placement $78.00D6110 Implant/abutment supported removable denture for edentulous arch – maxillary $253.00D6111 Implant/abutment supported removable denture for edentulous arch – mandibular $253.00D6112 Implant/abutment supported removable denture for partially edentulous arch –

maxillary$317.00

D6113 Implant/abutment supported removable denture for partially edentulous arch – mandibular

$317.00

D6114 Implant/abutment supported fixed denture for edentulous arch – maxillary $253.00D6115 Implant/abutment supported fixed denture for edentulous arch – mandibular $253.00D6116 Implant/abutment supported fixed denture for partially edentulous arch – maxillary $317.00

D6117 Implant/abutment supported fixed denture for partially edentulous arch – mandibular

$317.00

D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys $287.00D6121 Implant supported retainer for metal FPD – predominantly base alloys $287.00D6122 Implant supported retainer for metal FPD – noble alloys $279.00D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys $332.00D6210 Pontic – cast high noble metal $224.00D6211 Pontic – cast predominantly base metal $202.00D6212 Pontic – cast noble metal $182.00D6240 Pontic – porcelain fused to high noble metal $216.00D6241 Pontic – porcelain fused to predominantly base metal $200.00D6242 Pontic – porcelain fused to noble metal $198.00D6243 Pontic – porcelain fused to titanium and titanium alloys $198.00D6245 Pontic – porcelain/ceramic $227.00D6250 Pontic – resin with high noble metal $222.00D6251 Pontic – resin with predominantly base metal $250.00D6252 Pontic – resin with noble metal $222.00D6545 Retainer – cast metal for resin bonded fixed prosthesis $66.00D6548 Retainer – porcelain/ceramic for resin bonded fixed prosthesis $227.00D6549 Retainer – for resin bonded fixed prosthesis $66.00D6600 Retainer inlay – porcelain/ceramic, two surfaces $193.00

ProcedureCode

Description Fee

D6601 Retainer inlay – porcelain/ceramic, three or more surfaces $216.00D6602 Retainer inlay – cast high noble metal, two surfaces $193.00D6603 Retainer inlay – cast high noble metal, three or more surfaces $216.00D6604 Retainer inlay – cast predominantly base metal, two surfaces $193.00D6605 Retainer inlay – cast predominantly base metal, three or more surfaces $216.00D6606 Retainer inlay – cast noble metal, two surfaces $193.00D6607 Retainer inlay – cast noble metal, three or more surfaces $216.00D6608 Retainer onlay – porcelain/ceramic, two surfaces $110.00D6609 Retainer onlay – porcelain/ceramic, three or more surfaces $122.00D6610 Retainer onlay – cast high noble metal, two surfaces $110.00D6611 Retainer onlay – cast high noble metal, three or more surfaces $122.00D6612 Retainer onlay – cast predominantly base metal, two surfaces $110.00D6613 Retainer onlay – cast predominantly base metal, three or more surfaces $122.00D6614 Retainer onlay – cast noble metal, two surfaces $110.00D6615 Retainer onlay – cast noble metal, three or more surfaces $122.00D6720 Retainer crown – resin with high noble metal $249.00D6721 Retainer crown – resin with predominantly base metal $209.00D6722 Retainer crown – resin with noble metal $182.00D6740 Retainer crown – porcelain/ceramic $227.00D6750 Retainer crown – porcelain fused to high noble metal $221.00D6751 Retainer crown – porcelain fused to predominantly base metal $205.00D6752 Retainer crown – porcelain fused to noble metal $205.00D6753 Retainer crown – porcelain fused to titanium and titanium alloys $221.00D6780 Retainer crown – ¾ cast high noble metal $243.00D6781 Retainer crown – ¾ cast predominantly base metal $195.00D6782 Retainer crown – ¾ cast noble metal $197.00D6783 Retainer crown – ¾ porcelain/ceramic $227.00D6784 Retainer crown ¾ – titanium and titanium alloys $218.00D6790 Retainer crown – full cast high noble metal $218.00D6791 Retainer crown – full cast predominantly base metal $195.00D6792 Retainer crown – full cast noble metal $186.00D6920 Connector bar $67.00D6930 Re-cement or re-bond fixed partial denture $21.00D6980 Fixed partial denture repair necessitated by restorative material failure $43.00

Oral and maxillofacial surgeryD7111 Extraction, coronal remnants – primary tooth $22.00D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $22.00D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and

including elevation of mucoperiosteal flap if indicated$44.00

D7220 Removal of impacted tooth – soft tissue $62.00D7230 Removal of impacted tooth – partially bony $80.00D7240 Removal of impacted tooth – completely bony $92.00D7241 Removal of impacted tooth – completely bony, with unusual surgical complications $118.00

D7250 Removal of residual tooth roots (cutting procedure) $40.00D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $68.00

D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization)

$417.00

D7282 Mobilization of erupted or malpositioned tooth to aid eruption $88.00D7290 Surgical repositioning of teeth $74.00D7296 Corticotomy – one to three teeth or tooth spaces, per quadrant $94.00D7297 Corticotomy – four or more teeth or tooth spaces, per quadrant $94.00

ProcedureCode

Description Fee

D7310 Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant

$36.00

D7320 Alveoloplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant

$50.00

D7450 Removal of benign odontogenic cyst or tumor – lesion diameter up to 1.25 cm $72.00D7451 Removal of benign odontogenic cyst or tumor – lesion diameter greater than 1.25

cm$112.00

D7485 Reduction of osseous tuberosity $150.00D7510 Incision and drainage of abscess – intraoral soft tissue $23.00D7520 Incision and drainage of abscess – extraoral soft tissue $25.00D7922 Placement of intra-socket biological dressing to aid in hemostasis or clot

stabilization, per site$17.00

D7960 Frenulectomy – also known as frenectomy or frenotomy – separate procedure not incidental to another procedure

$81.00

D7970 Excision of hyperplastic tissue – per arch $39.00D7971 Excision of pericoronal gingiva $24.00D7972 Surgical reduction of fibrous tuberosity $154.00D7995 Synthetic graft – mandible or facial bones, by report $67.00

MiscellaneousD9110 Palliative (emergency) treatment of dental pain – minor procedure $20.00D9222 Deep sedation/general anesthesia – first 15 minutes $23.00D9223 Deep sedation/general anesthesia – each subsequent 15 minute increment $23.00D9230 Inhalation of nitrous oxide/analgesia, anxiolysis $8.00D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes $23.00D9243 Intravenous moderate (conscious) sedation/analgesia – each subsequent 15

minute increment$23.00

D9310 Consultation – diagnostic service provided by dentist or physician other than requesting dentist or physician

$17.00

D9430 Office visit for observation (during regularly scheduled hours) – no other services performed

$12.00

D9440 Office visit – after regularly scheduled hours $21.00D9450 Case presentation, detailed and extensive treatment planning $9.00D9930 Treatment of complications (post-surgical) – unusual circumstances, by report $8.00D9944 Occlusal guard – hard appliance, full arch $138.00D9945 Occlusal guard – soft appliance, full arch $34.00D9946 Occlusal guard – hard appliance, partial arch $69.00D9951 Occlusal adjustment – limited $14.00D9952 Occlusal adjustment – complete $128.00