{"text_format":"3","workbook":"xls","n_sheets":4,"sheets":["Base Plan","Low Plan ","High Plan"," DHMO Plan"],"not_rendered":{"external_links":1,"defined_names":1},"read":"whole","date_system":"1900","formulas":"cached_only"}

{"sheet":"Base Plan","index":0,"n_rows":21,"n_cols":7,"rows_kept":21,"merged":[[0,0,0,2],[2,0,2,2],[4,1,4,2],[4,3,4,4],[4,5,4,6],[5,1,5,2],[5,3,5,4],[5,5,5,6],[6,1,6,2],[6,3,6,4],[6,5,6,6],[7,1,7,2],[7,3,7,4],[7,5,7,6],[8,0,9,0],[9,1,9,2],[9,3,9,4],[9,5,9,6],[10,0,10,2],[10,3,10,4],[10,5,10,6],[11,1,11,2],[11,3,11,4],[11,5,11,6],[12,1,12,2],[12,3,12,4],[12,5,12,6],[13,1,13,2],[13,3,13,4],[13,5,13,6],[14,1,14,2],[14,3,14,4],[14,5,14,6],[15,1,15,2],[15,3,15,4],[15,5,15,6]],"flags":["formulas_cached_only"]}
["CITY OF KNOXVILLE\n2019 CITY CURRENT & REQUESTED DENTAL PLANS"]
[]
["Please note, City Requested Coverage refers to the plans the City wants carriers to quote. "]
[]
["COK Current/Requested Coverage","Current Base Plan Only",null,"Requeted Base Coverage",null,"Proposed Services"]
["Eligible EEs","Full-Time EEs only - no dependents ",null,"Same",null," "]
["Contributions","100% Paid by The City of Knoxville",null,"Same",null," "]
["Use of Network mandatory to receive benefits? ","No.  If an EE seeks services from a non-participating Dentist, benefits are reimbursed at the 85th percentile of UCR.",null,"Same",null," "]
["Waiting Period:","In Network","Out-of-Network","In Network","Out-of-Network","In Network","Out-of-Network"]
[null,"None",null,"Same",null," "]
["Base Plan includes the following services:"]
["Oral Exams, Cleanings, Flouride","Limited to one time per calendar year",null,"Same",null," "]
["Brush Biopsy (oral cancer)","Covered"]
["Radiographs","Bitewing x-rays once per calendar year"]
["High Risk health conditions*","Members may receive a total of four cleanings per calendar year.",null,"Same",null," "]
["X-Rays","One set of bite-wing x-rays is covered in a calendar year.",null,"Same",null," "]
["* - High risk health conditions represent:",{"$nulls":4},"High Risk Includes:"]
["Diabetics with peridontal disease"]
["Pregnant women with periodontal disease"]
["Individuals with renal failure/dialysis"]
["Individual with a suppressed immune system (undergoing chemo or radiation, HIV positive, organ stem cell transplants)"]

{"sheet":"Low Plan ","index":1,"n_rows":39,"n_cols":5,"rows_kept":39,"merged":[[0,0,0,2],[2,0,2,2],[4,1,4,2],[4,3,4,4],[6,1,6,2],[6,3,6,4],[7,1,7,2],[7,3,7,4],[8,1,8,2],[9,1,9,2],[9,3,9,4],[10,1,10,2],[10,3,10,4],[11,1,11,2],[11,3,11,4],[12,1,12,2],[13,1,13,2],[13,3,13,4],[14,1,14,2],[14,3,14,4],[15,1,15,2],[15,3,15,4],[16,1,16,2],[16,3,16,4],[17,1,17,2],[17,3,17,4],[18,1,18,2],[18,3,18,4],[33,1,33,2]],"flags":["formulas_cached_only"]}
["CITY OF KNOXVILLE\n2019 CITY CURRENT & REQUESTED DENTAL PLANS"]
[]
["Please note, City Requested Coverage refers to the plans the City wants carriers to quote. "]
[]
["COK Current/Requested Coverage","Current Low Plan",null,"Your Proposed Low Plan Coverage"]
[null,"In Network","Out-of-Network\nMAC","In Network","Out-of-Network"]
["Impact of Base Plan on Low plan","Employees who elect to buy-up to the low plan will receive the second cleaning per calendar year as noted below."]
["Calendar Maximum Benefit","$1,000\n(only applies to basic and major services, not preventive)"]
["Annual Deductible","Individual - $50\nFamily - $150\nDoes not apply to diagnositic and preventive"]
["Lifetime Maximum for Orthodontics","N/A"]
["Diagnositc and Preventive Services","Covered at 100% for both in and out-of-network"]
["Oral Exams including periodontal maintenance procedures; adult prophylaxis","Limited to 2 times per calendar year (including the Base exam)"]
["Waiting Period applicable to Diag. and Prevent.","None"]
["High Risk health conditions*","Members may receive a total of four cleanings per calendar year."]
["Bite-wing X-rays","1 set per calendar year (Base x-ray fulfills this)"]
["Full mouth x-rays","Once within 3 years unless a special need is shown."]
["Flouride","Covered for members up to 19 years of age."]
["Space maintainers","Covered for members up to 15 years of age"]
["Sealants","One benefit for each tooth for members up to 16 years of age"]
[null,"In Network","Out-of-Network","In Network","Out-of-Network"]
["Basic Benefits","80% after Deductile","80% after Deductible"]
["Simple Extractions","80% after Deductile","80% after Deductible"]
["Minor restorations - amalgams, composites, prefabricated stanless steel crown restorationss for treatment of tooth decay","80% after Deductile","80% after Deductible"]
["Emergency Palliative Treatment - to temporarily relieve pain","80% after Deductile","80% after Deductible"]
["General Anesthesia & I.V. sedation","50% after Deductile","80% after Deductible"]
["Endodontics - root canals","50% after Deductile","50% after Deductible"]
["Periodontic services","50% after Deductile","50% after Deductible"]
["Denture Repairs","50% after Deductile","50% after Deductible"]
["Major restorative services","50% after Deductible","50% after Deductible"]
["Prosthodontic services","50% after Deductible","50% after Deductible"]
["Implant benefits","50% after Deductible","50% after Deductible"]
["Oral Surgery - complex extratactions and surgical procedures","50% after Deductible","50% after Deductible"]
["Missing teeth","Covered","Covered"]
["Waiting Periods applicable to Basic, Major and Orthodonia benefits","None."]
["* - High risk health conditions represent:",null,null,"High Risk Includes:"]
["Diabetics with peridontal disease"]
["Pregnant women with periodontal disease"]
["Individuals with renal failure/dialysis"]
["Individual with a suppressed immune system (undergoing chemo or radiation, HIV positive, organ stem cell transplants)"]

{"sheet":"High Plan","index":2,"n_rows":39,"n_cols":5,"rows_kept":39,"merged":[[0,0,0,2],[2,0,2,2],[4,1,4,2],[4,3,4,4],[6,1,6,2],[6,3,6,4],[7,1,7,2],[7,3,7,4],[8,1,8,2],[9,1,9,2],[9,3,9,4],[10,1,10,2],[10,3,10,4],[11,1,11,2],[11,3,11,4],[12,1,12,2],[13,1,13,2],[13,3,13,4],[14,1,14,2],[14,3,14,4],[15,1,15,2],[15,3,15,4],[16,1,16,2],[16,3,16,4],[17,1,17,2],[17,3,17,4],[18,1,18,2],[18,3,18,4],[33,1,33,2]],"flags":["formulas_cached_only"]}
["CITY OF KNOXVILLE\n2019 CITY CURRENT & REQUESTED DENTAL PLANS"]
[]
["Please note, City Requested Coverage refers to the plans the City wants carriers to quote. "]
[]
["COK Current/Requested Coverage","Current High Plan",null,"Your Proposed High Plan Coverage"]
[null,"In Network","Out-of-Network\nReimbursed at the 85th percentile","In Network","Out-of-Network"]
["Impact of Base Plan on High plan","Employees who elect to buy-up to the high plan will receive the second cleaning per calendar year as noted below."]
["Calendar Maximum Benefit (excl. ortho)","$1,500\n(only applies to basic and major services, not preventive)"]
["Annual Deductible","Individual - $50\nFamily - $150\nDoes not apply to diagnositic and preventive, nor orthodontia"]
["Lifetime Maximum for Orthodontics","$1,500\n(Children only to age 19)"]
["Diagnositc and Preventive Services","Covered at 100% for both in and out-of-network"]
["Oral Exams including periodontal maintenance procedures; adult prophylaxis","Limited to 2 times per calendar year (inlcude the Base exam)"]
["Waiting Period applicable to Diag. and Prevent.","None"]
["High Risk health conditions*","Members may receive a total of four cleanings per calendar year."]
["Bite-wing X-rays","1 set per calendar year - (Base x-ray fulfills this)"]
["Full mouth x-rays","Once within 3 years unless a special need is shown."]
["Flouride","Covered for members up to 19 years of age."]
["Space maintainers","Covered for members up to 15 years of age"]
["Sealants","One benefit for each tooth for members up to 16 years of age"]
[null,"In Network","Out-of-Network","In Network","Out-of-Network"]
["Basic Benefits","80% after Deductile","80% after Deductible"]
["Simple Extractions","80% after Deductile","80% after Deductible"]
["Minor restorations - amalgams, composites, prefabricated stanless steel crown restorationss for treatment of tooth decay","80% after Deductile","80% after Deductible"]
["Emergency Palliative Treatment - to temporarily relieve pain","80% after Deductile","80% after Deductible"]
["General Anesthesia & I.V. sedation","50% after Deductile","80% after Deductible"]
["Oral Surgery - complex extratactionsand surgical procedures","50% after Deductile","50% after Deductible"]
["Endodontics - root canals","50% after Deductile","50% after Deductible"]
["Periodontic services","50% after Deductile","50% after Deductible"]
["Denture repairs","50% after Deductible","50% after Deductible"]
["Major restorative services","50% after Deductible","50% after Deductible"]
["Prosthodontic services","50% after Deductible","50% after Deductible"]
["Implant benefits","50% after Deductible","50% after Deductible"]
["Missing teeth","Covered","Covered"]
["Waiting Periods applicable to Basic, Major and Orthodonia benefits","None"]
["* - High risk health conditions represent:",null,null,"High Risk Includes:"]
["Diabetics with peridontal disease"]
["Pregnant women with periodontal disease"]
["Individuals with reneal failure/dialysis"]
["Individual with a suppressed immune system (undergoing chemo or radiation, HIV positive, organ stem cell transplants)"]

{"sheet":" DHMO Plan","index":3,"n_rows":297,"n_cols":4,"rows_kept":297,"merged":[[0,0,0,2],[2,0,2,2],[5,0,6,3],[9,0,9,1],[11,0,11,3],[47,0,47,3],[61,0,61,3],[128,0,128,3],[172,0,172,3],[197,0,197,3],[212,0,212,3],[220,0,220,3],[233,0,233,3],[238,0,238,3],[271,0,271,3],[287,0,287,3],[292,0,292,3],[295,0,295,3]],"flags":["formulas_cached_only"]}
["CITY OF KNOXVILLE\n2019 CITY CURRENT & REQUESTED DENTAL PLANS"]
[]
["Please note, City Requested Coverage refers to the plans the City wants carriers to quote. "]
["See Exhibit F - Current DHMO Summary of Benefits for the current DHMO Benefits"]
[]
["If the proposing firm does not have a DHMO or the DHMO plan does not include sufficient open in-network providers, provide a \"schedule plan\" that is similar to the attached"]
[]
["Proposed Plan"]
[]
["COK Current/Requested Coverage",null,"Current DHMO Patient Responsibility","Your Proposed DHMO Plan Coverage"]
[null,"Office Visit Fee",{"v":5,"d":"$5.00"}]
["Diagnostic/Preventive"]
["D9310","Consultation",{"v":0,"d":"$0.00"}]
["D9430","Office Visit for Observation",{"v":0,"d":"$0.00"}]
["D9450","Case Presentation",{"v":0,"d":"$0.00"}]
["D0120","Periodic Oral Evaluation - Established Patient",{"v":0,"d":"$0.00"}]
["D0140","Limited Oral Evaluation - Problem Focused",{"v":0,"d":"$0.00"}]
["D0150","Comprehensive Oral Evaluation - New or Established Patient",{"v":0,"d":"$0.00"}]
["D0170","Re-evaluation – Limited, Problem Focused (Not Postoperative Visit)",{"v":0,"d":"$0.00"}]
["D0210","X-Rays Intraoral – Complete Series (Including Bitewings) - Limit 1 every 3 years",{"v":0,"d":"$0.00"}]
["D0220","X-Rays Intraoral – Periapical – First Film",{"v":0,"d":"$0.00"}]
["D0230","X-Rays Intraoral – Periapical – Each Additional Film",{"v":0,"d":"$0.00"}]
["D0240","X-Rays Intraoral – Occlusal Film",{"v":0,"d":"$0.00"}]
["D0270","X-Rays (Bitewing) – Single Film",{"v":0,"d":"$0.00"}]
["D0272","X-Rays (Bitewings) – 2 Films",{"v":0,"d":"$0.00"}]
["D0273","X-Rays (Bitewings) – 3 Films",{"v":0,"d":"$0.00"}]
["D0274","X-Rays (Bitewings) – 4 Films",{"v":0,"d":"$0.00"}]
["D0277","X-Rays (Bitewings, Vertical) – 7 to 8 Films",{"v":0,"d":"$0.00"}]
["D0330","X-Rays (Panoramic Film) – (Limit 1 Every 3 Years)",{"v":0,"d":"$0.00"}]
["D0431","Oral Cancer Screening Using a Special Light Source",{"v":50,"d":"$50.00"}]
["D0460","Pulp Vitality Tests",{"v":13,"d":"$13.00"}]
["D0470","Diagnostic Casts",{"v":0,"d":"$0.00"}]
["D0472","Pathology Report – Gross Examination of Lesion (only when tooth related)",{"v":0,"d":"$0.00"}]
["D0473","Pathology Report – Microscopic Examination of Lesion (only when tooth related)",{"v":0,"d":"$0.00"}]
["D0474","Pathology Report – Microscopic Examination of Lesion and Area (only when tooth related)",{"v":0,"d":"$0.00"}]
["D1110","Prophylaxis (Cleaning) – Adult (Limit 2 per Calendar Year)",{"v":0,"d":"$0.00"}]
[null,"Additional Prophylaxis (Cleaning)",{"v":45,"d":"$45.00"}]
["D1120","Prophylaxis (Cleaning) – Child (Limit 2 per Calendar Year)",{"v":0,"d":"$0.00"}]
[null,"Additional Prophylaxis (Cleaning)",{"v":30,"d":"$30.00"}]
["D1203","Topical Application of Fluoride – Child (Up to 19th Birthday) - Total of 2 D1203s and/or D1206s per Calendar Year",{"v":0,"d":"$0.00"}]
["D1206","Topical Fluoride Varnish – Therapeutic Application for Moderate to High Caries Risk Patients – Child (Up to 19th birthday)",{"v":0,"d":"$0.00"}]
["D1330","Oral Hygiene Instructions",{"v":0,"d":"$0.00"}]
["D1351","Sealant – Per Tooth",{"v":16,"d":"$16.00"}]
["D1352","Preventive Resin Restoration in a Moderate to High Caries Risk (Patient - Permanent Tooth)",{"v":16,"d":"$16.00"}]
["D1510","Space Maintainer – Fixed – Unilateral",{"v":105,"d":"$105.00"}]
["D1515","Space Maintainer – Fixed – Bilateral",{"v":165,"d":"$165.00"}]
["D1555","Removal of Fixed Space Maintainer",{"v":0,"d":"$0.00"}]
["Restorative (Fillings)"]
["D2140","Amalgam – 1 Surface, Primary or Permanent",{"v":23,"d":"$23.00"}]
["D2150","Amalgam – 2 Surfaces, Primary or Permanent",{"v":28,"d":"$28.00"}]
["D2160","Amalgam – 3 Surfaces, Primary or Permanent",{"v":33,"d":"$33.00"}]
["D2161","Amalgam – 4 or More Surfaces, Primary or Permanent",{"v":39,"d":"$39.00"}]
["D2330","Resin-Based Composite – 1 Surface, Anterior",{"v":33,"d":"$33.00"}]
["D2331","Resin-Based Composite – 2 Surfaces, Anterior",{"v":39,"d":"$39.00"}]
["D2332","Resin-Based Composite – 3 Surfaces, Anterior",{"v":45,"d":"$45.00"}]
["D2335","Resin-Based Composite – 4 or More Surfaces or Involving Incisal Angle, Anterior",{"v":85,"d":"$85.00"}]
["D2390","Resin-Based Composite Crown, Anterior",{"v":135,"d":"$135.00"}]
["D2391","Resin-Based Composite – 1 Surface, Posterior",{"v":45,"d":"$45.00"}]
["D2392","Resin-Based Composite – 2 Surfaces, Posterior",{"v":57,"d":"$57.00"}]
["D2393","Resin-Based Composite – 3 Surfaces, Posterior",{"v":79,"d":"$79.00"}]
["D2394","Resin-Based Composite – 4 or More Surfaces, Posterior",{"v":110,"d":"$110.00"}]
["Restorative (Fillings)"]
["D2510","Inlay – Metallic – 1 Surface",{"v":425,"d":"$425.00"}]
["D2520","Inlay – Metallic – 2 Surfaces",{"v":425,"d":"$425.00"}]
["D2530","Inlay – Metallic – 3 or More Surfaces",{"v":425,"d":"$425.00"}]
["D2542","Onlay – Metallic – 2 Surfaces",{"v":495,"d":"$495.00"}]
["D2543","Onlay – Metallic – 3 Surfaces",{"v":495,"d":"$495.00"}]
["D2544","Onlay – Metallic – 4 or More Surfaces",{"v":495,"d":"$495.00"}]
["D2740","Crown – Porcelain/Ceramic Substrate",{"v":520,"d":"$520.00"}]
["D2750","Crown – Porcelain Fused to High Noble Metal",{"v":480,"d":"$480.00"}]
["D2751","Crown – Porcelain Fused to Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D2752","Crown – Porcelain Fused to Noble Metal",{"v":450,"d":"$450.00"}]
["D2780","Crown – 3/4 Cast High Noble Metal",{"v":480,"d":"$480.00"}]
["D2781","Crown – 3/4 Cast Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D2782","Crown – 3/4 Cast Noble Metal",{"v":450,"d":"$450.00"}]
["D2790","Crown – Full Cast High Noble Metal",{"v":480,"d":"$480.00"}]
["D2791","Crown – Full Cast Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D2792","Crown – Full Cast Noble Metal",{"v":450,"d":"$450.00"}]
["D2794","Crown – Titanium",{"v":480,"d":"$480.00"}]
["D2910","Recement Inlay – Onlay or Partial Coverage Restoration",{"v":42,"d":"$42.00"}]
["D2915","Recement Cast or Prefabricated Post and Core",{"v":42,"d":"$42.00"}]
["D2920","Recement Crown",{"v":42,"d":"$42.00"}]
["D2930","Prefabricated Stainless Steel Crown – Primary Tooth",{"v":105,"d":"$105.00"}]
["D2931","Prefabricated Stainless Steel Crown – Permanent Tooth",{"v":105,"d":"$105.00"}]
["D2932","Prefabricated Resin Crown",{"v":130,"d":"$130.00"}]
["D2933","Prefabricated Stainless Steel Crown with Resin Window",{"v":150,"d":"$150.00"}]
["D2934","Prefabricated Esthetic Coated Stainless Steel Crown – Primary Tooth",{"v":150,"d":"$150.00"}]
["D2940","Protective Restoration",{"v":23,"d":"$23.00"}]
["D2950","Core Buildup – Including Any Pins",{"v":120,"d":"$120.00"}]
["D2951","Pin Retention – Per Tooth – In Addition to Restoration",{"v":28,"d":"$28.00"}]
["D2952","Post and Core – In Addition to Crown, Indirectly Fabricated",{"v":165,"d":"$165.00"}]
["D2954","Prefabricated Post and Core – In Addition to Crown",{"v":135,"d":"$135.00"}]
["D2960","Labial Veneer (Resin Laminate) – Chairside",{"v":125,"d":"$125.00"}]
["D6210","Pontic – Cast High Noble Metal",{"v":480,"d":"$480.00"}]
["D6211","Pontic – Cast Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D6212","Pontic – Cast Noble Metal",{"v":450,"d":"$450.00"}]
["D6214","Pontic – Titanium",{"v":480,"d":"$480.00"}]
["D6240","Pontic – Porcelain Fused to High Noble Metal",{"v":480,"d":"$480.00"}]
["D6241","Pontic – Porcelain Fused to Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D6242","Pontic – Porcelain Fused to Noble Metal",{"v":450,"d":"$450.00"}]
["D6245","Pontic – Porcelain/Ceramic",{"v":470,"d":"$470.00"}]
["D6602","Inlay – Cast High Noble Metal, 2 Surfaces",{"v":470,"d":"$470.00"}]
["D6603","Inlay – Cast High Noble Metal, 3 or More Surfaces",{"v":480,"d":"$480.00"}]
["D6604","Inlay – Cast Predominantly Base Metal, 2 Surfaces",{"v":415,"d":"$415.00"}]
["D6605","Inlay – Cast Predominantly Base Metal, 3 or More Surfaces",{"v":415,"d":"$415.00"}]
["D6606","Inlay – Cast Noble Metal, 2 Surfaces",{"v":440,"d":"$440.00"}]
["D6607","Inlay – Cast Noble Metal, 3 or More Surfaces",{"v":440,"d":"$440.00"}]
["D6610","Onlay – Cast High Noble Metal, 2 Surfaces",{"v":470,"d":"$470.00"}]
["D6611","Onlay – Cast High Noble Metal, 3 or More Surfaces",{"v":480,"d":"$480.00"}]
["D6612","Onlay – Cast Predominantly Base Metal, 2 Surfaces",{"v":415,"d":"$415.00"}]
["D6613","Onlay – Cast Predominantly Base Metal, 3 or More Surfaces",{"v":415,"d":"$415.00"}]
["D6614","Onlay – Cast Noble Metal, 2 Surfaces",{"v":440,"d":"$440.00"}]
["D6615","Onlay – Cast Noble Metal, 3 or More Surfaces",{"v":450,"d":"$450.00"}]
["D6624","Inlay – Titanium",{"v":480,"d":"$480.00"}]
["D6634","Onlay – Titanium",{"v":480,"d":"$480.00"}]
["D6740","Crown – Porcelain/Ceramic",{"v":520,"d":"$520.00"}]
["D6750","Crown – Porcelain Fused to High Noble Metal",{"v":480,"d":"$480.00"}]
["D6751","Crown – Porcelain Fused to Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D6752","Crown – Porcelain Fused to Noble Metal",{"v":450,"d":"$450.00"}]
["D6780","Crown – 3/4 Cast High Noble Metal",{"v":480,"d":"$480.00"}]
["D6781","Crown – 3/4 Cast Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D6782","Crown – 3/4 Cast Noble Metal",{"v":450,"d":"$450.00"}]
["D6790","Crown – Full Cast High Noble Metal",{"v":480,"d":"$480.00"}]
["D6791","Crown – Full Cast Predominantly Base Metal",{"v":425,"d":"$425.00"}]
["D6792","Crown – Full Cast Noble Metal",{"v":450,"d":"$450.00"}]
["D6794","Crown – Titanium",{"v":480,"d":"$480.00"}]
[null,"Complex Rehabilitation - additional charge per unit for multiple crown units (6 or more units in one treatment)",{"v":135,"d":"$135.00"}]
["D6930","Recement Fixed Partial Denture",{"v":63,"d":"$63.00"}]
["Implant Supported Prosthetics"]
["D6053","Implant/Abutment Supported Removable Denture for Completely Edentulous Arch",{"v":975,"d":"$975.00"}]
["D6054","Implant/Abutment Supported Removable Denture for Partially Edentulous Arch",{"v":1080,"d":"$1,080.00"}]
["D6058","Abutment Supported Porcelain/Ceramic Crown",{"v":820,"d":"$820.00"}]
["D6059","Abutment Supported Porcelain Fused to Metal Crown (High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6060","Abutment Supported Porcelain Fused to Metal Crown (Predominantly Base Metal)",{"v":725,"d":"$725.00"}]
["D6061","Abutment Supported Porcelain Fused to Metal Crown (Noble Metal)",{"v":750,"d":"$750.00"}]
["D6062","Abutment Supported Cast Metal Crown (High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6063","Abutment Supported Cast Metal Crown (Predominantly Base Metal)",{"v":725,"d":"$725.00"}]
["D6064","Abutment Supported Cast Metal Crown (Noble Metal)",{"v":750,"d":"$750.00"}]
["D6065","Implant Supported Porcelain/Ceramic Crown",{"v":820,"d":"$820.00"}]
["D6066","Implant Supported Porcelain Fused to Metal Crown (Titanium, Titanium Alloy, High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6067","Implant Supported Metal Crown (Titanium, Titanium Alloy, High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6068","Abutment Supported Retainer for Porcelain/Ceramic Fixed Partial Denture",{"v":820,"d":"$820.00"}]
["D6069","Abutment Supported Retainer for Porcelain Fused to Metal Fixed Partial Denture (High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6070","Abutment Supported Retainer for Porcelain Fused to Metal Fixed Partial Denture (Predominantly Base Metal)",{"v":725,"d":"$725.00"}]
["D6071","Abutment Supported Retainer for Porcelain Fused to Metal Fixed Partial Denture (Noble Metal)",{"v":750,"d":"$750.00"}]
["D6072","Abutment Supported Retainer for Cast Metal Fixed Partial Denture (High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6073","Abutment Supported Retainer for Cast Metal Fixed Partial Denture (Predominantly Base Metal)",{"v":725,"d":"$725.00"}]
["D6074","Abutment Supported Retainer for Cast Metal Fixed Partial Denture (Noble Metal)",{"v":750,"d":"$750.00"}]
["D6075","Implant Supported Retainer for Ceramic Fixed Partial Denture",{"v":820,"d":"$820.00"}]
["D6076","Implant Supported Retainer for Porcelain Fused to Metal Fixed Partial Denture (Titanium, Titanium Alloy, High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6077","Implant Supported Retainer for Cast Metal Fixed Partial Denture (Titanium, Titanium Alloy, High Noble Metal)",{"v":780,"d":"$780.00"}]
["D6078","Implant/ Abutment Supported Fixed Denture for Completely Edentulous Arch",{"v":975,"d":"$975.00"}]
["D6079","Implant/Abutment Supported Fixed Denture for Partially Edentulous Arch",{"v":1080,"d":"$1,080.00"}]
["D6092","Recement Implant/Abutment Supported Crown",{"v":82,"d":"$82.00"}]
["D6093","Recement Implant/Abutment Supported Fixed Partial Denture",{"v":103,"d":"$103.00"}]
["D6094","Abutment Supported Crown (Titanium)",{"v":780,"d":"$780.00"}]
["D6194","Abutment Supported Retainer Crown for Fixed Partial Denture (Titanium)",{"v":780,"d":"$780.00"}]
[null,"Complex Rehabilitation on Implant Supported Prosthetic Procedures - additional charge per unit",{"v":135,"d":"$135.00"}]
["D3310","Anterior Root Canal – Permanent Tooth (Excluding Final Restoration)",{"v":375,"d":"$375.00"}]
["D3320","Bicuspid Root Canal – Permanent Tooth (Excluding Final Restoration)",{"v":445,"d":"$445.00"}]
["D3330","Molar Root Canal – Permanent Tooth (Excluding Final Restoration)",{"v":595,"d":"$595.00"}]
["D3331","Treatment of Root Canal Obstruction – Nonsurgical Access",{"v":160,"d":"$160.00"}]
["D3332","Incomplete Endodontic Therapy – Inoperable, Unrestorable or Fractured Tooth",{"v":175,"d":"$175.00"}]
["D3333","Internal Root Repair of Perforation Defects Retreatment of Previous Root Canal Therapy",{"v":175,"d":"$175.00"}]
["D3346","Anterior Retreatment of Previous Root Canal Therapy",{"v":510,"d":"$510.00"}]
["D3347","Bicuspid Retreatment of Previous Root Canal",{"v":580,"d":"$580.00"}]
["D3348","Molar Retreatment of Previous Root Canal",{"v":680,"d":"$680.00"}]
["D3410","Apicoectomy/Periradicular Surgery Anterior",{"v":420,"d":"$420.00"}]
["D3421","Apicoectomy/Periradicular Surgery Bicuspid",{"v":450,"d":"$450.00"}]
["D3425","Apicoectomy/Periradicular Surgery Molar",{"v":515,"d":"$515.00"}]
["D3426","Apicoectomy/Periradicular Surgery - Each Additional Root",{"v":170,"d":"$170.00"}]
["D3430","Retrograde Filling - Per Root",{"v":120,"d":"$120.00"}]
["Periodontics"]
["D0180","Comprehensive Periodontal Evaluation – New or Established Patient",{"v":70,"d":"$70.00"}]
["D4210","Gingivectomy or Gingivoplasty – 4 or More Teeth per Quadrant",{"v":320,"d":"$320.00"}]
["D4211","Gingivectomy or Gingivoplasty – 1 to 3 Teeth per Quadrant",{"v":160,"d":"$160.00"}]
["D4240","Gingival Flap (Including Root Planing) – 4 or More Teeth per quadrant",{"v":365,"d":"$365.00"}]
["D4241","Gingival Flap (Including Root Planing) – 1 to 3 Teeth per quadrant",{"v":210,"d":"$210.00"}]
["D4245","Apically Positioned Flap",{"v":365,"d":"$365.00"}]
["D4249","Clinical Crown Lengthening - Hard Tissue",{"v":405,"d":"$405.00"}]
["D4260","Osseous Surgery – 4 or More Teeth per Quadrant",{"v":640,"d":"$640.00"}]
["D4261","Osseous Surgery – 1 to 3 Teeth per Quadrant ",{"v":385,"d":"$385.00"}]
["D4263","Bone Replacement Graft – First Site in Quadrant",{"v":290,"d":"$290.00"}]
["D4264","Bone Replacement Graft – Each Additional Site in Quadrant",{"v":225,"d":"$225.00"}]
["D4266","Guided Tissue Regeneration – Resorbable Barrier per Site",{"v":380,"d":"$380.00"}]
["D4267","Guided Tissue Regeneration – Nonresorbable Barrier per Site (Includes Membrane Removal)",{"v":430,"d":"$430.00"}]
["D4270","Pedicle Soft Tissue Graft Procedure",{"v":495,"d":"$495.00"}]
["D4277","Free Soft Tissue Graft Procedure (Including Donor Site Surgery)",{"v":495,"d":"$495.00"}]
["D4275","Soft Tissue Allograft",{"v":495,"d":"$495.00"}]
["D4341","Periodontal Scaling and Root Planing – 4 or More Teeth per Quadrant (Limit 4 Quadrants per Consecutive 12 Months)",{"v":135,"d":"$135.00"}]
["D4342","Periodontal Scaling and Root Planing – 1 to 3 Teeth – per Quadrant (Limit 4 Quadrants per Consecutive 12 Months)",{"v":75,"d":"$75.00"}]
["D4355","Full Mouth Debridement to Allow Evaluation and Diagnosis - 1 per Lifetime",{"v":110,"d":"$110.00"}]
["D4381","Localized Delivery of Antimicrobial Agents per Tooth – By Report",{"v":45,"d":"$45.00"}]
["D4910","Periodontal Maintenance (Limited to 2 per Calendar Year) (Only Covered after Active Therapy)",{"v":93,"d":"$93.00"}]
["D9940","Occlusal Guard – By Report (Limit 1 per 24 Months)",{"v":360,"d":"$360.00"}]
["D9951","Occlusal Adjustment Limited ",{"v":71,"d":"$71.00"}]
["D9952","Occlusal Adjustment Complete",{"v":330,"d":"$330.00"}]
["Prosthetics"]
["D5110","Full Upper Denture",{"v":675,"d":"$675.00"}]
["D5120","Full Lower Denture",{"v":675,"d":"$675.00"}]
["D5130","Immediate Full Upper Denture",{"v":730,"d":"$730.00"}]
["D5140","Immediate Full Lower Denture",{"v":675,"d":"$675.00"}]
["D5211","Upper Partial Denture – Resin Base (Including Clasps, Rests and Teeth)",{"v":510,"d":"$510.00"}]
["D5212","Lower Partial Denture – Resin Base (Including Clasps, Rests and Teeth)",{"v":510,"d":"$510.00"}]
["D5213","Upper Partial Denture – Cast Metal Famework (Including Clasps, Rests and Teeth)",{"v":780,"d":"$780.00"}]
["D5214","Lower Partial Denture – Cast Metal Framework (Including Clasps, Rests and Teeth)",{"v":780,"d":"$780.00"}]
["D5225","Upper Partial Denture – Flexible Base (Including Clasps, Rests and Teeth)",{"v":555,"d":"$555.00"}]
["D5226","Lower Partial Denture – Flexible Base (Including Clasps, Rests and Teeth)",{"v":555,"d":"$555.00"}]
["D5410","Adjust Complete Denture - Upper",{"v":43,"d":"$43.00"}]
["D5411","Adjust Complete Denture – Lower",{"v":43,"d":"$43.00"}]
["D5421","Adjust Partial Denture – Upper",{"v":47,"d":"$47.00"}]
["D5422","Adjust Partial Denture – Lower",{"v":43,"d":"$43.00"}]
["Repairs to Prosthetics"]
["D5510","Repair Broken Complete Denture Base",{"v":88,"d":"$88.00"}]
["D5520","Replace Missing or Broken Teeth – Complete Denture (each tooth)",{"v":81,"d":"$81.00"}]
["D5610","Repair Resin Denture Base",{"v":88,"d":"$88.00"}]
["D5630","Repair or Replace Broken Clasp",{"v":110,"d":"$110.00"}]
["D5640","Replace Broken Teeth – Per Tooth",{"v":81,"d":"$81.00"}]
["D5650","Add Tooth to Existing Partial Denture",{"v":88,"d":"$88.00"}]
["D5660","Add Clasp to Existing Partial Denture",{"v":110,"d":"$110.00"}]
["Denture Relining"]
["D5710","Rebase Complete Upper Denture",{"v":245,"d":"$245.00"}]
["D5711","Rebase Complete Lower Denture",{"v":245,"d":"$245.00"}]
["D5720","Rebase Upper Partial Denture",{"v":245,"d":"$245.00"}]
["D5721","Rebase Lower Partial Denture",{"v":245,"d":"$245.00"}]
["D5730","Reline Complete Upper Denture – Chairside",{"v":150,"d":"$150.00"}]
["D5731","Reline Complete Lower Denture – Chairside",{"v":150,"d":"$150.00"}]
["D5740","Reline Upper Partial Denture – Chairside",{"v":150,"d":"$150.00"}]
["D5741","Reline Lower Partial Denture – Chairside",{"v":150,"d":"$150.00"}]
["D5750","Reline Complete Upper Denture – Laboratory",{"v":210,"d":"$210.00"}]
["D5751","Reline Complete Lower Denture – Laboratory",{"v":210,"d":"$210.00"}]
["D5760","Reline Upper Partial Denture – Laboratory",{"v":210,"d":"$210.00"}]
["D5761","Reline Lower Partial Denture – Laboratory",{"v":210,"d":"$210.00"}]
["Interim Dentures"]
["D5810","Interim Complete Denture – Upper",{"v":385,"d":"$385.00"}]
["D5811","Interim Complete Denture – Lower",{"v":385,"d":"$385.00"}]
["D5820","Interim Partial Denture – Upper",{"v":290,"d":"$290.00"}]
["D5821","Interim Partial Denture – Lower",{"v":290,"d":"$290.00"}]
["Oral Surgery"]
["D7111","Extraction of Coronal Remnants – Deciduous Tooth",{"v":60,"d":"$60.00"}]
["D7140","Extraction, Erupted Tooth or Exposed Root – Elevation and/or Forceps Removal",{"v":64,"d":"$64.00"}]
["D7210","Surgical Removal of Erupted Tooth – Removal of Bone and/or Section of Tooth",{"v":145,"d":"$145.00"}]
["D7220","Removal of Impacted Tooth – Soft Tissue",{"v":155,"d":"$155.00"}]
["D7230","Removal of Impacted Tooth – Partially Bony",{"v":225,"d":"$225.00"}]
["D7240","Removal of Impacted Tooth – Completely Bony",{"v":300,"d":"$300.00"}]
["D7241","Removal of Impacted Tooth – Completely Bony, Unusual Complications (Narrative Required)",{"v":300,"d":"$300.00"}]
["D7250","Surgical Removal of Residual Tooth Roots – Cutting Procedure",{"v":145,"d":"$145.00"}]
["D7251","Coronectomy - Intentional Partial Tooth Removal",{"v":225,"d":"$225.00"}]
["D7260","Oroantral Fistula Closure",{"v":450,"d":"$450.00"}]
["D7261","Primary Closure of a Sinus Perforation",{"v":415,"d":"$415.00"}]
["D7270","Tooth Stabilization of Accidentally Evulsed or Displaced Tooth",{"v":200,"d":"$200.00"}]
["D7280","Surgical Access of an Unerupted Tooth (Excluding Wisdom Teeth)",{"v":255,"d":"$255.00"}]
["D7283","Placement of Device to Facilitate Eruption of Impacted Tooth",{"v":65,"d":"$65.00"}]
["D7285","Biopsy of Oral Tissue – Hard (Bone, Tooth) (Tooth Related – Not allowed when in conjunction with another surgical procedure)",{"v":215,"d":"$215.00"}]
["D7286","Biopsy of Oral Tissue – Soft (All Others) (Tooth Related – Not allowed when in conjunction with another surgical procedure)",{"v":180,"d":"$180.00"}]
["D7287","Exfoliative Cytological Sample Collection",{"v":74,"d":"$74.00"}]
["D7288","Brush Biopsy – Transepithelial Sample Collection",{"v":74,"d":"$74.00"}]
["D7310","Alveoloplasty in Conjunction with Extractions – 4 or More Teeth or Tooth Spaces per Quadrant",{"v":120,"d":"$120.00"}]
["D7311","Alveoloplasty in Conjunction with Extractions – 1 to 3 Teeth or Tooth Spaces per Quadrant",{"v":65,"d":"$65.00"}]
["D7320","Alveoloplasty Not in Conjunction with Extractions – 4 or More Teeth or Tooth Spaces per Quadrant",{"v":155,"d":"$155.00"}]
["D7321","Alveoloplasty Not in Conjunction with Extractions – 1 to 3 Teeth or Tooth Spaces per Quadrant",{"v":77,"d":"$77.00"}]
["D7450","Removal of Benign Odontogenic Cyst or Tumor – Up to 1.25 cm",{"v":245,"d":"$245.00"}]
["D7451","Removal of Benign Odontogenic Cyst or Tumor – Greater than 1.25 cm",{"v":245,"d":"$245.00"}]
["D7471","Removal of Lateral Exostosis – Maxilla or Mandible",{"v":260,"d":"$260.00"}]
["D7472","Removal of Torus Palatinus",{"v":260,"d":"$260.00"}]
["D7473","Removal of Torus Mandibularis",{"v":260,"d":"$260.00"}]
["D7485","Surgical Reduction of Osseous Tuberosity",{"v":155,"d":"$155.00"}]
["D7510","Incision and Drainage of Abscess – Intraoral Soft Tissue",{"v":105,"d":"$105.00"}]
["D7511","Incision and Drainage of Abscess – Intraoral Soft Tissue Complicated",{"v":155,"d":"$155.00"}]
["D7960","Frenulectomy – Also Known as Frenectomy or Frenotomy – Separate Procedure",{"v":170,"d":"$170.00"}]
["D7963","Frenuloplasty",{"v":210,"d":"$210.00"}]
["Orthodontics"]
["D8050","Interceptive Orthodontic Treatment of the Primary Dentition – Banding",{"v":480,"d":"$480.00"}]
["D8060","Interceptive Orthodontic Treatment of the Transitional Dentition – Banding",{"v":480,"d":"$480.00"}]
["D8070","Comprehensive Orthodontic Treatment of the Transitional Dentition – Banding",{"v":500,"d":"$500.00"}]
["D8080","Comprehensive Orthodontic Treatment of the Adolescent Dentition – Banding",{"v":515,"d":"$515.00"}]
["D8090","Comprehensive Orthodontic Treatment of the Adult Dentition – Banding",{"v":515,"d":"$515.00"}]
["D8660","Pre-Orthodontic Treatment Visit",{"v":66,"d":"$66.00"}]
["D8670","Periodic Orthodontic Treatment Visit – As Part of Contract"]
[null,"Children (up to 19th birthday)"]
[null,"24 month treatment free",{"v":2465,"d":"$2,465.00"}]
[null,"Charge per month for 24 months",{"v":103,"d":"$103.00"}]
[null,"Adults"]
[null,"24 month treatment free",{"v":3375,"d":"$3,375.00"}]
[null,"Charge per month for 24 months",{"v":141,"d":"$141.00"}]
["D8680","Orthodontic Retention – Removal of Appliances, Construction and Placement of Retainer(s)",{"v":345,"d":"$345.00"}]
["D8999","Unspecified Orthodontic Procedure – By Report (Orthodontic Treatment Plan and Records)",{"v":195,"d":"$195.00"}]
["General Anesthesia/IV Sedation"]
["D9220","General Anesthesia – First 30 Minutes",{"v":180,"d":"$180.00"}]
["D9221","General Anesthesia – Each Additional 15 Minutes",{"v":80,"d":"$80.00"}]
["D9241","IV Conscious Sedation – First 30 Minutes",{"v":180,"d":"$180.00"}]
["D9242","IV Conscious Sedation – Each Additional 15 Minutes",{"v":73,"d":"$73.00"}]
["Emergency Services"]
["D9110","Palliative (Emergency) Treatment of Dental Pain – Minor procedure",{"v":65,"d":"$65.00"}]
["D9440","Office Visit – After Regularly Scheduled Hours",{"v":74,"d":"$74.00"}]
["Miscellaneous Services"]
["D9972","External Bleaching per Arch",{"v":175,"d":"$175.00"}]