Dental insurance with affordable group rates Simplify your ...€¦ · Dental insurance with affordable group rates Simplify your dental care and save. Trips to the dentist are a

No money is due at enrollment. Your premium simply comes out of your paycheck.

The Lincoln DentalConnect® DHMO Plan:

• Covers most preventive and

diagnostic care services at no

charge

• Also covers a wide variety of

specialty services - lowering

your out-of-pocket costs with

no deductibles or maximums

• Features group rates for

Pearland Independent School

District employees

• Lets you choose a participating

dentist from a regional network

• Saves you time and hassle with

no waiting periods and no claim

forms

Now Available to

Pearland Independent School District: Dental insurance with affordable group rates

Simplify your dental care and save. Trips to the dentist are a little less scary when you know how much you’ll pay ahead of time. And easier, too, with no claim forms or deductibles.

Here’s how this important coverage works.

• You choose your primary-care dentist when you enroll. To find a

participating dentist, visit ldc.lfg.com and select Find a Dentist. (You can also

print your dental ID card from this site once your coverage begins.)

• This dental plan offers a detailed list of covered procedures, each with a

dollar copayment (see the Summary of Benefits for details). You pay for

services provided during your visit.

• Emergency care away from home is covered up to a set dollar limit.

• You can change your primary-care dentist at any time by calling the

customer service number listed on your dental ID card.

A complete Summary of Benefits is included on the next few pages.

Here’s how little you pay with group rates.

As a Pearland Independent School District employee, you can take advantage of this dental insurance plan for less than $0.42 a day. Plus, you can add loved ones to the plan for just a little more.

Coverage Monthly Premium

Employee only $12.46

Employee & one family member $23.69

Employee & two or more family members $37.39

Lincoln DentalConnect® DHMO (policy series TX-EOC 08 2010) is underwritten in Texas by National Pacific Dental, Inc., Houston, TX. National Pacific Dental is not a Lincoln Financial Group® company. Coverage is subject to actual contract language. Each independent company is solely responsible for its own obligations.

visit%20ldc.lfg.com

dental planLincoln DentalConnect®DHMO LDCTXC5c/LDCTXV5c covered dental services 888-877-7828 http://ldc.lfg.com

ADA DESCRIPTION MEMBER PAYS ²

$0

$0

$0

$0

$0

$0

$5

$0

$5

$5

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$0

$5

DIAGNOSTIC SERVICES

D0120 PERIODIC ORAL EVALUATION EST PT

D0140 LTD ORAL EVALUATION - PROBLEM FOCUS

D0145 ORAL EVAL PT<3 AND COUNSEL

D0150 COMP ORAL EVALUATION - NEW/EST PT

D0160 DTL&EXT ORAL EVAL - PROB FOCUS RPT

D0170 RE-EVALUATION - LTD PROBLEM FOCUSED

D0171 RE-EVALUATION - POST-OPERATIVE OFFICE VISIT D0180 COMP PERIODONTAL EVAL - NEW/EST PT

D0190 SCREENING OF A PATIENT

D0191 ASSESMENT OF A PATIENT

D0210 INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGES D0220 INTRAORAL PERIAPICAL FIRST RADIOGRAPHIC IMAGE D0230 INTRAORL PERIAPICAL EA ADD RADIOGRAPHIC IMAGE D0240 INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE

D0250 EXTRA-ORAL - 2D PROJECTION RADIOGRAPHIC IMAGE D0251 EXTRA-ORAL POSTERIOR DENTAL RADIOGRAPHIC IMAGE D0270 BITEWING - SINGLE RADIOGRAPHIC IMAGE

D0272 BITEWINGS - TWO RADIOGRAPHIC IMAGES

D0273 BITEWINGS - THREE RADIOGRAPHIC IMAGES

D0274 BITEWINGS - FOUR RADIOGRAPHIC IMAGES

D0277 VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES D0330 PANORAMIC RADIOGRAPHIC IMAGE

$502D CEPHALOMETRIC RADIOGRAPHIC IMAGE - ACQUISITION, MEASUREMENT AND ANALYSIS

D0340

$5INTERPRETATION OF DIAGNOSTIC IMAGED0391

$0LABORATORY PROCESSING OF MICROBIAL SPECIMEN TO INCLUDE CULTURE AND SENSITIVITY STUDIES, PREPARATION AND TRANSMISSION OF WRITTEN REPORT

D0414

$0COLLECT MICROORAGNISMS CULT & SENSD0415

$10VIRAL CULTURED0416

$10COLLECTION & PREP OF SALIVA SAMPLED0417

$10ANALYSIS OF SALIVA SAMPLED0418

$0COLLECTION AND PREPARATION OF GENETIC SAMPLE MATERIAL FOR LABORATORY ANALYSIS AND REPORT

D0422

$0GENETIC TEST FOR SUSCEPTIBILITY TO DISEASES - SPECIMEN ANALYSISD0423

$0CARIES SUSCEPTIBILITY TESTSD0425

$20ADJUNCT PREDX TST NO CYTOL/BX PROCD0431

$0PULP VITALITY TESTSD0460

$12DIAGNOSTIC CASTSD0470

$0ACCESS TISS-GROSS EXAM-PREP & REPRTD0472

$0ACCESS TISS-GROSS/MICRO-PREP/REPRTD0473

$0ACSS TISS GR&MIC SURG MARG PREP/RPTD0474

$0CARIES RISK ASSESSMENT AND DOCUMENTATION, LOWD0601

$0CARIES RISK ASSESSMENT AND DOCUMENTATION, MODERATED0602

$0CARIES RISK ASSESSMENT AND DOCUMENTATION, HIGHD0603

$5OFFICE VISIT FEE - PER VISITD0999

PREVENTIVE SERVICES

$0 PROPHYLAXIS - ADULT D1110¹

$25- PROPHYLAXIS - ADULT 1 ADD. PROPHY WITHIN 6 MONTHSD1110¹

$0 PROPHYLAXIS - CHILD D1120¹

$25- PROPHYLAXIS - CHILD 1 ADD. PROPHY WITHIN 6 MONTHSD1120¹

$0TOP FLUORIDE VARNISHD1206

$0TOPICAL APPLICATION OF FLUORIDE - EXCLUDING VARNISHD1208

$0NUTRIT CNSL CONTROL DENTAL DISEASED1310

$0TOBACCO CNSL CNTRL&PREVION ORL DZD1320

NCA-01B(v1.0) ©2016-2017 This plan is underwritten by National Pacific Dental, Inc.


$0ORAL HYGIENE INSTRUCTIONSD1330

$8SEALANT - PER TOOTHD1351

$10PREV RESIN RESTORATION IN MOD HIGH CARIES RISK PATIENT- PERM TOOTHD1352

$5SEALANT REPAIR – PER TOOTHD1353

$32SPACE MAINTAINER - FIXED-UNILATERALD1510

$32SPACE MAINTAINER - FIXED-BILATERALD1515

$50SPACE MAINTAINER - REMOVABLE-UNID1520

$50SPACE MAINTAINER - REMOVABLE-BILD1525

$12RECEMENT OR RE-BOND SPACE MAINTAINERD1550

$12REMOVAL OF FIXED SPACE MAINTAINERD1555

$25DISTAL SHOE SPACE MAINTAINER – FIXED – UNILATERALD1575

RESTORATIVE SERVICES

$10AMALGAM-ONE SURFACE PRIMARY/PERMD2140

$14AMALGAM-TWO SURFACES PRIMARY/PERMD2150

$18AMALGAM-3 SURFACES PRIMARY/PERMD2160

$25AMALGAM-FOUR/MORE SURF PRIM/PERMD2161

$14RESIN COMPOS - ONE SURFACE ANTERIORD2330

$18RESIN COMPOS - 2 SURFACES ANTERIORD2331

$25RESIN COMPOS - 3 SURFACES ANTERIORD2332

$35RSN COMPOS-4/> SURF/W/INCISAL ANGD2335

$75RESIN COMPOS CROWN ANTERIORD2390

$40RESIN COMPOS - 1 SURFACE POSTERIORD2391

$50RESIN COMPOS - 2 SURFACES POSTERIORD2392

$70RESIN COMPOS - 3 SURFACES POSTERIORD2393

$90RESIN COMPOS - 4/MORE SURFACES POSTD2394

$185INLAY - METALLIC - ONE SURFACED2510

$185INLAY - METALLIC - TWO SURFACESD2520

$185INLAY - METALLIC - 3/MORE SURFACESD2530

$225ONLAY - METALLIC - TWO SURFACESD2542

$225ONLAY METALLIC THREE SURFACESD2543

$225ONLAY METALLIC FOUR OR MORE SURFD2544

$280INLAY - PORCELN/CERAMIC - 1 SURFACED2610

$280INLAY - PORCELN/CERAMIC - 2 SURFD2620

$280INLAY - PORCELN/CERAM - 3/MORE SURFD2630

$280ONLAY - PORCELN/CERAMIC - 2 SURFD2642

$280ONLAY - PORCELN/CERAMIC - 3 SURFD2643

$280ONLAY - PORCELN/CERAM - 4/MORE SURFD2644

$280INLAY-RSN COMPOS COMPOS/RSN-1 SURFD2650

$280INLAY-RSN COMPOS COMPOS/RSN-2 SURFD2651

$280INLAY-RSN COMPOS COMPOS/RSN-3/>SURFD2652

$280ONLAY-RSN COMPOS COMPOS/RSN-2 SURFD2662

$280ONLAY-RSN COMPOS COMPOS/RSN-3 SURFD2663

$280ONLAY-RSN COMPOS COMPOS/RSN-4/>D2664

$150CROWN RESINBASED COMPOSITE INDIRECTD2710

$150CROWN 3/4 RESNBASED COMPOS INDIRECTD2712

$225CROWN - RESIN WITH HIGH NOBLE METALD2720*

$225CROWN - RESIN W/PREDOM BASE METALD2721

$225CROWN - RESIN WITH NOBLE METALD2722*

$325CROWN - PORCELAIN/CERAMIC SUBSTRATED2740

$280CROWN - PORCELN FUSED HI NOBLE METLD2750*

$280CROWN-PORCELN FUSD PREDOM BASE METLD2751

$280CROWN - PORCELAIN FUSED NOBLE METALD2752*

$280CROWN - 3/4 CAST HIGH NOBLE METALD2780*

$280CROWN - 3/4 CAST PREDOM BASE METLD2781

$280CROWN - 3/4 CAST NOBLE METALD2782*

$280CROWN - 3/4 PORCELAIN/CERAMICD2783

$280CROWN - FULL CAST HIGH NOBLE METALD2790*

$280CROWN - FULL CAST PREDOM BASE METLD2791



$280

$280

$10

$10

$10

$65

$80

$50$60$40

$60

$60

$8$5$80

$10

$80

$80

$45$10

$30

$270

$465

$560

$50

$80

$45

$5

$0$0$0$20

$60

$60

$60

$115

$180$285

$85

$85

$85

$135

$200$315

$80

$55$60

$65

$65

$65

$125$145$150$85

$250

$55

$80

D2792* CROWN - FULL CAST NOBLE METAL

D2794* CROWN TITANIUM

D2910 RECEMENT OR RE-BOND INLAY ONLAY VENEER OR PART COV REST D2915 RECEMENT OR RE-BOND INDIRECTLY FABRICATED PREFAB POST & CORE D2920 RECEMENT OR RE-BOND CROWN

D2921 REATTACHMENT OF TOOTH FRAGMENT

D2929 PREFABRICATED PORCELAIN CROWN- PRIMARY

D2930 PRFABR STAINLESS STEEL CROWN-PRIM

D2931 PRFABR STAINLESS STEEL CROWN-PERM

D2932 PREFABRICATED RESIN CROWN

D2933 PRFABR STNLSS STEEL CROWN RSN WNDOW

D2934 PREFAB ESTHTC COATED STNLESS STEEL CROWN - PRIMARY

D2940 SEDATIVE FILLING

D2941 INTERIM THERAPEUTIC RESTORATION – PRIMARY DENTITION

D2950 CORE BUILDUP INCLUDING ANY PINS

D2951 PIN RETN - PER TOOTH ADDITION REST

D2952 POST & CORE ADD CROWN INDIRECT FAB

D2953 EA ADD INDIRECT FAB POST SAME TOOTH

D2954 PREFABR POST&CORE ADDITION CROWN

D2955 POST REMOVAL

D2957 EA ADD PREFABR POST - SAME TOOTH

D2960 LABIAL VENEER (LAMINATE) - CHAIRSIDE

D2961 LABIAL VENEER (RESIN LAMINATE) - LABORATORY

D2962 LABIAL VENEER (PORCELAIN LAMINATE) - LABORATORY

D2971 ADD PROC NEW CROWN XST PART DENTURE

D2975 COPING

D2980 CROWN REPAIR

D2990 RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS ENDODONTIC SERVICES

D3110 PULP CAP - DIRECT

D3120 PULP CAP - INDIRECT

D3220 TX PULPOT-CORONL DENTNOCEMENTL JUNC

D3221 PULPAL DEBRID PRIMARY&PERM TEETH

D3222 PARTIAL PULPOTOMY

D3230 PULPAL THERAPY - ANT PRIMARY TOOTH

D3240 PULPAL THERAPY - POST PRIMARY TOOTH

D3310 ANTERIOR ROOT CANALD3320 BICUSPID ROOT CANALD3330 MOLAR ROOT CANALD3331 TX RC OBSTRUCTION; NON-SURG ACCESS

D3332 INCMPL ENDO TX;INOP UNRSTR/FX TOOTH

D3333 INTRL ROOT REPAIR PERFORATION DEFEC

D3346 RETX PREVIOUS RC THERAPY - ANTERIOR

D3347 RETX PREVIOUS RC THERAPY - BICUSPID

D3348 RETX PREVIOUS RC THERAPY - MOLAR

D3351 APEXIFICAT/RECALCIFICAT - INIT VST

D3352 APEXIFICAT/RECALCIFICAT-INTERIM

D3353 APEXIFICAT/RECALCIFICAT-FINAL VISIT

D3355 PULPAL REGENERATION - INITIAL VISIT

D3356 PULPAL REGENERATION -INTERIM MEDICAMENT REPLACEMENT

D3357 PULPAL REGENERATION - COMPLETION OF TREATMENT

D3410 APICOECTOMY SURG - ANT

D3421 APICOECTOMY SURG-BICUSPID

D3425 APICOECTOMY SURG - MOLAR

D3426 APICOECTOMY SURGERY

D3427 PERIRADICULAR SURGERY WITHOUT APICOECTOMY

D3430 RETROGRADE FILLING - PER ROOT

D3450 ROOT AMPUTATION - PER ROOT



$970ENDODONTIC ENDOSSEOUS IMPLANTD3460

$25SURG PROC ISOLAT TOOTH W/RUBBER DAMD3910

$75HEMISECTION NOT INCL RC THERAPYD3920

$15CANAL PREP&FIT PREFORMED DOWEL/POSTD3950

PERIODONTIC SERVICES

$140GINGIVECT/PLSTY 4/>CNTIG TEETH QUADD4210

$70GINGIVECT/PLSTY 1-3CNTIG TEETH QUADD4211

$15GINGIVECT/PLSTY WITH REST PROC/TOOTHD4212

$180GINGL FLP 4/>CNTIG/BOUND TEETH QUADD4240

$90GINGL FLP 1-3 CNTIG/BND TEETH QUADD4241

$180APICALLY POSITIONED FLAPD4245

$195CLIN CROWN LEN - HARD TISSUED4249

$350OSSEOUS SURG 4/> CNTIG TEETH QUADD4260

$225OSSEOUS SURG 1-3 CNTIG TEETH QUADD4261

$215BONE REPLACEMENT GRAFT – RETAINED NATURAL TOOTH – FIRST SITE IN D4263

QUADRANT

$115BONE REPLACEMENT GRAFT – RETAINED NATURAL TOOTH – EACH ADDITIONAL D4264

$215SITE IN QUADRANT

D4270 PEDICLE SOFT TISSUE GRAFT PROCEDURE

$90MESIAL/DISTAL WEDGE PROCEDURE, SINGLE TOOTH (WHEN NOT PERFORMED IN CONJUNCTION WITH SURGICAL PROCEDURES IN THE SAME ANATOMICAL AREA)

D4274

$235FREE SOFT TISSUE GRAFT PROCEDURE -1ST TOOTHD4277

$275FREE SOFT TISSUE GRAFT PROCEDURE - ADD TOOTHD4278

$75PROVISIONAL SPLINTING - INTRACORONALD4320

$75PROVISIONAL SPLINTING - EXTRACORONALD4321

$50PRDNTL SCAL&ROOT PLAN 4/>TEETH-QUADD4341

$50PRDONTAL SCAL&ROOT PLAN 1-3 TEETHD4342

$30SCALING IN PRESENCE OF GENERALIZED MODERATE OR SEVERE GINGIVAL INFLAMMATION – FULL MOUTH, AFTER ORAL EVALUATION

D4346

$50FULL MOUTH DEBRID COMP EVAL&DXD4355

$35LOCALIZED DELIVERY OF ANTIMICROBIAL AGENTS VIA A CONTROLLED RELEASE D4381

$30

$0

$0

$365$365$385$385$335

$335

$405

$405

VEHICLE INTO DISEASED CREVICULAR TISSUE, PER TOOTH D4910 PERIODONTAL MAINTENANCED4920 UNSCHEDULED DRESSING CHANGED4921 GINGIVAL IRRIGATION - PER QUADRANT

REMOVABLE PROSTHODONTIC SERVICESD5110 COMPLETE DENTURE - MAXILLARYD5120 COMPLETE DENTURE - MANDIBULARD5130 IMMEDIATE DENTURE - MAXILLARYD5140 IMMEDIATE DENTURE - MANDIBULARD5211 MAX PARTIAL DENTURE - RESIN BASED5212 MAND PARTIAL DENTUR - RESIN BASED5213 MAX PART DENTUR-CAST METL W/RSND5214 MAND PART DENTUR- CAST METL W/RSN

$145IMMEDIATE MAXILLARY PARTIAL DENTURE – RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

D5221

$155IMMEDIATE MANDIBULAR PARTIAL DENTURE – RESIN BASE (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

D5222

$145IMMEDIATE MAXILLARY PARTIAL DENTURE – CASE METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

D5223

$155IMMEDIATE MANDIBULAR PARTIAL DENTURE – CASE METAL FRAMEWORK WITH RESIN DENTURE BASES (INCLUDING ANY CONVENTIONAL CLASPS, RESTS AND TEETH)

D5224

$475MAXILLARY PARTIAL DENTURE FLEX BASED5225

$475MANDIBULAR PART DENTURE FLEX BASED5226

$315REMV UNI PART DENTUR-1 PC CAST METLD5281



$10ADJUST COMPLETE DENTURE - MAXILLARYD5410

$10ADJUST COMPLETE DENTUR - MANDIBULARD5411

$10ADJUST PARTIAL DENTURE - MAXILLARYD5421

$10ADJUST PARTIAL DENTURE - MANDIBULARD5422

$40REPAIR BROKEN COMPLETE DENTURE BASED5510

$40REPL MISS/BROKEN TEETH-CMPL DENTURD5520

$40REPAIR RESIN DENTURE BASED5610

$40REPAIR CAST FRAMEWORKD5620

$40REPAIR OR REPLACE BROKEN CLASP - PER TOOTHD5630

$40REPLACE BROKEN TEETH - PER TOOTHD5640

$35ADD TOOTH EXISTING PARTIAL DENTURED5650

$50ADD CLASP EXISTING PARTIAL DENTURE - PER TOOTHD5660

$165REPL ALL TEETH&ACRYLC FRMEWRK MAXD5670

$165REPL ALL TEETH&ACRYLC FRMEWRK MANDD5671

$125REBASE COMPLETE MAXILLARY DENTURED5710

$125REBASE COMPLETE MANDIBULAR DENTURED5711

$125REBASE MAXILLARY PARTIAL DENTURED5720

$125REBASE MANDIBULAR PARTIAL DENTURED5721

$75RELINE CMPL MAXIL DENTURE CHAIRSIDED5730

$75RELINE CMPL MAND DENTURE CHAIRSIDED5731

$75RELINE MAXIL PART DENTURE CHAIRSIDED5740

$75RELINE MAND PART DENTURE CHAIRSIDED5741

$105$105

$105

$105

$125

$125

$30

$30

$425$450

$425

$450

$1,035

$1,185

$525

$390

$290

$395

$710

D5750 RELINE CMPL MAXIL DENTURE LAB

D5751 RELINE CMPL MAND DENTRUE LABORATORY

D5760 RELINE MAXIL PART DENTURE LAB

D5761 RELINE MAND PART DENTURE LABORATORY

D5820 INTERIM PARTIAL DENTURE MAXILLARY

D5821 INTERIM PARTIAL DENTURE MANDIBULAR

D5850 TISSUE CONDITIONING MAXILLARY

D5851 TISSUE CONDITIONING MANDIBULAR

D5863 OVERDENTURE - COMPLETE MAXILLARY

D5864 OVERDENTURE - PARTIAL MAXILLARYD5865 OVERDENTURE - COMPLETE MANDIBULARD5866 OVERDENTURE - PARTIAL MANDIBULAR

IMPLANT SERVICES

D6010 SURGICAL PLACEMENT OF IMPLANT BODY: ENDOSTEAL IMPLANT D6013 SURGICAL PLACEMENT OF A MINI-IMPLANT

D6052 SEMI-PRECISION ATTACHMENT ABUTMENT

D6055 DENTAL IMPLANT SUPPORTED CONNECTING BAR

D6056 PREFABRICATED ABUTMENT - INCLUDES MOD AND PLACEMENT D6057 CUSTOM FAB ABUTMENT - INCLUDES PLACEMENT

D6058 ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN

$710ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (HIGH NOBLE METAL)

D6059

$575ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (PREDOMINATELY BASE METAL)

D6060

$635ABUTMENT SUPPORTED PORCELAIN FUSED TO METAL CROWN (NOBLE METAL)D6061

$675ABUTMENT SUPPORTED CAST METAL CROWN (HIGH NOBLE METAL)D6062

$595ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMINATELY BASE METAL)D6063

$620ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE METAL)D6064

$740IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWND6065

$720IMPLANT SUPPORTED PORCELAIN FUSED TO METAL CROWND6066

$730IMPLANT SUPPORTED METAL CROWND6067

$680ABUTMENT SUPPORTED RETAINER FOR PORCELAIN/CERAMIC FPDD6068

$705ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (HIGH NOBLE METAL)

D6069

$630ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (PREDOMINATELY BASE METAL)

D6070



$680ABUTMENT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPD (NOBLE METAL)

D6071

$690ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (HIGH NOBLE METAL)D6072

$630ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (PREDOMINATELY BASE METAL)

D6073

$670ABUTMENT SUPPORTED RETAINER FOR CAST METAL FPD (NOBLE METAL)D6074

$740IMPLANT SUPPORTED RETAINER FOR CERAMIC FPDD6075

$705IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO METAL FPDD6076

$665IMPLANT SUPPORTED RETAINER FOR CASE METAL FPDD6077

$80IMPLANT MAINTENANCE PROCEDURES WHEN PROSTHESIS ARE REMOVED AND REINSERTED, INCLUDING CLEANSING OF PROSTHESIES AND ABUTMENTS

D6080

$190SCALING AND DEBRIDEMENT IN THE PRESENCE OF INFLAMMATION OR MUCOSITIS OF A SINGLE IMPLANT, INCLUDING CLEANING OF THE IMPLANT SURFACES, WITHOUT FLAP ENTRY AND CLOSURE

D6081

$55PROVISIONAL IMPLANT CROWND6085

$130REPAIR IMPLANT SUPPORTED PROSTHESIS, BY REPORTD6090

$200REPLACEMENT OF SEMI-PRECISION OR PRECISION ATTACHMENT(MALE OR FEMALE COMPONENT) OF IMPLANT/ABUTMENT SUPPORTED PROSTHESIS

D6091

$60RECEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED CROWND6092

$80RECEMENT OR RE-BOND IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE

D6093

$560ABUTMENT SUPPORTED CROWN - TITANIUMD6094

$150REPAIR IMPLANT ABUTMENT, BY REPORTD6095

$250IMPLANT REMOVAL, BY REPORTD6100

$255DEBRIDEMENT PERI IMPLANT DEFECT OR DEFECTS SURROUNDING A SINGLE IMPLANT

D6101

$315DEBRIDEMENT & OSSEOUS PERI IMPLANT DEFECT OR DEFECTS SURROUNDING A SINGLE IMPLANT

D6102

$265BONE GRAFT FOR REPAIR OF PERI IMPLANT DEFECTD6103

$925IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR EDENTULOUS ARCH – MAXILLARY

D6110

$925IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR EDENTULOUS ARCH –MANDIBULAR

D6111

$925IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLYEDENTULOUS ARCH – MAXILLARY

D6112

$925IMPLANT /ABUTMENT SUPPORTED REMOVABLE DENTURE FOR PARTIALLYEDENTULOUS ARCH – MANDIBULAR

D6113

$145

$575

$250

$280

$280

$280

$280

$280

$280

$280

$325$225$225$225

D6190 RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORTD6194 ABUTMENT SUPPORTED RETAINER CROWN FOR FPD - TITANIUM FIXED PROSTHODONTIC SERVICES

D6205 PONTIC- INDIRECT RESIN BASED COMPOSITE

D6210* PONTIC - CAST HIGH NOBLE METAL

D6211 PONTIC - CAST PREDOM BASE METAL

D6212* PONTIC - CAST NOBLE METAL

D6214* PONTIC TITANIUM

D6240* PONTIC-PORCELN FUSED HI NOBLE METL

D6241 PONTIC-PORCLN FUSD PREDOM BASE METL

D6242* PONTIC - PORCELN FUSED NOBLE METAL

D6245 PONTIC - PORCELAIN/CERAMIC

D6250* PONTIC - RESIN W/HIGH NOBLE METAL

D6251 PONTIC RESIN W/PREDOM BASE METAL

D6252* PONTIC RESIN W/NOBLE METAL

$175PROVISIONAL PONTIC - FURTHER TREATMENT OR COMPLETION OF DIAGNOSIS NECESSARY PRIOR TO FINAL IMPRESSION

D6253

$250RETAINER- CASE MTL FOR RESIN FXD PROSD6545

$300RET-PORC/CER FOR RESIN BONDED FIXED PROSD6548

$85RESIN RETAINER – FOR RESIN BONDED FIXED PROSTHESISD6549

$300RETAINER INLAY-PORCELAIN/CERAMIC 2 SURFACESD6600

$300RETAINER INLAY - PORCELN/CERAMIC 3/MORE SURFD6601

$185RETAINER INLAY - CAST HI NOBLE METAL 2 SURFD6602

$185RETAINER INLAY-CAST HI NOBLE METL 3/> SURFD6603



$185RETAINER INLAY-CAST PREDOM BASE METL 2 SURFD6604

$185RETAINER INLAY-CAST PREDOM BASE METL 3/>SURFD6605

$185RETAINER INLAY - CAST NOBLE METAL 2 SURFACESD6606

$185RETAINER INLAY - CAST NOBLE METL 3/MORE SURFD6607

$310RETAINER ONLAY - PORCELN/CERAMIC 2 SURFACESD6608

$310RETAINER ONLAY - PORCELN/CERAMIC 3/MORE SURFD6609

$185RETAINER ONLAY - CAST HI NOBLE METAL 2 SURFD6610

$185RETAINER ONLAY-CAST HI NOBLE METL 3/> SURFD6611

$185RETAINER ONLAY-CAST PREDOM BASE METL 2 SURFD6612

$185RETAINER ONLAY-CAST PREDOM BASE METL 3/>SURFD6613

$185RETAINER ONLAY - CAST NOBLE METAL 2 SURFACESD6614

$185RETAINER ONLAY - CAST NOBLE METL 3/MORE SURFD6615

$280RETAINER INLAY - TITANIUMD6624

$280RETAINER ONLAY - TITANIUMD6634

$185RETAINER CROWN - INDIRECT RESIN BASED COMPOSITED6710

$225RETAINER CROWN - RESIN WITH HIGH NOBLE METAL D6720*

$225RETAINER CROWN - RESIN PREDOMINANTLY BASE METALD6721

$225RETAINER CROWN - RESIN WITH NOBLE METAL D6722*

$325RETAINER CROWN - PORCELAIN/CERAMICD6740

$280RETAINER CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL D6750*

$280RETAINER CROWN - PORCELAIN FUSED TO PREDOMINANTLY BASE METALD6751

$280RETAINER CROWN - PORCELAIN FUSED TO NOBLE METAL D6752*

$280RETAINER CROWN - 3/4 CAST HIGH NOBLE METAL D6780*

$280RETAINER CROWN - 3/4 CAST PREDOMINANTLY BASE METALD6781

$280RETAINER CROWN - 3/4 CAST NOBLE METAL D6782*

$280RETAINER CROWN - 3/4 PORCELAIN/CERAMICD6783

$280RETAINER CROWN - FULL CAST HIGH NOBLE METAL D6790*

$280RETAINER CROWN - FULL CAST PREDOMINANTLY BASE METALD6791

$280RETAINER CROWN - FULL CAST NOBLE METAL D6792*

$280RETAINER CROWN - TITANIUM D6794*

$85CONNECTOR BARD6920

$10RECEMENT OR RE-BOND FIXED PARTIAL DENTURED6930

$135STRESS BREAKERD6940

$140FIXED PARTIAL DENTURE REPAIR, BY REPORTD6980

ORAL SURGERY SERVICES

$5XTRCT CORONL RMNNTS DECIDUOUS TOOTHD7111

$10EXTRAC ERUPTED TOOTH/EXPOSED ROOTD7140

$40EXTRACTION, ERUPTED TOOTH REQUIRING REMOVAL OF BONE AND/OR SECTIONING OF TOOTH, AND INCLUDING ELEVATION OF MUCOPERIOSTEAL

D7210

$65

$105$120$140

$55$150

$225

$95$120

FLAP IF INDICATEDD7220 REMOVAL IMPACT TOOTH - SOFT TISSUED7230 REMOVAL IMPACT TOOTH - PARTLY BONYD7240 REMOVAL IMPACTED TOOTH - CMPL BONYD7241 REMV IMP TOOTH-CMPL BNY W/SURG COMPD7250 REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) D7251 CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVAL D7261 PRIMARY CLOSURE OF A SINUS PERFORATIOND7270 TOOTH REIMPL&/STBL ACC DISPLCDD7280 EXPOSURE OF AN UNERUPTED TOOTH

$120MOBILZ ERUPT/MALPSTN TOOTH AID ERUPD7282

$115INCISIONAL BIOPSY OF ORAL TISSUE HARDD7285

$50INCISIONAL BIOPSY OF ORAL TISSUE SOFTD7286

$20EXTOLIATIVE CYTOLOGICAL SAMPLE COLLECTIOND7287

$20BRUSH BIOPSYD7288

$75SURGICAL REPOSITIONING OF TEETHD7290

$50ALVEOLOPLASTY W/EXT 4/> TEETH/SPACED7310

$45ALVEOLOPLSTY CONJNC XTRCT 1-3 TEETHD7311



$70ALVEOLOPLASTY NO EXT 4/> TEETH/SPACD7320

$70ALVEOLOPLSTY NOT W/XTRCT 1-3 TEETHD7321

$215VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY EPITHELIALIZATION)D7340

$670VESTIBULOPLASTY - RIDGE EXTENSION (INCLUDING SOFT TISSUE GRAFTS, MUSCLE REATTACHMENT, REVISION OF SOFT TISSUE ATTACHMENT

D7350

$70REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25 CM

D7450

$110REMOVAL OF BENIGN ODONTOGENIC CYST OR TUMOR - LESION DIAMETER GREATER THAN 1.25 CM

D7451

$100REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION DIAMETER UP TO 1.25 CM

D7460

$125REMOVAL OF BENIGN NONODONTOGENIC CYST OR TUMOR - LESION DIAMETER D7461

$115$115

$115

$115

$50$75$70

$190

$40

$10

$25

$110$65

$60$40

$100

$10

$0

$0

$0

$0

$75

$30

GREATER THAN 1.25 CMD7471 REMOVAL OF LATERAL EXOSTOSISD7472 REMOVAL OF TORUS PALATINUSD7473 REMOVAL OF TORUS MANDIBULARISD7485 REDUCTION OF OSSEOUS TUBEROSITY

D7510 I&D ABSCESS-INTRAORAL SOFT TISSD7511 I & D ABSC INTRAORAL SOFT TISS COMPD7520 I & D OF ABSCESS EXTRAORAL SOFT TISSUED7521 I & D OF ABSCESS EXTRAORAL COMPLICATEDD7530 REMOVAL OF FOREIGN BODY - SKIN SUBCUTANEOUSD7881 OCCLUSAL ORTHOTIC DEVICE ADJUSTMENTD7910 SUTURE RECENT SMALL WOUNDS UP 5 CMD7960 FRENULECTOMY SEPARATE PROCEDURED7963 FRENULOPLASTYD7970 EXC HYPERPLASTIC TISSUE-PER ARCHD7971 EXCISION OF PERICORONAL GINGIVAD7972 SURGICAL RDUC FIBROUS TUBEROSITY

ADJUNCTIVE GENERAL SERVICESD9110 PALLIATVE TX DENTAL PAIN-MINOR PROCD9211 REGIONAL BLOCK ANESTHESIAD9212 TRIGEMINAL DIVISION BLOCK ANESD9215 LOCAL ANESTHESIAD9219 EVALUATION FOR DEEP SEDATION OR GENERAL ANESTHESIAD9223 DEEP SEDATION/GENERAL ANESTHESIA - EACH 15 MINUTE INCREMENT D9230 ANALGESIA ANXIOLYSIS, INHALATION OF NITROUS OXIDE

$70INTRAVENOUS MODERATE (CONSCIOUS) SEDATION/ANALGESIA - EACH 15 MINUTE INCREMENT

D9243

$50NON-INTRAVENOUS (CONSCIOUS) SEDATION, THIS INCLUDES NON-IV MINIMAL AND MODERATE SEDATION

D9248

$10CNSLT DX DENT/PHY NOT REQ DENT/PHYD9310

$0OV OBS - NO OTH SERVICES PERFORMEDD9430

$50OV-AFTER REGULARLY SCHEDULED HRSD9440

$0CASE PRSATION DTL&EXT TX PLANNINGD9450

$0TREATMENT OF COMPLICATIONS - POST SURG.D9930

$105OCCLUSAL GUARD BY REPORTD9940

$10OCCLUSAL GUARD ADJUSTMENTD9943

$40OCCLUSAL ADJUSTMENT - LIMITEDD9951

$160OCCLUSAL ADJUSTMENT - COMPLETED9952

$20ODONTOPLASTYD9971

$125EXTERNAL BLEACHING - PER ARCH PERFORMED IN OFFICED9972

$125EXTERNAL BLEACHING FOR HOME APPLICATION, PER ARCHD9975

$15BROKEN APPOINTMENTD9999

ORTHODONTIC SERVICES

$1,895COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIONAL DENTITION)D8070

$1,895COMPREHENSIVE ORTHODONTIC TREATMENT ADOLESCENT DENTITIOND8080

$1,895COMPREHENSIVE ORTHODONTIC TREATMENT ADULT DENTITIOND8090



$250D8660

$300

$250

$150

PRE-ORTHODONTIC TREATMENT EXAM TO MONITOR GROWTH AND DEVELOPMENTORTHODONTIC RETENTION (REMOVAL OF APPLIANCES, CONSTRUCTION AND PLACEMENT OF RETAINERS)START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS, X-RAYS, TRACING,PHOTOS AND MODELSPOST TREATMENT RECORDS

D8680

D8999

D8999

¹Additional Prophy within 6 months will be based upon the necessity recommended by the provider. ²Copays listed are also applicable in the specialist office.*The plan provides for the user of noble metals for inlays, onlays, crowns and fixed bridges. When high noble metal is used, the Covered Person must pay: (a) the usual patient charge for the inlay, onlay,crown or fixed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal not to exceed $150.


Lincoln DentalConnect® dental exclusions and limitations LIMITATIONS OF BENEFITS

The following are the limitation of benefits, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits:

Limited to 1 time per 6 monthsDENTAL PROPHYLAXIS1.

Limited to one time per calendar yearFLUORIDE TREATMENTS2.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.CROWNS3.

Covered only for teeth that have had root canal therapy.POST AND CORES4.

Limited to 4 quadrants per calendar year.SCALING AND ROOT PLANING5.

Limited to once every 6 months, following active therapy, exclusive of gross debridementPERIODONTAL MAINTENANCE6.

Limited to 1 time in any 2 year periodINTRAORAL COMPLETE SERIES (INCLUDING BITEWINGS)

7.

Limited to 1 series of 4 films in any 6 month periodINTRAORAL BITEWING RADIOGRAPHS8.

Replacement of complete dentures, and fixed and removable partial dentures or crowns if damage or breakage was directly related to provider error. This type of replacement is the responsibility of the Dentist. If replacement is Necessary because of patient non-compliance, the patient is liable for the cost of replacement.

REMOVABLE PROSTHETICS/FIXED PROSTHETICS/CROWNS, INLAYS AND ONLAYS (MAJOR RESTORATIVE SERVICES)

9.

Limited to 1 time per tooth per 5 years.CROWNS RETAINERS/ABUTMENTS10.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.TEMPORARY CROWNS RESTORATIONS11.

Limited to 1 time per tooth per 5 years.INLAYS/ONLAYS RETAINERS/ABUTMENTS

12.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth.INLAYS/ONLAYS RESTORATIONS13.

Limited to 1 time per tooth per 5 years. Covered only when a filling cannot restore the tooth. Prefabricated esthetic coated stainless steel crown -primary tooth, are limited to primary anterior teeth.

STAINLESS STEEL CROWNS14.

The maximum benefit within a 12-month period is any combination of 7 crowns or pontics (artificial teeth that are part of a fixed bridge). If more than 7 crowns and/or pontics are done for a Member within a 12-month period, the dentist's fee for any additional crowns within that period would not be limited to the listed Copayment, but instead can reflect the Dentist's Billed Changes.

CROWNS AND FIXED BRIDGES15.

Limited to repairs or adjustments performed more than 6 months after the initial insertion.ADJUSTMENTS TO FULL DENTURES, PARTIAL DENTURES, BRIDGES OR CROWNS

16.

Administration of I.V. sedation or general anesthesia is limited to covered oral surgical procedures involving 1 or more impacted teeth (soft tissue, partial bony or complete bony impactions).

INTRAVENOUS SEDATION OR GENERAL ANESTHESIA

17.

That aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures - Limited to 1 time per year, to Covered Persons over the age of 30.

ADJUNCTIVE PRE-DIAGNOSTIC TEST18.


LIMITATIONS OF BENEFITS

The following are the limitation of benefits, unless otherwise specifically listed as a covered benefit on this Plan’s Schedule of Benefits:

(A) Pre-Authorized by us; and

(B) Coordinated by a Covered Person’s PCD with the exception of specialty referrals for children up to age 8 to see a pediatric dentist. Children aged 8 and older still require a referral from a primary care dentist. Children under age 8 who need services of a specialist beyond a pediatric dentist must still obtain a specialty referral. Any Covered Person who elects specialist care without prior referral by his or her PCD and approval by us is responsible for all charges incurred

• In order for specialty services to be Covered by this plan, the following referral process must be

followed:

• A Covered Person’s PCD must coordinate all Dental Services.

• When the care of a Network Specialist Dentist is required, the Covered Person’s PCD must contact usand request authorization...

• If the PCD’s request for specialist referral is denied, the PCD and the Covered Person will be notifi ed ofthe reason for the denial. If the service in question is a Covered service, and no limitations or exclusions apply, the PCD may be asked to perform the service.

• Covered Person who receives authorized specialty services must pay all applicable Copaymentsassociated with the services provided. When we authorize specialty dental care, a Covered Person will be referred to a Network Specialist Dentist for treatment. The Network includes Network Specialist Dentists in: (a) endodontics; (b) oral surgery; (c) pediatric dentistry; and (d) orthodontics; and (e) periodontics, located in the Covered Person’s Service Area. If there is no Network Specialist Dentist in the Covered Person’s Service Area, we will refer the Covered Person to a Non-Participating Specialist of our choice. Except for Emergency Dental Services, in no event will we cover dental care provided to a Covered Person by a specialist not preauthorized by us to provide such services.

• Covered Person’s financial responsibility is limited to applicable Copayments. Copayments are listed inthe Covered Person’s Schedule of Covered Dental Services.

ALL SPECIALTY REFERRAL SERVICES MUST BE

19.

Replacement of complete dentures, fixed or removable partial dentures, crowns, inlays or onlays previously submitted for payment under the plan is limited to 1 time per 5 years from initial or supplemental placement

REMOVABLE PROSTHETICS/FIXED PROSTHETICS/CROWNS, INLAYS AND ONLAYS (MINOR RESTORATIVE SERVICES)

20.

EXCLUSIONS OF BENEFITSThe following procedures and services are excluded and not Covered Services, unless otherwise specifically listed as a covered benefit on this

Plan’s Schedule of Benefits:

Dental Services that are not Necessary.1.

Any service done for cosmetic purposes that is not listed as a Covered cosmetic service in the Schedule of Covered Dental Services.2.

Any Dental Procedure not directly associated with dental disease.3.

Any implant procedures performed which are not listed as Covered implant procedures in the Schedule of Covered Dental Services.4.

Setting of facial bony fractures and any treatment associated with the dislocation of facial skeletal hard tissue.5.

Treatment of benign neoplasms, cysts, or other pathology involving benign lesions, except excisional removal. Treatment of malignant neoplasms orCongenital Anomalies of hard or soft tissue, including excision.

6.

Fixed or removable prosthodontic restoration procedures for complete oral rehabilitation or reconstruction.7.

Procedures related to the reconstruction of a patient's correct vertical dimension of occlusion (VDO).8.

Placement of fixed partial dentures solely for the purpose of achieving periodontal stability.9.

Dental Services received as a result of war or any act of war, whether declared or undeclared or caused during service in the armed forces of any country.10.

Any Dental Services or Procedures not listed in the Schedule of Covered Dental Services.11.

Drugs/medications, obtainable with or without a prescription, unless they are dispensed and utilized in the dental office during the patient visit.12.

Any Dental Procedure not performed in a participating dental setting. An exception is made for Emergency Dental Care, as defined in this Evidence of coverage.

13.

Costs for non-dental services related to the provision of dental services in hospitals, extended care facilities, or Member’s home are not covered. When deemed necessary by the Primary Care Dentist, the Member’s physician, and authorized by the Plan, covered dental services that are delivered in an inpatient or outpatient hospital setting are covered as indicated in the Schedule of Benefits.

14.


EXCLUSIONS OF BENEFITSThe following procedures and services are excluded and not Covered Services, unless otherwise specifically listed as a covered benefit on this

Plan’s Schedule of Benefits:

Any Covered Person request for: (a) specialist services or treatment which can be routinely provided by the PCD; or (b) treatment by a specialist without referral from the PCD and our approval.

15.

Any endodontic, periodontal, crown or bridge abutment procedure or appliance requested, recommended or performed for a tooth or teeth with a guarded, questionable or poor prognosis.

16.

Dental Services otherwise Covered under the Contract, but rendered after the date individual Coverage under the Contract terminates, including Dental Services for dental conditions arising prior to the date individual Coverage under the Contract terminates.

17.

Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays (Major Restorative Services) - The plan provides for the use of noble metals for inlays, onlays, crowns and fixed bridges. When high noble metal is used, the Covered Person must pay: (a) the Copayment for the inlay, onlay, crown or fixed bridge; and (b) an added charge equal to the actual laboratory cost of the high noble metal.

18.

Replacement of a lost, missing or stolen appliance or prosthesis or the fabrication of a spare appliance or prosthesis.19.

Services for injuries or conditions covered by Worker's Compensation or employer liability laws, and services that are provided without cost to the Covered Person by any municipality, county, or other political subdivision.

20.

Services related to the temporomandibular joint (TMJ), either bilateral or unilateral. Upper and lower jaw bone surgery (including that related to the temporomandibular joint). No Coverage is provided for orthognathic surgery, jaw alignment, or treatment.

21.

This exclusion does not apply to any services covered by Medicaid or Medicare.22.


Orthodontic Exclusions and Limitations

If you require the services of an orthodontist, a referral must first be obtained. If a referral is not obtained prior to the commencement of orthodontic treatment, the member will be responsible for all costs associated with any orthodontic treatment.

If you terminate coverage after the start of orthodontic treatment, you will be responsible for any additional charges incurred for the remaining orthodontic treatment.

1.The following are not Covered orthodontic benefits:• Extractions required for orthodontic purposes• Surgical orthodontics or jaw repositioning• Myofunctional therapy• Cleft palate• Micrognathia• Macroglossia• Hormonal imbalances• Orthodontic retreatment when initial treatment was rendered under this plan or for changes inorthodontic treatment necessitated by any kind of accident• Palatal expansion appliances• Replacement or repair of lost, stolen or broken appliances or appliances damaged due to theneglect of the Covered Person

2. If a treatment plan is for less than 24 months, then a prorated portion of the full Copaymentshall apply.

3. If Covered Person’s dental eligibility ends, for whatever reason, and the Covered Person isreceiving orthodontic treatment under the plan, the remaining cost for that treatment will be prorated at the orthodontist’s usual fees over the number of months of treatment remaining. TheCovered Person will be responsible for the payment of this balance under the terms and conditions pre-arranged with the orthodontist.

4. If the Covered Person has the orthodontist perform a “diagnostic work-up” (a consultation anddiagnosis) and then decides to forgo the treatment program, the Covered Person will be charged a $50 consultation fee, plus any lab costs incurred by the orthodontist.

5. One orthodontic benefit under this plan is available per lifetime, per Covered Person. ACovered Person may access this benefit for either Interceptive Orthodontic Treatment or Comprehensive Orthodontic Treatment, or both. If both interceptive treatment and comprehensive treatment are necessary, and both are completed within a 24 month period, the Copayments listed will apply. If both are necessary and active treatment for both extends beyond 24 months, the provider is obligated to accept the plan Copayment only for the first 24 months of active therapy. The provider may charge usual and customary fees for activetreatment extending beyond the 24 month benefit period.

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