Concordia Plus Schedule of Benefits
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1 Concordia Pls Schedle of Benefits Plan MD/DC 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 ORAL PATHOLOGY LABORATORY D12 Periodic Oral Evalation - Established Patient D1 Limited Oral Evalation - Problem Focsed D1 Oral Evalation For A Patient Under 3 Years Of Age And Conseling With Primary Caregiver D1 Comprehensive Oral Evalation - New Or Established Patient D17 Re-Evalation-Limited, Problem Focsed (Established Patient; Not Post-Operative Visit) D171 Re Evalation Post-Operative Office Visit D18 Comprehensive Periodontal Evalation RADIOGRAPHS/DIAGNOSTIC IMAGING (inclding interpretation) D21 Intraoral - Complete Series Of Radiographic Images D22 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 D33 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 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 D111 Prophylaxis, Adlt D112 Prophylaxis, Child TOPICAL FLUORIDE TREATMENT (office procedre) D1 Topical Application Of Floride Varnish D128 Topical Application Of Floride Exclding Varnish OTHER PREVENTIVE SERVICES D133 Oral Hygiene Instrction D131 Sealant - Per D133 Sealant Repair - Per D13 Interim Caries Arresting Medicament Application - Per 1 SPACE MAINTENANCE (passive appliances) D11 Space Maintainer - Fixed, Unilateral ( Nmbers Or Area Reqired) 69 D11 Space Maintainer - Fixed, Bilateral 18 D12 Space Maintainer - Removable, Unilateral 86 D12 Space Maintainer - Removable, Bilateral 122 D1 Re Cement Or Re Bond Space Maintainer 12 D1 Removal Of Fixed Space Maintainer D1 Distal shoe space maintainers - fixed - nilateral 69 AMALGAM RESTORATIONS (inclding polishing) D21 Amalgam - One Srface, Primary Or 9 D21 Amalgam - Two Srfaces, Primary Or 12 D216 Amalgam - Three Srfaces, Primary Or 1 D2161 Amalgam - For Or More Srfaces, Primary Or 17 MD/DC Crrent Dental Terminology 217 American Dental Association. All rights reserved. MD Base 1 (1/1)
2 RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D233 Resin-Based Composite - One Srface, 2 D2331 Resin-Based Composite - Two Srfaces, 3 D2332 Resin-Based Composite - Three Srfaces, 3 D233 Resin-Based Composite - For Or More Srfaces Or Involving Incisal Angle () 2 D2391 Resin-Based Composite - One Srface, D2392 Resin-Based Composite - Two Srfaces, D2393 Resin-Based Composite - Three Srfaces, 88 D239 Resin-Based Composite - For Or More Srfaces, 1 INLAY/ONLAY RESTORATIONS D21 Inlay - Metallic - One Srface 222 D22 Inlay - Metallic - Two Srfaces 28 D23 Inlay - Metallic - Three Or More Srfaces 37 D22 Onlay - Metallic-Two Srfaces 282 D23 Onlay - Metallic - Three Srfaces 33 D2 Onlay - Metallic - For Or More Srfaces 363 CROWNS - SINGLE RESTORATIONS ONLY D271 Crown-Resin-Based Composite (Indirect) 119 D2712 Crown - 3/ Resin-Based Composite (Indirect) 119 D27 Crown, Porcelain/Ceramic D2 Crown, Porcelain Fsed To High Noble Metal 2 D21 Crown-Porcelain Fsed To Predominantly Base Metal D22 Crown, Porcelain Fsed To Noble Metal 1 D279 Crown, Fll Cast High Noble Metal 2 D2791 Crown - Fll Cast Predominantly Base Metal D2792 Crown, Fll Cast Noble Metal 1 D279 Crown-Titanim D2799 Provisional Crown - Frther Treatment Or Completion Of Diagnosis Necessary Prior To Final Impression OTHER RESTORATIVE SERVICES D291 Re-Cement Or Re Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration 23 D291 Re Cement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core 2 D292 Re-Cement Or Re Bond Crown 2 D293 Prefabricated Stainless Steel Crown - Primary 81 D2931 Prefabricated Stainless Steel Crown - D299 Restorative Fondation For An Indirect Restoration D29 Core Bildp Inclding Any Pins When Reqired D291 Pin Retention - Per, In Addition To Restoration 13 D292 Post And Core In Addition To Crown, Indirectly Fabricated 12 D293 Each Additional Indirectly Fabricated Post - Same 62 D29 Prefabricated Post And Core In Addition To Crown 8 OTHER RESTORATIVE SERVICES D2 Each Additional Prefabricated Post - Same D21 Additional Procedres To Constrct New Crown Under Existing Partial Dentre Framework 2 PULP CAPPING D311 Plp Cap - Direct (Exclding Final Restoration) D312 Plp Cap - Indirect (Exclding Final Restoration) PULPOTOMY D322 Therapetic Plpotomy (Exclding Final Restoration) 2 D3221 Plpal Debridement, Primary And Teeth D3222 Partial Plpotomy For Apexogenesis- With Incomplete Root Development 2 ENDODONTIC THERAPY ON PRIMARY TEETH D323 Plpal Therapy (Resorbable Filling)-, Primary (Exclding Final Restoration) 1 D32 Plpal Therapy (Resorbable Filling)-, Primary (Exclding Final Restoration) 123 ENDODONTIC THERAPY (inclding treatment plan, clinical procedres and follow-p care) D331 Endodontic Therapy, (Exclding Final Restoration) 2 D332 Endodontic Therapy, Premolar (Exclding Final Restoration) 2 D333 Endodontic Therapy, Molar (Exclding Final Restoration) 33 ENDODONTIC RETREATMENT D336 Retreatment Of Previos Root Canal Therapy - 29 D337 Retreatment Or Previos Root Canal Therapy - Premolar 3 D338 Retreatment Of Previos Root Canal Therapy - Molar 28 APICOECTOMY/PERIRADICULAR SERVICES D31 Apicoectomy - 22 D321 Apicoectomy - Premolar (First Root) 2 D32 Apicoectomy - Molar (First Root) 2 D3 Apicoectomy (Each Additional Root) D327 Periradiclar Srgery Withot Apicoectomy 2 D33 Retrograde Filling - Per Root D3 Root Amptation - Per Root 13 OTHER ENDODONTIC PROCEDURES D392 Hemisection (Inclding Any Root Removal) Not Inclding Root Canal Therapy 13 D39 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 27 D211 Gingivectomy Or Gingivoplasty - One To Three Contigos Teeth Or Bonded Spaces Per Qadrant 6 D212 Gingivectomy Or Gingivoplasty To Allow Access For Restorative Procedre, Per MD/DC Crrent Dental Terminology 217 American Dental Association. All rights reserved. MD Base 1 (1/1)
3 SURGICAL SERVICES (inclding sal postoperative care) D2 Gingival Flap Procedre, Inclding Root Planing - For Or More Contigos Teeth Or Bonded Spaces Per Qadrant 188 D21 Gingival Flap Procedre, Inclding Root Planing - One To Three Contigos Teeth Or Bonded Spaces Per Qadrant D29 Clinical Crown Lengthening-Hard Tisse 29 D Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) For Or More Contigos Teeth Or Bonded Spaces Per Qadrant 36 D1 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) One To Three Contigos Teeth Or Bonded Spaces Per Qadrant 1 D3 Bone Replacement Graft - Retained Natral - First Site In Qadrant 13 D Bone Replacement Graft - Retained Natral - Each Additional Site In Qadrant 12 D27 Mesial/Distal Wedge Procedre, Single (When Not Performed In Conjnction With Srgical Procedres In The Same Anatomical Area) NON-SURGICAL PERIODONTAL SERVICES 22 D31 Periodontal Scaling And Root Planing - For Or More Teeth Per Qadrant D32 Periodontal Scaling And Root Planing - One To Three Teeth Per Qadrant 19 D36 Scaling In Presence Of Generalized Moderate Or Severe Gingival Inflammation - Fll Moth, After Oral Evalation 8 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 8 D921 Gingival Irrigation - Per Qadrant 2 COMPLETE DENTURES (inclding rotine post delivery care) D11 Complete Dentre - Maxillary 3 D12 Complete Dentre - Mandiblar 3 D13 Immediate Dentre - Maxillary D1 Immediate Dentre - Mandiblar PARTIAL DENTURES (inclding rotine post-delivery care) D211 Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests 3 D212 Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests 3 D213 Maxillary Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests 2 D21 Mandiblar Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rest And Teeth) 2 D221 Immediate Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 3 PARTIAL DENTURES (inclding rotine post-delivery care) D222 Immediate Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 3 D223 Immediate Maxillary Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests 2 D22 Immediate Mandiblar Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests 2 D22 Maxillary Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 89 D2 Mandiblar Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 89 D281 Removable Unilateral Partial Dentre-One Piece Cast Metal (Inclding Clasps 19 ADJUSTMENTS TO DENTURES D1 Adjst Complete Dentre - Maxillary 2 D11 Adjst Complete Dentre - Mandiblar 2 D21 Adjst Partial Dentre - Maxillary 2 D22 Adjst Partial Dentre - Mandiblar 2 REPAIRS TO COMPLETE DENTURES D11 Repair Broken Complete Dentre Base, Mandiblar 6 D12 Repair Broken Complete Dentre Base, Maxillary 6 D2 Replace Missing Or Broken Teeth-Complete Dentre (Each ) REPAIRS TO PARTIAL DENTURES D611 Repair Resin Partial Dentre Base, Mandiblar 6 D612 Repair Resin Partial Dentre Base, Maxillary 6 D621 Repair Cast Partial Framework, Mandiblar D622 Repair Cast Partial Framework, Maxillary D63 Repair Or Replace Broken Clasp - Per D6 Replace Broken Teeth-Per 6 D6 Add To Existing Partial Dentre D66 Add Clasp To Existing Partial Dentre - Per D67 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary) 276 D671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandiblar) 276 DENTURE REBASE PROCEDURES D71 Rebase Complete Maxillary Dentre 1 D711 Rebase Complete Mandiblar Dentre 1 D72 Rebase Maxillary Partial Dentre 1 D721 Rebase Mandiblar Partial Dentre 1 DENTURE RELINE PROCEDURES D73 Reline Complete Maxillary Dentre (Chairside) 9 D731 Reline Complete Mandiblar Dentre (Chairside) 9 D7 Reline Maxillary Partial Dentre (Chairside) 8 D71 Reline Mandiblar Partial Dentre (Chairside) 8 D Reline Complete Maxillary Dentre (Laboratory) 13 D1 Reline Complete Mandiblar Dentre 13 (Laboratory) MD/DC Crrent Dental Terminology 217 American Dental Association. All rights reserved. MD Base 1 (1/1)
4 DENTURE RELINE PROCEDURES D76 Reline Maxillary Partial Dentre (Laboratory) 13 D761 Reline Mandiblar Partial Dentre (Laboratory) 13 OTHER REMOVABLE PROSTHETIC SERVICES D8 Tisse Conditioning, Maxillary D81 Tisse Conditioning, Mandiblar D863 Overdentre - Complete Maxillary 3 D86 Overdentre - Partial Maxillary 2 D86 Overdentre - Complete Mandiblar 3 D866 Overdentre - Partial Mandiblar 2 FIXED PARTIAL DENTURE PONTICS D62 Pontic - Indirect Resin Based Composite D621 Pontic-Cast High Noble Metal 2 D6211 Pontic-Cast Predominatly Base Metal D6212 Pontic-Cast Noble Metal 1 D621 Pontic - Titanim D62 Pontic-Porcelain Fsed To High Noble Metal 2 D621 Pontic-Porcelain Fsed To Predominantly Base Metal D622 Pontic-Porcelain Fsed To Noble Metal 1 D62 Pontic - Procelain/Ceramic FIXED PARTIAL DENTURE RETAINERS - CROWNS D671 Retainer Crown - Indirect Resin Based Composite D67 Retainer Crown - Porcelain/Ceramic D6 Retainer Crown, Porcelain Fsed To High Noble Metal 2 D61 Retainer Crown - Porcelain Fsed To Predominantly Base Metal D62 Retainer Crown, Porcelain Fsed To Noble 1 Metal D679 Retainer Crown, Fll Cast High Noble Metal 2 D6791 Retainer Crown, Fll Cast Predominantly Base Metal D6792 Retainer Crown, Fll Cast Noble Metal 1 D679 Retainer Crown - Titanim OTHER FIXED PARTIAL DENTURE SERVICES D693 Re Cement Or Re-Bond Fixed Partial Dentre 2 EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D7111 Extraction, Coronal Remnants - Primary 1 D71 Extraction, Erpted Or Exposed Root (Elevation And/Or Forceps Removal) 3 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 6 D722 Removal Of Impacted - Soft Tisse 78 D723 Removal Of Impacted - Partially Bony 1 D72 Removal Of Impacted - Completely Bony 13 D721 Removal Of Impacted - Completely Bony, With Unsal Srgical Complications 11 D72 Removal Of Residal Roots (Ctting Procedre) 76 SURGICAL EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D721 Coronectomy-Intentional Partial Removal 13 OTHER SURGICAL PROCEDURES D728 Exposre Of An Unerpted 121 D7283 Placement Of Device To Facilitate Erption Of Impacted 3 D7288 Brsh Biopsy - Transepithelial Sample Collection ALVEOLOPLASTY (srgical preparation of ridge for dentres) D731 Alveoloplasty In Conjnction With Extractions - For Or More Teeth Or Spaces, Per Qadrant 6 D732 Alveoloplasty Not In Conjnction With Extractions - For Or More Teeth Or Spaces, Per Qadrant 76 D7321 Alveoloplasty Not In Conjnction With Extractions - One To Three Teeth Or Spaces, Per Qadrant 3 SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS D7 Removal Of Benign Odontogenic Cyst Or 81 Tmor - Lesion Diameter Up To 1.2 Cm OTHER REPAIR PROCEDURES D796 Frenlectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedre Not Incidental To Another Procedre 18 D7963 Frenloplasty LIMITED ORTHODONTIC TREATMENT D81 Limited Orthodontic Treatment Of Primary D82 Limited Orthodontic Treatment Of Transitional D83 Limited Orthodontic Treatment Of Adolescent D8 Limited Orthodontic Treatment Of The Adlt INTERCEPTIVE ORTHODONTIC TREATMENT D8 Interceptive Orthodontic Treatment Of Primary 9 D86 Interceptive Orthodontic Treatment Of Transitional 9 COMPREHENSIVE ORTHODONTIC TREATMENT D87 Comprehensive Orthodontic Treatment Of Transitional 29 D88 Comprehensive Orthodontic Treatment Of Adolescent 29 D89 Comprehensive Orthodontic Treatment Of Adlt 29 MINOR TREATMENT TO CONTROL HARMFUL HABITS D821 Removable Appliance Therapy For Control Of Harmfl Habits 3 D822 Fixed Appliance Therapy For Control Of Harmfl Habits 3 OTHER ORTHODONTIC SERVICES D868 Orthodontic Retention (Removal Of Appliances, Constrction And Placement Of Retainer(S) 2 U Orthodontic Records Fee UNCLASSIFIED TREATMENT 2 MD/DC Crrent Dental Terminology 217 American Dental Association. All rights reserved. MD Base 1 (1/1)
5 UNCLASSIFIED TREATMENT D911 Palliative (Emergency) Treatment Of Dental Pain, Minor Procedres PROFESSIONAL CONSULTATION D931 Consltation - Diagnostic Service Provided By Dentist Or Physician Other Than Reqesting Dentist Or Physician 3 D9311 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 MISCELLANEOUS SERVICES D9932 Cleaning And Inspection Of Removable Complete Dentre, Maxillary D9933 Cleaning And Inspection Of Removable Complete Dentre, Mandiblar D993 Cleaning And Inspection Of Removable Partial Dentre, Maxillary D993 Cleaning And Inspection Of Removable Partial Dentre, Mandiblar D9986 Missed Appointment 11 D9987 Cancelled appointment 11 D9991 Dental Case Management - Addressing Appointment Compliance Barriers D9992 Dental Case Management - Care Coordination D9993 Dental Case Management - Motivational Interviewing D999 Dental Case Management - Patient Edcation To Improve Oral Health Literacy D999 Teledentistry - Synchronos; Real-Time Enconter D9996 Teledentistry - Asynchronos; Information Stored and Forwarded to Dentist for Sbseqent Review FOOTNOTES U 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 $12 for these materials. Please Report Under D8999 "Unspecified Orthodontic Procedre, By Report." Records Inclde All Diagnostic Procedres, Sch As Cephalometric Films, Fll Moth X-Rays, Models, And Treatment Plans. MD/DC Crrent Dental Terminology 217 American Dental Association. All rights reserved. MD Base 1 (1/1)
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