Common use of Preventive Clause in Contracts

Preventive. D1110 Prophylaxis - adult $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1120 Prophylaxis - child $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish $10 1 of (D1206, D1208) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1208 Topical application of fluoride - excluding varnish $10 1 of (D1206, D1208) per 6 months D1351 Sealant - per tooth $20 Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $20 Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - per tooth $10 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant $150 D1516 Space maintainer - fixed - bilateral, maxillary $225 D1517 Space maintainer - fixed - bilateral, mandibular $225 D1520 Space maintainer - removable, unilateral - per quadrant $150 D1526 Space maintainer - removable - bilateral, maxillary $225 D1527 Space maintainer - removable - bilateral, mandibular $225 D1551 Re-cement or re-bond bilateral space maintainer - maxillary $30 D1552 Re-cement or re-bond bilateral space maintainer - mandibular $30 D1553 Re-cement or re-bond unilateral space maintainer - per quadrant $30 D1556 Removal of fixed unilateral space maintainer- per quadrant $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant $150 1 per quadrant per lifetime; Age 8 and under

Preventive. D1110 Prophylaxis - adult $15 No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months 1 per 6 months D1120 Prophylaxis - child $15 Not a benefit Cleaning; 1 of (D1110, D1120, D4346) per 6 months Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1206 Topical application of fluoride varnish $10 No Cost 1 of (D1206, D1208) per D1208)per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees 1 of (D1206 or D1208)per 6 months D1208 Topical application of fluoride - excluding varnish $10 No Cost 1 of (D1206, D1208) per D1208)per 6 months 1 of (D1206 or D1208)per 6 months D1310 Nutritional counseling for control of dental disease Not a benefit No Cost D1330 Oral hygiene instructions Not a benefit No Cost D1351 Sealant - per tooth $20 Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $20 Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - per tooth pertooth $10 No Cost 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant $150 Not a benefit D1516 Space maintainer - fixed - bilateral, maxillary $225 Not a benefit D1517 Space maintainer - fixed - bilateral, mandibular $225 Not a benefit D1520 Space maintainer - removable, unilateral - per quadrant $150 Not a benefit D1526 Space maintainer - removable - bilateral, maxillary $225 Not a benefit D1527 Space maintainer - removable - bilateral, mandibular $225 Not a benefit D1551 Re-cement or re-bond bilateral space maintainer - maxillary $30 Not a benefit D1552 Re-cement or re-bond bilateral space maintainer - mandibular $30 Not a benefit D1553 Re-cement or re-bond unilateral space maintainer - per quadrant $30 Not a benefit D1556 Removal of fixed unilateral space maintainer- maintainer - per quadrant $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/treatingdentist/ dental office Code Description Pediatric Enrollee CostShare1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1557 Removal of fixed bilateral space maintainer - maxillary $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentisttreatingdentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original theoriginal treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant $150 Not a benefit 1 per quadrant per lifetime; Age 8 and under

Preventive. D1110 Prophylaxis - adult $15 No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1120 Prophylaxis - child $15 No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish $10 No cost 1 of (D1206, D1208) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1208 Topical application of fluoride - excluding varnish $10 No cost 1 of (D1206, D1208) per 6 months D1351 Sealant - per tooth $20 No cost Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $20 No cost Permanent molars without restorations or decay; 1 per 36 months 36months D1354 Interim caries arresting medicament application - application- per tooth $10 No cost 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant $150 No cost D1516 Space maintainer - fixed - bilateral, maxillary $225 No cost D1517 Space maintainer - fixed - bilateral, mandibular $225 No cost D1520 Space maintainer - removable, unilateral - per quadrant $150 No cost D1526 Space maintainer - removable - bilateral, maxillary $225 No cost Code Description Pediatric Enrollee Cost Share Clarification/Limitations for Pediatric Enrollees D1527 Space maintainer - removable - bilateral, mandibular $225 No cost D1551 Re-cement or re-bond bilateral space maintainer - maxillary $30 No cost D1552 Re-cement or re-bond bilateral space maintainer - mandibular $30 No cost D1553 Re-cement or re-bond unilateral space maintainer - per quadrant $30 No cost D1556 Removal of fixed unilateral space maintainer- maintainer - per quadrant $10 No cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary $10 No cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular $10 No cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant $150 No cost 1 per quadrant per lifetime; Age 8 and under

Preventive. D1110 Prophylaxis - adult $15 No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months 1 per 6 months D1120 Prophylaxis - child $15 Not a benefit Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish $10 No Cost 1 of (D1206, D1208) per D1208)per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees 1 of (D1206 or D1208)per 6 months D1208 Topical application of fluoride - excluding varnish $10 No Cost 1 of (D1206, D1208) per D1208)per 6 months 1 of (D1206 or D1208)per 6 months D1310 Nutritional counseling for control of dental disease Not a benefit No Cost D1330 Oral hygiene instructions Not a benefit No Cost D1351 Sealant - per tooth $20 Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $20 Not a benefit Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - per tooth $10 No Cost 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant $150 Not a benefit D1516 Space maintainer - fixed - bilateral, maxillary $225 Not a benefit D1517 Space maintainer - fixed - bilateral, mandibular $225 Not a benefit D1520 Space maintainer - removable, unilateral - per quadrant $150 Not a benefit D1526 Space maintainer - removable - bilateral, maxillary $225 Not a benefit Code Description Pediatric Enrollee Cost Share1 Adult Enrollee Cost Share2 Clarification/ Limitations for Pediatric Enrollees Clarification/ Limitations for Adult Enrollees D1527 Space maintainer - removable - bilateral, mandibular $225 Not a benefit D1551 Re-cement or re-bond bilateral space maintainer - maxillary $30 Not a benefit D1552 Re-cement or re-bond bilateral space maintainer - mandibular $30 Not a benefit D1553 Re-cement or re-bond unilateral space maintainer - per quadrant $30 Not a benefit D1556 Removal of fixed unilateral space maintainer- maintainer - per quadrant $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/treatingdentist/ dental office D1557 Removal of fixed bilateral space maintainer - maxillary $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentisttreatingdentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular $10 Not a benefit Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original theoriginal treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant $150 Not a benefit 1 per quadrant per lifetime; Age 8 and under

Preventive. D1110 Prophylaxis - adult $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1120 Prophylaxis - child $15 Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish $10 1 of (D1206, D1208) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1208 Topical application of fluoride - excluding varnish $10 1 of (D1206, D1208) per 6 months D1351 Sealant - per tooth $20 Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $20 Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - per tooth $10 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant $150 D1516 Space maintainer - fixed - bilateral, maxillary $225 D1517 Space maintainer - fixed - bilateral, mandibular $225 D1520 Space maintainer - removable, unilateral - per quadrant $150 D1526 Space maintainer - removable - bilateral, maxillary $225 D1527 Space maintainer - removable - bilateral, mandibular $225 D1551 Re-cement or re-bond bilateral space maintainer - maxillary $30 D1552 Re-cement or re-bond bilateral space maintainer - mandibular $30 D1553 Re-cement or re-bond unilateral space maintainer - per quadrant $30 D1556 Removal of fixed unilateral space maintainer- per quadrant $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular $10 Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant $150 1 per quadrant per lifetime; Age 8 and underunder Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees

Preventive. D1110 Prophylaxis - adult $15 No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1120 Prophylaxis - child $15 No cost Cleaning; 1 of (D1110, D1120, D4346) per 6 months D1206 Topical application of fluoride varnish $10 No cost 1 of (D1206, D1208) per 6 months Code Description Pediatric Enrollee Cost Share1 Clarification/Limitations for Pediatric Enrollees D1208 Topical application of fluoride - excluding varnish $10 No cost 1 of (D1206, D1208) per 6 months D1351 Sealant - per tooth $20 No cost Permanent molars without restorations or decay; 1 per 36 months D1352 Preventive resin restoration in a moderate to high caries risk patient - permanent tooth $20 No cost Permanent molars without restorations or decay; 1 per 36 months D1354 Interim caries arresting medicament application - application- per tooth $10 No cost 1 per 6 months D1510 Space maintainer - fixed, unilateral - per quadrant $150 No cost D1516 Space maintainer - fixed - bilateral, maxillary $225 No cost D1517 Space maintainer - fixed - bilateral, mandibular $225 No cost D1520 Space maintainer - removable, unilateral - per quadrant $150 No cost D1526 Space maintainer - removable - bilateral, maxillary $225 No cost D1527 Space maintainer - removable - bilateral, mandibular $225 No cost D1551 Re-cement or re-bond bilateral space maintainer - maxillary $30 No cost D1552 Re-cement or re-bond bilateral space maintainer - mandibular $30 No cost D1553 Re-cement or re-bond unilateral space maintainer - per quadrant $30 No cost Code Description Pediatric Enrollee Cost Share Clarification/Limitations for Pediatric Enrollees D1556 Removal of fixed unilateral space maintainer- maintainer - per quadrant $10 No cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1557 Removal of fixed bilateral space maintainer - maxillary $10 No cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1558 Removal of fixed bilateral space maintainer - mandibular $10 No cost Included in case by dentist/dental office who placed appliance; a separate charge applies for service provided by a dentist other than the original treating dentist/dental office D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant $150 No cost 1 per quadrant per lifetime; Age 8 and under