ADP TOTALSOURCE, INC.

Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

PATIENT PATIENT
CODE PROCEDURE PAYS CODE PROCEDURE PAYS
Office Visit Copay $5 Test text
DIAGNOSTIC
D0120-D0180 Oral Evaluations No Charge D0277 Vertical Bitewings - 7 to 8 Films No Charge
D0210 Full mouth series Images No Charge D0330 Panoramic Image No Charge
D0220-D0230 Periapicals No Charge D0391 Interpretation of Diagnostic Image No Charge
D0240 Intraoral, Occlusal Image No Charge D0470 Diagnostic Casts No Charge
D0250-D0251 Extraoral Images No Charge D0472-D0474 Accession of Tissue No Charge
D0270-D0274 Bitewings No Charge
PREVENTIVE
D1110 Prophy - Adult No Charge D1510 Space Maintainer - Fixed Unilateral $60
D1120 Prophy - Child No Charge D1516-17 Space Maintainer - Fixed Bilateral $60
D4346 Scaling in presence of generalized $30 D1520 Space Maintainer - Removable Unilateral $70
moderate/severe gingival inflammation - full
mouth, after oral evaluation
D1208 Fluoride - Child No Charge D1526-27 Space Maintainer - Removable Bilateral $70
D1206 Application of Topical Fluoride Varnish No Charge D1551-52 Recement Space Maintainer $12
D1330 Oral Hygiene Instruction No Charge Recement or re-bond unilateral space $6
D1553 maintainer - per quad
D1351, D1354 Sealant No Charge Removal of fixed unilateral space maintainer - $6
D1556 per quad
D1352 Preventive Resin Restoration No Charge D1557-58 Removal of Space Maintainer $12
D1353 Sealant Repair - Per Tooth No Charge Distal shoe space maintainer - fixed - $66
D1575 unilateral
D1355 Caries preventive medicament application, per No Charge No Charge
tooth D2990 Resin Infiltration of Lesion
Diagnostic and Preventive services may be subject to age and frequency limitations. See your booklet for details.
RESTORATIVE
PRIMARY OR PERMANENT TEETH
D2140 Amalgam - 1 Surf Primary or Permanent $10 D2391 Resin-Based Composite 1 Surf, Posterior, bi- $10
cuspid*
D2150 Amalgam - 2 Surf Primary or Permanent $12 D2392 Resin-Based Composite 2 Surf, Posterior, bi- $12
cuspid*
D2160 Amalgam - 3 Surf Primary or Permanent $16 D2393 Resin-Based Composite 3 Surf, Posterior, bi- $16
cuspid*
D2161 Amalgam - 4+ Surf Primary or Permanent $18 D2394 Resin-Based Composite 4+ Surf, Posterior, bi- $18
cuspid*
D2330 Resin-Based Composite 1 Surf, Anterior $15 D2921 Reattachment of tooth fragment, incisal edge $4
or dusp
D2331 Resin-Based Composite 2 Surf, Anterior $21 D2940 Protective Restoration $3
D2332 Resin-Based Composite 3 Surf, Anterior $25 D2941 Interim therapeutic restoration - primary $1
D2335 Resin-Based Composite 4+ Surf; Anterior (or $35 D2951 Pin Retention - In Addition to Restoration $6
involving Incisal angle)
D2390 Resin-Based Composite Crown, Anterior $50
*If the patient elects to have a resin restoration on a molar or on the stress-bearing surfaces of a premolar, the patient is responsible for the copayment, if
any, for an amalgam restoration plus the difference between the dentist's Aetna approved fees for the resin restoration and the amalgam restoration.
CROWNS/BRIDGES
D2510 Inlay - Metallic 1 Surf $180 D6094 Abutment Supported Crown - (Titanium) $210
D2520 Inlay - Metallic 2 Surf $180 D6097 Abutment Sup Crown - porcelain/titanium and $210
titanium alloys
D2530 Inlay - Metallic 3 Surf $180 D6098 Implant Sup retainer - $210
porcelain/predominantly base alloys
D2542 Onlay - Metallic 2 Surf $180 D6099 Implant Sup retainer for FPD - porcelain / $210
noble alloys

ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

D2543 Onlay - Metallic 3 Surf $180 D6110 Implant Abut Sup Removable Dent-MaxCom $275

D2544 Onlay, Metallic - 4 or More Surf $180 D6111 Implant Abut Sup Removable Dent-Mand $275
Com
D2610 Inlay, Porcelain/Ceramic - 1 Surf $180 D6112 Implant Abut Sup Removable Dent-Max Par $275

D2620 Inlay, Porcelain/Ceramic - 2 Surf $180 D6113 Implant Abut Sup Removable Dent-Mand Par $275

D2630 Inlay, Porcelain/Ceramic - 3 or More Surf $180 D6114 Implant Abut Sup Fixed Dent-Max Com $275
D2642 Onlay, Porcelain/Ceramic - 2 Surf $180 D6115 Implant Abut Sup Fixed Dent-Mand Com $275
D2643 Onlay, Porcelain/Ceramic - 3 Surf $180 D6116 Implant Abut Sup Fixed Dent-Max Par $275
D2644 Onlay, Porcelain/Ceramic - 4 or More Surf $180 D6117 Implant Abut Sup Fixed Dent-Mand Par $275
D2650 Inlay, Composite/Resin - 1 Surf $180 D6120 Abutment Sup Retainer - porcelain/titanium $210
and titanium alloys
D2651 Inlay, Composite/Resin - 2 Surf $180 D6121 Implant Sup Retainer for metal FPD- $210
predominantly base alloys
D2652 Inlay, Composite/Resin - 3 Surf $180 D6122 Implant Sup Retainer for metal FPD- noble $210
alloys
D2662 Onlay, Composite/Resin - 2 Surf $180 D6123 Abutment Sup Retainer for metal FPD- $210
titanium and titanium alloys
D2663 Onlay, Composite/Resin - 3 Surf $180 D6195 Abutment Sup Retainer - porcelain /titanium $210
and titanium alloys
D2664 Onlay, Composite/Resin - 4 or More Surf $180 D6205 Pontic - Indirect Resin Based Composite $210
D2710 Crown - Resin-Based Composite, Indirect $210 D6210 Pontic - Cast High Noble Metal $210
D2712 Crown - 3/4 Resin-Based Composite, Indirect $176 D6211 Pontic - Cast Predominantly Base Metal $210
D2720 Crown - Resin With High Noble Metal $210 D6212 Pontic - Cast Noble Metal $210
D2721 Crown - Resin With Predominantly Base Metal $210 D6214 Pontic - Titanium $210

D2722 Crown - Resin With Noble Metal $210 D6240 Pontic - Porcelain Fused to High Noble Metal $210
D2740 Crown - Porcelain/Ceramic Substrate $210 D6241 Pontic - Porcelain Fused to Predominantly $210
Base Metal
D2750 Crown - Porcelain Fused to High Noble Metal $210 D6242 Pontic - Porcelain Fused to Noble Metal $210
D2751 Crown - Porcelain Fused to Predominantly Base $210 D6243 Pontic - porcelain fused to titanium and $210
Metal titanium alloys
D2752 Crown - Porcelain Fused to Noble Metal $210 D6245 Pontic - Porcelain/Ceramic $210
D2753 Crown - Porcelain fused to titanium and titanium $210 D6250 Pontic - Resin With High Noble Metal $210
alloys
D2780 Crown - 3/4 Cast High Noble Metal $220 D6251 Pontic - Resin With Predominantly Base Metal $210
D2781 Crown - 3/4 Cast Predominantly Base Metal $220 D6252 Pontic - Resin With Noble Metal $210
D2782 Crown - 3/4 Cast Noble Metal $220 D6545 Retainer - Cast Metal for Resin-Bonded Fixed $180
D2783 Crown - 3/4 Porcelain/Ceramic $220 D6548 Retainer - Porcelain/Ceramic for Resin- $180
Bonded Fixed Prosthesis
D2790 Crown - Full Cast High Noble Metal $210 D6549 Resin Retainer - Resin Bonded Prosthesis $105
D2791 Crown - Full Cast Predominantly Base Metal $210 D6600 Inlay - Porcelain/Ceramic, 2 Surf $180
D2792 Crown - Full Cast Noble Metal $210 D6601 Inlay - Porcelain/Ceramic, 3+ Surf $180
D2794 Crown - Titanium $210 D6602 Inlay - Cast High Noble Metal, 2 Surf $200
D2910 Recement Inlay, Onlay or Partial Coverage $10 D6603 Inlay - Cast High Noble Metal, 3+ Surf $200
D2915 Recement Cast or Prefab Post and Core $5 D6604 Inlay - Cast Predominantly Base Metal, 2 Surf $180
D2920 Recement Crown $10 D6605 Inlay - Cast Predominantly Base Metal, 3+ $180
D2929 Prefab Porcelain/Ceramic Crown - Primary $49 D6606 Inlay - Cast Noble Metal, 2 Surf $200
D2930 Prefab, Stainless Steel Crown - Primary Tooth $35 D6607 Inlay - Cast Noble Metal, 3+ Surf $200
D2931 Prefab, Stainless Steel Crown - Permanent Tooth $50 D6608 Onlay - Porcelain/Ceramic, 2 Surf $180

D2934 Prefabricated Esthetic Coated Stainless Steel $35 D6609 Onlay - Porcelain/Ceramic, 3+ Surf $180
D2950 Core Buildup, Including Any Pins $40 D6610 Onlay - Cast High Noble Metal, 2 Surf $200
ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

D2952 Post & Core in Addition to Crown $70 D6611 Onlay - Cast High Noble Metal, 3+ Surf $200
D6058 Abutment Supported Porcelain/Ceramic Crown $210 D6612 Onlay - Cast Predominantly Base Metal, 2 $180
D6059 Abutment Supported Porcelain Fused to Metal $210 D6613 Surf
Onlay - Cast Predominantly Base Metal, 3+ $180
Crown (High Noble Metal) Surf
Abutment Supported Porcelain Fused to Metal $210 D6614 Onlay - Cast Noble Metal, 2 Surf $200
D6060 Crown (Predominantly Base Metal)
D6061 Abutment Supported Porcelain Fused to Metal $210 D6615 Onlay - Cast Noble Metal, 3+ Surf $200
Crown (Noble Metal)
D6062 Abutment Supported Cast Metal Crown (High $210 D6624 Inlay - Titanium $200
Noble Metal)
D6063 Abutment Supported Cast Metal Crown $210 D6634 Onlay - Titanium $200
(Predominantly Base Metal)
D6064 Abutment Supported Cast Metal Crown (Noble $210 D6710 Crown - Indirect Resin Based Composite $210
D6065 Implant Supported Porcelain/Ceramic Crown $210 D6720 Crown - Resin With High Noble Metal $210
D6066 Implant Supported Porcelain Fused to High $210 D6721 Crown - Resin With Predominantly Base $210
Noble alloys Metal
D6067 Implant Supported Crown - High Noble alloys $210 D6722 Crown - Resin With Noble Metal $210
D6068 Abutment Supported Retainer for $210 D6740 Crown - Porcelain/Ceramic $210
Porcelain/Ceramic FPD
D6069 Abutment Supported Retainer for Porcelain $210 D6750 Crown - Porcelain Fused to High Noble Metal $210
Fused to Metal FPD (High Noble Metal)
D6070 Abutment Supported Retainer for Porcelain $210 D6751 Crown - Porcelain Fused to Predominantly $210
Fused to Metal FPD (Predominantly Base Metal) Base Metal
D6071 Abutment Supported Retainer for Porcelain $210 D6752 Crown - Porcelain Fused to Noble Metal $210
Fused to Metal FPD (Noble Metal)
D6072 Abutment Supported Retainer for Cast Metal $210 D6753 Crown - porcelain fused to titanium and $210
FPD (High Noble Metal) titanium alloys
D6073 Abutment Supported Retainer for Cast Metal $210 D6780 Crown - 3/4 Cast High Noble Metal $210
FPD (Predominantly Base Metal)
D6074 Abutment Supported Retainer for Cast Metal $210 D6781 Crown - 3/4 Cast Predominantly Base Metal $210
FPD (Noble Metal)
D6075 Implant Supported Retainer for Ceramic FPD $210 D6782 Crown - 3/4 Cast Noble Metal $210
D6076 Implant Supported Retainer for FPD - porcelain $210 D6783 Crown - 3/4 Porcelain/Ceramic $210
fused to high noble alloys
D6077 Implant Supported Retainer for FPD - high noble $210 D6784 Crown 3/4 - titanium and titanium alloys $210
alloys
D6082 Implant Sup Crown - porcelain/predominantly $210 D6790 Crown - Full Cast High Noble Metal $210
base alloys
D6083 Implant Sup Crown - porcelain fused to noble $210 D6791 Crown - Full Cast Predominantly Base Metal $210
alloys
D6084 Implant Sup Crown - porcelain/titanium and $210 D6792 Crown - Full Cast Noble Metal $210
titanium alloys
D6086 Implant Sup Crown - predominantly base alloys $210 D6794 Crown - Titanium $210

D6087 Implant Sup Crown - noble alloys $210 D6930 Recement Fixed Partial Denture $15
D6088 Implant Sup Crown - titanium and titanium alloys $210 Additional Charge per Unit for Full Mouth Rehabilitation. $125

Full mouth rehabilitation is defined as 6 or more units of covered crowns and/or pontics under one treatment plan.
Charges for crowns and bridgework are per unit. There will be additional charges for the actual cost for gold/high noble metal.
ENDODONTICS
D3110 Pulp Cap - Direct (excluding final restoration) $4 D3348 Retreatment of Previous Root Canal Therapy - $340
D3120 Pulp Cap - Indirect (excluding final restoration) $4 D3410 (1) Apicoectomy/Periradicular Surgery - Anterior $85

D3220 Therapeutic Pulpotomy (excluding final $14 D3421 (1) Apicoectomy/Periradicular Surgery - Bicuspid $85
restoration) (First Root)

ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

D3221 Pulpal Debridement, Primary and Permanent $10 D3425 (1) Apicoectomy/Periradicular Surgery - Molar $90
Teeth (First Root)
D3222 Partial Pulpotomy $13 D3426 (1) Apicoectomy/Periradicular Surgery- Each $55
D3230 Pulpal Therapy (Resorbable Filling) - Anterior, $14 D3430 (1) Retrograde Filling - Per Root $40
Primary Tooth
D3240 Pulpal Therapy (Resorbable Filling) - Posterior, $14 D3450 (1) Root Amputation - Per Root $70
Primary Tooth
D3310 Root Canal Therapy - Anterior (excluding final $70 D3471 (1) Surgical repair of root resorption, anterior $38
restoration)
D3320 Root Canal Therapy - Bicuspid (excluding final $85 D3472 (1) Surgical repair of root resorption, premolar $51
restoration)
D3330 Root Canal Therapy - Molar (excluding final $240 D3473 (1) Surgical repair of root resorption, molar $64
restoration)
D3331 Treatment of Root Canal Obstruction, $70 D3501 (1) Surgical exposure of root surface without $66
Nonsurgical Access apicoectomy or repair of root resorption,
anterior
D3332 Incomplete Endodontic Therapy; Inoperable, $43 D3502 (1) Surgical exposure of root surface without $88
Unrestorable or Fractured Tooth apicoectomy or repair of root resorption,
premolar
D3333 Internal Root Repair of Perforation Defects $55 D3503 (1) Surgical exposure of root surface without $110
apicoectomy or repair of root resorption, molar

D3346 Retreatment of Previous Root Canal Therapy - $170

Anterior
D3347 Retreatment of Previous Root Canal Therapy - $185
Bicuspid
(1) Certain services may be covered under the Medical Plan. Contact Member Services for more details.
PERIODONTICS
D4210 (1) Gingivectomy or Gingivoplasty - 4 or More $100 D4275 (1) Soft Tissue Allograft $275
Teeth - Per Quadrant
D4211 (1) Gingivectomy or Gingivoplasty - 1-3 Teeth - Per $38 D4276 (1) Connective Tissue/Pedicle Graft, Per Tooth $227
Quadrant
D4212 (1) Gingivectomy to allow access, per tooth $15 D4277 (1) Free soft tissue graft - first tooth $98
D4240 (1) Gingival Flap Procedure, Including Root Planing $110 D4278 (1) Free soft tissue graft - each additional tooth $49
- 4 or More Teeth - Per Quadrant
D4241 (1) Gingival Flap Procedure, Including Root Planing $66 D4283 (1) Autogenous connective tissue graft $76
- 1-3 Teeth - Per Quadrant
D4245 (1) Apically Positioned Flap $110 D4285 (1) Non-autogenous connective tissue graft $151

D4249 Clinical Crown Lengthening, Hard Tissue $180 D4341 Periodontal Scaling and Root Planing - 4 or $45
More Teeth - Per Quadrant
D4260 (1) Osseous Surgery (Including Flap Entry and $300 D4342 Periodontal Scaling and Root Planing - 1-3 $27
Closure) - 4 or More Teeth - Per Quadrant Teeth - Per Quadrant
D4261 (1) Osseous Surgery (Including Flap Entry and $180 D4355 Debridement $60
Closure) - 1-3 Teeth - Per Quadrant
D4268 (1) Surgical Revision Procedure, Per Tooth $120 D4910 Periodontal Maintenance $30
D4270 (1) Pedicle Soft Tissue Graft Procedure $230 D4920 Unscheduled Dressing Change (By Someone $10
Other Than Treating Dentist)
D4273 (1) Subepithelial Connective Tissue Graft, Per Tooth $138

(1) Certain services may be covered under the Medical Plan. Contact Member Services for more details.
PROSTHODONTICS-REMOVABLE (2)
D5110 Complete Denture - Maxillary $275 D5223-D5224 Immediate max/mand partial denture - cast $403
base framework w/resin denture base
(including any conventional clasps, rests and
D5120 Complete Denture - Mandibular $275 D5225 teeth)
Maxillary Partial Denture - Flexible Base $330
(including any clasps, rests and teeth)
ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

D5130 Immediate Denture - Maxillary $315 D5226 Mandibular Partial Denture - Flexible Base $330
(including any clasps, rests and teeth)
D5140 Immediate Denture - Mandibular $315 D5282-83 Removable Unilateral Partial Denture - One $275
Piece Cast Metal (including clasps and teeth)
D5211 Maxillary Partial Denture - Resin Base $275 D5284 Removable Unilateral Partial Denture - one $165
(including any conventional clasps, rests and piece flex base (including clasps and teeth) -
teeth) per quad
D5212 Mandibular Partial Denture - Resin Base $275 D5286 Removable Unilateral Partial Denture - one $138
(including any conventional clasps, rests and piece resin (including clasps and teeth) - per
teeth) quad
D5213 Maxillary Partial Denture - Cast Metal $350 D5410 Adjust Complete Denture - Maxillary $10
Framework with Resin Denture Bases (including
any conventional clasps, rests and teeth)
D5214 Mandibular Partial Denture - Cast Metal $350 D5411 Adjust Complete Denture - Mandibular $10
Framework with Resin Denture Bases (including
any conventional clasps, rests and teeth)
D5221-D5222 Immediate max/mand partial dental - resin base $316 D5421 Adjust Partial Denture - Maxillary $10
(including any conventional clasps, rests and
teeth)
D5422 Adjust Partial Denture - Mandibular $10
(2) Includes relines, adjustments, rebases within the 1st six months. Adjustments to dentures that are done within six months of placement of the denture,
are limited to no more than four adjustments.
REPAIRS TO PROSTHETICS
D5511-D5512 Repair Broken Complete Denture Base $25 D5730 Reline Complete Maxillary Denture $45
D5520 Replace Missing or Broken Teeth - Complete $20 D5731 Reline Complete Mandibular Denture $45
Denture (each tooth) (Chairside)
D5611-D5612 Repair Resin Partial Denture Base $35 D5740 Reline Maxillary Partial Denture (Chairside) $45
D5621-D5622 Repair Cast Partial Framework $35 D5741 Reline Mandibular Partial Denture (Chairside) $45
D5630 Repair or Replace Broken Clasp $35 D5750 Reline Complete Maxillary Denture (Lab) $85
D5640 Replace Broken Teeth - Per Tooth $35 D5751 Reline Complete Mandibular Denture (Lab) $85
D5650 Add Tooth to Existing Partial Denture $35 D5760 Reline Maxillary Partial Denture (Lab) $85
D5660 Add Clasp to Existing Partial Denture $40 D5761 Reline Mandibular Partial Denture (Lab) $85
D5670 Replace All Teeth and Acrylic on Cast Metal $86 D5820 Interim Partial Denture (Maxillary) (3) $60
Framework (Maxillary)
D5671 Replace All Teeth and Acrylic on Cast Metal $86 D5821 Interim Partial Denture (Mandibular) (3) $60
Framework (Mandibular)
D5710 Rebase Complete Maxillary Denture $86 D5850 Tissue Conditioning, Maxillary $20
D5711 Rebase Complete Mandibular Denture $86 D5851 Tissue Conditioning, Mandibular $20
D5720 Rebase Maxillary Partial Denture $86 D5876 Add metal substructure to acrylic full denture $25
(per arch)
D5721 Rebase Mandibular Partial Denture $86
(3) Eligible on Anterior Teeth only.
ORAL SURGERY
D7111 Extraction, Coronal Remnants - Deciduous Tooth $4 D7285 (1) Biopsy of Oral Tissue - Hard (Bone, Tooth) $30

D7140 Extraction, Erupted Tooth or Exposed Root $11 D7286 (1) Biopsy of Oral Tissue - Soft $30
(Elevation and/or Forceps Removal)
D7210 (1) Surgical Removal of Erupted Tooth $28 D7287 (1) Cytological Sample Collection $15
D7220 (1) Removal of Impacted Tooth - Soft Tissue $46 D7310 (1) Alveoloplasty in Conjunction With $25
Extractions - 4 or More Teeth or Tooth
D7230 (1) Removal of Impacted Tooth - Partially Bony $58 D7311 (1) Alveoloplasty in Conjunction With $13
Extractions - 1 to 3 Teeth or Tooth Spaces -
D7240 (1) Removal of Impacted Tooth - Completely Bony $100 D7320 (1) Alveoloplasty Not in Conjunction With $40
Extractions - 4 or More Teeth or Tooth
Spaces - Per Quadrant
ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

D7241 (1) Removal of Impacted Tooth - Completely Bony, $100 D7321 (1) Alveoloplasty Not in Conjunction With $20
With Unusual Surgical Complications Extractions - 1-3 Teeth or Tooth Spaces - Per
Quadrant
D7250 (1) Surgical Removal of Residual Tooth Roots $25 D7510 (1) Incision and Drainage of Abcess - Intraoral $20
Soft Tissue
D7251 Coronectomy - intentional partial tooth removal $50 D7511 (1) Incision and Drainage of Abcess - Intraoral $22
Soft Tissue - Complicated
D7280 (1) Surgical Access of Unerupted Tooth $26 D7961 (1) Buccal / labial frenectomy (frenulectomy) $34

D7282 (1) Mobilization of Erupted or Malpositioned Tooth $30 D7962 (1) Lingual frenectomy (frenulectomy) $34
to Aid Eruption
D7283 Placement of Device to Facilitate Eruption of $6 D7963 (1) Frenuloplasty $36
Impacted Tooth
(1) Certain services may be covered under the Medical Plan. Contact Member Services for more details.
OTHER (ADJUNCTIVE) SERVICES
D9110 Palliative (Emergency) Treatment of Dental Pain $10 D9942 Repair and/or Reline of Occlusal Guard $18
- minor procedure
D9222 Deep sedation/general anesthesia - 1st 15 min $104 D9943 Occlusal guard adjustment $9

D9223 Deep sedation/general anesthesia - each 15 $83 $81

D9944 Occlusal guard - hard appliance, full arch
minute increment
D9239 Intravenous conscious sedation/analgesia - 1st $104 $70
D9945 Occlusal guard - soft appliance, full arch
15 min
D9243 Intravenous conscious sedation/analgesia - each $83 $42
D9946 Occlusal guard - hard appliance, partial arch
15 minute increment
D9310 Consultation - Diagnostic Service Provided by No Charge D9951 Occlusal Adjustment - limited $10
Dentist or Physician Other Than Requesting
Dentist or Physician
D9311 Consultation with a medical health care No Charge D9952 Occlusal Adjustment - complete $60
professional

D9932-D9935 Denture cleaning and inspection $25

ORTHODONTICS
Comprehensive Orthodontic Treatment Includes exam, records, retention and appliance
Adolescent - excludes transitional dentition $2,000

Adult - excludes transitional dentition $2,000

Other Important Information
This Benefit summary of the Aetna Dental Maintenance Organization (DMO®) provides information on benefits provided when services are
rendered by a participating dentist. In order for a covered person to be eligible for benefits, dental services must be provided by a primary
care dentist selected from the network of participating DMO dentists. Out of network benefits may apply. Please refer to your Schedule of
Benefits.
Employees in AZ, CA, GA, MA, MD, MO, NC, NJ and TX must either live or work within the approved DMO® service area to be eligible to
enroll in the DMO®
Due to state law, limited (varying by state) DMO® benefits for non-emergency services rendered by non-participating providers are available
for plan contracts written in: CT, IL, KY, MA and OH and for members residing in OK (regardless of contract situs state).

Attention Massachusetts residents: Before enrolling, you should be aware that our network of preferred providers in Massachusetts has
providers mainly in the following counties: Barnstable, Berkshire, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth,
Suffolk and Worcester. Your out of pocket expenses will be higher if you do not see an in-network provider and, in some plans, benefits may
not be available at all for out-of-network providers.
PLAN EXCLUSIONS AND LIMITATIONS*
Some Services Not Covered Under the Plan Are:
1. Services or supplies that are covered in whole or in part:
(a) under any other part of this Dental Care Plan; or
ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

(b) under any other plan of group benefits provided by or through your employer.
2. Services and supplies to diagnose or treat a disease or injury that is not:
(a) a non-occupational disease; or
(b) a non-occupational injury.
3. Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate.
4. Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse,
misuse or neglect.
5. Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to improve, alter or
enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar
crowns and pontics will always be considered cosmetic.
6. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under
clinical investigation by health professionals.
7. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical
dimension, to restore occlusion, or to correct attrition, abrasion or erosion. Does not apply to CA contracts.
8. Those for any of the following services (Does not apply to TX contracts):
(a) An appliance or modification of one if an impression for it was made before the person became a covered person;
(b) A crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person;
(c) Root canal therapy if the pulp chamber for it was opened before the person became a covered person.

9. Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are
prescribed, recommended or approved by the attending physician or dentist.

10. Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate.
11. Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth.
12. Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate.
13. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be
eligible for benefits unless done in conjunction with another necessary covered service.
14. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be done by a
licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.
15. Those in connection with a service given to a dependent age 5 or older if that dependent becomes a covered dependent other than:
(a) during the first 31 days the dependent is eligible for this coverage, or
(b) as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to charges incurred:
(i) after the end of the 12-month period starting on the date the dependent became a covered dependent; or
(ii) as a result of accidental injuries sustained while the dependent was a covered dependent; or
(iii) for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and
Pathology.
16. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the services shown in
the Dental Care Schedule that applies.
17. Those for a crown, cast or processed restoration unless:
(a) It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or
(b) The tooth is an abutment to a covered partial denture or fixed bridge.
18. Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in the Booklet-
19. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the Booklet-Certificate.
20. Services needed solely in connection with non-covered services.
21. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services. Does not apply to
CA contracts.
Any exclusion above will not apply to the extent that coverage of the charge is required under any law that applies to the coverage.
*This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.
Specialty Referrals
1. Under the DMO dental plan, services performed by specialists are eligible for coverage only when prescribed by the primary care dentist
and authorized by Aetna Dental. If Aetna's payment to the specialty dentist is based on a negotiated fee, then the member's copayment for the
service will be based on the same negotiated fee.
2. DMO members may visit an orthodontist without first obtaining a referral from their primary care dentist. In an effort to ease
the administrative burden on both participating Aetna dentists and members, Dental has opened direct access for
DMO members to orthodontic services.
Emergency Dental Care
ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

If you need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a
day, 7 days a week. You should contact your Primary Care Dentist to receive treatment. If you are unable to contact your PCD, contact
Member Services for assistance in locating a dentist. Refer to your plan documents for details. Subject to state requirements. Out-of-area
emergency dental care may be reviewed by our dental consultants to verify appropriateness of treatment.
Your Dental Care Plan Coverage Is Subject to the Following Rules:
Replacement Rule
The replacement of; addition to; or modification of:
existing dentures;
crowns;
casts or processed restorations;
removable denture;
fixed bridgework; or
other prosthetic services
is covered only if one of the following terms is met:

The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed.
This coverage must have been in force for the covered person when the extraction took place.

The existing denture, crown; cast or processed restoration, removable denture, bridgework, or other prosthetic service cannot be made
serviceable, and was installed at least 5 years before its replacement.

The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered, and cannot be
made permanent, and replacement by a permanent denture is required. The replacement must take place within 12 months from the date of
initial installation of the immediate temporary denture.

The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or
teeth.

Tooth Missing But Not Replaced Rule (Does not apply to TX and CA contracts.)
Coverage for the first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the requirements that
such removable dentures; fixed bridgework and other prosthetic services are (i) needed to replace one or more natural teeth that were removed
while this policy was in force for the covered person; and (ii) are not abutments to a partial denture; removable bridge; or fixed bridge
installed during the prior 5 years.
Alternate Treatment Rule: If more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize
coverage only for a less costly covered service provided that all of the following terms are met:
(a) the service must be listed on the Dental Care Schedule;
(b) the service selected must be deemed by the dental profession to be an appropriate method of treatment; and
(c) the service selected must meet broadly accepted national standards of dental practice.
If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service than that for which
coverage is approved, the specific copayment for such service will consist of:
(a) the copayment for the approved less costly service; plus
(b) the difference in cost between the approved less costly service and the more costly covered service.

Finding Participating Providers

Consult Aetna Dental’s online provider search for the most current provider listings. Participating providers are independent contractors in
private practice and are neither employees nor agents of Aetna Dental or its affiliates. The availability of any particular provider cannot be
guaranteed, and provider network composition is subject to change without notice. Not every provider listed in the directory will be accepting
new patients. Although Aetna Dental has identified providers who were not accepting patients in our DMO plan as known to Aetna Dental at
the time the provider directory was created, the status of a provider’s practice may have changed. For the most current information, please
contact the selected provider or Aetna Member Services at the toll-free number on your online ID card, or use our Internet-based provider
search available at www.aetna.com.

Specific products may not be available on both a self-funded and insured basis. The information in this document is subject to change without
notice. In case of a conflict between your plan documents and this information, the plan documents will govern. In the event of a problem
with coverage, members should contact Member Services at the toll-free number on their online ID cards for information on how to utilize the
grievance procedure when appropriate. All member care and related decisions are the sole responsibility of participating providers. Aetna
Dental does not provide health care services and, therefore, cannot guarantee any results or outcomes.

ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

Telehealth Services: The plan will reimburse the treating or consulting provider for the diagnosis, consultation, or treatment of an enrollee via
telehealth on the same basis and to the same extent that the plan would reimburse the same covered in-person service.
Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc. and/or Aetna
Health Inc.
In Arizona, DMO Dental Plans are provided or administered by Aetna Health Inc.

This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general
description of plan or program benefits and does not constitute a contract. Aetna does not provide dental services and, therefore, cannot
guarantee any results or outcomes. The availability of a plan or program may vary by geographic service area. Certain dental plans are
available only for groups of a certain size in accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions.
Consult the plan documents (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement, Group
Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to your plan.

Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race,

Aetna provides free aids/services to people with disabilities and to people who need language assistance.

If you need a qualified interpreter, written information in other formats, translation or other services, call 877-238-6200.

If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a
grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
CRCoordinator@aetna.com.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal,
available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue
SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).

TTY:711
English To access language services at no cost to you, call the number on your ID card.
Albanian Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të identitetit.
Amharic የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ፡፡
.‫ اﻟﺮﺟﺎء اﻻﺗﺼﺎل ﻋﻠﻰ اﻟﺮﻗﻢ اﻟﻤﻮﺟﻮد ﻋﻠﻰ ﺑﻄﺎﻗﺔ اﺷﺘﺮاﻛﻚ‬،‫ﻟﻠﺤﺼﻮل ﻋﻠﻰ اﻟﺨﺪﻣﺎت اﻟﻠﻐﻮﯾﺔ دون أي ﺗﻜﻠﻔﺔ‬
Arabic
Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար զանգահարեք ձեր բժշկական
Armenian
ապահովագրության քարտի վրա նշված հէրախոսահամարով
Bantu-Kirundi Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu kawe
Bengali আপনােক িবনামূেল ভাষা পিরেষবা পেত হেল আপনার পিরচয়পে দওয়া ন ের টিলেফান ক ন।

Burmese

Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número indicat a la seva targeta d’identificació.
Catalan
Cebuano Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang numero nga anaa sa imong kard sa ID.
Chamorro Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion.
Cherokee ᏩᎩᏍᏗ ᎦᏬᏂᎯᏍᏗ ᎢᏅᎾᏓᏛᏁᏗ Ꮭ ᎪᎱᏍᏗ ᏗᏣᎬᏩᎳᏁᏗ ᏱᎩ, ᏫᎨᎯᏏᎳᏛᏏ ᎾᏍᎩ ᏗᏎᏍᏗ ᏥᏕᎪᏪᎵ ᎤᎾᎢ ID ᏆᏂᏲᏍᏗ ᏣᏤᎵᎢ.
Chinese 如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼
Traditional
Choctaw Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini holhtena takanli ma i payah
ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

Chuukese Ren omw kopwe angei aninisin eman chon awewei (ese kamé), kopwe kééri ewe nampa mei mak won noum ena katen ID
Cushitic- Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa eenyummaa (ID) kee irraa jiruun bilbili.
Oromo
Dutch Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.
Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro indiqué sur votre carte d'assurance santé.
French

Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon asirans sante ou.
French Creole
(Haitian)

German Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an.

Για πρόσβαση στις υπηρεσίες γλώσσας χωρίς χρέωση, καλέστε τον αριθμό στην κάρτα ασφάλισής σας.
Greek
Gujarati તમારે કોઇ પણ તના ખચ િવના ભાષા સેવાઓ મેળવવા માટે , તમારા આઇડી કાડ પર રહેલ નંબર પર કૉલ કરવો.
Hawaiian No ka walaʻau ʻana me ka lawelawe ʻōlelo e kahea aku i ka helu kelepona ma kāu kāleka ID. Kāki ʻole ʻia kēia kōkua nei.

Hindi िबना िकसी कीमत के भाषा सेवाओं का उपयोग करने के िलए, अपने आईडी काड पर िदए नंबर पर कॉल कर।

Hmong Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID.
Inweta enyemaka asụsụ na akwughi ụgwọ obụla, kpọọ nọmba nọ na kaadi njirimara gị
Igbo

Ilocano Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga adda ayan ti ID kardmo.

Indonesian Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon di kartu asuransi Anda.
Italian Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera identificativa.
Japanese 無料の言語サービスは、IDカードにある番号にお電話ください。
Karen vXw>urRM>usdmw>rRpXRtw>zH;w>rRwz. vXwtd.'D;tyShRvXeub.[h.tDRt*D><ud;b.vDwJpdeD.*H>vXttd.vXecd.*DR A (ID)
Korean 무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해 주십시오.
Kru-Bassa I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i kat yong matibla
Kurdish .‫( ﮐﺎرﺗﯽ ﺧﯚت‬ID)‫ژﻣﺎرەی ﺳ ر ﺋﺎی دی‬ ‫ ﯾﻮەﻧﺪی ﮑ‬،‫ﺗ ﭽﻮون ﺑﯚ ﺗﯚ‬ ‫ﺧﺰﻣ ﺗﮕﻮزاری زﻣﺎن‬ ‫ﺑﯚ دەﺳﭙ ا ﺸ‬
ເພື່ອເຂ້ົ າເຖິງບໍລິການພາສາທ່ີ ບ່ໍ ເສຍຄ່ າ, ໃຫ້ ໂທຫາເບີໂທຢູ ່ ໃນບັດປະຈໍາຕົວຂອງທ່ ານ.
Lao

Marathi आप ाला कोण ाही शु ािशवाय भाषा सेवां पयत पोहोच ासाठी, आप ा ID काडावरील मां कावर फोन करा.

Marshallese Ņan bōk jipan̄ kōn kajin ilo an ejjeļọk wōņean n̄ an kwe, kwōn kallok nōṃba eo ilo kaat in ID eo aṃ.
Micronesian- Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID.
Ponapean
Mon-Khmer, េដម ីទទួ ល នេស កម ែដលឥតគិតៃថស ប់េ កអក សូ មេ ទូ រសពេ ន់េលខែដល នេ េលបណស ល់ខន
Cambodian របស់េ កអក។
Navajo

Nepali भाषास ी सेवाह मािथ िनःशु प ँ च रा आ नो काडमा रहे को न रमा कल गनुहोस्।

Nilotic-Dinka Të kɔɔr yïn ran de wɛ̈ɛr̈ de thokic ke cïn wëu kɔr keek tënɔŋ yïn. Ke yïn cɔl ran ye kɔc kuɔny në namba de abac tɔ̈ në ID kard duɔ̈n
Norwegian For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.
Pennsylvanian Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
-Dutch
Persian Farsi .‫ ﺎ ﺷﻤﺎرە ﻗ ﺪ ﺷﺪە روی ﺎرت ﺷﻨﺎﺳﺎ ﺧﻮد ﺗﻤﺎس ﮕ ﺪ‬،‫ﻪ ﺧﺪﻣﺎت ز ﺎن ﻪ ﻃﻮر را ﺎن‬ ‫ﺑﺮای دﺳ‬
Polish Aby uzyskać dostęp do bezpłatnych usług językowych, należy zadzwonić pod numer podany na karcie identyfikacyjnej.
Portuguese Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado no seu cartão de identificação.
Punjabi ਤੁ ਹਾਡੇ ਲਈ ਿਬਨਾਂ ਿਕਸੇ ਕੀਮਤ ਵਾਲੀਆਂ ਪੰਜਾਬੀ ਸੇਵਾਵਾਂ ਦੀ ਵਰਤ ਕਰਨ ਲਈ, ਆਪਣੇ ਆਈਡੀ ਕਾਰਡ ‘ਤੇ ਿਦੱਤੇ ਨੰਬਰ 'ਤੇ ਫ਼ੋਨ ਕਰੋ।
Romanian Pentru a accesa gratuit serviciile de limbă, apelați numărul de pe cardul de membru.
Russian Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на вашей
Samoan Mō le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i luga o lau pepa ID.
Serbo- Za besplatne prevodilačke usluge pozovite broj naveden na Vašoj identifikacionoj kartici.
Croatian
Spanish Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura en su tarjeta de identificación.
ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.
 ADP TOTALSOURCE, INC.
Plan 54
Effective Date: 06-01-2021

DMO® Dental Benefits Summary

Sudanic Heeɓa a naasta nder ekkitol jaangirde woldeji walla yoɓugo, ewnu lamba je ɗon windi ha do ɗerowol maaɗa.
Fulfulde
Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.
ܿ ܵ ܵܵ ܿ ܵ ܵ ܿ ܵܵ ܵ ܿ
Syriac- .‫ܼܿ ܸ ܵ ܼܿܗ ܵܕ ܵ ܼ ܬ ܕ ܼܵ ܼ ܢ‬ ܸ ‫ ܼ ܢ‬، ܼ ܼ ܸ
ܿ
ܼ ‫̄ܬܘܢ ܼܿ ܸ ܼ ܹ ̈ܐ‬
‫ܕܗ ܿ ܼ ܬ‬ ܼ ‫ܝ‬
ܵ
ܼ ‫ܐܢ‬
ܸ
Assyrian
Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.
Tagalog Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa iyong ID card.
Telugu ష వల ఖ ం అం ం , ఐ ఉన నంబ యం .
Thai หากท่านต ้องการเข ้าถึงการบริการทางด ้านภาษาโดยไม่มค ี า่ ใช ้จ่าย โปรดโทรหมายเลขทีแสดงอยูบ่ นบัตรประจําตัวของท่าน
Tongan Kapau ‘oku ke fiema’u ta’etōtōngi ‘a e ngaahi sēvesi kotoa pē he ngaahi lea kotoa, telefoni ki he fika ‘oku hā atu ‘i ho’o ID kaati.
Turkish Dil hizmetlerine ücretsiz olarak erişmek için kimlik kartınızdaki numarayı arayın.
Ukrainian Щоб безкоштовнj отримати мовні послуги, задзвоніть за номером, вказаним на вашій ідентифікайній картці.

Urdu ‫ ﺎرڈ ﭘﺮ درج ﻧﻤ ﭘﺮ ﺎل ﮐ ﮟ۔‬ID ‫ اﭘ ﺑ ﻤﮧ‬، ‫ﻟ‬ ‫ﻟﺴﺎ ﺧﺪﻣﺎت ﺗﮏ ُﻣﻔﺖ رﺳﺎ‬

Vietnamese Để sử dụng các dịch vụ ngôn ngữ miễn phí, vui lòng gọi số điện thoại ghi trên thẻ ID của quý vị.
Yiddish .‫ קארטל‬ID ‫ רופט דעם נומער אויף אייער‬,‫צו באקומען שפראך סערוויסעס פריי פון אפצאל‬
Yoruba Láti ráyèsí àwọn iṣẹ́ èdè fún ọ lọ́fẹ̀ ẹ́, pe nọ́mbà tó wà lórí káàdì ìdánimọ̀ rẹ.

ed.2021 "Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2021 American Dental Association. All rights reserved.