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Dental insurance coverage and plan features

BrightSmile for Students

Share your BrightSmile with the world.

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Oral health Dental care and coverage

Regular visits to the dentist are essential for maintaining your BrightSmile. In fact, the American Dental Association recommends you go every six months, and your dentist may suggest even more frequent visits if you need additional help. During a regular dental checkup, your dentist (or a dental hygienist) will take a look at your face, head and neck and conduct a thorough dental examination on your teeth, gums and throat. They will evaluate the health of your mouth because an exam can uncover signs of oral cancer, diabetes or vitamin deficiencies.

Your dentist will assess the overall state of your teeth, gums and oral health by examining the following: Overall face and neck

Your bite

Lymph nodes and lower jaw joints (TMJs)

Damaged fillings

Any changes in the gums covering your teeth

Gums and signs of gum disease

Any loose or missing teeth and signs of decay

Plaque & tartar buildup or cavities

Tongue and mouth tissue

X-rays of your mouth

Your dental professional will also clean your teeth, discuss the results of your exam and X-rays and provide recommendations for your general oral care routine.

With dental insurance, your exam and cleaning are covered. 1 (855) 557-6463

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We care about student smiles. Your BrightSmile dental plan can help you maintain a healthy mouth by helping manage the cost of care - whether it’s preventive or an emergency. The plan fully covers the cost of almost any dental service or procedure at your school’s onsite dental clinic, which means you have convenient care nearby that won’t cost you a thing when you visit the dentist.

BrightSmile for Students dental insurance. BrightSmile for Students is a dental insurance plan built with you in mind. It’s easy to use and provides great coverage on over 200 services and procedures. Plus, once the annual premium has been paid, there’s no limit to how many times you see the dentist. You just have to be under the age of 65 and have a physical address in the same state as your school - that’s it!

Covered services and procedures Be confident in getting the care you need to maintain a healthy smile. Your BrightSmile for Students plan offers a generous reimbursement on 200+ services and procedures, or visit the campus dental clinic and pay nothing.

Routine dental exam

Fillings

Emergency pain treatment

Teeth cleaning

Root canals

X-Rays

Crowns

Tooth extraction

Plus over 200 others.....

We made it easy. We kept it simple and straightforward for busy students there are no deductibles, no co-insurance and no network to stay within. When you visit the onsite Campus Smiles clinic, your service is fully covered, which means you’ll pay $0 when you visit*. Want to visit an off-campus dentist? No problem. You can go to any dentist, pay for the service at that time, and then send us the claim for a reimbursement. See the Covered Services list on page 8 for reimbursement amounts. *Once the annual premium is paid. $2,000 annual max. as allowed by the policy.

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A dental clinic, right where you are. Campus Smiles provides comprehensive dental services to the school and surrounding community, and the clinic is conveniently located right on campus. The dental care team at Campus Smiles are licensed professionals who provide students, faculty and staff with the most affordable, high-quality, and convenient dental care available.

Campus Smiles Campus Smiles is dedicated to providing patients full service dentistry, from exams and procedures to cosmetic whitening, aligners and more. Here’s what you can expect on your first visit:

Comprehensive exam

Friendly staff

Teeth cleaning

Licensed dental experts

Full series of X-Rays

$0 cost with your BrightSmile plan

Campus Smiles is open during normal business hours and is usually located inside the student wellness center. If you have a dental emergency or need an appointment outside of regular hours, call us, and we will do our best to accommodate you. To find your nearest Campus Smiles office and phone number, visit us online:

www.Campus-Smiles.com

1 (855) 557-6463

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Convenient care, for $0 out-of-pocket.* Healthy teeth and gums support overall wellness1, and insurance helps keep the cost of dental care affordable. When you’re healthy and happy, you may find it easier to concentrate, get better sleep and be active - all of which can contribute to academic success. It’s not surprising then, that your school actively seeks ways to help you maintain your health and happiness. Your school partners with Campus Smiles and BrightBenefits to bring students the highest quality care, utmost convenience and generous coverage; it’s truly a concierge care experience.

1. “Six Reasons You Need Regular Dental Checkups”, 2016. www.123dentist.com/six-reasons-need-regular-dental-checkups/

Concierge experience Use your BrightSmile for Students plan at Campus Smiles for the most seamless experience possible. Enjoy the convenience of an on-campus clinic, and pay $0 for almost any service once your annual premium is paid. When a school that cares for its student population brings the ease of an onsite clinic together with a generous dental plan, students are able to maintain their oral health without worrying about the cost or the paperwork. It is a recipe for success. Here’s how we work together to keep it simple for you:

No network to search No deductibles No co-insurance No cost* for 200+ services No claim forms to submit* No limit to how often you visit the dentist Simple eligibility requirements

*Applies Campus Smiles and may vary by provider. Up to $2,000 annual maximum, as allowed by the policy. Campus Smiles agrees to charge what the plan covers. Prices may vary by location. Coverage up to the stated amounts will be paid by the plan in the form of a reimbursement at other provider locations once the claim has been submitted.

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Questions? Congratulations! You are the beneficiary of an incredible delivery system for dental care. We understand it is a little different from most dental insurance you may have enjoyed in the past. It’s unique, and you likely have questions. Here, you’ll find the answers to a few common questions, but if you need additional help, just contact us at (855) 557-6463 or BrightBenefits@careington.com.

What services and procedures does the plan cover? How much will I have to pay? See page 8 for a complete list of covered services and procedures. Once the annual premium is paid, the plan pays up to the amount listed for those services, up to $2,000 max each year. Any cost beyond the listed amount is your responsibility. Campus Smiles has agreed to not charge more than the amounts listed, which results in $0 out-of-pocket for you! Procedures not listed are not covered in any amount.

When is my policy effective, and when will it renew? Your policy is effective the first of the month in which the premium is paid and is valid for 12 months of coverage. Before the policy expires, you will have the opportunity to renew coverage for another benefit year.

What are the eligibility requirements for coverage and how can I check that? A member must be under the age of 65 and have a physical address in the same state as the school. To verify eligibility or coverage amounts, please contact BrightSmile for Students Member Services at (855) 557-6463 or BrightBenefits@Careington.com.

Is there a member ID card? What information do I need to make an appointment? When making an appointment at Campus Smiles, you should have your Member ID number. No information is needed when scheduling at other dentists. Your ID number can be found on your ID card or by calling Member Services. Your ID card is sent to the provided email address, along with a welcome letter and copy of your official policy on or around your effective date. If you need those materials sent again, or if you require a paper copy, contact Member Services at (855) 557-6463 or BrightBenefits@Careington.com.

Will I need to submit a claim form? Typically, your dentist will submit a claim for you. If not, you will pay for the service rendered and submit a Claim Form by email, fax or postal service to receive reimbursement. See the reverse side of your Member ID card for claims submission information. If you need a Claim Form, contact BrightBenefits at (855) 557-6463 or BrightBenefits@Careington.com or your school’s plan administrator.

Are any dental prescriptions covered on this policy? No. BrightSmile for Students only covers services and procedures.

For any questions not addressed here, please refer to your Policy Document or contact Member Services at (855) 557-6463 or BrightBenefits@careington.com.

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Important Info. We have come together to deliver a system that works - quality care, amazing affordability, and an institution working on your behalf to keep your smile bright - because we believe in healthy smiles, and we believe in you. If you have questions or need guidance on your oral health journey, reach out to us - we are here to help.

Questions about BrightSmile for Students coverage, eligibility or plan features in general?

Ready for a dental checkup or procedure?

BrightSmile for Students

Campus Smiles

Member Services

Find your school’s dental office and

1 (855) 557-6463

phone number, or schedule an

BrightBenefits@Careington.com

appointment online.

P.O. Box 2568

www.Campus-Smiles.com

Frisco, TX 75034

3 out of 10

In a 2019 study on dental health issues among college

college students

students, 31.3% of college students have a current untreated dental health issue, with common barriers being cost and

have an untreated dental issue.

lack of time.

Corey H. Basch, William D. Kernan & Sarah A. MacLean (2019) Improving understanding about dental health issues in college students, Journal of Prevention & Intervention in the Community, 47:1, 25-31, DOI: 10.1080/10852352.2018.1547306

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BrightBenefits will pay the Schedule Amount shown below (in dollars) for each procedure listed when a charge is incurred for a Covered Dental Procedure. This Policy must be in force when the charge is incurred. We will not pay a benefit for any charged incurred for a procedure not listed in this Schedule of Covered Procedures.

Covered Procedures

BrightSmile for Students by BrightBenefits

Your BrightSmile for Students plan pays up to the amount listed for the 228 services and procedures listed here, once your

Schedule of covered procedures premium is paid and the policy is effective ($2,000 annual max.). Any amount incurred beyond what you find here is your

Plan C

responsibility. Campus Smiles has agreed to not charge more than these amounts listed, which means you will pay $0 outof-pocket! Procedures not found here are not covered in any amount.

Covered Procedure Codes

Description

Schedule Amount Plan C

D0120 D0140 D0150 D0160 D0170 D0180 D0210 D0220 D0230 D0240 D0270 D0272 D0273 D0274 D0330

Periodic oral evaluation-established patient $37 Limited oral evaluation-problem focused $62 Comprehensive oral evaluation-new or established patient $65 Detailed, extensive oral evaluation – problem focused $65 Re-evaluation – limit, assess previously existing condition $62 Comprehensive periodontal evaluation-new or established patient $71 Intraoral-complete series of radiographic images $99 Intraoral-periapical first radiographic image $20 Intraoral-periapical each additional radiographic image $18 Intraoral-occlusal radiographic image $31 Bitewing-single radiographic image $21 Bitewings-two radiographic images $33 Bitewings-three radiographic images $40 Bitewings-four radiographic images $46 Panoramic radiographic image $84 Cone beam ct capture and interpretation, limited field – less than one $217 D0364 whole jaw D0365 Cone beam ct capture and interpretation, one full arch – mandible $217 D0366 Cone beam ct capture and interpretation, both jaws $217 D0367 Cone Beam ct capture and interpretation, both jaws $217 D1110 Prophylaxis – adult $68 D1120 Prophylaxis – child $47 D1206 Topical application of fluoride varnish $36 D1208 Topical application of fluoride - excluding varnish $24 D1351 Sealant-per tooth $39 Preventive resin restoration, moderate to high caries risk, permanent $39 D1352 tooth D1510 Space maintainer-fixed-unilateral (quad) $247 D1516 Space maintainer-fixed-bilateral-maxillary $345 D1517 Space maintainer – fixed – bilateral – mandibular $345 D1551 Re-cement or re-bond space maintainer – maxillary $53 D1552 Re-cement or re-bond bilateral space maintainer – mandibular $53 D1553 Re-cement or re-bond unilateral space maintainer – per quadrant $53 D2140 Amalgam-one surface, primary or permanent $93 D2150 Amalgam-two surfaces, primary or permanent $120 Schedule D2160 of covered procedures Amalgam-three surfaces, primary or permanent $145 D2161 Amalgam-four or more surfaces, primary or permanent $177 Plan C D2330 Resin-based composite-one surface, anterior $106 D2331 surfaces, anterior $135 Covered Procedure Codes Resin-based composite-two Description Schedule Amount Plan C

BrightSmile for Students by BrightBenefits

D2332 D2335 D2390 D2391 D2392 D2393 D2394 D2520 1 (855) 557-6463 D2530 D2542

Resin-based composite-three surfaces, anterior Resin-based composite-four or more surfaces or involving incisal Page 1 of 7 angle, anterior Resin-based composite crown, anterior (primary only) Resin-based composite-one surface, posterior Resin-based composite-two surfaces, posterior Resin-based composite-three surfaces, posterior Resin-based composite-four or more surfaces, posterior Inlay-metallic-two surfaces Inlay-metallic-three or more surfaces 8 Onlay-metallic-two surfaces

$165 $195 $217 $124 $162 $201 $247 $632 $728 $714


D2392 D2393 D2394 D2520 D2530 D2542 D2543 D2544 D2643 D2644 D2710

Resin-based composite-two surfaces, posterior Resin-based composite-three surfaces, posterior Resin-based composite-four or more surfaces, posterior Inlay-metallic-two surfaces Inlay-metallic-three or more surfaces Onlay-metallic-two surfaces Onlay-metallic-three surfaces Onlay-metallic-four or more surfaces Onlay-porcelain/ceramic-three surfaces Onlay-porcelain/ceramic-four or more surfaces Crown – resin-based composite (indirect)

$162 $201 $247 $632 $728 $714 $747 $777 $772 $819 $743

D2712

Crown – ¾ resin-based composite (indirect; excluding facial veneers)

$743

D2720 D2721 D2722 D2740 D2750 D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 D2794 D2799

Crown–resin with high noble metal Crown–resin with predominantly base metal Crown – resin with noble metal Crown-porcelain/ceramic substrate Crown-porcelain fused to high noble metal Crown-porcelain fused to predominantly base metal Crown-porcelain fused to noble metal Crown – porcelain fused to titanium and titanium alloy Crown – ¾ cast high noble metal Crown – ¾ cast high predominantly base metal Crown – ¾ cast noble metal Crown ¾ porcelain/ceramic Crown-full cast high noble metal Crown-full cast predominantly base metal Crown-full cast noble metal Crown – titanium and titanium allows Provisional crown–further treatment, diagnosis necessary Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration Re-cement or re-bond indirectly fabricated or prefabricated post and core Re-cement or re-bond crown Reattachment of tooth fragment, incisal edge or cusp Prefabricated crown – porcelain/ceramic, primary tooth Prefabricated stainless steel crown-primary tooth Prefabricated stainless steel crown-permanent tooth

$743 $743 $743 $823 $812 $756 $775 $743 $743 $743 $743 $801 $784 $743 $756 $743 $223

D2910 D2915 D2920 D2921 D2929 D2930 D2931

$71 $71 $72 $223 $223 $197 $223

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BrightSmile for Students by BrightBenefits Schedule of covered Procedures procedures Covered Plan C Covered Procedure Codes

Description

Schedule Amount Plan C

D2932 D2933

Prefabricated resin crown Prefabricated stainless steel crown with resin window

$223 $273

D2934

Prefabricated crown – esthetic coated stainless steel, primary tooth

$223

D2950 D2951 D2952 D2953 D2957 D2954 D2980 D2981 D2982 D3110 D3120 D3220 D3221

Core buildup, including any pins when required Pin retention, per tooth, in addition to restoration Post and core in addition to crown Each additional indirectly fabricated post – same tooth Each additional prefabricated post – same tooth Prefabricated post and core in addition to crown Crown repair necessitated by restorative material failure Inlay repair necessitated by restorative material failure Onlay repair necessitated by restorative material failure Pulp cap - direct (excluding final restoration) Pulp cap - indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) Pulpal debridement, primary and permanent teeth Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) Endodontic therapy, anterior tooth Endodontic therapy, bicuspid tooth Endodontic therapy, molar Retreatment of previous root canal therapy-anterior Retreatment of previous root canal therapy-bicuspid Retreatment of previous root canal therapy-molar Apicoectomy – anterior Apicoectomy - bicuspid (first root) Apicoectomy - molar (first root) Apicoectomy (each additional root) Retrograde filling-per root Root amputation-per root Hemisection (including any root removal), not including root canal therapy Canal Preparation and fitting of preformed dowel or post Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant Gingivectomy or gingivolplasty - one to three contiguous teeth or bounded teeth spaces per quadrant Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth Anatomical crown exposure – four or more contiguous teeth or tooth bounded spaces per quadrant Anatomical crown exposure – one to three contiguous teeth or tooth bounded spaces per quadrant

$188 $43 $297 $238 $238 $238 $71 $71 $71 $65 $52 $134 $147

D3240 D3310 D3320 D3330 D3346 D3347 D3348 D3410 D3421 D3425 D3426 D3430 D3450 D3920 D3950 D4210 D4211 D4212 D4230 D4231

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$170 $541 $663 $822 $721 $849 $1,050 $572 $636 $721 $244 $179 $373 $283 $129 $454 $202 $161 $161 $161


D3430 D3450

Retrograde filling-per root Root amputation-per root Hemisection (including any root removal), not including root canal D3920 therapy D3950 Canal Preparation and fitting of preformed dowel or post Gingivectomy or gingivoplasty - four or more contiguous teeth or D4210 bounded teeth spaces per quadrant Gingivectomy or gingivolplasty - one to three contiguous teeth or D4211 bounded teeth spaces per quadrant Gingivectomy or gingivoplasty to allow access for restorative D4212 procedure, per tooth Schedule of covered procedures Anatomical crown exposure – four or more contiguous teeth or tooth D4230 bounded spaces per quadrant Plan C Anatomical crown exposure – one to three contiguous teeth or tooth D4231 Covered Procedure Codes bounded spaces per quadrantDescription

BrightSmile for Students by BrightBenefits

Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces, per quadrant Gingival flap procedure, including root planing - one to three Page 3 of 7 contiguous teeth Apically positioned flap Clinical crown lengthening - hard tissue Osseous surgery (including elevation of full thickness flap and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (including flap entry and closure) - one to three contiguous teeth or tooth bounded teeth spaces per quadrant

D4240 D4241 D4245 D4249 D4260 D4261 D4263

Bone replacement graft – retained natural tooth - first site in quadrant Bone replacement graft – retained natural tooth - each additional site in quadrant Guided tissue regeneration - resorbable barrier, per site Guided tissue regeneration - nonresorbable barrier, per site (includes membrane removal) Surgical revision, per tooth Pedicle soft tissue graft procedure Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same area) Non-autogenous connective tissue graft (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft

D4264 D4266 D4267 D4268 D4270 D4273 D4274 D4275

$179 $373 $283 $129 $454 $202 $161 $161 $161 Schedule Amount Plan C $575 $333 $161 $630 $958 $514 $343 $292 $353 $454 $161 $681 $832 $472 $625

D4341

Periodontal scaling and root planing - four or more teeth per quadrant

$176

D4342

Periodontal scaling and root planing - one to three teeth per quadrant

$102

Scaling in presence of generalized moderate or severe gingival inflammation – full mouth after oral evaluation Full mouth debridement to enable comprehensive oral evaluation, diagnosis, on subsequent visit Periodontal maintenance Complete denture – maxillary Complete denture – mandibular Immediate denture – maxillary Immediate denture – mandibular Maxillary partial denture - resin base (including any conventional clasps Mandibular partial denture - resin base (including any conventional clas Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, clasping materials, rests and teeth)

D4346 D4355 D4910 D5110 D5120 D5130 D5140 D5211 D5212 D5213

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$102 $120 $108 $1,050 $1,050 $1,145 $1,145 $886 $1,030 $1,161

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BrightSmile for Students by BrightBenefits Schedule of covered procedures

Covered Procedures

Covered Procedure Codes D5214

Plan C Description

Mandibular partial denture - cast metal framework with resin denture bases (including any retentive /clasping materials, rests and teeth)

Schedule Amount Plan C $1,161

Maxillary partial denture - flexible base (including any clasps, rests $886 and teeth) Mandibular partial denture - flexible base (including any clasps, rests D5226 $1,030 and teeth) Removable unilateral partial denture - one piece cast metal (including D5282 $677 clasps and teeth), maxillary Removable unilateral partial denture – one piece cast metal (including D5283 $677 clasps and teeth), mandibular D5410 Adjust complete denture – maxillary $58 D5411 Adjust complete denture – mandibular $58 D5421 Adjust partial denture – maxillary $58 D5422 Adjust partial denture – mandibular $58 D5511 Repair broken complete denture base, mandibular $115 D5512 Repair broken complete denture base, maxillary $115 D5520 Replace missing or broken teeth - complete denture (each tooth) $96 D5630 Repair or replace broken clasp – per tooth $163 D5640 Replace broken teeth - per tooth $105 D5650 Add tooth to existing partial denture $144 D5660 Add clasp to existing partial denture - per tooth $173 D5710 Rebase complete maxillary denture $426 D5711 Rebase complete mandibular denture $407 D5720 Rebase maxillary partial denture $403 D5721 Rebase mandibular partial denture $403 D5730 Reline complete maxillary denture (chairside) $241 D5731 Reline complete mandibular denture (chairside) $241 D5740 Reline maxillary partial denture (chairside) $220 D5741 Reline mandibular partial denture (chairside) $220 D5750 Reline complete maxillary denture (laboratory) $321 D5751 Reline complete mandibular denture (laboratory) $321 D5760 Reline maxillary partial denture (laboratory) $316 D5761 Reline mandibular partial denture (laboratory) $316 D5820 Interim partial denture (maxillary) $393 D5821 Interim partial denture (mandibular) $417 D6010 Surgical placement of implant body: endosteal implant $1,755 D6056 Prefabrication abutment - includes modification and placement $364 D6057 Custom abutment - includes placement $450 D6058 Abutment supported porcelain/ceramic crown $1,010 Schedule of covered procedures Abutment supported porcelain fused to metal crown (high noble D6059 $997 metal) Plan C Abutment supported porcelain fused to metal crown (predominantly D6060 Covered Procedure Codes base metal ) Description Schedule $942 Amount Plan C D5225

BrightSmile for Students by BrightBenefits

D6061

Abutment supported porcelain fused to metal crown (noble metal )

$961

D6062

Abutment supported cast metal crown (high noble metal )

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$957

D6063

Abutment supported cast metal crown (predominantly base metal )

$834

Implant supported porcelain/ceramic crown) Implant supported porcelain fused to high noble metal alloys Pontic - Cast high noble metal Pontic - Cast predominately base metal 12 Pontic - Cast noble metal Pontic - Porcelain fused to high noble metal

$994 $968 $781 $732 $761 $771

D6065 D6066 D6210 D6211 1 (855) 557-6463 D6212 D6240


Covered Procedure Codes

Description

Schedule Amount Plan C

D6061

Abutment supported porcelain fused to metal crown (noble metal )

$961

D6062

Abutment supported cast metal crown (high noble metal )

$957

D6063

Abutment supported cast metal crown (predominantly base metal )

$834

D6065 D6066 D6210 D6211 D6212 D6240 D6241 D6242 D6245 D6545 D6548 D6740 D6750 D6751 D6752 D6790 D6792 D6930 D7111

Implant supported porcelain/ceramic crown) Implant supported porcelain fused to high noble metal alloys Pontic - Cast high noble metal Pontic - Cast predominately base metal Pontic - Cast noble metal Pontic - Porcelain fused to high noble metal Pontic - Porcelain fused to predominantly base metal Pontic - Porcelain fused to noble metal Pontic - Porcelain/ceramic Retainer-cast metal for resin bonded fixed prosthesis Retainer-porcelain/ceramic for resin bonded fixed prosthesis Retainer Crown - porcelain/ceramic Retainer Crown - porcelain fused to high noble metal Retainer Crown - porcelain fused to predominantly base metal Retainer Crown - porcelain fused to noble metal Retainer Crown - full cast high noble metal Retainer Crown - full cast noble metal Re-cement or re-bond fixed partial denture Extraction, coronal remnants - primary tooth Extraction, erupted tooth or exposed root (elevation and/or forceps removal) Extraction of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated. Removal of impacted tooth - soft tissue Removal of impacted tooth - partially bony Removal of impacted tooth - complete bony Removal of impacted tooth - completely bony, with unusual surgical complications Surgical removal of residual tooth roots (cutting procedure) Coronectomy – intentional partial tooth removal Exposure of an unerupted tooth Placement of device to facilitate eruption of impacted tooth Incisional biopsy of oral tissue-soft Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant Alveoloplasty in conjunction with extractions -one to three teeth or tooth spaces, per quadrant

$994 $968 $781 $732 $761 $771 $712 $752 $796 $293 $322 $816 $795 $742 $760 $768 $754 $105 $91

D7140 D7210 D7220 D7230 D7240 D7241 D7250 D7251 D7280 D7283 D7286 D7310 D7311

$121 $195 $245 $326 $383 $481 $206 $206 $373 $160 $319 $204 $178

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D7210

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 - complete bony Removal of impacted tooth - completely bony, with unusual surgical D7241 complications D7250 Surgical removal of residual tooth roots (cutting procedure) D7251 Coronectomy – intentional partial tooth removal D7280 Exposure of an unerupted tooth D7283 Placement of device to facilitate eruption of impacted tooth D7286 Incisional biopsy of oral tissue-soft Schedule of covered procedures Alveoloplasty in conjunction with extractions - four or more teeth or D7310 tooth spaces, per quadrant Plan C Alveoloplasty in conjunction with extractions -one to three teeth or D7311 Covered Procedure Codes tooth spaces, per quadrant Description

Covered Procedures

BrightSmile for Students by BrightBenefits

D7320 D7321 D7510 D7511 D7953 D7961 D7962 D9110 D9222 D9223 D9230 D9239 D9243 D9310 D9944 D9995

Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant Page 6 of 7 Incision and drainage of abscess - intraoral soft tissue Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) Bone replacement graft for ridge preservation - per site Buccal/labial frenectomy (frenulectomy) Lingual frenectomy (frenulectomy) Palliative (emergency) treatment of dental pain - minor procedure Deep sedation/general anesthesia - first 15 minutes Deep sedation/general anesthesia - each subsequent 15 minute increment Inhalation of nitrous oxide/analgesia, anxiolysis Intravenous conscious sedation/analgesia - first 15 minutes Intravenous conscious sedation/analgesia – each 15 minute increment Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Occlusal guard-hard appliance, full arch Teledentistry – synchronous; real-time encounter

$195 $245 $326 $383 $481 $206 $206 $373 $160 $319 $204 $178 Schedule Amount Plan C $331 $280 $219 $331 $346 $280 $280 $85 $190 $145 $54 $156 $123 $97 $324 $37

Policy is underwritten by National Guardian Life Insurance Company, Madison, WI. Policy form number NDNINDSBP 2021. National Guardian Life Insurance Company is not affiliated with the Guardian Life Insurance Company of America, a/k/a The Guardian or Guardian Life. Careington Benefit Solutions is a third-party administrator. BSPLANCBROC0821

1 (855) 557-6463

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