EXHIBIT A FEE-FOR-SERVICE (FFS) General Dentist ... Dental... · D5510 Repair Broken Complete Denture Base $53.76 D5520 Replace Missing or Broken Teeth $57.60 D5610 Repair Resin Denture

A.3

EXHIBIT A FEE-FOR-SERVICE (FFS)

General Dentist, Pedodontics and Prosthodontic COMPENSATION

MCS Advantage will pay Dental Provider for the provision of Covered Services to Members the lesser of: (1) the amount invoiced by the Provider or (2) 100% of MCS Fee Schedule for contracted services. MCS Advantage may amend compensation with at least thirty (30) days prior written notice. Effective Date: 6/1/2020

Dental Fee Schedule Medicare Advantage (MCS Classicare)

Procedure Procedure Description General Dentistry/

Pedodontics & Prosthodontist

D0120 Periodic Oral Evaluation $17.00

D0140 Limited Oral Evaluation $21.00

D0150 Comprehensive Oral Evaluation (New or establish patient) $25.00

D0160 Consultation (diagnostic services provided by dentist or physician other than practitioner providing treatment)

Not Contracted

D0180 Comprehensive Periodontal Evaluation Not Contracted

D0210 Intra oral – complete series of radiographic images $50.00

D0220 Intraoral – periapical radiographic image $8.50

D0230 Intraoral – periapical each additional radiographic image

$8.50

D0240 Intraoral – occlusal radiographic image $8.96

D0270 Bitewing – single radiographic image $8.80

D0272 Bitewings – two radiographic images $17.00

D0274 Bitewings – two radiographic images $44.80

D0330 Panoramic radiographic image $40.00

D0350 2D Oral/facial photographic image obtained intra-orally or extra-orally

$12.80

D0460 Pulp Vitality Tests $6.40

D0480 Accession of exfoliative cytologic smear, microscopic, examination, preparation and transmission of written report

$160.00

D0482 Direct immunofluorescence $32.00

D0999 Unspecified Diagnostic Procedures, by Report By Report

DocuSign Envelope ID: 749D5DC4-909D-4C0F-8894-A2168BB67C57




D1110 Prophylaxis – Adult (Over 12 yrs old) $40.00

D1120 Prophylaxis – Child (Under 11 yrs old) $21.00

D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients

$20.00

D1208 Topical application of fluoride - excluding varnish (child only)

$16.00

D1351 Sealant Per Tooth $17.00

D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth

$23.04

D1516 Space Maintainer – Fixed Bilateral, Maxillary $183.04

D1517 Space Maintainer – Fixed Bilateral, Mandibular $183.04

D1520 Space Maintainer Removable Unilateral $83.20

D1526 Space Maintainer Removable Bilateral, Maxillary $121.60

D1527 Space Maintainer Removable Bilateral, Mandibular $121.60

D1550 Re-cementation or re-bond space maintainer $21.76

D1999 Unspecified preventive procedure, By Report By Report *40.00

D2140 Amalgam One Surfaces primary or permanent $38.00

D2150 Amalgam Two Surfaces primary or permanent $45.00

D2160 Amalgam Three Surfaces primary or permanent $55.00

D2161 Amalgam Four or More Surfaces primary or permanent

$65.00

D2330 Resin Based Composite – One Surface anterior $40.00

D2331 Resin Based Composite – Two Surfaces anterior $50.00

D2332 Resin Based Composite – Three Surfaces anterior $60.00

D2335 Resin Based Composite – Four or More surface or involving incisal angle

$75.00

D2391 Resin Based Composite – Posterior buccal surface only $50.00

D2392 Resin based composite-Two surfaces, posterior $56.32

D2393 Resin based composite-Three surfaces, posterior $66.56





D2394 Resin based composite-Four or more surfaces, posterior

$70.40

D2410 Gold foil-one surface $192.00

D2420 Gold foil-two surface $249.60

D2430 Gold foil-three surface $358.40

D2510 Inlay-metallic-one surface $192.00

D2520 Inlay-metallic-two surfaces $230.40

D2530 Inlay-metallic-three or more surfaces $256.00

D2542 Onlay metallic -two surfaces $165.12

D2543 Onlay metallic -three surfaces $263.68

D2544 Onlay metallic -four or more surfaces $416.00

D2610 Inlay-porcelain/ceramic - one surface $166.40

D2620 Inlay-porcelain/ceramic - two surfaces $230.40

D2642 Onlay porcelain/ceramic -two surfaces $165.12

D2643 Onlay porcelain/ceramic -three surfaces $263.68

D2644 Onlay porcelain/ceramic -four or more surfaces $416.00

D2650 Inlay-resin based-composite-one surface $128.00

D2651 Inlay-resin based-composite-two surfaces $224.00

D2652 Inlay-resin based-composite-three or more surfaces $288.00

D2662 Onlay – resin-based composite – two surfaces $230.40

D2663 Onlay – resin-based composite – three surfaces $294.40

D2664 Onlay – resin-based composite – four or more surfaces $320.00

D2720 Crown – resin with high noble metal $384.00

D2722 Crown – resin with noble metal $288.00

D2740 Crown Porcelain/Ceramic Substrate $448.00

D2750 Crown Porcelain Fused to High Noble Metal $480.00





D2751 Crown Porcelain Fused to predominantly base metal $384.00

D2752 Crown Porcelain Fused to Noble Metal $416.00

D2780 Crown 3/4 Cast High Noble Metal $416.00

D2781 Crown – ¾ cast predominantly base metal $256.00

D2782 Crown 3/4 Cast Noble Metal $320.00

D2783 Crown 3/4porcelain /ceramic $263.68

D2790 Crown Full Cast High Noble Metal $416.00

D2791 Crown – full cast predominantly base metal $384.00

D2792 Crown Full Cast Noble Metal $384.00

D2794 Crown – titanium $480.00

D2799 Provisional crown- further treatment or completion of diagnosis necessary to final impression

$64.00

D2910 Re-cementation or re-bond inlay, onlay, veneer or partial coverage restoration.

$26.88

D2915 Re- cement or re-bond indirectly fabricated or prefabricated post and core.

$25.60

D2920 Re-cement or re-bond crown $26.88

D2930 Prefabricated Stainless Steel Crown – Primary $70.00

D2931 Prefabricated Stainless Steel Crown – Permanent $89.60

D2940 Protective restoration $31.25

D2950 Core Buildup, Including Any Pins, when required $70.40

D2951 Pin Retention Per Tooth in addition to restoration $16.64

D2952 Cast Post and Core in Addition to Crown $128.00

D2954 Prefabricated Post and Core in Addition to Crown $96.00

D2962 Labial veneer (porcelain laminate)-laboratory $384.00

D2971 Additional procedures to construct new crown under existing partial denture framework

$38.40

D2980 Crown repair necessitated by restorative material failure $76.80

D2999 Unspecified restorative procedure, by report By Report





D3110 Pulp Cap Direct (excluding final restoration) $25.60

D3120 Pulp Cap Indirect (excluding final restoration) $20.00

D3220 Therapeutic Pulpotomy (excluding final restoration) $48.85

D3221 Pulpal Debridement, Primary and Permanent $24.15

D3230 Pulpal Therapy (resorbable) anterior tooth $83.20

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

$102.40

D3310 Anterior Canal Therapy (excluding final restoration) $165.00

D3320 Bicuspid Canal Therapy (excluding final restoration) $250.00

D3330 Molar Canal Therapy (excluding final restoration) $384.00

D3333 Internal root repair of perforation defects Not Contracted

D3346 Retreatment of previous root canal therapy – Anterior $211.20

D3347 Retreatment of previous root canal therapy –Bicuspid $300.00

D3348 Retreatment of previous root canal therapy – Molar $425.00

D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.)

Not Contracted

D3352 Apexification/recalcification – interim medication replacement

Not Contracted

D3353 Apexification/Recalcification – Final Visit Not Contracted

D3410 Apicoectomy – Anterior Not Contracted

D3421 Apicoectomy – Bicuspid (first root) Not Contracted

D3425 Apicoectomy – Molar (first root) Not Contracted

D3426 Apicoectomy - each additional root Not Contracted

D3430 Retrograde Filling – Per Root Not Contracted

D3450 Root Amputation – Per Root Not Contracted

D3920 Hemisection Not Contracted

D3999 Unspecified endodontic procedure, by report Not Contracted

D4210 Gingivectomy or Gingivoplasty – Four or More contiguous teeth per quadrant

$200.00





D4211 Gingivectomy or Gingivoplasty – One to Three teeth per quadrant

$75.00

D4240 Gingival Flap Procedure Four or More Teeth Not Contracted

D4241 Gingival Flap Procedure – One to Three Teeth Not Contracted

D4245 Apically Positioned Flap Not Contracted

D4249 Clinical Crown Lengthening – Hard Tissue Not Contracted

D4260 Osseous surgery (including elevation of a full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant.

Not Contracted

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

Not Contracted

D4263 Bone Replacement Graft – First Site Not Contracted

D4264 Bone Replacement Graft NC Each Additional Site Not Contracted

D4265 Biologic materials to aid in soft and osseous tissue regeneration

Not Contracted

D4266 Guided tissue regeneration- resorbable barrier, per site Not Contracted

D4267 Guided tissue regeneration- nonresorbable barrier, per site (includes membrane removal

Not Contracted

D4270 Pedicle soft tissue graft procedure Not Contracted

D4273 Autogenous connective tissue graft procedures (including donor or recipient surgical sites) first tooth, implant, or edentulous tooth position in graft

Not Contracted

D4277 Free soft tissue graft procedure (including recipient and donor site (surgery) first tooth , implant, or edentulous tooth position in graft

Not Contracted

D4320 Provisional splinting - intracoronal $38.40

D4321 Provisional splinting-extracoronal Not Contracted

D4341 Periodontal Scaling/Root Planning, Four or More contiguous teeth per quadrant

$83.20

D4342 Periodontal Scaling/Root Planning, One to Three per quadrant

$51.20

D4355 Full Mouth Debridement to enable comprehensive evaluation and diagnosis

$46.08

D4910 Periodontal Maintenance Not Contracted





D4920 Unscheduled dressing change - by someone other than treating dentist or their staff.

$25.60

D4999 Unspecified Periodontics procedures Not Contracted

D5110 Complete Denture – Maxillary $448.00

D5120 Complete Denture – Mandibular $448.00

D5130 Immediate Denture – Maxillary $512.00

D5140 Immediate Denture – Mandibular $512.00

D5211 Maxillary Partial Denture – Resin Base $256.00

D5212 Mandibular Partial Denture – Resin Base $256.00

D5213 Maxillary Partial Denture – Cast Metal Framework $518.40

D5214 Mandibular Partial Denture–Cast Metal Framework $518.40

D5282 Removable Unilateral Partial Denture-Maxillary $256.00

D5283 Removable Unilateral Partial Denture-Mandibular $256.00

D5410 Adjust Complete Denture – Maxillary $32.00

D5411 Adjust Complete Denture – Mandibular $32.00

D5421 Adjust Partial Denture – Maxillary $32.00

D5422 Adjust Partial Denture – Mandibular $32.00

D5510 Repair Broken Complete Denture Base $53.76

D5520 Replace Missing or Broken Teeth $57.60

D5610 Repair Resin Denture Base $53.76

D5621 Repair Cast Framework-Mandibular $89.60

D5622 Repair Cast Framework-Maxillary $89.60

D5630 Repair or Replace Broken Clasp - per tooth $76.80

D5640 Repair Broken Teeth NC Per Tooth $53.76

D5650 Add Tooth to Existing Partial Denture $53.76

D5660 Add Clasp to Existing Partial Denture - per tooth $89.60





D5710 Rebase Complete Maxillary Denture $128.00

D5711 Rebase Complete Mandibular Denture $128.00

D5720 Rebase Maxillary Partial Denture $121.60

D5721 Rebase Mandibular Partial Denture $121.60

D5730 Reline Complete Maxillary Denture (chairside) $102.40

D5731 Reline Complete Mandibular Denture (chairside) $102.40

D5740 Reline Maxillary Partial Denture (chairside) $96.00

D5741 Reline Mandibular Partial Denture (chairside) $96.00

D5750 Reline Complete Maxillary Denture (laboratory) $89.60

D5751 Reline complete mandibular denture (laboratory) $89.60

D5760 Reline Maxillary Partial Denture (laboratory) $89.60

D5761 Reline mandibular partial denture (laboratory) $89.60

D5850 Tissue Conditioning, Maxillary $38.40

D5851 Tissue Conditioning, Mandibular $38.40

D5899 Unspecified removable prosthodontics procedure, by report

By Report

D5986 Fluoride gel carrier $46.08

D6010 Surgical Placement of implant body: endosteal implant Not Contracted

D6058 Abutment supported porcelain/ceramic crown $448.00

D6059 Abutment supported porcelain fused to metal crown (high noble metal)

$480.00

D6060 Abutment supported porcelain fused to metal crown (predominantly base metal)

$384.00

D6061 Abutment supported porcelain fused to metal crown (noble metal)

$416.00

D6062 Abutment supported cast metal crown (high noble metal)

$416.00

D6063 Abutment supported cast metal crown (predominantly base metal)

$364.80

D6064 Abutment supported cast metal crown (noble metal) $384.00





D6065 Implant supported porcelain/ceramic crown $448.00

D6066 Implant Support Porcelain Fused to Metal Crown (Titanium, Alloy, High Noble Metal)

$480.00

D6067 Implant Support Metal Crown (Titanium, Alloy, High Noble Metal)

$416.00

D6068 Abutment supported retainer for porcelain/ceramic FPD $492.80

D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal)

$524.80

D6070 Abutment supported retainer for porcelain fused to metal FPD

$428.80

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal)

$460.80

D6072 Abutment supported retainer for cast metal FPD (high noble metal)

$460.80

D6073 Abutment supported retainer for cast metal FPD (predominantly base metal)

$409.60

D6074 Abutment supported retainer for cast metal FPD (noble metal)

$428.80

D6075 Implant supported retainer for ceramic FPD $441.60

D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal)

$441.60

D6077 Implant supported retainer for cast metal FPS (titanium, titanium alloy, or high noble metal

$367.36

D6210 Pontic Cast High Noble Metal $448.00

D6211 Pontic Cast Predominantly base metal $352.00

D6212 Pontic Cast Noble Metal $384.00

D6214 Pontic – titanium $416.00

D6240 Pontic Porcelain Fused to High Noble Metal $460.80

D6241 Pontic- porcelain fused to predominantly base metal $384.00

D6242 Pontic Porcelain Fused to Noble Metal $416.00

D6250 Pontic resin with high noble metal $448.00

D6545 Retainer – Cast Metal for Resin Bonded Fixed $192.00

D6606 Retainer inlays – cast noble metal, two surfaces $185.60





D6607 Retainer inlay – cast noble metal, three or more surfaces

$211.20

D6608 Retainer onlay – porcelain/ceramic, two surfaces $281.60

D6609 Retainer onlay – porcelain/ceramic, three or more surfaces

$332.80

D6610 Retainer onlay – cast high noble metal, two surfaces $256.00

D6710 Retainer crown – indirect resin based composite $192.00

D6720 Retainer crown - resin with high noble metal $384.00

D6750 Retainer crown Porcelain Fused to High Noble Metal $480.00

D6751 Retainer crown Porcelain Fused to High Noble Metal $384.00

D6752 Retainer crown Porcelain Fused Noble Metal $416.00

D6780 Retainer crown 3/4 cast high noble metal $416.00

D6781 Retainer crown – ¾ cast predominantly base metal $352.00

D6782 Retainer crown – ¾ cast noble metal $384.00

D6783 Retainer crown 3/4 Porcelain/Ceramic $480.00

D6790 Retainer crown Full Cast High Noble Metal $416.00

D6791 Retainer crown – full cast predominantly base metal $352.00

D6792 Retainer crown Full Cast Noble Metal $384.00

D6794 Retainer crown – titanium $460.80

D6930 Re-cement or re-bond fixed partial denture $38.40

D6980 Fixed partial denture repair necessitated by restorative material failure

By Report

D6999 Unspecified fixed prosthodontics procedure, by report By Report

D7111 Coronal Remnants – Deciduous Tooth $32.00

D7140 Extraction, Erupted Tooth or Exposed Root $39.28

D7210 Surgical Removal or Erupted Tooth $70.10

D7220(4) Removal of Impacted Tooth Soft Tissue $112.15

D7230(4) Removal of Impacted Tooth Partially Bony $138.25





D7240(4) Removal of Impacted Tooth Completely Bony $159.81

D7241(4) Removal of Impacted Tooth – Complicated Not Contracted

D7250 Surgical Removal of Residual Tooth Roots $50.00

D7260 Oroantral Fistula Closure $96.00

D7261 Primary Closure of a Sinus Perforation $38.40

D7270 Tooth Reimplantation and/or Stabilization $102.40

D7272 Tooth Transportation Not Contracted

D7280 Surgical Access of an Unerupted Tooth $134.40

D7283 Placement of device to facilitate eruption of impacted tooth

$51.20

D7285 Incisional biopsy of oral tissue - hard (bone - tooth) $74.24

D7286 Incisional biopsy of oral tissue -soft $64.00

D7290 Surgical Repositioning of Teeth $102.40

D7291 Transseptal fibertomy/supra crestal fiberotomy, by report

Not Contracted

D7310 Alveoloplasty in Conjunction with Extractions $76.80

D7311 Alveoloplasty in Conjunction with Extractions-one to three teeth or tooth spaces, per quadrant

$51.20

D7320 Alveoloplasty not in Conjunction with Extractions $89.60

D7321 Alveoloplasty in Conjunction with Extractions-one to three teeth or tooth spaces, per quadrant

$76.80

D7340 Vestibuloplasty Secondary Epithelialization Not Contracted

D7350 Vestibuloplasty –Soft Tissue Grafts Not Contracted

D7471 Removal of Lateral Exostosis $115.20

D7472 Removal of Torus Palatinus $115.20

D7473 Removal of Torus Mandibularis $115.20

D7510 Incision and Drainage of Abscess Intraoral $22.41

D7520 Incision and Drainage of Abscess – Extraoral Not Contracted

D7550 Partial oslectomy/sequestrecstomy for removal on non-vitals

Not Contracted





D7670 Alveolus – closed reduction, may include stabilization of teeth

Not Contracted

D7671 Alveolus – open reduction, may include stabilization of teeth

Not Contracted

D7960 Frenulectomy Separate Procedure $102.40

D7970 Excision of Hyperplastic Tissue Per Arch $121.60

D7971 Excision of Pericoronal Gingiva $64.00

D7999 Unspecified oral surgery procedure, by report Not Contracted

D9110 Palliative (Emergency) Treatment of Dental Pain $23.90

D9222 Deep sedation /general anesthesia - First 15 minutes increment

$173.95

D9223 Deep sedation /general anesthesia - each subsequent 15 minutes increment

$173.95

D9239 Intravenous moderate (conscious) sedation/analgesia - First 15 minutes

Not Contracted

D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minutes increment

Not Contracted

D9420 Hospital & Ambulatory Center care $206.43

D9630 Other drugs and/or medicaments, by report Not Contracted

D9910 Application of desensitizing resin for cervical and/or root surface, per tooth

$25.60

D9930 Treatment of complications (post-surgical)-unusual circumstances, by report

By Report

D9940 Occlusal guard, by report $160.00

D9951 Occlusal adjustment - limited Not Contracted

D9952 Occlusal adjustment - complete Not Contracted

D9999 Unspecified adjunctive procedure, by report $25.60

* D1999 – Effective 5/1/2020 until 7/31/2020 can be billed per patient visit to cover the cost related to

Protective Personal Equipment (PPE). Future rate will be communicated after 7/31/2020.


2020-05-02T13:29:03-0700Digitally verifiable PDF exported from www.docusign.com

Documents

EXHIBIT A FEE-FOR-SERVICE (FFS) General Dentist ... Dental... · D5510 Repair Broken Complete Denture Base $53.76 D5520 Replace Missing or Broken Teeth $57.60 D5610 Repair Resin Denture