Concordia Plus Schedule of Benefits Plan MD/DC 6 IMPORTANT INFORMATION ABOUT YOUR PLAN This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment, the amount to be paid is shown in the column titled. You pay these copayments to the dental office at the time of service. You must select a United Concordia Primary Dental Office (PDO) to receive covered services. Your PDO will perform the below procedures or refer you to a specialty care dentist for further care. Treatment by an Out-of-Network dentist is not covered, except as described in the Certificate of Coverage. Only procedures listed on this Schedule of Benefits are Covered Services. For services not listed (not covered), You are responsible for the full fee charged by the dentist. Procedure codes and member Copayments may be updated to meet American Dental Association () Current Dental Terminology (CDT) in accordance with national standards. For a complete description of your plan, please refer to the Certificate of Coverage and the Schedule of Exclusions and Limitations in addition to this Schedule of Benefits. If you have any questions about your United Concordia dental plan, please call our Customer Service Department toll-free at 1-866- 37-334 or access our website at www.unitedconcordia.com. CLINICAL ORAL EVALUATIONS ORAL PATHOLOGY LABORATORY D12 Periodic Oral Evaluation - Established Patient D14 Limited Oral Evaluation - Problem Focused D14 Oral Evaluation For A Patient Under 3 Years Of Age And Counseling With Primary Caregiver D1 Comprehensive Oral Evaluation - New Or Established Patient D17 Re-Evaluation-Limited, Problem Focused (Established Patient; Not Post-Operative Visit) D171 ReEvaluation Post-Operative Office Visit D18 Comprehensive Periodontal Evaluation RADIOGRAPHS/DIAGNOSTIC IMAGING (including interpretation) D21 Intraoral - Complete Series Of Radiographic Images D22 Intraoral- Periapical First Radiographic Image D23 Intraoral- Periapical Each Additional Radiographic Image D24 Intraoral - Occlusal Radiographic Image D27 Bitewing - Single Radiographic Image D272 Bitewings - Two Radiographic Images D273 Bitewings - Three Radiographic Images D274 Bitewings - Four Radiographic Images D277 Vertical Bitewings - 7 To 8 Radiographic Images D33 Panoramic Radiographic Image D34 2D Cephalometric Radiographic Image - Acquisition, Measurement And Analysis TESTS AND EXAMINATIONS D46 Pulp Vitality Tests D47 Diagnostic Casts ORAL PATHOLOGY LABORATORY D61 Caries Risk Assessment And Documentation, With A Finding Of Low Risk D62 Caries Risk Assessment And Documentation, With A Finding Of Moderate Risk D63 Caries Risk Assessment And Documentation, With A Finding Of High Risk DENTAL PROPHYLAXIS D1 Prophylaxis, Adult D2 Prophylaxis, Child TOPICAL FLUORIDE TREATMENT (office procedure) D126 Topical Application Of Fluoride Varnish D128 Topical Application Of Flouride Excluding Varnish OTHER PREVENTIVE SERVICES D133 Oral Hygiene Instruction D131 Sealant - Per D133 Sealant Repair - Per D134 Interim Caries Arresting Medicament Application 1 SPACE MAINTENANCE (passive appliances) D Space Maintainer - Fixed, Unilateral ( Numbers Or Area Required) 3 D Space Maintainer - Fixed, Bilateral 4 D12 Space Maintainer - Removable, Unilateral 43 D12 Space Maintainer - Removable, Bilateral 86 D1 ReCement Or ReBond Space Maintainer 6 D1 Removal Of Fixed Space Maintainer 26 AMALGAM RESTORATIONS (including polishing) D214 Amalgam - One Surface, Primary Or D21 Amalgam - Two Surfaces, Primary Or D2 Amalgam - Three Surfaces, Primary Or MD/DC 6 Current Dental Terminology 21 American Dental Association. All rights reserved. MD Base 14 (1/1)
AMALGAM RESTORATIONS (including polishing) D21 Amalgam - Four Or More Surfaces, Primary Or RESIN-BASED COMPOSITE RESTORATIONS - DIRECT D233 Resin-Based Composite - One Surface, D2331 Resin-Based Composite - Two Surfaces, D2332 Resin-Based Composite - Three Surfaces, D233 Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle () D2391 Resin-Based Composite - One Surface, 4 D2392 Resin-Based Composite - Two Surfaces, 6 D2393 Resin-Based Composite - Three Surfaces, 8 D2394 Resin-Based Composite - Four Or More Surfaces, 8 INLAY/ONLAY RESTORATIONS D21 Inlay - Metallic - One Surface 186 D22 Inlay - Metallic - Two Surfaces 27 D23 Inlay - Metallic - Three Or More Surfaces 26 D242 Onlay - Metallic-Two Surfaces 23 D243 Onlay - Metallic - Three Surfaces 27 D244 Onlay - Metallic - Four Or More Surfaces 32 CROWNS - SINGLE RESTORATIONS ONLY D271 Crown-Resin-Based Composite (Indirect) 8 D2712 Crown - 3/4 Resin-Based Composite (Indirect) 8 D274 Crown, Porcelain/Ceramic Substrate 4 D27 Crown, Porcelain Fused To High Noble Metal 3 D271 Crown-Porcelain Fused To Predominantly 32 Base Metal D272 Crown, Porcelain Fused To Noble Metal 33 D279 Crown, Full Cast High Noble Metal 3 D2791 Crown - Full Cast Predominantly Base Metal 32 D2792 Crown, Full Cast Noble Metal 33 D2794 Crown-Titanium 32 D2799 Provisional Crown - Further Treatment Or 66 Completion Of Diagnosis Necessary Prior To Final Impression OTHER RESTORATIVE SERVICES D291 Re-Cement Or ReBond Inlay, Onlay, Veneer Or Partial Coverage Restoration 12 D291 ReCement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core 13 D292 Re-Cement Or ReBond Crown 13 D293 Prefabricated Stainless Steel Crown - Primary 2 D2931 Prefabricated Stainless Steel Crown - 6 D2949 Restorative Foundation For An Indirect Restoration D29 Core Buildup Including Any Pins When Required 8 D291 Pin Retention - Per, In Addition To Restoration 1 D292 Post And Core In Addition To Crown, Indirectly Fabricated 81 OTHER RESTORATIVE SERVICES D293 Each Additional Indirectly Fabricated Post - Same 41 D294 Prefabricated Post And Core In Addition To Crown 79 D297 Each Additional Prefabricated Post - Same 4 D2971 Additional Procedures To Construct New Crown Under Existing Partial Denture Framework 2 PULP CAPPING D3 Pulp Cap - Direct (Excluding Final D312 Pulp Cap - Indirect (Excluding Final PULPOTOMY D322 Therapeutic Pulpotomy (Excluding Final 3 D3221 Pulpal Debridement, Primary And Teeth 26 D3222 Partial Pulpotomy For Apexogenesis- With Incomplete Root Development 3 ENDODONTIC THERAPY ON PRIMARY TEETH D323 Pulpal Therapy (Resorbable Filling)-, Primary (Excluding Final 6 D324 Pulpal Therapy (Resorbable Filling)-, Primary (Excluding Final 72 ENDODONTIC THERAPY (including treatment plan, clinical procedures and follow-up care) D331 Endodontic Therapy, (Excluding Final D332 Endodontic Therapy, Bicuspid (Excluding Final 2 D333 Endodontic Therapy, Molar (Excluding Final 273 ENDODONTIC RETREATMENT D3346 Retreatment Of Previous Root Canal Therapy - 2 D3347 Retreatment Or Previous Root Canal Therapy - Bicuspid 241 D3348 Retreatment Of Previous Root Canal Therapy - Molar 313 APICOECTOMY/PERIRADICULAR SERVICES D341 Apicoectomy - 147 D3421 Apicoectomy - Bicuspid (First Root) 144 D342 Apicoectomy - Molar (First Root) 144 D3426 Apicoectomy (Each Additional Root) 6 D3427 Periradicular Surgery Without Apicoectomy 144 D343 Retrograde Filling - Per Root D34 Root Amputation - Per Root 81 OTHER ENDODONTIC PROCEDURES D392 Hemisection (Including Any Root Removal) Not Including Root Canal Therapy 76 D39 Canal Preparation And Fitting Of Preformed Dowel Or Post SURGICAL SERVICES (including usual postoperative care) D421 Gingivectomy Or Gingivoplasty - Four Or More 173 Contiguous Teeth Or Bounded Spaces Per Quadrant MD/DC 6 Current Dental Terminology 21 American Dental Association. All rights reserved. MD Base 14 (1/1)
SURGICAL SERVICES (including usual postoperative care) D42 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Bounded 4 D4212 Gingivectomy Or Gingivoplasty To Allow Access For Restorative Procedure, Per D424 Gingival Flap Procedure, Including Root Planing - Four Or More Contiguous Teeth Or Bounded 2 D4241 Gingival Flap Procedure, Including Root Planing - One To Three Contiguous Teeth Or Bounded 6 D4249 Clinical Crown Lengthening-Hard Tissue 2 D426 Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) Four Or More Contiguous Teeth Or Bounded 26 D4261 Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) One To Three Contiguous Teeth Or Bounded 14 D4263 Bone Replacement Graft - First Site In Quadrant 86 D4264 Bone Replacement Graft - Each Additional Site In Quadrant 82 D4274 Distal Or Proximal Wedge Procedure (When Not Performed In Conjunction With Surgical Procedures In The Same Anatomical Area) NON-SURGICAL PERIODONTAL SERVICES D4341 Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant 6 D4342 Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant D43 Full Mouth Debridement To Enable Comprehensive Evaluation And Diagnosis 3 D4381 Localized Delivery Of Antimicrobial Agents Via Controlled Release Vehicle Into Diseased Crevicular Tissue, Per 1 OTHER PERIODONTAL SERVICES D491 Periodontal Maintenance 4 D4921 Gingival Irrigation - Per Quadrant 2 COMPLETE DENTURES (including routine post delivery care) D Complete Denture - Maxillary 32 D12 Complete Denture - Mandibular 32 D13 Immediate Denture - Maxillary 3 D14 Immediate Denture - Mandibular 3 PARTIAL DENTURES (including routine post-delivery care) D2 Maxillary Partial Denture - Resin Base 24 D212 Mandibular Partial Denture - Resin Base 24 D213 Maxillary Partial Denture - Cast Metal Framework With Resin Denture Bases 3 D214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases (Including Any Conventional Clasps, Rest And Teeth) 3 D221 Immediate Maxillary Partial Denture - Resin Base (Including Any Conventional Clasps, Rests and Teeth) 24 PARTIAL DENTURES (including routine post-delivery care) D222 Immediate Mandibular Partial Denture - Resin Base (Including Any Conventional Clasps, Rests and Teeth) 24 D223 Immediate Maxillary Partial Denture - Case Metal Framework With Resin Denture Bases 3 D224 Immediate Mandibular Partial Denture - Case Metal Framework With Resin Denture Bases 3 D22 Maxillary Partial Denture - Flexible Base (Including Any Clasps, Rests 43 D226 Mandibular Partial Denture - Flexible Base (Including Any Clasps, Rests 43 D281 Removable Unilateral Partial Denture-One Piece Cast Metal (Including Clasps 14 ADJUSTMENTS TO DENTURES D41 Adjust Complete Denture - Maxillary D4 Adjust Complete Denture - Mandibular D421 Adjust Partial Denture - Maxillary D422 Adjust Partial Denture - Mandibular REPAIRS TO COMPLETE DENTURES D1 Repair Broken Complete Denture Base D2 Replace Missing Or Broken Teeth-Complete 4 Denture (Each ) REPAIRS TO PARTIAL DENTURES D61 Repair Resin Denture Base D62 Repair Cast Framework 6 D63 Repair Or Replace Broken Clasp - Per 6 D64 Replace Broken Teeth-Per D6 Add To Existing Partial Denture 6 D66 Add Clasp To Existing Partial Denture - Per 6 D67 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary) 228 D671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) 228 DENTURE REBASE PROCEDURES D71 Rebase Complete Maxillary Denture 13 D7 Rebase Complete Mandibular Denture 13 D72 Rebase Maxillary Partial Denture D721 Rebase Mandibular Partial Denture DENTURE RELINE PROCEDURES D73 Reline Complete Maxillary Denture (Chairside) 6 D731 Reline Complete Mandibular Denture (Chairside) 6 D74 Reline Maxillary Partial Denture (Chairside) 6 D741 Reline Mandibular Partial Denture (Chairside) 6 D7 Reline Complete Maxillary Denture (Laboratory) 8 D71 Reline Complete Mandibular Denture (Laboratory) 8 D76 Reline Maxillary Partial Denture (Laboratory) 8 D761 Reline Mandibular Partial Denture (Laboratory) 8 OTHER REMOVABLE PROSTHETIC SERVICES D8 Tissue Conditioning, Maxillary 4 MD/DC 6 Current Dental Terminology 21 American Dental Association. All rights reserved. MD Base 14 (1/1)
OTHER REMOVABLE PROSTHETIC SERVICES D81 Tissue Conditioning, Mandibular 4 D863 Overdenture - Complete Maxillary 32 D864 Overdenture - Partial Maxillary 3 D86 Overdenture - Complete Mandibular 32 D866 Overdenture - Partial Mandibular 3 FIXED PARTIAL DENTURE PONTICS D62 Pontic - Indirect Resin Based Composite 4 D621 Pontic-Cast High Noble Metal 3 D62 Pontic-Cast Predominatly Base Metal 32 D6212 Pontic-Cast Noble Metal 33 D6214 Pontic - Titanium 32 D624 Pontic-Porcelain Fused To High Noble Metal 3 D6241 Pontic-Porcelain Fused To Predominantly 32 Base Metal D6242 Pontic-Porcelain Fused To Noble Metal 33 D624 Pontic - Procelain/Ceramic 4 FIXED PARTIAL DENTURE RETAINERS - CROWNS D671 Retainer Crown - Indirect Resin Based Composite 4 D674 Retainer Crown - Porcelain/Ceramic 4 D67 Retainer Crown, Porcelain Fused To High Noble Metal 3 D671 Retainer Crown - Porcelain Fused To 32 Predominantly Base Metal D672 Retainer Crown, Porcelain Fused To Noble 33 Metal D679 Retainer Crown, Full Cast High Noble Metal 3 D6791 Retainer Crown, Full Cast Predominantly Base 32 Metal D6792 Retainer Crown, Full Cast Noble Metal 33 D6794 Retainer Crown - Titanium 32 OTHER FIXED PARTIAL DENTURE SERVICES D693 ReCement Or Re-Bond Fixed Partial Denture 31 EXTRACTIONS (includes local anesthesia, suturing, if needed, and routine postoperative care) D71 Extraction, Coronal Remnants - Deciduous D714 Extraction, Erupted Or Exposed Root (Elevation And/Or Forceps Removal) 28 SURGICAL EXTRACTIONS (includes local anesthesia, suturing, if needed, and routine postoperative care) D721 Surgical Removal Of Erupted Requiring Removal Of Bone And/Or Sectioning Of, And Including Elevation Of Mucoperiosteal Flap If Indicated 2 D722 Removal Of Impacted - Soft Tissue 64 D723 Removal Of Impacted - Partially Bony 86 D724 Removal Of Impacted - Completely Bony D7241 Removal Of Impacted - Completely Bony, With Unusual Surgical Complications 121 D72 Surgical Removal Of Residual Roots (Cutting Procedure) D721 Coronectomy-Intentional Partial Removal OTHER SURGICAL PROCEDURES D728 Surgical Access Of An Unerupted 12 D7283 Placement Of Device To Facilitate Eruption Of 2 Impacted OTHER SURGICAL PROCEDURES D7288 Brush Biopsy - Transepithelial Sample 4 Collection ALVEOLOPLASTY (surgical preparation of ridge for dentures) D731 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or 49 D732 Alveoloplasty Not In Conjunction With Extractions - Four Or More Teeth Or 6 D7321 Alveoloplasty Not In Conjunction With Extractions - One To Three Teeth Or 24 SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS D74 Removal Of Benign Odontogenic Cyst Or 76 Tumor - Lesion Diameter Up To 1.2 Cm OTHER REPAIR PROCEDURES D796 Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure Not Incidental To Another Procedure 1 D7963 Frenuloplasty LIMITED ORTHODONTIC TREATMENT D81 Limited Orthodontic Treatment Of Primary 7 D82 Limited Orthodontic Treatment Of Transitional 7 D83 Limited Orthodontic Treatment Of Adolescent 7 D84 Limited Orthodontic Treatment Of The Adult 7 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 Adult 29 MINOR TREATMENT TO CONTROL HARMFUL HABITS D821 Removable Appliance Therapy For Control Of Harmful Habits 37 D822 Fixed Appliance Therapy For Control Of Harmful Habits 37 OTHER ORTHODONTIC SERVICES D868 Orthodontic Retention (Removal Of Appliances, Construction And Placement Of Retainer(S) 27 Orthodontic Records Fee UNCLASSIFIED TREATMENT 2 D9 Palliative (Emergency) Treatment Of Dental 26 Pain, Minor Procedures PROFESSIONAL CONSULTATION D931 Consultation - Diagnostic Service Provided By 28 Dentist Or Physician Other Than Requesting Dentist Or Physician PROFESSIONAL VISITS MD/DC 6 Current Dental Terminology 21 American Dental Association. All rights reserved. MD Base 14 (1/1)
PROFESSIONAL VISITS D943 Office Visit For Observation (During Regularly Scheduled Hours) - No Other Services Performed D944 Office Visit After Regularly Scheduled Hours 4 MISCELLANEOUS SERVICES D9932 Cleaning And Inspection Of Removable Complete Denture, Maxillary D9933 Cleaning And Inspection Of Removable Complete Denture, Mandibular D9934 Cleaning And Inspection Of Removable Partial Denture, Maxillary D993 Cleaning And Inspection Of Removable Partial Denture, Mandibular D9986 Broken Appointment Per 1 Minutes (Without 24-Hour Notice) D9987 Cancelled Appointment Per 1 Minutes (Without 24-Hour Notice) FOOTNOTES Charges for the use of precious (high noble) or semi precious (noble) metal are not included in the copayment for crowns, bridges, pontics, inlays and onlays. The decision to use 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 Procedure, By Report." Records Include All Diagnostic Procedures, Such As Cephalometric Films, Full Mouth X-Rays, Models, And Treatment Plans. MD/DC 6 Current Dental Terminology 21 American Dental Association. All rights reserved. MD Base 14 (1/1)