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Home My WebLink AboutEMPLOYEE GROUP INSURANCE RENEWALS/LONG TERM DISABILITY, MEDICAL, DENTAL, VISION, EMPLOYEE ASSISTANCE, GROUP LIFE/ ACCIDENTAL DEATH/DISMEMBERMENT - 2014INSURANCE NOT REQUIRED WORK MAY PROCEED CLERK OF COUNCIL n . 1?j �Y)� A -2014 -176 AMENDMENT NO. 9 TO AGREEMENT RENEWAL GROUP #00599 AGREEMENT dated January 1, 2005, as amended, between CITY OF SANTA ANA and DELTA DENTAL OF CALIFORNIA "Delta Dental," is hereby further amended, effective January 1, 2015, as follows: Paragraph 1.4 is amended to read: 1.4 "Contract Term" means the period beginning on January 1, 2015, and ending on December 31, 2015 and each subsequent yearly period during which this Contract remains in effect. Paragraph 9.2 is amended to read: 9.2 If Delta Dental terminates this Contract under paragraph 9.1 (a), all Benefits end and Delta Dental is released from all further obligations of this Contract, effective the last day of the month in which written notice of termination is given. The Contractholder will remain liable to Delta Dental for the greater of: (1) the unpaid Premiums applicable for the period this Contract was in effect before termination; or (2) the full amount of all Dentist's statements paid or otherwise discharged by Delta Dental during the full term of this Contract, plus 15.55% of such amount (to compensate Delta Dental for its administration of the dental plan), less amounts actually paid by the Contractholder to Delta Dental during the term of such Contract. Appendix B, CODE ON DENTAL PROCEDURES AND NOMENCLATURE, attached hereto, is hereby amended. ~v - | ` AGREEMENT dated DENTAL OFCALIFORNIA AMENDMENT NO. 9 TO AGREEMENT RENEWAL GROUP #00599 January 1, 2005/ as amended, between CITY OF SANTA ANA and DELTA "Delta Dental," is hereby further amended, effective January 1, 2015, as Paragraph 1^4|samended to read: 1.4 "Contract Term" means the period beginning on January 1, 2015, and ending on December 31, 2015 and each subsequent yearly period during which this Contract remains in effect. Paragraph 9.2 is amended to read: 9.2 If Delta Dental terminates this Contract under paragraph 9.1 (a), all Benefits end and Delta Dental is released from all further obligations of this Contract, effective the last day of the month in which written notice of termination is given, The Contractholder will remain liable to Delta Dental for the greater of: (1) the unpaid Premiums applicable for the period this Contract was in effect before termination; or (2) the full amount of all Dentist's statements paid or otherwise discharged by Delta Dental during the full term of this Contract, plus 15.55% of such amount (to compensate Delta Dental for its administration of the dental plan), less amounts actually paid by the Contractholder to Delta Dental during the term of such Contract. Appendix B/ CODE ON DENTAL PROCEDURES AND NOMENCLATURE/ attached hereto, is hereby amended. INSURANCE NOT REQUIRED ilz WORK MAY PROCEED CLERK OF COUNCI[, ~v - | ` AGREEMENT dated DENTAL OFCALIFORNIA AMENDMENT NO. 9 TO AGREEMENT RENEWAL GROUP #00599 January 1, 2005/ as amended, between CITY OF SANTA ANA and DELTA "Delta Dental," is hereby further amended, effective January 1, 2015, as Paragraph 1^4|samended to read: 1.4 "Contract Term" means the period beginning on January 1, 2015, and ending on December 31, 2015 and each subsequent yearly period during which this Contract remains in effect. Paragraph 9.2 is amended to read: 9.2 If Delta Dental terminates this Contract under paragraph 9.1 (a), all Benefits end and Delta Dental is released from all further obligations of this Contract, effective the last day of the month in which written notice of termination is given, The Contractholder will remain liable to Delta Dental for the greater of: (1) the unpaid Premiums applicable for the period this Contract was in effect before termination; or (2) the full amount of all Dentist's statements paid or otherwise discharged by Delta Dental during the full term of this Contract, plus 15.55% of such amount (to compensate Delta Dental for its administration of the dental plan), less amounts actually paid by the Contractholder to Delta Dental during the term of such Contract. Appendix B/ CODE ON DENTAL PROCEDURES AND NOMENCLATURE/ attached hereto, is hereby amended. CITY OF SANTA ANA DELTA DENTAL GROUP #00599 Date Amendment M David Cavazos Printed Name City Manager Title DATE: January 16, 2015 DELTA DENTAL OF CALIFORNIA Belinda Martinez Senior Vice President Sales /Marketing Kevin Jackson Group Vice President Underwriting & Actuarial APPROVED AS TO FORM LISA E. STORCK Assistant City Attorney ATTEST: MARIA D. HUIZAR CLERK OF THE COUNCIL CODE ON DENTAL PROCEDURES AND NOMENCLATURE NOTE: All the listed procedures may not be benefits under the terms of your contract. Refer to your contract for your specific benefits. D010O - D0999 DIAGNOSTIC Clinical oral evaluations D0120 Periodic oral evaluation - established patient D0140 Limited oral evaluation — problem focused DO145 Oral evaluation for a patient under three years of age and counseling with primary caregiver D0150 Comprehensive oral evaluation — new or established patient D0160 Detailed and extensive oral evaluation — problem focused, by report D0170 Re- evaluation — limited, problem focused (established patient; not post- operative visit) D0180 Comprehensive periodontal evaluation — new or established patient D0190 Screening of a patient D0191 Assessment of a patient Radiographs /diagnostic imaging (including interpretation) D0210 Intraoral — complete series of radiographic images D0220 Intraoral — periapical first radiographic image D0230 Intraoral — periapical each additional radiographic image D0240 Intraoral — occlusal radiographic image D0250 Extraoral — first radiographic image D0260 Extraoral — each additional radiographic image D0270 Bitewing — single radiographic image D0272 Bitewings — two radiographic images DO273 Bitewings - three radiographic images D0274 Bitewings — four radiographic images D0277 Vertical bitewings — 7 to 8 radiographic images D0290 Posterior — anterior or lateral skull and facial bone survey radiographic image D0310 Sialography D0320 Temporomandibular joint arthrogram, including injection D0321 Other temporomandibular joint radiographic images, by report D0322 Tomographic survey D0330 Panoramic radiographic image D0340 Cephalometric radiographic image D0350 Oral /facial photographic images obtained intraorally or extraorally Tests and examinations D0415 Collection of microorganisms for culture and sensitivity D0416 Viral culture D0421 Genetic test for susceptibility to oral diseases D0425 Caries susceptibility tests D0431 Adjunctive pre- diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures D0460 Pulp vitality tests D0470 Diagnostic casts Oral pathology laboratory D0472 Accession of tissue, gross examination, preparation and transmission of written report D0473 Accession of tissue, gross and microscopic examination, preparation and transmission of written report CDT2015 (Eff. 01- 01 -15) D0474 Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report D0475 Decalcification procedure D0476 Special stains for microorganisms D0477 Special stains, not for microorganisms D0478 Immunohistochemical stains D0479 Tissue in -situ hybridization, including interpretation D0480 Accession of exfoliative cytologic smears, microscopic examination, preparation and transmission of written report D0481 Electron microscopy - diagnostic D0482 Direct immunofluorescence D0483 Indirect immunofluorescence D0484 Consultation on slides prepared elsewhere D0485 Consultation, including preparation of slides from biopsy material supplied by referring source D0486 Accession of brush biopsy sample, microscopic examination, preparation and transmission of written report D0502 Other oral pathology procedures, by report D0601 Caries risk assessment and documentation, with a finding of low risk D0602 Caries risk assessment and documentation, with a finding of moderate risk D0603 Caries risk assessment and documentation, with a finding of high risk D0999 Unspecified diagnostic procedure, by report D1000 - D1999 PREVENTIVE Dental prophylaxis D1110 Prophylaxis — adult D1120 Prophylaxis — child through age 13 Topical fluoride treatment (office procedure) D1206 Topical application of fluoride varnish D1208 Topical application of fluoride - excluding varnish Other preventive services D1310 Nutritional counseling for control of dental disease D1320 Tobacco counseling for the control and prevention of oral D1330 Oral hygiene instructions D1351 Sealant — per tooth D1352 Preventive resin restoration in a moderate to high caries D1555 tooth Space maintenance (passive appliances) D1510 Space maintainer — fixed — unilateral D1515 Space maintainer — fixed — bilateral D1520 Space maintainer — removable — unilateral D1525 Space maintainer — removable — bilateral D1550 Re- cement or re -bond space maintainer D1555 Removal of fixed space maintainer disease risk patient - permanent D2000 - D2999 RESTORATIVE Amalgam restorations (including polishing) D2140 Amalgam — one surface, primary or permanent D2150 Amalgam — two surfaces, primary or permanent D2160 Amalgam — three surfaces, primary or permanent D2161 Amalgam — four or more surfaces, primary or permanent CDT2015 (Eff. 01- 01 -15) Resin -based composite restorations- direct D2330 Resin -based composite — one surface, anterior D2331 Resin -based composite — two surfaces, anterior D2332 Resin -based composite — three surfaces, anterior D2335 Resin -based composite — four or more surfaces or involving incisal angle (anterior) D2390 Resin -based composite crown, anterior D2391 Resin -based composite — one surface, posterior D2392 Resin -based composite — two surfaces, posterior D2393 Resin -based composite — three surfaces, posterior D2394 Resin -based composite — four or more surfaces, posterior Gold foil restorations D2410 Gold foil — one surface D2420 Gold foil — two surfaces D2430 Gold foil — three surfaces Inlay /onlay restorations D2510 Inlay — metallic — one surface D2520 Inlay — metallic — two surfaces D2530 Inlay — metallic — three or more surfaces D2542 Onlay — metallic — two surfaces D2543 Onlay — metallic — three surfaces D2544 Onlay — metallic — four or more surfaces D2610 Inlay — porcelain /ceramic — one surface D2620 Inlay — porcelain /ceramic — two surfaces D2630 Inlay — porcelain /ceramic — three or more surfaces D2642 Onlay — porcelain /ceramic — two surfaces D2643 Onlay — porcelain /ceramic — threesurfaces D2644 Onlay — porcelain /ceramic — four or more surfaces D2650 Inlay — resin -based composite — one surface D2651 Inlay — resin -based composite — two surfaces D2652 Inlay — resin -based composite — three or more surfaces D2662 Onlay — resin -based composite — two surfaces D2663 Onlay — resin -based composite — three surfaces D2664 Onlay — resin -based composite — four or more surfaces Crowns — single restorations only D2710 Crown — resin -based composite (indirect) D2712 Crown — 3/4 resin -based composite (indirect) D2720 Crown — resin with high noble metal D2721 Crown — resin with predominantly base metal D2722 Crown — resin with noble metal D2740 Crown — porcelain /ceramic substrate D2750 Crown — porcelain fused to high noble metal D2751 Crown — porcelain fused to predominantly base metal D2752 Crown — porcelain fused to noble metal D2780 Crown — 3/4 cast high noble metal D2781 Crown — 3/4 cast predominantly base metal D2782 Crown — 3/4 cast noble metal D2783 Crown — 3/4 porcelain /ceramic D2790 Crown — full cast high noble metal D2791 Crown — full cast predominantly base metal D2792 Crown — full cast noble metal D2794 Crown — titanium D2799 Provisional crown- further treatment or completion of a diagnosis necessary prior to final impression CDT2015 (Eff. 01- 01 -15) Other restorative services D2910 Re- cement or re -bond inlay, onlay, veneer or partial coverage restorations D2915 Re- cement or re -bond indirectly fabricated or prefabricated post and core D2920 Re- cement or re -bond crown D2921 Reattachment of tooth fragment, incisal edge or cusp D2929 Prefabricated porcelain /ceramic crown - primary tooth D2930 Prefabricated stainless steel crown — primary tooth D2931 Prefabricated stainless steel crown — permanent tooth D2932 Prefabricated resin crown D2933 Prefabricated stainless steel crown with resin window D2934 Prefabricated esthetic coated stainless steel crown — primary tooth D2940 Sedative filling D2941 Interim therapeutic restoration - primary dentition D2950 Core buildup, including any pins when required D2951 Pin retention — per tooth, in addition to restoration D2952 Post and core in addition to crown, indirectly fabricated D2953 Each additional indirectly fabricated post — same tooth D2954 Prefabricated post and core in addition to crown D2955 Post removal D2957 Each additional prefabricated post — same tooth D2960 Labial veneer (resin laminate) — chairside D2961 Labial veneer (resin laminate) — laboratory D2962 Labial veneer (porcelain laminate) — laboratory D2970 Temporary crown (fractured tooth) D2971 Additional procedures to construct new crown under existing partial denture framework D2975 Coping D2980 Crown repair, necessitated by restorative material failure D2999 Unspecified restorative procedure, by report D3000 - D3999 ENDODONTICS Pulp capping D3110 Pulp cap — direct (excluding final restoration) D3120 Pulp cap — indirect (excluding final restoration) Pulpotomy D3220 Therapeutic pulpotomy (excluding final restoration) — removal of pulp corona) to the dentinocemental junction and application of medicament D3221 Pulpal debridement, primary and permanent teeth D3222 Partial pulpotomy for apexogenesis- permanent tooth with incomplete root development D3230 Pulpal therapy (resorbable filling) — anterior, primary tooth (excluding final restoration) D3240 Pulpal therapy (resorbable filling) — posterior, primary tooth (excluding final restoration) Endodontic therapy on primary teeth (including treatment plan, clinical procedures and follow -up care) D3310 Endodontic therapy, anterior tooth (excluding final restoration) D3320 Endodontic therapy, bicuspid tooth (excluding final restoration) D3330 Endodontic therapy, molar tooth (excluding final restoration) D3331 Treatment of root canal obstruction; non - surgical access D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth D3333 Internal root repair of perforation defects CDT2015 (Eff. 01- 01 -15) Endodontic retreatment D3346 Retreatment of previous root canal therapy — anterior D3347 Retreatment of previous root canal therapy — bicuspid D3348 Retreatment of previous root canal therapy — molar Apexification /recalcification procedures D3351 Apexification /recalcif!cation — initial visit (apical closure /calcific repair of perforations, root resorption, etc.) D3352 Apexification /recalcif!cation — interim medication replacement (apical closure /calcific repair of perforations, root resorption, pulpal space disinfection, etc.) D3353 Apex! fication /recal cif! cation — final visit (includes completed root canal therapy — apical closure /calcific repair of perforations, root resorption, etc.) Apicoectomy /periradicular services D3410 Apicoectomy — anterior D3421 Apicoectomy — bicuspid (first root) D3425 Apicoectomy — molar (first root) D3426 Apicoectomy (each additional root) D3427 Periadicular surgery without apicoectomy D3430 Retrograde filling — per root D3450 Root amputation — per root D3460 Endodontic endosseous implant D3470 Intentional reimplantation (including necessary splinting) Other endodontic procedures D3910 Surgical procedure for isolation of tooth with rubber dam D3920 Hemisection (including any root removal), not including root canal therapy D3950 Canal preparation and fitting of preformed dowel or post D3999 Unspecified endodontic procedure, by report D4000 - D4999 PERIODONTICS Surgical services (including usual post - operative care) D4210 Gingivectomy or gingivoplasty — four or more contiguous teeth or bounded teeth spaces per quadrant D4211 Gingivectomy or gingivoplasty — one to three contiguous teeth or bounded teeth spaces per quadrant D4212 Gingivectomy or gingivoplasty - to allow access for restorative procedure, per tooth D4230 Anatomical crown exposure - four or more contiguous teeth per quadrant D4231 Anatomical crown exposure - one to three teeth per quadrant D4240 Gingival flap procedure, including root planing — four or more contiguous teeth or bounded teeth spaces per quadrant D4241 Gingival flap procedure, including root planing — one to three contiguous teeth or bounded teeth spaces per quadrant D4245 Apically positioned flap D4249 Clinical crown lengthening — hard tissue D4260 Osseous surgery (including elevation of a full thickness flap and closure) — four or more contiguous teeth or tooth bounded spaces per quadrant D4261 Osseous surgery (including elevation of a full thickness flap and closure) — one to three contiguous teeth or tooth bounded spaces per quadrant D4263 Bone replacement graft — first site in quadrant D4264 Bone replacement graft — each additional site in quadrant D4265 Biologic materials to aid in soft and osseous tissue regeneration D4266 Guided tissue regeneration — resorbable barrier, per site D4267 Guided tissue regeneration — nonresorbable barrier, per site (includes membrane removal) D4268 Surgical revision procedure, per tooth CDT2015 (Eff. 01- 01 -15) D4270 Pedicle soft tissue graft procedure D4273 Subepithelial connective tissue graft procedures, per tooth D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) D4275 Soft tissue allograft D4276 Combined connective tissue and double pedicle graft, per tooth D4277 Free soft tissue graft procedure (including donor site surgery), first tooth or edentulous tooth position in graft D4278 Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site Non - surgical periodontal service D4320 Provisional splinting — intracoronal D4321 Provisional splinting — extracoronal D4341 Periodontal scaling and root planing — four or more teeth per quadrant D4342 Periodontal scaling and root planing, — one to three teeth, per quadrant D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis D4381 Localized delivery of antimicrobial agents via controlled release vehicle into diseased crevicular tissue, per tooth Other periodontal services D4910 Periodontal maintenance D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) D4999 Unspecified periodontal procedure, by report D5000 - D5899 PROSTHODONTICS (REMOVABLE) Complete dentures (including routine post - delivery care) D5110 Complete denture — maxillary D5120 Complete denture — mandibular D5130 Immediate denture — maxillary D5140 Immediate denture — mandibular Partial dentures (including routine post - delivery care) D5211 Maxillary partial denture — resin base (including any conventional clasps, rests and teeth) D5212 Mandibular partial denture — resin base (including any conventional clasps, rests and teeth) D5213 Maxillary partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5214 Mandibular partial denture — cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) D5225 Maxillary partial denture — flexible base (including any clasps, rests and teeth) D5226 Mandibular partial denture — flexible base (including any clasps, rests and teeth) D5281 Removable unilateral partial denture — one piece cast metal (including clasps and teeth) Adjustments to dentures D5410 Adjust complete denture — maxillary D5411 Adjust complete denture — mandibular D5421 Adjust partial denture — maxillary D5422 Adjust partial denture — mandibular Repairs to complete dentures D5510 Repair broken complete denture base D5520 Replace missing or broken teeth — complete denture (each tooth) CDT2015 (Eff. 01- 01 -15) Repairs to partial dentures D5610 Repair resin denture base D5620 Repair cast framework D5630 Repair or replace broken clasp D5640 Replace broken teeth — per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5670 Replace all teeth and acrylic on cast metal framework (maxillary) D5671 Replace all teeth and acrylic on cast metal framework (mandibular) Denture rebase procedures D5710 Rebase complete maxillary denture D5711 Rebase complete mandibular denture D5720 Rebase maxillary partial denture D5721 Rebase mandibular partial denture Denture reline procedures D5730 Reline complete maxillary denture (chairside) D5731 Reline complete mandibular denture (chairside) D5740 Reline maxillary partial denture (chairside) D5741 Reline mandibular partial denture (chairside) D5750 Reline complete maxillary denture (laboratory) D5751 Reline complete mandibular denture (laboratory) D5760 Reline maxillary partial denture (laboratory) D5761 Reline mandibular partial denture (laboratory) Interim prosthesis D5810 Interim complete denture (maxillary) D5811 Interim complete denture (mandibular) D5820 Interim partial denture (maxillary) D5821 Interim partial denture (mandibular) Other removable prosthetic services D5850 Tissue conditioning — maxillary D5851 Tissue conditioning — mandibular D5862 Precision attachment, by report D5863 Overdenture - complete maxillary D5864 Overdenture - partial maxillary D5865 Overdenture - complete mandibular D5866 Overdenture - partial mandibular D5867 Replacement of replaceable part of semi - precision or precision attachment (male or female component) D5875 Modification of removable prosthesis following implant surgery D5899 Unspecified removable prosthodontic procedure, by report D590O - D5999 MAXILLOFACIAL PROSTHETICS D5911 Facial moulage (sectional) D5912 Facial moulage (complete) D5913 Nasal prosthesis D5914 Auricular prosthesis D5915 Orbital prosthesis D5916 Ocular prosthesis D5919 Facial prosthesis D5922 Nasal septal prosthesis D5923 Ocular prosthesis, interim D5924 Cranial prosthesis CDT2015 (Eff. 01- 01 -15) D5925 Facial augmentation implant prosthesis D5926 Nasal prosthesis, replacement D5927 Auricular prosthesis, replacement D5928 Orbital prosthesis, replacement D5929 Facial prosthesis, replacement D5931 Obturator prosthesis, surgical D5932 Obturator prosthesis, definitive D5933 Obturator prosthesis, modification D5934 Mandibular resection prosthesis with guide flange D5935 Mandibular resection prosthesis without guide flange D5936 Obturator prosthesis, interim D5937 Trismus appliance (not for TMD treatment) D5951 Feeding aid D5952 Speech aid prosthesis, pediatric D5953 Speech aid prosthesis, adult D5954 Palatal augmentation prosthesis D5955 Palatal lift prosthesis, definitive D5958 Palatal lift prosthesis, interim D5959 Palatal lift prosthesis, modification D5960 Speech aid prosthesis, modification D5982 Surgical stent D5983 Radiation carrier D5984 Radiation shield D5985 Radiation cone locator D5986 Fluoride gel carrier D5987 Commissure splint D5988 Surgical splint D5999 Unspecified maxillofacial prosthesis, by report D6OOO — D6199 IMPLANT SERVICES D6010 Surgical placement of implant body: endosteal implant D6012 Surgical placement of interim implant body for transitional implant D6013 Surgical placement of mini implant D6040 Surgical placement: eposteal implant D6050 Surgical placement: transosteal implant Implant supported prosthetics prosthesis: endosteal D6055 Dental implant supported connecting bar D6056 Prefabricated abutment — includes modification and placement D6057 Custom fabricated abutment — includes placement D6058 Abutment supported porcelain /ceramic crown D6059 Abutment supported porcelain fused to metal crown (high noble metal) D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) D6061 Abutment supported porcelain fused to metal crown (noble metal) D6062 Abutment supported cast metal crown (high noble metal) D6063 Abutment supported cast metal crown (predominantly base metal) D6064 Abutment supported cast metal crown (noble metal) D6065 Implant supported porcelain /ceramic crown D6066 Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) D6067 Implant supported metal crown (titanium, titanium alloy, high noble metal) D6068 Abutment supported retainer for porcelain /ceramic FPD D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) CDT2015 (Eff. 01- 01 -15) D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) D6072 Abutment supported retainer for cast metal FPD (high noble metal) D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) D6074 Abutment supported retainer for cast metal FPD (noble metal) D6075 Implant supported retainer for ceramic FPD D6076 Implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) D6077 Implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) Other implant services D6080 Implant maintenance procedures, including removal of prosthesis, cleansing of prosthesis and abutments and reinsertion of prosthesis D6090 Repair implant supported prosthesis, by report D6091 Replacement of semi - precision or precision attachment (male or female component) of implant /abutment supported prosthesis, per attachment D6092 Re- cement or re -bond implant /abutment supported crown D6094 Abutment supported crown — (titanium) D6095 Repair implant abutment, by report D6100 Implant removal, by report D6101 Debridement of a periimplant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure D6102 Debridement and osseous contouring of a periimplant defect or defects surrounding a single implant, and surface cleaning includes surface cleaning of the exposed implant surfaces, including flap entry and closure D6110 Implant /abutment supported removable denture for edentulous arch- maxillary D6111 Implant/ abutment supported removable denture for edentulous arch- mandibular D6112 Implant /abutment supported removable denture for partially edentulous arch - maxillary D6113 Implant /abutment supported removable denture for partially edentulous arch - mandibular D6114 Implant/ abutment supported fixed denture for edentulous arch - maxillary D6115 Implant / abutment supported fixed denture for edentulous arch - mandibular D6116 Implant / abutment supported fixed denture for partially edentulous arch - maxillary D6117 Implant / abutment supported fixed denture for partially edentulous arch - mandibular D6190 Radiographic /surgical implant index; by Report D6093 Re- cement or re -bond implant /abutment supported fixed partial denture D6194 Abutment supported retainer crown for FPD — (titanium) D6199 Unspecified implant procedure, by report D6200 - D6999 PROSTHODONTICS, FIXED (Each retainer and each pontic constitutes a unit in a fixed partial denture) Fixed partial denture poetics D6205 Pontic — indirect resin based composite D6210 Pontic — cast high noble metal D6211 Pontic — cast predominantly base metal D6212 Pontic — cast noble metal D6214 Pontic — titanium D6240 Pontic — porcelain fused to high noble metal D6241 Pontic — porcelain fused to predominantly base metal D6242 Pontic — porcelain fused to noble metal D6245 Pontic — porcelain /ceramic D6250 Pontic — resin with high noble metal D6251 Pontic — resin with predominantly base metal D6252 Pontic — resin with noble metal D6253 Provisional pontic - further treatment or completion of a impression diagnosis necessary prior to CDT2015 (Eff. 01- 01 -15) Fixed partial denture retainers — inlays/ onlays D6545 Retainer — cast metal for resin bonded fixed prosthesis D6548 Retainer — porcelain /ceramic for resin bonded fixed prosthesis D6549 Resin retainer - for resin bonded fixed prosthesis D6600 Inlay — porcelain /ceramic, two surfaces D6601 Inlay — porcelain /ceramic, three or more surfaces D6602 Inlay — cast high metal, two surfaces D6603 Inlay — cast high metal, three or more surfaces D6604 Inlay — cast predominantly base metal, two surfaces D6605 Inlay — cast predominantly base metal, three or more surfaces D6606 Inlay — cast noble metal, two surfaces D6607 Inlay — cast noble metal, three or more surfaces D6608 Onlay — porcelain /ceramic, two surfaces D6609 Onlay — porcelain /ceramic, three or more surfaces D6610 Onlay — cast high noble metal, two surfaces D6611 Onlay — cast high noble metal, three or more surfaces D6612 Onlay — cast predominantly base metal, two surfaces D6613 Onlay — cast predominantly base metal, three or more surfaces D6614 Onlay — cast noble metal, two surfaces D6615 Onlay — cast noble metal, three or more surfaces D6624 Inlay — titanium D6634 Onlay — titanium Fixed partial denture retainers — crowns D6710 Crown — indirect resin based composite D6720 Crown — resin with high noble metal D6721 Crown — resin with predominantly base metal D6722 Crown — resin with noble metal D6740 Crown — porcelain /ceramic D6750 Crown — porcelain fused to high noble metal D6751 Crown — porcelain fused to predominantly base metal D6752 Crown — porcelain fused to noble metal D6780 Crown — 3/4 cast high noble metal D6781 Crown — 3/4 cast predominantly base metal D6782 Crown — 3/4 cast noble metal D6783 Crown — 3/4 porcelain /ceramic D6790 Crown — full cast high noble metal D6791 Crown — full cast predominantly base metal D6792 Crown — full cast noble metal D6793 Provisional retainer crown - further treatment of completion or a diagnosis necessary prior to final impression D6794 Crown — titanium Other fixed partial denture services D6920 Connector bar D6930 Re- cement or re -bond fixed partial denture D6940 Stress breaker D6950 Precision attachment D6980 Fixed partial denture repair necessitated by restorative material D6985 Pediatric partial denture, fixed D6999 Unspecified, fixed prosthodontic procedure, by report D7000 - D7999 ORAL AND MAXILLOFACIAL SURGERY Extractions (includes local anesthesia, suturing, if needed, and routine postoperative care) D7111 Extraction, coronal remnants — deciduous tooth D7140 Extraction, erupted tooth or exposed root (elevation and /or forceps removal) CDT2015 (Eff. 01- 01 -15) Surgical extractions (includes local anesthesia, suturing, if needed, and routine postoperative care) D7210 Surgical removal of erupted tooth requiring removal of bone and /or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated D7220 Removal of impacted tooth — soft tissue D7230 Removal of impacted tooth — partially bony D7240 Removal of impacted tooth — completely bony D7241 Removal of impacted tooth — completely bony, with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) Other surgical procedures D7260 Oroantral fistual closure D7261 Primary closure of a sinus perforation D7270 Tooth reimplantation and /or stabilization of accidentally evulsed or displaced tooth D7272 Tooth transplantation (includes reimplantation from one site to another and splinting and /or stabilization) D7280 Surgical access of an unerupted tooth D7282 Mobilization of erupted or malpositioned tooth to aid eruption D7283 Placement of device to facilitate eruption of impacted tooth D7285 Incisional biopsy of oral tissue — hard (bone, tooth) D7286 Incisional biopsy of oral tissue — soft D7287 Exfoliative cytological sample collection D7288 Brush biopsy — transepithelial sample collection D7290 Surgical repositioning of teeth D7291 Transseptal fiberotomy /supra crestal fiberotomy, by report D7292 Placement of temporary anchorage device [screw retained plate] requiring surgical flap; includes device removal D7293 Placement of temporary anchorage device requiring surgical flap; includes device removal D7294 Placement of temporary anchorage device without surgical flap; includes device removal Alveoloplasty — surgical preparation of ridge for dentures D7310 Alveoloplasty in conjunction with extractions — four or more teeth or tooth spaces, per quadrant D7311 Alveoloplasty in conjunction with extractions — one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions — four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions — one to three teeth or tooth spaces, per quadrant Vestibuloplasty D7340 Vestibuloplasty — ridge extension (secondary epithelialization) D7350 Vestibuloplasty — ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) Surgical excision of of soft tissue lesions D7410 Excision of benign lesion up to 1.25 cm D7411 Excision of benign lesion greater than 1.25 cm D7412 Excision of benign lesion, complicated D7413 Excision of malignant lesion up to 1.25 cm D7414 Excision of malignant lesion greater than 1.25 cm D7415 Excision of malignant lesion complicated D7465 Destruction of lesion(s) by physical or chemical method, by report CDT2015 (Eff. 01- 01 -15) Surgical excision of intra - osseous lesions D7440 Excision of malignant tumor — lesion diameter up to 1.25 cm D7441 Excision of malignant tumor — lesion diameter greater than 1.25 cm D7450 Removal of benign odontogenic cyst or tumor — lesion diameter up to 1.25 cm D7451 Removal of benign odontogenic cyst or tumor — lesion diameter greater than 1.25 cm D7460 Removal of benign nonodontogenic cyst or tumor — lesion diameter up to 1.25 cm D7461 Removal of benign nonodontogenic cyst or tumor — lesion diameter greater than 1.25 cm Excision of bone tissue D7471 Removal of lateral exostosis (maxilla or mandible) D7472 Removal of torus palatinus D7473 Removal of torus manibularis D7485 Surgical reduction of osseous tuberosity D7490 Radical resection of maxilla or mandible Surgical incision D7510 Incision and drainage of abscess — intraoral soft tissue D7511 Incision and drainage of abscess — intraoral soft tissue — complicated (includes drainage of multiple fascia) spaces) D7520 Incision and drainage of abscess — extraoral soft tissue D7521 Incision and drainage of abscess — extraoral soft tissue — complicated (includes drainage of multiple fascial spaces) D7530 Removal of foreign body from mucosa, skin or subcutaneous alveolar tissue D7540 Removal of reaction - producing foreign bodies, musculoskeletal system D7550 Partial ostectomy /sequestrectomy for removal of non -vital bone D7560 Maxillary sinusotomy for removal of tooth fragment or foreign body Treatment of fractures — simple D7610 Maxilla — open reduction (teeth immobilized, if present) D7620 Maxilla — closed reduction (teeth immobilized, if present) D7630 Mandible — open reduction (teeth immobilized, if present) D7640 Mandible — closed reduction (teeth immobilized, if present) D7650 Malar and /or zygomatic arch — open reduction D7660 Malar and /or zygomatic arch — closed reduction D7670 Alveolus — closed reduction, may include stabilization of teeth D7671 Alveolus — open reduction, may include stabilization of teeth D7680 Facial bones — complicated reduction with fixation and multiple surgical approaches Treatment of fractures — compound D7710 Maxilla — open reduction D7720 Maxilla — closed reduction D7730 Mandible — open reduction D7740 Mandible — closed reduction D7750 Malar and /or zygomatic arch — open reduction D7760 Malar and /or zygomatic arch — closed reduction D7770 Alveolus — open reduction splinting stabilization of teeth D7771 Alveolus — closed reduction stabilization of teeth D7780 Facial bones — complicated reduction with fixation and multiple surgical approaches Reduction of dislocation and management of other temporomandibular joint dysfunctions D7810 Open reduction of dislocation D7820 Closed reduction of dislocation D7830 Manipulation under anesthesia D7840 Condylectomy D7850 Surgical discectomy, with /without implant CDT2015 (Eff. 01- 01 -15) D7852 Disc repair D7854 Synovectomy D7856 Myotomy D7858 Joint reconstruction D7860 Arthrotomy D7865 Arthroplasty D7870 Arthrocentesis D7871 Non - arthroscopic lysis and lavage D7872 Arthroscopy — diagnosis, with or without biopsy D7873 Arthroscopy — surgical: lavage and lysis of adhesions D7874 Arthroscopy — surgical: disc repositioning and stabilization D7875 Arthroscopy — surgical: synovectomy D7876 Arthroscopy — surgical: discectomy D7877 Arthroscopy — surgical: debridement D7880 Occlusal orthotic device, by report D7899 Unspecified TMD therapy, by report Repair of traumatic wounds D7910 Suture of recent small wounds up to 5 cm Complicated suturing (reconstruction requiring delicate handling of tissues and wide undermining for meticulous closure) D7911 Complicated suture — up to 5 cm D7912 Complicated suture — greater than 5 cm Other repair procedures D7920 Skin graft (identify defect covered, location and type of graft) D7940 Osteoplasty — for orthognathic deformities D7941 Osteotomy — mandibular rami D7943 Osteotomy — mandibular rami with bone graft; includes obtaining the graft D7944 Osteotomy — segmented or subapical D7945 Osteotomy — body of mandible D7946 LeFort I (maxilla — total) D7947 LeFort I (maxilla — segmented) D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface hypoplasia or retrusion) — without bone graft D7949 LeFort II or LeFort III — with bone graft D7950 Osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report D7951 Sinus augmentation with bone or bone substitutes via a lateral open approach D7952 Sinus augmentation via a vertical approach D7953 Bone replacement graft for ridge preservation — per site D7955 Repair of maxillofacial soft and /or hard tissue defect D7960 Frenulectomy - also known as frenectomy or frenotomy — incidental to another procedure D7963 Frenuloplasty D7970 Excision of hyperplastic tissue — per arch D7971 Excision of pericoronal gingiva D7972 Surgical reduction of fibrous tuberosity D7980 Sialolithotomy D7981 Excision of salivary gland, by report D7982 Sialodochoplasty D7983 Closure of salivary fistula D7990 Emergency tracheotomy D7991 Coronoidectomy D7995 Synthetic graft — mandible or facial bones, by report separate procedure not CDT2015 (Eff. 01- 01 -15) D7996 Implant — mandible for augmentation purposes (excluding alveolar ridge), by report D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar D7998 Intraoral placement of a fixation device not in conjunction with a fracture D7999 Unspecified oral surgery procedure, by report D8000 - D8999 ORTHODONTICS Limited orthodontic treatment D8010 Limited orthodontic treatment of the primary dentition D8020 Limited orthodontic treatment of the transitional dentition D8030 Limited orthodontic treatment of the adolescent dentition D8040 Limited orthodontic treatment of the adult dentition Interceptive orthodontic treatment D8050 Interceptive orthodontic treatment of the primary dentition D8060 Interceptive orthodontic treatment of the transitional dentition Comprehensive orthodontic treatment D8070 Comprehensive orthodontic treatment of the transitional dentition D8080 Comprehensive orthodontic treatment of the adolescent dentition D8090 Comprehensive orthodontic treatment of the adult dentition Minor treatment to control harmful habits D8210 Removable appliance therapy D8220 Fixed appliance therapy Other orthodontic services D8660 Pre - orthodontic treatment examination to monitor growth and development D8670 Periodic orthodontic treatment visit D8680 Orthodontic retention (removal of appliances, construction and placement of retainer[s]) D8690 Orthodontic treatment (alternative billing to a contract fee) D8691 Repair of orthodontic appliance D8692 Replacement of lost or broken retainer D8693 Re -bond or re- cement fixed retainer D8694 Repair of fixed retainers, includes reattachment D8999 Unspecified orthodontic procedure, by report D9000 - D9999 ADJUNCTIVE GENERAL SERVICES Unclassified treatment D9110 Palliative (emergency) treatment of dental pain — minor procedure D9120 Fixed partial denture sectioning Anesthesia D9210 Local anesthesia not in conjunction with operative or surgical procedures D9211 Regional block anesthesia D9212 Trigeminal division block anesthesia D9215 Local anesthesia D9220 Deep sedation /general anesthesia — first 30 minutes D9221 Deep sedation /general anesthesia — each additional 15 minutes D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9241 Intravenous moderate (conscious) sedation /analgesia - first 30 minutes D9242 Intravenous moderate (conscious) sedation /analgesia - each additional 15 minutes D9248 Non - intravenous moderate (conscious) sedation Professional consultation D9310 Consultation (diagnostic service provided by dentist or physician other than requesting dentist or physician CDT2015 (Eff. 01- 01 -15) Professional visits D9410 House /extended care facility call D9420 Hospital call D9430 Office visit for observation (during regularly scheduled hours) — no other services performed D9440 Office visit — after regularly scheduled hours D9450 Case presentation, detailed and extensive treatment planning Drugs D9610 Therapeutic parenteral drug, single administration D9612 Therapeutic parenteral drugs, two or more administrations, different medications D9630 Other drugs and /or medicaments, by report Miscellaneous services D9910 Application of desensitizing medicament D9911 Application of desensitizing resin for cervical and /or root surface, per tooth D9920 Behavior management, by report D9930 Treatment of complications (post - surgical) — unusual circumstances, by report D9940 Occlusal guard, by report D9941 Fabrication of athletic mouthguard D9942 Repair and /or reline of occlusal guard D9950 Occlusion analysis — mounted case D9951 Occlusal adjustment — limited D9952 Occlusal adjustment — complete D9970 Enamel microabrasion D9971 Odontoplasty 1 -2 teeth; includes removal of enamel projections D9972 External bleaching — per arch - performed in office D9973 External bleaching — pertooth D9974 Internal bleaching — pertooth D9999 Unspecified adjunctive procedure, by report Note: This Appendix represents codes and nomenclature excerpted from the version of Current Dental Terminology (CDT) in effect at the date of this printing. CDT coding and nomenclature are the copyright of the American Dental Association, and have been accepted as the standard for data transmission purposes under federal Administrative Simplification regulations. For the purposes of this Appendix, Delta Dental's administration of Benefits, Limitations and Exclusions under this Contract will at all times be based on the then - current version of CDT whether or not a revised Appendix B is provided. CDT2015 (Eff. 01- 01 -15)