Concordia Plus Schedule of Benefits
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- Jonas McKenzie
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1 Concordia Pls Schedle of Benefits Plan TX 2 IMPORTANT INFORMATION ABOUT YOUR PLAN This schedle of benefits provides a listing of procedres covered by yor plan. For procedres that reqire a copayment, the amont to be paid is shown in the colmn titled. Yo pay these copayments to the dental office at the time of service. Yo mst select a United Concordia Primary Dental Office (PDO) to receive covered services. Yor PDO will perform the below procedres or refer yo to a specialty care dentist for frther care. Treatment by an Ot-of-Network dentist is not covered, except as described in the Certificate of Coverage. Only procedres listed on this Schedle of Benefits are Covered Services. For services not listed (not covered), Yo are responsible for the fll fee charged by the dentist. Procedre codes and member Copayments may be pdated to meet American Dental Association () Crrent Dental Terminology (CDT) in accordance with national standards. For a complete description of yor plan, please refer to the Certificate of Coverage and the Schedle of Exclsions and Limitations in addition to this Schedle of Benefits. If yo have any qestions abot yor United Concordia dental plan, please call or Cstomer Service Department toll-free at or access or website at CLINICAL ORAL EVALUATIONS D12 Periodic Oral Evalation - Established Patient D1 Limited Oral Evalation - Problem Focsed D15 Oral Evalation For A Patient Under 3 Years Of Age And Conseling With Primary Caregiver D15 Comprehensive Oral Evalation - New Or Established Patient D16 Detailed And Extensive Oral Evalation - Problem Focsed, By Report D Re-Evalation-Limited, Problem Focsed (Established Patient; Not Post-Operative Visit) D1 Re Evalation Post-Operative Office Visit D18 Comprehensive Periodontal Evalation RADIOGRAPHS/DIAGNOSTIC IMAGING (inclding interpretation) D21 Intraoral - Complete Series Of Radiographic Images D Intraoral- Periapical First Radiographic Image D23 Intraoral- Periapical Each Additional Radiographic Image D2 Intraoral - Occlsal Radiographic Image D27 Bitewing - Single Radiographic Image D272 Bitewings - Two Radiographic Images D273 Bitewings - Three Radiographic Images D27 Bitewings - For Radiographic Images D277 Vertical Bitewings - 7 To 8 Radiographic Images D Panoramic Radiographic Image D3 2D Cephalometric Radiographic Image - Acqisition, Measrement And Analysis TESTS AND EXAMINATIONS D6 Plp Vitality Tests D7 Diagnostic Casts ORAL PATHOLOGY LABORATORY D61 Caries Risk Assessment And Docmentation, With A Finding Of Low Risk ORAL PATHOLOGY LABORATORY D62 Caries Risk Assessment And Docmentation, With A Finding Of Moderate Risk D63 Caries Risk Assessment And Docmentation, With A Finding Of High Risk DENTAL PROPHYLAXIS D1 Prophylaxis, Adlt D2 Prophylaxis, Child 1 TOPICAL FLUORIDE TREATMENT (office procedre) D126 Topical Application Of Floride Varnish D128 Topical Application Of Floride Exclding Varnish OTHER PREVENTIVE SERVICES D1 Oral Hygiene Instrction D1351 Sealant - Per 6 D1353 Sealant Repair - Per 6 D135 Interim Caries Arresting Medicament Application - Per 15 SPACE MAINTENANCE (passive appliances) D151 Space Maintainer - Fixed, Unilateral ( Nmbers Or Area Reqired) D1515 Space Maintainer - Fixed, Bilateral 77 D152 Space Maintainer - Removable, Unilateral D1525 Space Maintainer - Removable, Bilateral D1 Re Cement Or Re Bond Space Maintainer D15 Removal Of Fixed Space Maintainer D1575 Distal shoe space maintainers - fixed - nilateral AMALGAM RESTORATIONS (inclding polishing) D21 Amalgam - One Srface, Primary Or D215 Amalgam - Two Srfaces, Primary Or D216 Amalgam - Three Srfaces, Primary Or 2 Base 16 (1/12) TX 2 Crrent Dental Terminology 2 American Dental Association. All rights reserved. TX 2
2 AMALGAM RESTORATIONS (inclding polishing) D2161 Amalgam - For Or More Srfaces, Primary Or RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D2 Resin-Based Composite - One Srface, D21 Resin-Based Composite - Two Srfaces, D22 Resin-Based Composite - Three Srfaces, D25 Resin-Based Composite - For Or More Srfaces Or Involving Incisal Angle () 75 D2 Resin-Based Composite Crown, 75 D21 Resin-Based Composite - One Srface, D22 Resin-Based Composite - Two Srfaces, D23 Resin-Based Composite - Three Srfaces, 72 D2 Resin-Based Composite - For Or More Srfaces, INLAY/ONLAY RESTORATIONS D251 Inlay - lic - One Srface 6 D252 Inlay - lic - Two Srfaces 2 D253 Inlay - lic - Three Or More Srfaces 275 D252 Onlay - lic-two Srfaces 26 D253 Onlay - lic - Three Srfaces 26 D25 Onlay - lic - For Or More Srfaces 26 CROWNS - SINGLE RESTORATIONS ONLY D271 Crown-Resin-Based Composite (Indirect) 165 D2712 Crown - 3/ Resin-Based Composite (Indirect) 165 D27 Crown, Porcelain/Ceramic D275 Crown, Porcelain Fsed To High Noble 38 D2751 Crown-Porcelain Fsed To Predominantly 27 Base D2752 Crown, Porcelain Fsed To Noble 38 D278 Crown - 3/ Cast High Noble 38 D2781 Crown - 3/ Cast Predominantly Base D2782 Crown - 3/ Cast Noble 38 D27 Crown - 3/ Porcelain/Ceramic D279 Crown, Fll Cast High Noble 38 D2791 Crown - Fll Cast Predominantly Base D2792 Crown, Fll Cast Noble 38 D279 Crown-Titanim 27 D27 Provisional Crown - Frther Treatment Or 5 Completion Of Diagnosis Necessary Prior To Final Impression OTHER RESTORATIVE SERVICES D291 Re-Cement Or Re Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration D2915 Re Cement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core D292 Re-Cement Or Re Bond Crown D293 Prefabricated Stainless Steel Crown - Primary D2931 Prefabricated Stainless Steel Crown - D29 Protective Restoration OTHER RESTORATIVE SERVICES D2 Restorative Fondation For An Indirect Restoration D295 Core Bildp Inclding Any Pins When Reqired D2951 Pin Retention - Per, In Addition To Restoration 9 D2952 Post And Core In Addition To Crown, Indirectly Fabricated D2953 Each Additional Indirectly Fabricated Post - Same 5 D295 Prefabricated Post And Core In Addition To Crown D29 Post Removal D2957 Each Additional Prefabricated Post - Same 5 D1 Additional Procedres To Constrct New Crown Under Existing Partial Dentre Framework 25 PULP CAPPING D3 Plp Cap - Direct (Exclding Final Restoration) D312 Plp Cap - Indirect (Exclding Final Restoration) PULPOTOMY D3 Therapetic Plpotomy (Exclding Final Restoration) D31 Plpal Debridement, Primary And Teeth D32 Partial Plpotomy For Apexogenesis- With Incomplete Root Development ENDODONTIC THERAPY ON PRIMARY TEETH D323 Plpal Therapy (Resorbable Filling)-, Primary (Exclding Final Restoration) D32 Plpal Therapy (Resorbable Filling)-, Primary (Exclding Final Restoration) ENDODONTIC THERAPY (inclding treatment plan, clinical procedres and follow-p care) D1 Endodontic Therapy, (Exclding Final Restoration) D2 Endodontic Therapy, Premolar (Exclding Final Restoration) D3 Endodontic Therapy, Molar (Exclding Final Restoration) 28 ENDODONTIC RETREATMENT D6 Retreatment Of Previos Root Canal Therapy - 6 D7 Retreatment Or Previos Root Canal Therapy - Premolar 231 D8 Retreatment Of Previos Root Canal Therapy - Molar 286 APICOECTOMY/PERIRADICULAR SERVICES D31 Apicoectomy D321 Apicoectomy - Premolar (First Root) 193 D325 Apicoectomy - Molar (First Root) 2 D326 Apicoectomy (Each Additional Root) D327 Periradiclar Srgery Withot Apicoectomy 2 D Retrograde Filling - Per Root D35 Root Amptation - Per Root OTHER ENDODONTIC PROCEDURES Base 16 (1/12) TX 2 Crrent Dental Terminology 2 American Dental Association. All rights reserved. TX 2
3 OTHER ENDODONTIC PROCEDURES D1 Srgical Procedre For Isolation Of With Rbber Dam D2 Hemisection (Inclding Any Root Removal) Not Inclding Root Canal Therapy D5 Canal Preparation And Fitting Of Preformed Dowel Or Post SURGICAL SERVICES (inclding sal postoperative care) D21 Gingivectomy Or Gingivoplasty - For Or More Contigos Teeth Or Bonded Spaces Per Qadrant 15 D2 Gingivectomy Or Gingivoplasty - One To Three Contigos Teeth Or Bonded Spaces Per Qadrant 62 D212 Gingivectomy Or Gingivoplasty To Allow Access For Restorative Procedre, Per D2 Gingival Flap Procedre, Inclding Root Planing - For Or More Contigos Teeth Or Bonded Spaces Per Qadrant 165 D21 Gingival Flap Procedre, Inclding Root Planing - One To Three Contigos Teeth Or Bonded Spaces Per Qadrant D25 Apically Positioned Flap 261 D29 Clinical Crown Lengthening-Hard Tisse 37 D26 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) For Or More Contigos Teeth Or Bonded Spaces Per Qadrant D261 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) One To Three Contigos Teeth Or Bonded Spaces Per Qadrant D27 Mesial/Distal Wedge Procedre, Single (When Not Performed In Conjnction With Srgical Procedres In The Same Anatomical Area) 1 NON-SURGICAL PERIODONTAL SERVICES D31 Periodontal Scaling And Root Planing - For Or More Teeth Per Qadrant D32 Periodontal Scaling And Root Planing - One To Three Teeth Per Qadrant 1 D36 Scaling In Presence Of Generalized Moderate Or Severe Gingival Inflammation - Fll Moth, After Oral Evalation D3 Fll Moth Debridement To Enable a Comprehensive Oral Evalation And Diagnosis on a Sbseqent Visit D381 Localized Delivery Of Antimicrobial Agents Via Controlled Release Vehicle Into Diseased Creviclar Tisse, Per 1 OTHER PERIODONTAL SERVICES D91 Periodontal Maintenance D921 Gingival Irrigation - Per Qadrant 25 COMPLETE DENTURES (inclding rotine post delivery care) D5 Complete Dentre - Maxillary D512 Complete Dentre - Mandiblar D513 Immediate Dentre - Maxillary 13 D51 Immediate Dentre - Mandiblar 13 PARTIAL DENTURES (inclding rotine post-delivery care) D52 Maxillary Partial Dentre - Resin Base 13 (Inclding Any Conventional Clasps, Rests PARTIAL DENTURES (inclding rotine post-delivery care) D5212 Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests 13 D5213 Maxillary Partial Dentre - Cast Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests 13 D521 Mandiblar Partial Dentre - Cast Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rest And Teeth) 68 D51 Immediate Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 13 D52 Immediate Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 13 D53 Immediate Maxillary Partial Dentre - Case Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests 13 D5 Immediate Mandiblar Partial Dentre - Case Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests 68 D Maxillary Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 75 D56 Mandiblar Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 538 D5 Removable Unilateral Partial Dentre-One Piece Cast (Inclding Clasps 13 ADJUSTMENTS TO DENTURES D51 Adjst Complete Dentre - Maxillary D5 Adjst Complete Dentre - Mandiblar D521 Adjst Partial Dentre - Maxillary D5 Adjst Partial Dentre - Mandiblar REPAIRS TO COMPLETE DENTURES D Repair Broken Complete Dentre Base, Mandiblar 28 D12 Repair Broken Complete Dentre Base, Maxillary 28 D2 Replace Missing Or Broken Teeth-Complete Dentre (Each ) 52 REPAIRS TO PARTIAL DENTURES D56 Repair Resin Partial Dentre Base, Mandiblar D5612 Repair Resin Partial Dentre Base, Maxillary D5621 Repair Cast Partial Framework, Mandiblar D56 Repair Cast Partial Framework, Maxillary D563 Repair Or Replace Broken Clasp - Per D56 Replace Broken Teeth-Per D565 Add To Existing Partial Dentre D5 Add Clasp To Existing Partial Dentre - Per 77 D567 Replace All Teeth And Acrylic On Cast Framework (Maxillary) 269 D5671 Replace All Teeth And Acrylic On Cast Framework (Mandiblar) 3 DENTURE REBASE PROCEDURES D571 Rebase Complete Maxillary Dentre 167 D57 Rebase Complete Mandiblar Dentre 167 Base 16 (1/12) TX 2 Crrent Dental Terminology 2 American Dental Association. All rights reserved. TX 2
4 DENTURE REBASE PROCEDURES D572 Rebase Maxillary Partial Dentre 198 D5721 Rebase Mandiblar Partial Dentre 198 DENTURE RELINE PROCEDURES D573 Reline Complete Maxillary Dentre (Chairside) D5731 Reline Complete Mandiblar Dentre (Chairside) D57 Reline Maxillary Partial Dentre (Chairside) D571 Reline Mandiblar Partial Dentre (Chairside) D575 Reline Complete Maxillary Dentre (Laboratory) 15 D5751 Reline Complete Mandiblar Dentre (Laboratory) 15 D576 Reline Maxillary Partial Dentre (Laboratory) 15 D5761 Reline Mandiblar Partial Dentre (Laboratory) 15 OTHER REMOVABLE PROSTHETIC SERVICES D585 Tisse Conditioning, Maxillary D5851 Tisse Conditioning, Mandiblar D5863 Overdentre - Complete Maxillary D586 Overdentre - Partial Maxillary 13 D5865 Overdentre - Complete Mandiblar D58 Overdentre - Partial Mandiblar 68 FIXED PARTIAL DENTURE PONTICS D625 Pontic - Indirect Resin Based Composite D621 Pontic-Cast High Noble D62 Pontic-Cast Predominatly Base 27 D6212 Pontic-Cast Noble D621 Pontic - Titanim 27 D62 Pontic-Porcelain Fsed To High Noble D621 Pontic-Porcelain Fsed To Predominantly 27 Base D6 Pontic-Porcelain Fsed To Noble D625 Pontic - Procelain/Ceramic FIXED PARTIAL DENTURE RETAINTERS - INLAYS/ONLAYS D1 Retainer Onlay - Cast High Noble, Two Srfaces 26 D12 Retainer Onlay - Cast Predominantly Base 26, Two Srfaces D1 Retainer Onlay - Cast Noble, Two 26 Srfaces FIXED PARTIAL DENTURE RETAINERS - CROWNS D671 Retainer Crown - Indirect Resin Based Composite 38 D67 Retainer Crown - Porcelain/Ceramic 38 D675 Retainer Crown, Porcelain Fsed To High Noble 38 D6751 Retainer Crown - Porcelain Fsed To 27 Predominantly Base D6752 Retainer Crown, Porcelain Fsed To Noble 38 D678 Retainer Crown, 3/ Cast High Noble D6781 Retainer Crown - 3/ Cast Predominantly Base D6782 Retainer Crown - 3/ Cast Noble 38 D67 Retainer Crown - 3/ Porcelain/Ceramic D679 Retainer Crown, Fll Cast High Noble 38 FIXED PARTIAL DENTURE RETAINERS - CROWNS D6791 Retainer Crown, Fll Cast Predominantly Base 27 D6792 Retainer Crown, Fll Cast Noble 38 D679 Retainer Crown - Titanim 27 OTHER FIXED PARTIAL DENTURE SERVICES D693 Re Cement Or Re-Bond Fixed Partial Dentre EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D71 Extraction, Coronal Remnants - Primary 7 D71 Extraction, Erpted Or Exposed Root (Elevation And/Or Forceps Removal) SURGICAL EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D721 Extraction, Erpted Reqiring Removal Of Bone And/Or Sectioning Of, And Inclding Elevation Of Mcoperiosteal Flap If Indicated 5 D7 Removal Of Impacted - Soft Tisse 61 D723 Removal Of Impacted - Partially Bony D72 Removal Of Impacted - Completely Bony D721 Removal Of Impacted - Completely Bony, With Unsal Srgical Complications D725 Removal Of Residal Roots (Ctting Procedre) D7251 Coronectomy-Intentional Partial Removal OTHER SURGICAL PROCEDURES D728 Exposre Of An Unerpted 123 D72 Placement Of Device To Facilitate Erption Of Impacted 31 D72 Brsh Biopsy - Transepithelial Sample Collection 5 ALVEOLOPLASTY (srgical preparation of ridge for dentres) D731 Alveoloplasty In Conjnction With Extractions - For Or More Teeth Or Spaces, Per Qadrant D732 Alveoloplasty Not In Conjnction With Extractions - For Or More Teeth Or Spaces, Per Qadrant D7321 Alveoloplasty Not In Conjnction With Extractions - One To Three Teeth Or Spaces, Per Qadrant SURGICAL INCISION D751 Incision And Drainage Of Abscess - Intraoral Soft Tisse OTHER REPAIR PROCEDURES D796 Frenlectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedre Not Incidental To Another Procedre D7963 Frenloplasty 2 LIMITED ORTHODONTIC TREATMENT D81 Limited Orthodontic Treatment Of Primary 187 D82 Limited Orthodontic Treatment Of Transitional 198 D Limited Orthodontic Treatment Of Adolescent 29 D8 Limited Orthodontic Treatment Of The Adlt Base 16 (1/12) TX 2 Crrent Dental Terminology 2 American Dental Association. All rights reserved. TX 2
5 INTERCEPTIVE ORTHODONTIC TREATMENT MISCELLANEOUS SERVICES D85 Interceptive Orthodontic Treatment Of Primary 963 D86 Interceptive Orthodontic Treatment Of Transitional 963 COMPREHENSIVE ORTHODONTIC TREATMENT D87 Comprehensive Orthodontic Treatment Of Transitional 26 D Comprehensive Orthodontic Treatment Of Adolescent 286 D89 Comprehensive Orthodontic Treatment Of Adlt 38 MINOR TREATMENT TO CONTROL HARMFUL HABITS D821 Removable Appliance Therapy For Control Of Harmfl Habits D8 Fixed Appliance Therapy For Control Of Harmfl Habits 77 OTHER ORTHODONTIC SERVICES D8 Pre Orthodontic Treatment Examination To Monitor Growth And Development D868 Orthodontic Retention (Removal Of Appliances, Constrction And Placement Of Retainer(S) 275 U Orthodontic Records Fee UNCLASSIFIED TREATMENT 28 D9 Palliative (Emergency) Treatment Of Dental Pain, Minor Procedres ANESTHESIA D92 Dental Case Management - Care Coordination D93 Dental Case Management - Motivational Interviewing D9 Dental Case Management - Patient Edcation To Improve Oral Health Literacy D95 Teledentistry - Synchronos; Real-Time Enconter D96 Teledentistry - Asynchronos; Information Stored and Forwarded to Dentist for Sbseqent Review U FOOTNOTES Charges for the se of precios (high noble) or semi precios (noble) metal are not inclded in the copayment for crowns, bridges, pontics, inlays and onlays. The decision to se these materials is a cooperative effort between the provider and the patient, based on the professional advice of the provider. Providers are expected to charge no more than an additional $125 for these materials. Please Report Under D89 "Unspecified Orthodontic Procedre, By Report." Records Inclde All Diagnostic Procedres, Sch As Cephalometric Films, Fll Moth X-Rays, Models, And Treatment Plans. D9219 Evalation For Deep Sedation Or General Anesthesia D92 Deep Sedation/General Anesthesia - First 15 Mintes D93 Deep Sedation/General Anesthesia - Each Sbseqent 15 Minte Increment D92 Intravenos Moderate (Conscios) Sedation/Analgesia - First 15 Mintes D923 Intravenos Moderate (Conscios) Sedation/Analgesia - Each Sbseqent 15 Minte Increment PROFESSIONAL CONSULTATION D931 Consltation - Diagnostic Service Provided By Dentist Or Physician Other Than Reqesting Dentist Or Physician D93 Consltation With A Medical Health Care Professional PROFESSIONAL VISITS D93 Office Visit For Observation (Dring Reglarly Schedled Hors) - No Other Services Performed D9 Office Visit After Reglarly Schedled Hors 3 MISCELLANEOUS SERVICES D32 Cleaning And Inspection Of Removable Complete Dentre, Maxillary D Cleaning And Inspection Of Removable Complete Dentre, Mandiblar D3 Cleaning And Inspection Of Removable Partial Dentre, Maxillary D35 Cleaning And Inspection Of Removable Partial Dentre, Mandiblar D91 Dental Case Management - Addressing Appointment Compliance Barriers Base 16 (1/12) TX 2 Crrent Dental Terminology 2 American Dental Association. All rights reserved. TX 2
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