Concordia Pls Schedle of Benefits Plan PA/NJ/OH 16 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 1-866- 357-33 or access or website at www.unitedconcordia.com. CLINICAL ORAL EVALUATIONS ORAL PATHOLOGY LABORATORY D12 Periodic Oral Evalation - Established Patient D1 Limited Oral Evalation - Problem Focsed D Oral Evalation For A Patient Under 3 Years Of Age And Conseling With Primary Caregiver D 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 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 D1 Prophylaxis, Adlt D2 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 D13 Sealant - Per 8 D1353 Sealant Repair - Per 8 D135 Interim Caries Arresting Medicament Application SPACE MAINTENANCE (passive appliances) D1 Space Maintainer - Fixed, Unilateral ( Nmbers Or Area Reqired) 2 D Space Maintainer - Fixed, Bilateral 6 D2 Space Maintainer - Removable, Unilateral 55 D Space Maintainer - Removable, Bilateral 72 D55 Removal Of Fixed Space Maintainer AMALGAM RESTORATIONS (inclding polishing) D21 Amalgam - One Srface, Primary Or 13 D2 Amalgam - Two Srfaces, Primary Or D216 Amalgam - Three Srfaces, Primary Or Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH 16
AMALGAM RESTORATIONS (inclding polishing) D2161 Amalgam - For Or More Srfaces, Primary 23 Or RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D233 Resin-Based Composite - One Srface, D2331 Resin-Based Composite - Two Srfaces, 2 D23 Resin-Based Composite - Three Srfaces, 23 D2335 Resin-Based Composite - For Or More Srfaces Or Involving Incisal Angle () INLAY/ONLAY RESTORATIONS D1 Inlay - Metallic - One Srface 236 D2 Inlay - Metallic - Two Srfaces D3 Inlay - Metallic - Three Or More Srfaces 279 D2 Onlay - Metallic-Two Srfaces D3 Onlay - Metallic - Three Srfaces D Onlay - Metallic - For Or More Srfaces 361 CROWNS - SINGLE RESTORATIONS ONLY D271 Crown-Resin-Based Composite (Indirect) 1 D2712 Crown - 3/ Resin-Based Composite (Indirect) 128 D27 Crown, Porcelain/Ceramic Sbstrate 31 D275 Crown, Porcelain Fsed To High Noble Metal 9 D27 Crown-Porcelain Fsed To Predominantly 29 D2752 Crown, Porcelain Fsed To Noble Metal 316 D278 Crown - 3/ Cast High Noble Metal D2781 Crown - 3/ Cast Predominantly D2782 Crown - 3/ Cast Noble Metal D2783 Crown - 3/ Porcelain/Ceramic D279 Crown, Fll Cast High Noble Metal D2791 Crown - Fll Cast Predominantly 293 D2792 Crown, Fll Cast Noble Metal 3 D279 Crown-Titanim 29 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 D29 Re Cement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core D292 Re-Cement Or Re Bond Crown D293 Prefabricated Stainless Steel Crown - Primary 3 D2931 Prefabricated Stainless Steel Crown - D29 Protective Restoration D299 Restorative Fondation For An Indirect Restoration D295 Core Bildp Inclding Any Pins When Reqired 36 D29 Pin Retention - Per, In Addition To Restoration 12 D2952 Post And Core In Addition To Crown, Indirectly Fabricated 92 D2953 Each Additional Indirectly Fabricated Post - Same 5 OTHER RESTORATIVE SERVICES D295 Prefabricated Post And Core In Addition To Crown 2 D2957 Each Additional Prefabricated Post - Same D2971 Additional Procedres To Constrct New Crown Under Existing Partial Dentre Framework PULP CAPPING D3 Plp Cap - Direct (Exclding Final D312 Plp Cap - Indirect (Exclding Final PULPOTOMY D Therapetic Plpotomy (Exclding Final D1 Plpal Debridement, Primary And Teeth 16 D2 Partial Plpotomy For Apexogenesis- With Incomplete Root Development ENDODONTIC THERAPY ON PRIMARY TEETH D3 Plpal Therapy (Resorbable Filling)-, Primary (Exclding Final D Plpal Therapy (Resorbable Filling)-Posterior, Primary (Exclding Final ENDODONTIC THERAPY (inclding treatment plan, clinical procedres and follow-p care) D331 Endodontic Therapy, (Exclding Final 75 D3 Endodontic Therapy, Bicspid (Exclding Final 9 D333 Endodontic Therapy, Molar (Exclding Final 8 ENDODONTIC RETREATMENT D336 Retreatment Of Previos Root Canal Therapy - 69 D Retreatment Or Previos Root Canal Therapy - Bicspid 8 D338 Retreatment Of Previos Root Canal Therapy - Molar 28 APICOECTOMY/PERIRADICULAR SERVICES D31 Apicoectomy - D Apicoectomy - Bicspid (First Root) 183 D3 Apicoectomy - Molar (First Root) 6 D3 Apicoectomy (Each Additional Root) 69 D7 Periradiclar Srgery Withot Apicoectomy 6 D35 Root Amptation - Per Root OTHER ENDODONTIC PROCEDURES D392 Hemisection (Inclding Any Root Removal) Not Inclding Root Canal Therapy 8 D395 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 82 D2 Gingivectomy Or Gingivoplasty - One To Three Contigos Teeth Or Bonded Spaces Per Qadrant 37 Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH 16
SURGICAL SERVICES (inclding sal postoperative care) 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 D21 Gingival Flap Procedre, Inclding Root Planing - One To Three Contigos Teeth Or Bonded Spaces Per Qadrant 7 D Apically Positioned Flap 138 D29 Clinical Crown Lengthening-Hard Tisse 168 D Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) For Or More Contigos Teeth Or Bonded Spaces Per Qadrant D1 Osseos Srgery (Inclding Elevation Of A Fll Thickness Flap And Closre) One To Three Contigos Teeth Or Bonded Spaces Per Qadrant 87 D27 Distal Or Proximal Wedge Procedre (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 D Periodontal Scaling And Root Planing - One To Three Teeth Per Qadrant D355 Fll Moth Debridement To Enable Comprehensive Evalation And Diagnosis 22 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 COMPLETE DENTURES (inclding rotine post delivery care) D5 Complete Dentre - Maxillary 33 D2 Complete Dentre - Mandiblar 33 D3 Immediate Dentre - Maxillary 359 D Immediate Dentre - Mandiblar 359 PARTIAL DENTURES (inclding rotine post-delivery care) D52 Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests 28 D5212 Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests 335 D5213 Maxillary Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D521 Mandiblar Partial Dentre - Cast Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rest And Teeth) D5221 Immediate Maxillary Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 28 D5222 Immediate Mandiblar Partial Dentre - Resin Base (Inclding Any Conventional Clasps, Rests and Teeth) 335 PARTIAL DENTURES (inclding rotine post-delivery care) D5223 Immediate Maxillary Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D522 Immediate Mandiblar Partial Dentre - Case Metal Framework With Resin Dentre Bases (Inclding Any Conventional Clasps, Rests D52 Maxillary Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 33 D52 Mandiblar Partial Dentre - Flexible Base (Inclding Any Clasps, Rests 33 D5281 Removable Unilateral Partial Dentre-One Piece Cast Metal (Inclding Clasps 2 ADJUSTMENTS TO DENTURES D Adjst Complete Dentre - Maxillary 1 D5 Adjst Complete Dentre - Mandiblar 1 D521 Adjst Partial Dentre - Maxillary D522 Adjst Partial Dentre - Mandiblar REPAIRS TO COMPLETE DENTURES D5 Repair Broken Complete Dentre Base D552 Replace Missing Or Broken Teeth-Complete Dentre (Each ) REPAIRS TO PARTIAL DENTURES D561 Repair Resin Dentre Base D562 Repair Cast Framework 2 D563 Repair Or Replace Broken Clasp - Per 23 D56 Replace Broken Teeth-Per D565 Add To Existing Partial Dentre 2 D566 Add Clasp To Existing Partial Dentre - Per 2 D567 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary) 22 D5671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandiblar) 22 DENTURE REBASE PROCEDURES D571 Rebase Complete Maxillary Dentre 6 D57 Rebase Complete Mandiblar Dentre 6 D572 Rebase Maxillary Partial Dentre 58 D5721 Rebase Mandiblar Partial Dentre 58 DENTURE RELINE PROCEDURES D573 Reline Complete Maxillary Dentre (Chairside) 36 D5731 Reline Complete Mandiblar Dentre (Chairside) 36 D57 Reline Maxillary Partial Dentre (Chairside) 33 D571 Reline Mandiblar Partial Dentre (Chairside) 33 D575 Reline Complete Maxillary Dentre (Laboratory) D57 Reline Complete Mandiblar Dentre (Laboratory) D576 Reline Maxillary Partial Dentre (Laboratory) 9 D5761 Reline Mandiblar Partial Dentre (Laboratory) 8 OTHER REMOVABLE PROSTHETIC SERVICES D585 Tisse Conditioning, Maxillary 33 D58 Tisse Conditioning, Mandiblar 33 D5863 Overdentre - Complete Maxillary 33 Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH 16
OTHER REMOVABLE PROSTHETIC SERVICES D586 Overdentre - Partial Maxillary D5865 Overdentre - Complete Mandiblar 33 D5866 Overdentre - Partial Mandiblar FIXED PARTIAL DENTURE PONTICS D6 Pontic - Indirect Resin Based Composite 29 D621 Pontic-Cast High Noble Metal 3 D62 Pontic-Cast Predominatly 298 D6212 Pontic-Cast Noble Metal 312 D621 Pontic - Titanim 299 D62 Pontic-Porcelain Fsed To High Noble Metal 7 D621 Pontic-Porcelain Fsed To Predominantly 289 D622 Pontic-Porcelain Fsed To Noble Metal 3 D6 Pontic - Procelain/Ceramic 29 FIXED PARTIAL DENTURE RETAINTERS - INLAYS/ONLAYS D661 Retainer Onlay - Cast High Noble Metal, Two Srfaces D6612 Retainer Onlay - Cast Predominantly Base Metal, Two Srfaces D661 Retainer Onlay - Cast Noble Metal, Two Srfaces FIXED PARTIAL DENTURE RETAINERS - CROWNS D671 Retainer Crown - Indirect Resin Based Composite 295 D67 Retainer Crown - Porcelain/Ceramic 295 D675 Retainer Crown, Porcelain Fsed To High Noble Metal 9 D67 Retainer Crown - Porcelain Fsed To 29 Predominantly D6752 Retainer Crown, Porcelain Fsed To Noble 316 Metal D678 Retainer Crown, 3/ Cast High Noble Metal D6781 Retainer Crown - 3/ Cast Predominantly D6782 Retainer Crown - 3/ Cast Noble Metal D6783 Retainer Crown - 3/ Porcelain/Ceramic D679 Retainer Crown, Fll Cast High Noble Metal 7 D6791 Retainer Crown, Fll Cast Predominantly Base 292 Metal D6792 Retainer Crown, Fll Cast Noble Metal 3 D679 Retainer Crown - Titanim 292 OTHER FIXED PARTIAL DENTURE SERVICES D693 Re Cement Or Re-Bond Fixed Partial Dentre 3 EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D71 Extraction, Coronal Remnants - Decidos 1 D71 Extraction, Erpted Or Exposed Root (Elevation And/Or Forceps Removal) 16 SURGICAL EXTRACTIONS (incldes local anesthesia, string, if needed, and rotine postoperative care) D721 Srgical Removal Of Erpted Reqiring Removal Of Bone And/Or Sectioning Of, And Inclding Elevation Of Mcoperiosteal Flap If Indicated D722 Removal Of Impacted - Soft Tisse 72 D723 Removal Of Impacted - Partially Bony 98 D72 Removal Of Impacted - Completely Bony 3 SURGICAL EXTRACTIONS (incldes local anesthesia, string, if needed and rotine postoperative care) D721 Removal Of Impacted - Completely Bony, With Unsal Srgical Complications 12 D7 Srgical Removal Of Residal Roots (Ctting Procedre) 53 D71 Coronectomy-Intentional Partial Removal 3 OTHER SURGICAL PROCEDURES D728 Srgical Access Of An Unerpted 97 D7283 Placement Of Device To Facilitate Erption Of Impacted D7288 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 8 D7 Alveoloplasty Not In Conjnction With Extractions - For Or More Teeth Or Spaces, Per Qadrant 6 D7 Alveoloplasty Not In Conjnction With Extractions - One To Three Teeth Or Spaces, Per Qadrant OTHER REPAIR PROCEDURES D796 Frenlectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedre Not Incidental To Another Procedre 89 D7963 Frenloplasty LIMITED ORTHODONTIC TREATMENT D81 Limited Orthodontic Treatment Of Primary 599 D82 Limited Orthodontic Treatment Of Transitional 759 D83 Limited Orthodontic Treatment Of Adolescent 1 D8 Limited Orthodontic Treatment Of The Adlt 927 INTERCEPTIVE ORTHODONTIC TREATMENT D85 Interceptive Orthodontic Treatment Of Primary 885 D86 Interceptive Orthodontic Treatment Of Transitional 139 COMPREHENSIVE ORTHODONTIC TREATMENT D87 Comprehensive Orthodontic Treatment Of Transitional 3 D88 Comprehensive Orthodontic Treatment Of Adolescent 35 D89 Comprehensive Orthodontic Treatment Of Adlt 35 MINOR TREATMENT TO CONTROL HARMFUL HABITS D821 Removable Appliance Therapy For Control Of Harmfl Habits 33 D822 Fixed Appliance Therapy For Control Of Harmfl Habits 537 OTHER ORTHODONTIC SERVICES D868 Orthodontic Retention (Removal Of 33 Appliances, Constrction And Placement Of Retainer(S) UNCLASSIFIED TREATMENT D9 Palliative (Emergency) Treatment Of Dental Pain, Minor Procedres Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH 16
PROFESSIONAL CONSULTATION D931 Consltation - Diagnostic Service Provided By Dentist Or Physician Other Than Reqesting Dentist Or Physician PROFESSIONAL VISITS D93 Office Visit For Observation (Dring Reglarly Schedled Hors) - No Other Services Performed MISCELLANEOUS SERVICES D99 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 D9935 Cleaning And Inspection Of Removable Partial Dentre, Mandiblar D9986 Broken Appointment Per Mintes (Withot 2-Hor Notice) D9987 Cancelled Appointment Per Mintes (Withot 2-Hor Notice) 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 $1 for these materials. Base 5 (1/) Crrent Dental Terminology 2 American Dental Association. All rights reserved. PA/NJ/OH 16