Select Plan Premium Kids 706s (DC) - Dominion National · Select Plan Premium Kids 706s (DC) Description of Benefits & Member Copayments for Pediatric Services (under age 19) Coverage

DMNDC19DBHINDPEDEHB All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.

D2950 Core buildup, including any pins ....................................63D2951 Pin retention - per tooth, in addition to restoration .........11D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) ............16 CROWNS & BRIDGES

D2510/20 Inlay- metallic - 1-2 surfaces ........................................204D2530 Inlay - metallic - three or more surfaces ......................213D2542 Onlay - metallic-two surfaces .......................................229D2543/44 Onlay - metallic - three or more surfaces .....................262D2610/20 Inlay - porcelain/ceramic - 1-2 surfaces .......................214D2630 Inlay - porcelain/ceramic - >=3 surfaces ......................223D2642 Onlay - porcelain/ceramic - two surfaces .....................240D2643/44 Onlay - porcelain/ceramic - >=3 surfaces ....................250D2650/51/52 Inlay-resin-basedcomposite->=1surface(s) ...........220D2662/63/64 Onlay - resin-based composite - >=2 surfaces ............222D2710 Crown-resinbasedcomposite(indirect) ....................136D2712 Crown-3/4resin-basedcomposite(indirect) ..............243D2720/21/22 Crown - resin with metal ..............................................248D2740 Crown - porcelain/ceramic ...........................................280D2750/51/52 Crown - porcelain fused metal .....................................262D2780/81/82 Crown - 3/4 cast with metal .........................................239D2783 Crown - 3/4 porcelain/ceramic .....................................256D2790/91/92 Crown - full cast metal .................................................248D2794 Crown - titanium ...........................................................248D2910/20 Recement inlay/crown ...................................................22D2929 Procelain/cermaic crown - prim. tooth .........................280D2930 Prefab. stainless steel crown - prim. tooth .....................55D2931 Prefab. stainless steel crown - perm. tooth ....................61D2932 Prefabricated resin crown ..............................................70D2941 Interim therapeutic restoration, primary dentition ..........16D2952 Cast post and core in addition to crown .........................93D2954 Prefab. post and core in addition to crown ....................77D2955 Postremoval(notinconj.withendo.therapy) ...............53D2970 Temporarycrown(fracturedtooth) ...................................0D2980 Crown repair, by report ..................................................51D2981/82/83 Inlay, only or veneer repair ............................................51D2990 Resininfitrationlesion ....................................................21 PROSTHETICS (DENTURES)D5110/20 Complete denture - maxillary/mandibular ....................349D5130/40 Immediate denture - maxillary/mandibular ...................361D5211/12 Maxillary/mandibular partial denture - resin base ........325D5213/14 Maxillary/mandibular partial denture - cast metal ........375D5221/22 Immediate maxillary/mandibular partial denture - resin base ...........................................................325D5223/24 Immediate maxillary/mandibular partial denture - cast metal ...........................................................375D5225/26 Maxillary/mandibularpartialdenture-flexiblebase .....375D5281 Rem. unilateral partial denture - one piece cast metal 210D5410/11 Adjust complete denture - maxillary/mandibular ............19D5421/22 Adjust partial denture - maxillary/mandibular .................19D5511/12 Repair broken complete denture base - maxillary/mandibular ............................................44D5520 Replace missing or broken teeth - complete denture ........44D5611/12 Repair resin partial denture base - maxillary/mandibular ..44 D5621/22 Repair cast partial framework - maxillary/mandibular ........ 44 D5630/60 Clasp repaired, replaced or added ................................58

D9439 Officevisit ........................................................................0

DIAGNOSTIC/PREVENTIVED0120 Periodic oral eval - established patient ............................0D0140 Limited oral eval - problem focused .................................0D0145 Oral eval for a patient under 3 years of age ....................0D0150 Comprehensive oral eval - new or established patient ....0D0160 Detailed and extensive oral eval - problem focused ........0D0170 Re-evaluation - limited, problem focused ........................0D0210 Intraoral-completeseries(includingbitewings) ..............0D0220/30 Intraoral-periapicalfirstfilmandeachadditional ...........0D0240 Intraoral-occlusalfilm .....................................................0D0250 Extraoralfilm ....................................................................0D0270-74 Bitewingx-rays-1-4films ................................................0D0277 Verticalbitewings-7to8films ........................................0D0330 Panoramicfilm .................................................................0D0340 2D cephalometric radiographic image .............................0D0350 2Doral/facialphotographicimages(intraoral/extraoral) ..0D0351 3D photographic image ....................................................0D0391 Interpretation of diagnostic image only ............................0D0460 Pulp vitality tests ..............................................................0D0470 Diagnostic casts ...............................................................0D1110 Prophylaxis(cleaning)-adult ..........................................0D1120 Prophylaxis(cleaning)-child ...........................................0D1206 Topicalfluoridevarnishformod/highriskcariespatients 0D1208 Topicalapplicationoffluoride ...........................................0D1310 Nutritional counseling for control of dental disease .........0D1320 Tobacco counseling for control of prev. oral disease .......0D1330 Oral hygiene instructions .................................................0D1351 Sealant - per tooth ...........................................................0D1352 Prev resin rest. mod/high caries risk – perm. tooth .........0 SPACE MAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral ..............0D1515/25 Spacemaintainer-fixed/removable-bilateral ................0D1550 Re-cementation of space maintainer ...............................0 D1575 Distalshoespacemaintainer-fixed-unilateral ..............0 RESTORATIVE DENTISTRY (FILLINGS)D2140 Amalgam - one surface, prim. or perm. .........................21D2150 Amalgam - two surfaces, prim. or perm. ........................26D2160 Amalgam - three surfaces, prim. or perm. .....................32D2161 Amalgam - >=4 surfaces, prim. or perm. .......................39

RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED)D2330 Resin-based composite - one surface, anterior .............35D2331 Resin-based composite - two surfaces, anterior ............42D2332 Resin-based composite - three surfaces, anterior .........50D2335 Resin-based composite - >=4 surfaces, anterior ...........60D2390 Resin-based composite crown, anterior ........................96D2391 Resin-based composite - one surface, posterior ...........37D2392 Resin-based composite - two surfaces, posterior ..........44D2393 Resin-based composite - three surfaces, posterior .......51D2394 Resin-based composite - >=4 surfaces, posterior .........62 D2940 Protective restoration .....................................................20D2949 Restorative foundation for an indirect restoration ............0

ADA MEMBERCODE BENEFIT COPAYMENT(S)


Annual Out-of-Pocket Maximum: $350 per child per calendar year for medically necessary treatment (maximum of $700 for policy covering two or more children)

Select Plan Premium Kids 706s (DC)Description of Benefits & Member Copayments for Pediatric Services (under age 19)

Coverage continues through end of month in which the Member turns 19.

The dental plan is underwritten by Dominion Dental Services, Inc. d/b/a Dominion National.

D5640 Replace broken teeth - per tooth ...................................44D5650 Add tooth to existing partial denture ..............................44D5670/71 Replace all teeth and acrylic on cast metal framework (maxillary/mandibular) ..........................................144D5710/11 Rebase complete maxillary/mandibular denture ..........130D5720/21 Rebase maxillary/mandibular partial denture ..............130D5730/31 Relinecompletemaxillary/mandibulardenture(chairside) ..80D5740/41 Relinemaxillary/mandibularpartialdenture(chairside) .78D5750/51 Relinecompletemaxillary/mandibulardenture(lab) ....112D5760/61 Relinemaxillary/mandibularpartialdenture(lab) ........112D5810/11 Interim complete denture - maxillary/mandibular .........181D5820/21 Interim partial denture - maxillary/mandibular ..............181D5850/51 Tissue conditioning - maxillary/mandibular ....................40 BRIDGES & PONTICS

D6010 Surgical placement of implant body, endosteal ...........858D6011 Second stage implant surgery .....................................100D6012 Surgical placement of interim implant body .................891D6013 Surgical placement of mini implant ..............................286D6040 Surgical placement, eposteal implant ........................1782D6050 Surgical placement, transosteal implant ....................2228D6055 Dental implant supported connecting bar ....................806D6056 Prefabricated abutment ...............................................228D6058 Abutment supported porcelain/ceramic crown .............280D6059/60/61 Abutment supported porcelain fused to metal crown - metal .....................................................................262D6062/63/64 Abutment supported cast metal crown - metal ............248D6065 Implant supported porcelain/ceramic crown ................280D6066 Implant supported porcelain fused to metal crown - titanium, titanium allow, high noble metal ..........262D6067 Implant supported metal crown - titanium, titanium alloy, high noble metal ..........................................262D6068 Abutment supported retainer for porc/ceramic ............394D6069 Abutment supp. retainer for porc/high noble ................422D6070 Abutment supp. retainer for porc/pred. base ...............348D6071 Abutment supp. retainer for porc/noble .......................352D6072 Abutment supp retainer for cast high noble .................394D6073 Abutment supp. retainer for cast high noble ................375D6074 Abutment supp. retainer for cast noble metal ..............379D6075 Implant supported retainer for ceramic FPD ................437D6076 Implant supported retainer for porc/metal FPD ............412D6077 Implant supported retainer for cast metal FPD ............436D6080 Implant maintenance procedures ..................................31D6081 Scalinganddebridementinthepresenceofinflammation or mucositis of a single implant, including cleaning of theimplantsurfaces,withoutflapentryandclosure .. 32 D6090 Repair implant supported prosthesis ...........................181D6091 Replacement of Precision Attachment ...........................17D6095 Repair implant abutment, by report .............................196D6100 Implant removal, by report ...........................................121D6101 Debribement periimplant defect .....................................45D6102 Deridement and osseous contouring periimplant defect 90D6103 Bone graft repair perrimplant defect ............................300D6104 Bone graft at time of implant placement ......................300D6190 Radiographic surgical implant index, by report ................0D6210 Pontic - cast high noble metal ......................................248D6211 Pontic - cast predominately base metal .......................248D6212 Pontic - cast noble metal .............................................248D6214 Pontic - titanium ...........................................................248D6240/41/42 Pontic - porcelain fused to metal .................................262D6245 Pontic - porcelain/ceramic ...........................................280D6250/51/52 Pontic - resin with metal ...............................................248D6545 Ret.-castmetalforresinbondedfixedprosthesis ......126D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis 197D6549 Resinretainer-forresinbondedfixedprosthesis .......126D6600 Inlay - porc./ceramic, two surfaces ..............................214D6601 Inlay - porc./ceramic, >=3 surfaces ..............................223

D6602 Inlay - cast high noble metal, two surfaces ..................204D6603 Inlay - cast high noble metal, >=3 surfaces .................213D6604 Inlay - cast predominantly base metal, two surfaces ...204D6605 Inlay - cast predominantly base metal, >=3 surfaces ..213D6606 Inlay - cast noble metal, two surfaces ..........................204D6607 Inlay - cast noble metal, >=3 surfaces .........................213D6608 Onlay -porc./ceramic, two surfaces .............................240D6609 Onlay - porc./ceramic, three or more surfaces ............250D6610 Onlay - cast high noble metal, two surfaces ................229D6611 Onlay - cast high noble metal, >=3 surfaces ...............262D6612 Onlay - cast predominantly base metal, two surfaces .229D6613 Onlay - cast predominantly base metal, >=3 surfaces .262D6614 Onlay - cast noble metal, two surfaces ........................229D6615 Onlay - cast noble metal, >=3 surfaces .......................262D6720/21/22 Crown - resin with metal ..............................................248D6740 Crown - porcelain/ceramic ...........................................280D6750/51/52 Crown - porcelain fused to metal .................................262D6780/81/82 Crown - 3/4 cast metal .................................................235D6783 Crown - 3/4 porc./ceramic ............................................256D6790/91/92 Crown - full cast metal .................................................248D6930 Recementfixedpartialdenture ......................................35D6980 Fixed partial denture repair, by report ............................86 ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain ............22D9210/15 Local anesthesia ..............................................................0D9211/12 Regional block anesthesia ...............................................0D9222 Deepsedation/generalanesthesia-first15min. ..........52 D9223 Deep sedation/general anesthesia - each subsequent 15 min. increment .................................. 52D9230 Analgesia, anxiolysis, inhalation of nitrous oxide ...........19D9239 Intravenousmoderatesedation/analgesia–first15min. .. 52 D9243 Intravenous conscious sedation/analgesia - each subsequent 15 min. increment .................................52D9310 Consultation(diagnosticservicebynontreatingdentist) 22D9910 Application of desensitizing medicament .......................16D9930 Treatmentofcomplications(post-surgical) ....................22D9940 Occlusal guard, by report .............................................136D9950 Occlusion analysis - mounted case ...............................52D9951 Occlusal adjustment - limited .........................................33D9952 Occlusal adjustment - complete ...................................133D9986 Missed appointment .......................................................50D9995 Teledentistry – synchronous; real-time encounter (whenavailable) .....................................................20 D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review (whenavailable) .....................................................20 ENDODONTICS1

D3220 Therapeuticpulpotomy(excl.finalrestor.) .....................41D3221 Pulpal debridement, prim. and perm. teeth ....................47D3222 Partial pulpotomy for apexogenesis ...............................80D3230 Pulpaltherapy-resorbablefilling,anterior ....................80D3240 Pulpaltherapy-resorbablefilling,posterior ..................82D3310 Endodontic therapy, anterior tooth ...............................171D3320 Endodontic therapy, premolar tooth (excludingfinalrestoration) ..................................209D3330 Endodontic therapy, molar tooth (excludingfinalrestoration) ..................................256D3333 Internal root repair of perforation defects .......................53D3346 Retreat of prev. root canal therapy, anterior.................194D3347 Retreat of prev. root canal therapy, premolar ...............233D3348 Retreat of prev. root canal therapy, molar ....................279D3351 Apexification/recalcification-initialvisit .......................101D3352 Apexification/recalcification-interimmed.repl. ...........295D3353 Apexification/recalcification-finalvisit .........................225D3355 Pulpal regeneration - initial visit ...................................101



All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.

1 Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. 2 See exclusion #14 and limitation #28 for additional coverage information.

Only current ADA CDT codes are considered valid by Dominion NationalCurrent Dental Terminology © American Dental Association.

D3356 Pulpal regeneration - interim medication replacement 295D3357 Pulpal regeneration - completion of treatment .............225D3410 Apicoectomy - anterior .................................................162D3421 Apicoectomy-premolar(firstroot) ..............................182D3425 Apicoectomy-molar(firstroot) ....................................209D3426 Apicoectomy(eachadd.root) ........................................76D3427 Periradicular surgery w/o apicoectomy ........................133D3430 Retrogradefilling-perroot ............................................60D3450 Root amputation - per root ...........................................117D3920 Hemisection, not inc. root canal therapy ......................117D3950 Canalprep/fittingofpreformeddowelorpost ................68 PERIODONTICS1

D0180 Comp. periodontal eval - new or established patient .......0D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad. ....................................140D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad. ...50D4212 Gingivectomy or gingivoplasty, rest., per tooth ..............20D4240 Gingivalflapproc.,inc.rootplaning - >3 cont. teeth, per quad .............................................173D4241 Gingivalflapproc,inc.rootplaning - <=3 cont. teeth, per quad ............................................. 53D4249 Clinical crown lengthening - hard tissue ......................288D4260 Osseous surgery - >3 cont. teeth, per quad ................250D4261 Osseous surgery - <=3 cont. teeth, per quad ..............196D4268 Surgical revision proc., per tooth .................................179D4270 Pedicle soft tissue graft procedure ..............................322D4273 Subepithelial connective tissue graft proc. ..................400D4274 Mesial/distal wedge procedure, single tooth ................154D4277 Free soft tissue graft, per tooth ....................................327D4278 Free soft tissue graft, each add. tooth ...........................50D4341 Perio scaling and root planing - >3 cont teeth, per quad. ..55D4342 Perio scaling and root planing - <= 3 teeth, per quad ....32D4346 Scaling in presence of generalized moderate or severegingivalinflammation-fullmouth,after oral evaluation ............................................................. 23 D4355 Full mouth debridement .................................................45D4381 Localized delivery of chemotherapeutic agents .............49D4910 Periodontal maintenance ...............................................37D4921 Gingival irrigation, per quadrant .......................................0 ORAL SURGERY1

D7111 Extraction, coronal remnants - primary tooth .................28D7140 Extraction, erupted tooth or exposed root ......................35D7210 Extraction, erupted tooth req elev, etc ..........................67D7220 Removal of impacted tooth - soft tissue .........................76D7230 Removal of impacted tooth - partially bony ....................98D7240 Removal of impacted tooth - completely bony .............121D7241 Removal of imp. tooth - completely bony, with unusual surg. complications ..........................109D7250 Removal of residual tooth roots ....................................71D7251 Coronectomy-intentional partial tooth removal ............109D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth ........................................113D7280 Exposure of an unerupted tooth ....................................77D7291 Transseptalfiberotomy/supracrestalfiberotomy, by report .................................................................30D7310/20 Alveoloplasty, >=4 per quad. .........................................71D7321 Alveoloplasty not in conj. w/ extractions, 1-3 per quad. .71D7471 Removal of lateral exostosis ........................................176D7510 Incision and drainage of abscess - intraoral soft tissue .48D7910 Suture of recent small wounds up to 5 cm .....................30D7921 Collection application of blood concentrate ...................20D7960 Frenulectomy(frenectomy/frenotomy)-separateproc. 132D7971 Excision of pericoronal gingiva ......................................66D7979 Non-surgical sialolithotomy ............................................22


ADA MEMBERCODE BENEFIT COPAYMENT(S)ORTHODONTICS2 - PRE-AUTHORIZATION REQUIREDD8010 Limited ortho. treatment of the primary dentition .......3304D8020 Limited ortho. treatment of the transitional dentition ....3304D8030 Limited ortho treatment - adolescent dentition ...........3422D8050 Interceptive ortho. treatment of the primary dentition ....3304D8060 Interceptive ortho. treatment of the transitional dentition ...3304D8070 Comp. ortho. treatment - transitional dentition ...........3304D8080 Comp. ortho. treatment - adolescent dentition ...........3422D8090 Comp. ortho. treatment - adult dentition ....................3658D8210 Removable appliance therapy .....................................770D8220 Fixed appliance therapy ...............................................783D8660 Pre-orthodontic treatment visit .....................................413D8670 Periodicortho.treatmentvisit(aspartofcontract) ......118D8680 Ortho.ret.(rem.ofappl./placementofretainer(s)) ......413

Plan Exclusions1. Services which are covered under worker’s compensation or employer’s liability laws.2. Services which are not necessary for the patient’s dental health as determined by the Plan.3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan.4. Oral surgery requiring the setting of fractures or dislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where,intheopinionofthePlan,suchservicesshouldnotbeperformedinadentaloffice.6. Dispensing of drugs.7. Hospitalization for any dental procedure.8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation.9. Replacement due to loss or theft of prosthetic appliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpreauthorizedbysuchofficeorthePlan(withtheexception ofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(TemporomandibularDisorder)exceptifTMDiscausedbysevere,dysfunctional,handicapping malocclusion that requires medically necessary orthodontia services.13. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth as determined by the Plan. The prophylactic removal of these teeth for medically necessary orthodontia services may be covered subject to review.14. Non-medicallynecessaryorthodontiaisnotacoveredbenefitunderthispolicy.AdiscountisprovidedtomembersthroughthePlan’s agreements with its participating orthodontists. The provider agreements create no liability for payment by the Plan, and payments by the member for these services do not contribute to the Out-of-Pocket Maximum. The Invisalign system and similar specialized braces are not acoveredbenefit.Seelimitation#28concerningmedicallynecessaryorthodontia.

Plan Limitations1. Oneevaluation(D0120,D0140,D0145,D0150,D0160,D0180)iscoveredoncepersixmonths,perpatient.D0150limitedtooncein12 months.2. One(1)teethcleaning(D1110orD1120)per6months,perpatient.3. One(1)fluorideapplicationevery6months,perpatient.4. One(1)setofbitewingx-raysarecoveredpersix(6)months,perpatientstartingatagetwo.5. One(1)setoffullmouthx-raysorpanoramicfilmiscoveredeveryfive(5)years.Panoramicx-raysarelimitedtoages6-18.Nomorethan one set of x-rays are covered per visit. 6. One(1)sealantpertoothiscoveredper36months,perpatientuptoage18(limitedtoocclusalsurfacesofposteriorpermanentteeth withoutrestorationsordecay).7. One(1)spacemaintainer(D1510,D1520,D1515orD1525)iscoveredper24monthsperpatient,perarch.D1575limitedtoonceperlifetime. 8. Replacementofafillingiscoveredifitismorethanthree(3)yearsfromthedateoforiginalplacement.9. Replacementofaprimarystainlesssteelcrown(underage15),crown,denture,orotherprosthodonticapplianceiscoveredifitismore thanfive(5)yearsfromthedateoforiginalplacement.10. Crownandbridgefeesapplytotreatmentinvolvingfiveorfewerunitswhenpresentedinasingletreatmentplan.Additionalcrownor bridgeunits,beginningwiththesixthunit,areavailableattheprovider’sUsual,Customary,andReasonable(UCR)fee,minus25%.11. Relining and rebasing of dentures is covered once per 24 months, per patient.12. Root canal treatment is covered once per lifetime.13. Periodontalscalingandrootplaning(D4341orD4342),limitedtoone(1)per24months,perpatient,perquadrant.14. Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation-fullmouth,afteroralevaluationandinlieuofacovered D1110/D1120, limited to once per two years. 15. Osseoussurgery(D4260orD4261),gingivalflapprocedure(D4240),andgingivectomyorgingivoplasy(D4210-D4212)arelimitedtoone (1)per36months.16. Full mouth debridement is covered once per lifetime, per patient.17. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthreeteethperquadrant;oratotalof12teethforallfourquadrantsper twelve(12)months.Musthavepocketdepthsoffive(5)millimetersorgreater.18. Periodontal surgery of any type, including any associated material, is covered once every 24 months, per quadrant or surgical site.19. Periodontalmaintenanceiscoveredtwicepercalendaryearinadditiontoadultprophylaxis,within24monthsafterdefinitiveperiodontal therapy.20. Denture rebase and denture reline is limited to 1 in a 36 month period 6 months after initial placement.21. One(1)scalinganddebridementinthepresenceofinflammationormucositisofasingleimplant,includingcleaningoftheimplant surfaces,withoutflapentryandclosure,pertwo(2)years. 22. Coronectomy,intentionalpartialtoothremoval,one(1)perlifetime. 23. Anesthesia requires a narrative of medical necessity be maintained in patient records. A maximum of 60 minutes of services are allowed for general anesthesia and intravenous or non-intravenous conscious sedation. General anesthesia is not covered with procedure codes D9230, D9239 or D9243. Intravenous conscious sedation is not covered with procedure codes D9222, D9223 or D9230. Nonintravenous conscioussedationisnotcoveredwithprocedurecodesD9222,D9223orD9230.Analgesia(nitrousoxide)isnotcoveredwithprocedure codes D9222, D9223, D9239 or D9243.24. Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for the treatment of bruxismordiagnosesotherthantemporomandibulardysfunction(TMD).Occlusalguardsarelimitedtooneper12consecutive month period. 25. Deepsedation/generalanesthesiaandintravenousconscioussedationarecovered(byreport)onlywhenprovidedinconnectionwith acoveredprocedure(s)whendeterminedtobemedicallyordentallynecessaryfordocumentedhandicappedoruncontrollablepatientsor justifiablemedicalordentalconditions.26. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are only covered if deemed necessary by the Plan.27. Onlays, crowns, and posts and cores for members 12 years of age or younger are only covered if deemed necessary by the Plan. Cast postsandcores(D2952)areprocessedasanalternatebenefitofaprefabricatedpostandcore.Postsareeligibleonlywhenprovided as part of a crown buildup or implant and are considered integral to the buildup or implant. 28. Orthodontics is only covered if medically necessary as determined by the Plan. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility. 29.Teledentistry,synchronous(D9995)orasynchronous(D9996),limitedtotwopercalendaryear(whenavailable).

Exclusions & Limitations

D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) ....................16 CROWNS & BRIDGES

D2510/20 Inlay-metallic-1-2surfaces ................................................204D2530 Inlay-metallic-threeormoresurfaces ...............................213D2542 Onlay-metallic-twosurfaces ...............................................229D2543/44 Onlay-metallic-threeormoresurfaces .............................262D2610/20 Inlay-porcelain/ceramic-1-2surfaces ...............................214D2630 Inlay-porcelain/ceramic->=3surfaces ..............................223D2642 Onlay-porcelain/ceramic-twosurfaces .............................240D2643/44 Onlay-porcelain/ceramic->=3surfaces ............................250D2650/51/52 Inlay-resin-basedcomposite->=1surface(s) ....................220D2662/63/64 Onlay-resin-basedcomposite->=2surfaces ....................222D2710 Crown-resinbasedcomposite(indirect) ............................136D2712 Crown-3/4resin-basedcomposite(indirect) ......................243D2720/21/22 Crown-resinwithmetal ......................................................248D2740 Crown-porcelain/ceramic ...................................................280D2750/51/52 Crown-porcelainfusedmetal .............................................262D2780/81/82 Crown-3/4castwithmetal ..................................................239D2783 Crown-3/4porcelain/ceramic .............................................256D2790/91/92 Crown-fullcastmetal .........................................................248D2799 Provisionalcrown .....................................................................0D2910/20 Recementinlay/crown ............................................................22D2915 Recementcastorprefab.postandcore ................................41D2930 Prefab.stainlesssteelcrown-prim.tooth .............................55D2931 Prefab.stainlesssteelcrown-perm.tooth ............................61D2932 Prefabricatedresincrown ......................................................70D2933 Prefab.stainlesssteelcrownw/resinwindow .....................136D2941 Interimtherapeuticrestoration,primarydentition ...................16D2952 Castpostandcoreinadditiontocrown .................................93D2953 Eachadd.indirectlyfabricatedpost-sametooth ..................25D2954 Prefab.postandcoreinadditiontocrown .............................77D2955 Postremoval(notinconj.withendo.therapy) .......................53D2957 Eachadd.prefabpost-sametooth .......................................20D2970 Temporarycrown(fracturedtooth) ...........................................0D2980 Crownrepair,byreport ..........................................................51 PROSTHETICS (DENTURES)D5110/20 Completedenture-maxillary/mandibular ............................349D5130/40 Immediatedenture-maxillary/mandibular ...........................361D5211/12 Maxillary/mandibularpartialdenture-resinbase ................325D5213/14 Maxillary/mandibularpartialdenture-castmetal ................375D5221/22 Immediatemaxillary/mandibularpartialdenture -resinbase ......................................................................325D5223/24 Immediatemaxillary/mandibularpartialdenture -castmetal ......................................................................375 D5225/26 Maxillary/mandibularpartialdenture-flexiblebase .............375D5281 Rem.unilateralpartialdenture-onepiececastmetal .........210D5410/11 Adjustcompletedenture-maxillary/mandibular ....................19D5421/22 Adjustpartialdenture-maxillary/mandibular .........................19D5511/12 Repairbrokencompletedenturebase-maxillary/mandibular ... 44D5520 Replacemissingorbrokenteeth-completedenture ............44D5611/12 Repairresinpartialdenturebase-maxillary/mandibular .......44D5621/22 Repaircastpartialframework-maxillary/mandibular ............44D5630/60 Clasprepaired,replacedoradded .........................................58D5640 Replacebrokenteeth-pertooth ...........................................44D5650 Addtoothtoexistingpartialdenture ......................................44D5670/71 Replaceallteethandacryliconcastmetalframework (maxillary/mandibular) ......................................................144D5710/11 Rebasecompletemaxillary/mandibulardenture ..................130

D9439 Officevisit ................................................................................0

DIAGNOSTIC/PREVENTIVED0120 Periodicoraleval-establishedpatient ....................................0D0140 Limitedoraleval-problemfocused .........................................0D0145 Oralevalforapatientunder3yearsofage .............................0D0150 Comprehensiveoraleval-neworestablishedpatient ............0D0160 Detailedandextensiveoraleval-problemfocused ................0D0170 Re-evaluation-limited,problemfocused .................................0D0210 Intraoral-completeseries(includingbitewings) ......................0D0220/30 Intraoral-periapicalfirstradiographicimage/eachadd ...........0D0240 Intraoral-occlusalradiographicimage ....................................0D0250 Extraoral-2Dprojectionradiographicimage ...........................0D0270-74 Bitewing-1-4radiographicimages ..........................................0D0277 Verticalbitewings-7to8radiographicimages ........................0D0322 Tomographicsurvey .................................................................0D0330 Panoramicradiographicimage ................................................0D0340 2Dcephalometricradiographicimage .....................................0D0350 2Doral/facialphotographicimages(intraoral/extraoral) ..........0D0460 Pulpvitalitytests ......................................................................0D0470 Diagnosticcasts .......................................................................0D0999 Unspecifieddiagnosticprocedure,byreport ............................0D1110 Prophylaxis(cleaning)-adult ...................................................0D1120 Prophylaxis(cleaning)-child ...................................................0D1206 Topicalfluoridevarnishformod/highriskcariespatients .........0D1208 Topicalapplicationoffluoride ...................................................0D1310 Nutritionalcounselingforcontrolofdentaldisease .................0D1320 Tobaccocounselingforcontrolofprev.oraldisease ...............0D1330 Oralhygieneinstructions .........................................................0D1351 Sealant-pertooth ...................................................................0D1352 Prevresinrest.mod/highcariesrisk–perm.tooth ..................0 SPACE MAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral .......................0D1515/25 Spacemaintainer-fixed/removable-bilateral .........................0D1550 Re-cementationofspacemaintainer .......................................0D1555 Removaloffixedspacemaintainer,bynon-originatingdentist ...... 0D1575 Distalshoespacemaintainer-fixed-unilateral .............................. 0 RESTORATIVE DENTISTRY (FILLINGS) AMALGAMRESTORATIONS(SILVER)D2140 Amalgam-onesurface,prim.orperm. .................................21D2150 Amalgam-twosurfaces,prim.orperm. ................................26D2160 Amalgam-threesurfaces,prim.orperm. .............................32D2161 Amalgam->=4surfaces,prim.orperm. ...............................39

RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED)D2330 Resin-basedcomposite-onesurface,anterior .....................35D2331 Resin-basedcomposite-twosurfaces,anterior ....................42D2332 Resin-basedcomposite-threesurfaces,anterior .................50D2335 Resin-basedcomposite->=4surfaces,anterior ...................60D2390 Resin-basedcompositecrown,anterior .................................96D2391 Resin-basedcomposite-onesurface,posterior ...................37D2392 Resin-basedcomposite-twosurfaces,posterior ..................44D2393 Resin-basedcomposite-threesurfaces,posterior ...............51D2394 Resin-basedcomposite->=4surfaces,posterior .................62 D2940 Protectiverestoration .............................................................20D2950 Corebuildup,includinganypins ............................................63D2951 Pinretention-pertooth,inadditiontorestoration ................. 11

DMNDE19DBHINDPEDEHB Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused.



ThedentalplanisunderwrittenbyDominionDentalServices,Inc.d/b/aDominionNational.


Select Plan Premium Kids 706s (DE)Description of Benefits & Member Copayments for Pediatric Services (under age 19)

CoveragecontinuesthroughendofmonthinwhichtheMemberturns19.

D5720/21 Rebasemaxillary/mandibularpartialdenture .......................130D5730/31 Relinecompletemaxillary/mandibulardenture(chairside) ....80D5740/41 Relinemaxillary/mandibularpartialdenture(chairside) .........78D5750/51 Relinecompletemaxillary/mandibulardenture(lab) ............ 112D5760/61 Relinemaxillary/mandibularpartialdenture(lab) ................. 112D5810/11 Interimcompletedenture-maxillary/mandibular .................181D5820/21 Interimpartialdenture-maxillary/mandibular ......................181D5850/51 Tissueconditioning-maxillary/mandibular ............................40D5932 Obturatorprosthesis,definitive ..........................................2400D5933 Obturatorprosthesis,modification .......................................355D5934 Mandibularresectionprosthesisw/guideflange ...............2021D5935 Mandibularresectionprosthesisw/oguideflange .............1885D5936 Obturatorprosthesis,interim ..............................................1025D5937 Trismusappliance,notinconj.withTMD ............................327D5986 Fluoridegelcarrier .................................................................63D5991 Topicalmedicamentcarrier ....................................................63 BRIDGES & PONTICS

D6210 Pontic-casthighnoblemetal ..............................................248D6211 Pontic-castpredominatelybasemetal ...............................248D6240/41/42 Pontic-porcelainfusedtometal ..........................................262D6245 Pontic-porcelain/ceramic ....................................................280D6250/51/52 Pontic-resinwithmetal .......................................................248D6545 Ret.-castmetalforresinbondedfixedprosthesis ..............126D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis .........197D6600 Inlay-porc./ceramic,twosurfaces ......................................214D6601 Inlay-porc./ceramic,>=3surfaces ......................................223D6602 Inlay-casthighnoblemetal,twosurfaces ..........................204D6603 Inlay-casthighnoblemetal,>=3surfaces .........................213D6604 Inlay-castpredominantlybasemetal,twosurfaces ...........204D6605 Inlay-castpredominantlybasemetal,>=3surfaces ...........213D6606 Inlay-castnoblemetal,twosurfaces ..................................204D6607 Inlay-castnoblemetal,>=3surfaces .................................213D6608 Onlay-porc./ceramic,twosurfaces ......................................240D6609 Onlay-porc./ceramic,threeormoresurfaces .....................250D6610 Onlay-casthighnoblemetal,twosurfaces ........................229D6611 Onlay-casthighnoblemetal,>=3surfaces ........................262D6612 Onlay-castpredominantlybasemetal,twosurfaces .........229D6613 Onlay-castpredominantlybasemetal,>=3surfaces .........262D6614 Onlay-castnoblemetal,twosurfaces ................................229D6615 Onlay-castnoblemetal,>=3surfaces ...............................262D6720/21/22 Crown-resinwithmetal ......................................................248D6740 Crown-porcelain/ceramic ...................................................280D6750/51/52 Crown-porcelainfusedtometal .........................................262D6780/81/82 Crown-3/4castmetal .........................................................235D6783 Crown-3/4porc./ceramic ....................................................256D6790/91/92 Crown-fullcastmetal .........................................................248D6930 Recementfixedpartialdenture ..............................................35D6980 Fixedpartialdenturerepair,byreport ....................................86D6985 Pediatricpartialdenture,fixed .............................................280 ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain .....................22D9210/15 Localanesthesia ......................................................................0D9211/12 Regionalblockanesthesia .......................................................0D9222 Deepsedation/generalanesthesia-first15min ....................52 D9223 Deepsedation/generalanesthesia-eachsubsequent15min. 52D9230 Analgesia,anxiolysis,inhalationofnitrousoxide ...................19D9239 Intravenousmoderate(conscious) sedation/analgesia–first15minutes .................................52 D9243 Intravenous(conscious)sedation/analgesia-each subsequent5min. ...............................................................52D9248 Non-intravenousconscioussedation .....................................73D9310 Consultation(diagnosticservicebynontreatingdentist) ........22D9440 Officevisitafterregularlyscheduledhours ............................45D9610 Therapeuticparenteraldrug,singleadmin. ...........................13D9612 Therapeuticparenteraldrug,2ormoreadmin.,diff.med. .....35D9910 Applicationofdesensitizingmedicament ...............................16D9920 Behaviormanagement,byreport ...........................................34D9930 Treatmentofcomplications(post-surgical) ............................22

D9940 Occlusalguard,byreport .....................................................136D9950 Occlusionanalysis-mountedcase .......................................52D9951 Occlusaladjustment-limited .................................................33D9952 Occlusaladjustment-complete ...........................................133D9986 Missedappointment ...............................................................50D9995 Teledentistry–synchronous;real-timeencounter (whenavailable) .................................................................20 D9996 Teledentistry–asynchronous;informationstored andforwardedtodentistforsubsequentreview (whenavailable) .................................................................20 ENDODONTICS1

D3220 Therapeuticpulpotomy(excl.finalrestor.) .............................41D3221 Pulpaldebridement,prim.andperm.teeth ............................47D3222 Partialpulpotomyforapexogenesis .......................................80D3230 Pulpaltherapy-resorbablefilling,anterior ............................80D3240 Pulpaltherapy-resorbablefilling,posterior ...........................82D3310 Endodontictherapy,anteriortooth(excluding finalrestoration) ...............................................................171D3320 Endodontictherapy,premolartooth(excluding finalrestoration) ...............................................................209D3330 Endodontictherapy,molartooth(excluding finalrestoration) ...............................................................256D3332 Incomp.endo.therapy-inop.orfracturedtooth ......................92D3333 Internalrootrepairofperforationdefects ...............................53D3346 Retreatofprev.rootcanaltherapy,anterior .........................194D3347 Retreatofprev.rootcanaltherapy,premolar .......................233D3348 Retreatofprev.rootcanaltherapy,molar ............................279D3351 Apexification/recalcification-initialvisit ...............................101D3352 Apexification/recalcification-interimmed.repl. ...................295D3353 Apexification/recalcification-finalvisit .................................225D3355 Pulpalregeneration-initialvisit ...........................................101D3356 Pulpalregeneration-interimmedicationreplacement .........295D3357 Pulpalregeneration-completionoftreatment .....................225D3410 Apicoectomy,anterior...........................................................162D3421 Apicoectomy,premolar(firstroot) ..........................................182D3425 Apicoectomy,molar(firstroot) .............................................209D3426 Apicoectomy,(eachadd.root) ...............................................76D3427 Periradicularsurgeryw/oapicoectomy ................................133D3428 Bonegraftinconj.w/periradicularsurg.,pertooth,singlesite ... 372D3429 Bonegraftinconj.w/periradicularsurg., add.contiguoustooth,samesite .....................................291D3430 Retrogradefilling-perroot ....................................................60D3431 Biologicmaterialstoaidsoft/osseoustissueregen. inconj.w/periradicularsurg. ...........................................204D3432 Guidedtissueregen.,resorbablebarrier,persite, inconj.w/periradicularsurg. ...........................................408D3450 Rootamputation-perroot ................................................... 117D3920 Hemisection,notinc.rootcanaltherapy .............................. 117D3950 Canalprep/fittingofpreformeddowelorpost ........................68 PERIODONTICS1

D0180 Comp.periodontaleval-neworestablishedpatient ...............0D4210 Gingivectomyorgingivoplasty->3cont.teeth,perquad. ...140D4211 Gingivectomyorgingivoplasty-<=3teeth,perquad. ............50D4212 Gingivectomyorgingivoplasty,rest.,pertooth ......................20D4240 Gingivalflapproc.,inc.rootplaning->3cont.teeth,perquad ... 173D4241 Gingivalflapproc,inc.rootplaning-<=3cont.teeth,perquad ... 53D4260 Osseoussurgery->3cont.teeth,perquad.........................250D4261 Osseoussurgery-<=3cont.teeth,perquad ......................196D4263 Bonereplacementgraft-retainednaturaltooth-first siteinquad. ......................................................................372D4264 Bonereplacementgraft-retainednaturaltooth-each add.siteinquad. ..............................................................291D4265 Biologicmaterials .................................................................204D4266 Guidedtissueregen.-resorb.barrier,persite ....................408D4267 Guidedtissueregen.-non-resorb.barrier,persite .............399D4268 Surgicalrevisionproc.,pertooth .........................................179D4270 Pediclesofttissuegraftprocedure .......................................322



Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused.


1 Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. 2 Phase I Treatment (D8010 - D8050) is provided at a 15% reduction from the orthodontist’s UCR fees. See exclusion #14 and limitation #24 for additional coverage information.

OnlycurrentADACDTcodesareconsideredvalidbyDominionNationalCurrent Dental Terminology © American Dental Association.

D4273 Subepithelialconnectivetissuegraftproc. ...........................400D4274 Mesial/distalwedgeprocedure,singletooth ........................154D4275 Softtissueallograft ..............................................................427D4276 Comb.connec.tissue/doublepediclegraft,pertooth ..........510D4320 Provisionalsplinting-intracoronal .......................................214D4321 Provisionalsplinting-extracoronal ......................................189D4341 Perioscalingandrootplaning->3contteeth,perquad. ......55D4342 Perioscalingandrootplaning-<=3teeth,perquad ............32D4346 Scalinginpresenceofgeneralizedmoderateorsevere gingivalinflammation-fullmouth,afteroralevaluation .......... 23D4355 Fullmouthdebridement .........................................................45D4381 Localizeddeliveryofchemotherapeuticagents .....................49D4910 Periodontalmaintenance .......................................................37D4920 Unscheduleddressingchangebynon-treatingdentist ..........42 ORAL SURGERY1

D7111 Extraction,coronalremnants-primarytooth .........................28D7140 Extraction,eruptedtoothorexposedroot ..............................35D7210 Extraction,eruptedtoothreqelev,etc ..................................67D7220 Removalofimpactedtooth-softtissue .................................76D7230 Removalofimpactedtooth-partiallybony ............................98D7240 Removalofimpactedtooth-completelybony .....................121D7241 Removalofimp.tooth-completelybony, withunusualsurg.complications .....................................109D7250 Removalofresidualtoothroots .............................................71D7251 Coronectomy-intentionalpartialtoothremoval ....................109 D7270 Toothreimplant./stabiliz.ofacc.evulsed/displacedtooth .... 113D7272 Toothtransplantation ............................................................308D7280 Exposureofanuneruptedtooth .............................................77D7282 Mobil.oferupted/malpositionedtoothtoaideruption .......... 116D7283 Place.ofdevicetofacilitateerupt.ofimpactedtooth .............72D7291 Transseptalfiberotomy/supracrestalfiberotomy,byreport ...30D7310/20 Alveoloplasty,>=4perquad. ..................................................71D7340 Vestibuloplasty-ridgeext.sec.epithel. ...............................462D7350 Vestibuloplasty-ridgeext.inc.grafts,etc ............................888D7510 Incisionanddrainageofabscess-intraoralsofttissue .........48D7511 Incision/drainageofabscess-intra.softtissue,comp. .........56D7520 Incision/drainageofabscess-extra.softtissue ....................58D7521 Incision/drainageofabscess-extra.softtissue,comp. ........60D7910 Sutureofrecentsmallwoundsupto5cm .............................30D7911 Complicatedsuture,<=5cm .................................................35D7912 Complicatedsuture,>5cm ...................................................40D7960 Frenulectomy(frenectomy/frenotomy)-separateproc. .......132D7963 Frenuloplasty .......................................................................147D7970 Excisionofhyperplastictissue-perarch ............................. 117D7971 Excisionofpericoronalgingiva ..............................................66D7979 Non-surgicalsialolithotomy ....................................................22 ORTHODONTICS2 - PRE-AUTHORIZATION REQUIREDD8060 Interceptiveortho.treatment-transitionaldentition .............3304D8070 Comp.ortho.treatment-transitionaldentition ...................3304D8080 Comp.ortho.treatment-adolescentdentition ...................3422D8090 Comp.ortho.treatment-adultdentition ............................3658D8660 Pre-orthodontictreatmentvisit .............................................413D8670 Periodicortho.treatmentvisit(aspartofcontract) .............. 118D8680 Ortho.ret.(rem.ofappl./placementofretainer(s)) ..............413D8692 Replacementoflostorbrokenretainer ................................179

Plan Exclusions1. Serviceswhicharecoveredunderworker’scompensationoremployer’sliabilitylaws.2. Serviceswhicharenotnecessaryforthepatient’sdentalhealthasdeterminedbythePlan.3. Cosmetic,electiveoraestheticdentistryexceptasrequiredduetoaccidentalbodilyinjurytosoundnaturalteethasdeterminedbythe Plan.4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Serviceswithrespecttomalignancies,cystsorneoplasms,hereditary,congenital,mandibularprognathismordevelopmentmalformations where,intheopinionofthePlan,suchservicesshouldnotbeperformedinadentaloffice.6. Dispensingofdrugs.7. Hospitalizationforanydentalprocedure.8. Treatmentrequiredforconditionsresultingfrommajordisaster,epidemic,war,actsofwar,whetherdeclaredorundeclared,orwhileon activedutyasamemberofthearmedforcesofanynation.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpreauthorizedbysuchofficeorthePlan(withtheexception ofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(TemporomandibularDisorder)exceptifTMDiscausedbysevere,dysfunctional,handicapping malocclusionthatrequiresmedicallynecessaryorthodontiaservices.13. Electivesurgeryincluding,butnotlimitedto,extractionofnon-pathologic,asymptomaticimpactedteethasdeterminedbythePlan.The prophylacticremovaloftheseteethformedicallynecessaryorthodontiaservicesmaybecoveredsubjecttoreview.14. Non-medicallynecessaryorthodontiaandPhaseITreatmentformedicallynecessaryorthodontiaarenotcoveredbenefitsunderthis policy.DiscountsareprovidedtomembersthroughthePlan’sagreementswithitsparticipatingorthodontists.Theprovideragreements createnoliabilityforpaymentbythePlan,andpaymentsbythememberfortheseservicesdonotcontributetotheOut-of-Pocket Maximum.TheInvisalignsystemandsimilarspecializedbracesarenotacoveredbenefit.Seelimitation#24concerningmedically necessaryorthodontia.

Plan Limitations1. One(1)evaluation(D0120,D0145,D0150orD0160)persix(6)months,perpatient.2. One(1)teethcleaning(D1110orD1120)persix(6)months,perpatient.3. Onefluoridetreatmentpersix(6)months,perpatient.4. Fourbitewingx-rayfilmspersix(6)months,perpatient.5. One(1)setoffullmouthx-raysorpanoramicfilmiscoveredeverythree(3)years.6. Onesealantpertooth,perpatientuptoage19(limitedtoocclusalsurfacesofposteriorpermanentteethwithoutrestorationsordecay).7. Onefixedspacemaintainer(D1510,D1515)per5years,perarch,perpatientuptoage14,topreservespacebetweenteethfor prematurelossofaprimarytooth(doesnotincludeusefororthodontictreatment).D1575limitedtoonceperlifetime.8. Replacementofafillingiscoveredifitismorethantwo(2)yearsfromthedateoforiginalplacement.9. Replacementofacrown(forteethwithextensivecariesorfracturethatisunabletoberestoredwithanamalgamorcompositefilling), bridge(thatcannotberepaired)ordentureiscoveredifitismorethanfive(5)yearsfromthedateoforiginalplacementandcannotbe restored.10. Crownandbridgefeesapplytotreatmentinvolvingfive(5)orfewerunitswhenpresentedinasingletreatmentplan.Additionalcrownor bridgeunits,beginningwiththesixthunit,areavailableattheprovider’sUsual,Customary,andReasonable(UCR)fee,minus25%.11. Reliningandrebasingofdenturesiscoveredonceper24months,perpatient,onlyaftersix(6)monthsofinitialplacement.12. Periodontalscalingandrootplaning(D4341orD4342),osseoussurgery(D4260orD4261)andgingivectomyorgingivoplasy(D4210or D4211)arelimitedtoone(1)perpatient,perquadrant. 13. Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation-fullmouth,afteroralevaluationandinlieuofacovered D1120/D1110,limitedtooncepertwoyears.14. Fullmouthdebridementiscoveredonceper36months,perpatient.15. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthreeteethperquadrant;oratotalof12teethforallfourquadrantsper twelve(12)months.Musthavepocketdepthsoffive(5)millimetersorgreater.16. Periodontalsurgeryofanytype,includinganyassociatedmaterial,iscoveredonceevery24months,perquadrantorsurgicalsite.17. Periodontalmaintenancefollowingsurgery(D4341isnotconsideredsurgery)iscoveredonceperthree(3)months.18. Alldentalservicesthataretoberenderedinahospitalsettingrequirecoordinationandapprovalfromboththedentalinsurerandthe medicalinsurerbeforeservicescanberendered.Servicesdeliveredtothepatientonthedateofservicearedocumentedseparatelyusing applicableprocedurecodes.19. Coronectomy,intentionalpartialtoothremoval,one(1)perlifetime. 20. Anesthesiarequiresanarrativeofmedicalnecessitybemaintainedinpatientrecords.Amaximumof60minutesofservicesareallowedfor generalanesthesiaandintravenousornon-intravenousconscioussedation.GeneralanesthesiaisnotcoveredwithprocedurecodesD9230 orD9243.IntravenousconscioussedationisnotcoveredwithprocedurecodesD9223orD9230.Nonintravenousconscioussedationisnot coveredwithprocedurecodesD9223orD9230.Analgesia(nitrousoxide)isnotcoveredwithprocedurecodesD9223orD9243.21. Occlusalguardwithcoveredsurgery,byreport.22. Gingivectomy,onceperquadrant.23. Onepedicle,freesofttissue,subepithelialconnectivetissueordoublepediclegraftpersite.24. OrthodonticsisonlycoveredifmedicallynecessaryasdeterminedbythePlan.Patientcopaymentswillapplytotheroutineorthodontic applianceportionofservicesonly.Additionalcostsincurredwillbecomethepatient’sresponsibility.


DMNMD19DBHINDPEDEHB All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.

D2331 Resin-based composite - two surfaces, anterior .............42D2332 Resin-based composite - three surfaces, anterior ..........50D2335 Resin-based composite - >=4 surfaces, anterior ............60D2390 Resin-based composite crown, anterior ..........................96D2391 Resin-based composite - one surface, posterior .............37D2392 Resin-based composite - two surfaces, posterior ...........44D2393 Resin-based composite - three surfaces, posterior .........51D2394 Resin-based composite - >=4 surfaces, posterior ...........62 D2940 Protective restoration .....................................................20D2950 Core buildup, including any pins .....................................63D2951 Pin retention - per tooth, in addition to restoration .......... 11D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) .............16 CROWNS & BRIDGESD2510 Inlay- metallic - one surface ..........................................204D2520 Inlay- metallic - two surfaces .........................................204D2530 Inlay - metallic - three or more surfaces ........................213D2542 Onlay - metallic-two surfaces ........................................229D2543 Onlay - metallic - three surfaces ...................................262 D2544 Onlay - metallic - four or more surfaces ........................262D2610 Inlay - porcelain/ceramic - one surface .........................214 D2620 Inlay - porcelain/ceramic - two surfaces ........................214D2630 Inlay - porcelain/ceramic - >=3 surfaces .......................223D2642 Onlay - porcelain/ceramic - two surfaces ......................240D2643/44 Onlay - porcelain/ceramic - >=3 surfaces .....................250D2650/51/52 Inlay-resin-basedcomposite->=1surface(s) .............220D2662/63/64 Onlay - resin-based composite - >=2 surfaces .............222D2710 Crown-resinbasedcomposite(indirect) ......................136D2712 Crown-3/4resin-basedcomposite(indirect) ...............243D2720/21/22 Crown - resin with metal ................................................248D2740 Crown - porcelain/ceramic ............................................280D2750/51/52 Crown - porcelain fused metal ......................................262D2780/81/82 Crown - 3/4 cast with metal ...........................................239D2783 Crown - 3/4 porcelain/ceramic ......................................256D2790/91/92 Crown - full cast metal ...................................................248D2794 Crown - titanium ............................................................248D2910/20 Recement inlay/crown .....................................................22D2930 Prefab. stainless steel crown - prim. tooth ......................55D2931 Prefab. stainless steel crown - perm. tooth .....................61D2932 Prefabricated resin crown ...............................................70D2933 Prefab. stainless steel crown w/ resin window ..............136D2934 Prefab. esthetic coated primary tooth ...........................148D2941 Interim therapeutic restoration, primary dentition ............16D2952 Cast post and core in addition to crown ..........................93D2954 Prefab. post and core in addition to crown ......................77D2955 Postremoval(notinconj.withendo.therapy) ................53D2960 Labialveneer(resinlaminate)-chairside .....................217D2961 Labialveneer(resinlaminate)-laboratory ....................301D2962 Labialveneer(porcelainlaminate)-laboratory .............225D2970 Temporarycrown(fracturedtooth) ....................................0D2980 Crown repair, by report ....................................................51 PROSTHETICS (DENTURES)D5110/20 Complete denture - maxillary/mandibular .....................349D5130/40 Immediate denture - maxillary/mandibular ....................361D5211/12 Maxillary/mandibular partial denture - resin base .........325

D9439 Officevisit ..........................................................................0

DIAGNOSTIC/PREVENTIVED0120 Periodic oral eval - established patient .............................0D0140 Limited oral eval - problem focused ..................................0D0145 Oral eval for a patient under 3 years of age ......................0D0150 Comprehensive oral eval - new or established patient .....0D0160 Detailed and extensive oral eval - problem focused .........0D0170 Re-evaluation - limited, problem focused ..........................0D0210 Intraoral-completeseries(includingbitewings) ...............0D0220/30 Intraoral-periapicalfirstradiographicimage/eachadd. ...0D0240 Intraoral - occlusal radiographic image .............................0D0250 Extraoral - 2D projection radiographic image ....................0D0270 Bitewing - 1 radiographic image ........................................0D0272 Bitewing - 2 radiographic images ......................................0D0273 Bitewing - 3 radiographic images ......................................0D0274 Bitewing - 4 radiographic images ......................................0D0277 Vertical bitewings - 7 to 8 radiographic images .................0D0290 Posterior/anterior or lateral skull bone radiographic image ...........................................................................0D0310 Sialography .......................................................................0D0320 Temporomandibular joint arthrogram, incl. injection ..........0D0321 Other temporomandibular joint radiographic images, by report .......................................................................0D0330 Panoramic radiographic image .........................................0D0340 2D cephalometric radiographic image ...............................0D0350 2Doral/facialphotographicimages(intraoral/extraoral) ...0D0351 3D photographic image .....................................................0D0460 Pulp vitality tests ...............................................................0D0470 Diagnostic casts ................................................................0D0486 Accession of Brush Biopsy Sample ..................................0D1110 Prophylaxis(cleaning)-adult ............................................0D1120 Prophylaxis(cleaning)-child ............................................0D1206 Topicalfluoridevarnishformod/highriskcariespatients ..0D1208 Topicalapplicationoffluoride ............................................0D1310 Nutritional counseling for control of dental disease ...........0D1320 Tobacco counseling for control of prev. oral disease ........0D1330 Oral hygiene instructions ...................................................0D1351 Sealant - per tooth .............................................................0D1352 Prev resin rest. mod/high caries risk – perm. tooth ...........0 SPACE MAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral ................0D1515/25 Spacemaintainer-fixed/removable-bilateral ..................0D1550 Re-cementation of space maintainer ................................0D1555 Removaloffixedspacemaintainer, by non-originating dentist ..................................................0 D1575 Distalshoespacemaintainer-fixed-unilateral .....................0 RESTORATIVE DENTISTRY (FILLINGS) AMALGAMRESTORATIONS(SILVER)D2140 Amalgam - one surface, prim. or perm. ...........................21D2150 Amalgam - two surfaces, prim. or perm. .........................26D2160 Amalgam - three surfaces, prim. or perm. .......................32D2161 Amalgam - >=4 surfaces, prim. or perm. .........................39

RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED)D2330 Resin-based composite - one surface, anterior ..............35



Annual Out-of-Pocket Maximum: $350 per child per calendar year for medically necessary treatment (maximum of $700 for policy covering two or more children)For any medically necessary treatments in which the member copayment listed below is over the annual out-of-pocket maximum, the member shall only be responsible up to the maximum and the Plan would be responsible for the remainder.

Select Plan Premium Kids 706s (MD)Description of Benefits & Member Copayments for Pediatric Services (under age 19)





D5213/14 Maxillary/mandibular partial denture - cast metal ..........375D5221/22 Immediate maxillary/mandibular partial denture - resin base ..............................................................325D5223/24 Immediate maxillary/mandibular partial denture - cast metal ...............................................................375 D5225/26 Maxillary/mandibularpartialdenture-flexiblebase ......375D5281 Rem. unilateral partial denture - one piece cast metal ..210D5410/11 Adjust complete denture - maxillary/mandibular .............19D5421/22 Adjust partial denture - maxillary/mandibular ..................19D5511/12 Repair broken complete denture base, maxillary/mandibular ..................................................44D5520 Replace missing or broken teeth - complete denture ......44D5611/12 Repair resin partial denture base, maxillary/mandibular .44 D5621/22 Repair cast partial framework, maxillary/mandibular ......44D5630/60 Clasp repaired, replaced or added ..................................58D5640 Replace broken teeth - per tooth .....................................44D5650 Add tooth to existing partial denture ................................44D5670/71 Replace all teeth and acrylic on cast metal framework (maxillary/mandibular) ..............................................144D5710/11 Rebase complete maxillary/mandibular denture ...........130D5720/21 Rebase maxillary/mandibular partial denture ................130D5730/31 Relinecompletemaxillary/mandibulardenture(chairside) ..80D5740/41 Relinemaxillary/mandibularpartialdenture(chairside) ..78D5750/51 Relinecompletemaxillary/mandibulardenture(lab) ..... 112D5760/61 Relinemaxillary/mandibularpartialdenture(lab) .......... 112D5810/11 Interim complete denture - maxillary/mandibular ..........181D5820/21 Interim partial denture - maxillary/mandibular ...............181D5850/51 Tissue conditioning - maxillary/mandibular .....................40D5863/65 Overdenture - complete maxillary/mandibular ..............847D5864/66 Overdenture - partial maxillary/mandibular ...................834D5992 Adjustment of prosthetic appliance, by report .................12D5993 Cleaning and maintenance prosthetic appliance ..............9 BRIDGES & PONTICSD6058 Abutment supported porcelain/ceramic crown ..............280D6059/60/61 Abutment supported porcelain fused to metal crown - metal ......................................................................262D6066 Implant supported porcelain fused to metal crown - titanium, titanium allow, high noble metal ..............262D6081 Scaling and debridement in the presence of inflammationormucositisofasingleimplant, including cleaning of the implant surfaces, without flapentryandclosure .................................................63D6210/11/12 Pontic - cast high noble metal .......................................248D6240/41/42 Pontic - porcelain fused to metal ...................................262D6245 Pontic - porcelain/ceramic .............................................280D6250/51/52 Pontic - resin with metal ................................................248D6545 Ret.-castmetalforresinbondedfixedprosthesis .......126D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis ..197D6549 Resinretainer-forresinbondedfixedprosthesis .........126D6600 Inlay - porc./ceramic, two surfaces ................................214D6601 Inlay - porc./ceramic, >=3 surfaces ...............................223D6602 Inlay - cast high noble metal, two surfaces ...................204D6603 Inlay - cast high noble metal, >=3 surfaces ...................213D6604 Inlay - cast predominantly base metal, two surfaces ....204D6605 Inlay - cast predominantly base metal, >=3 surfaces ....213D6606 Inlay - cast noble metal, two surfaces ...........................204D6607 Inlay - cast noble metal, >=3 surfaces ..........................213D6608 Onlay -porc./ceramic, two surfaces ...............................240D6609 Onlay - porc./ceramic, three or more surfaces ..............250D6610 Onlay - cast high noble metal, two surfaces .................229D6611 Onlay - cast high noble metal, >=3 surfaces .................262D6612 Onlay - cast predominantly base metal, two surfaces ...229D6613 Onlay - cast predominantly base metal, >=3 surfaces ..262D6614 Onlay - cast noble metal, two surfaces .........................229D6615 Onlay - cast noble metal, >=3 surfaces .........................262D6720/21/22 Crown - resin with metal ................................................248D6740 Crown - porcelain/ceramic ............................................280

D6750/51/52 Crown - porcelain fused to metal ..................................262D6780/81/82 Crown - 3/4 cast metal ..................................................235D6783 Crown - 3/4 porc./ceramic .............................................256D6790/91/92 Crown - full cast metal ...................................................248D6930 Recementfixedpartialdenture .......................................35D6980 Fixed partial denture repair, by report .............................86 ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain ..............22D9210/15 Local anesthesia ...............................................................0D9211/12 Regional block anesthesia ................................................0D9222 Deepsedation/generalanesthesia-first15min. ............52 D9223 Deep sedation/general anesthesia - each subsequent 15 min. increment ........................................52D9230 Analgesia, anxiolysis, inhalation of nitrous oxide ............19D9239 Intravenousmoderate(conscious)sedation/analgesia –first15min. ....................................................................52D9243 Intravenousmoderate(conscious)sedation/analgesia- each subsequent 15 min. increment ..............................52D9248 Non-intravenous conscious sedation ..............................73D9310 Consultation(diagnosticservicebynontreatingdentist) .22D9410 House/extended care facility call ...................................100D9420 Hospital call ...................................................................175D9910 Application of desensitizing medicament ........................16D9930 Treatmentofcomplications(post-surgical) .....................22D9940 Occlusal guard, by report ..............................................136D9941 Fabrication of athletic mouthguard ..................................51D9950 Occlusion analysis - mounted case .................................52D9951 Occlusal adjustment - limited ..........................................33D9952 Occlusal adjustment - complete ....................................133D9986 Missed appointment ........................................................50D9995 Teledentistry – synchronous; real-time encounter (whenavailable) ..........................................................20 D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review (whenavailable) ...............................................................20 ENDODONTICS1

D3220 Therapeuticpulpotomy(excl.finalrestor.) ......................41D3221 Pulpal debridement, prim. and perm. teeth .....................47D3230 Pulpaltherapy-resorbablefilling,anterior ......................80D3240 Pulpaltherapy-resorbablefilling,posterior ....................82D3310 Endodontic therapy, anterior tooth ................................171D3320 Endodontic therapy, premolar tooth (excluding finalrestoration) .......................................................209D3330 Endodontic therapy, molar tooth (excluding finalrestoration) .......................................................256D3332 Incomp. endo. therapy-inop. or fractured tooth ...............92D3333 Internal root repair of perforation defects ........................53D3346 Retreat of prev. root canal therapy, anterior ..................194D3347 Retreat of prev root canal therapy - premolar ...............233D3348 Retreat of prev. root canal therapy, molar .....................279D3351 Apexification/recalcification-initialvisit ........................101D3352 Apexification/recalcification-interimmed.repl. ............295D3353 Apexification/recalcification-finalvisit ..........................225D3355 Pulpal regeneration - initial visit ....................................101D3356 Pulpal regeneration - interim medication replacement ..295D3357 Pulpal regeneration - completion of treatment ..............225D3410 Apicoectomy, anterior ....................................................162D3421 Apicoectomy-premolar(firstroot) ..................................182D3425 Apicoectomy,molar(firstroot).......................................209D3426 Apicoectomy(eachadditionalroot) .................................76D3427 Periradicular surgery w/o apicoectomy .........................133D3430 Retrogradefilling-perroot .............................................60D3450 Rootamputation(resection)-perroot .......................... 117D3470 Intentional reimplantation ..............................................359D3920 Hemisection, not inc. root canal therapy ....................... 117D3950 Canalprep/fittingofpreformeddowelorpost .................68


1 Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist.

2 See exclusion #11 and limitation #24 for additional coverage information.

Only current ADA CDT codes are considered valid by Dominion NationalCurrent Dental Terminology © American Dental Association.

PERIODONTICS1

D0180 Comp. periodontal eval - new or established patient ........0D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad. ..................................................................140D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad. .....50D4230 Anatomical crown exposure, >=4 teeth per quad. .........227D4231 Anatomical crown exposure, 1-3 teeth per quad. ..........212D4240 Gingivalflapproc.,inc.rootplaning->3cont.teeth, per quad .............................................................................173D4241 Gingivalflapproc,inc.rootplaning-<=3cont.teeth, per quad ...............................................................................53D4249 Clinical crown lengthening - hard tissue ........................288D4260 Osseous surgery - >3 cont. teeth, per quad ..................250D4261 Osseous surgery - <=3 cont. teeth, per quad ................196D4268 Surgical revision proc., per tooth ...................................179D4274 Mesial/distal wedge procedure, single tooth .................154D4320 Provisional splinting - intracoronal ................................214D4321 Provisional splinting - extracoronal ...............................189D4341 Perio scaling and root planing - >3 cont teeth, per quad...55D4342 Perio scaling and root planing - <= 3 teeth, per quad .....32 D4346 Scaling in presence of generalized moderate or severe gingivalinflammation-fullmouth, after oral evaluation ....................................................45 D4355 Full mouth debridement ..................................................45D4381 Localized delivery of chemotherapeutic agents ..............49D4910 Periodontal maintenance ................................................37D4920 Unscheduled dressing change by non-treating dentist ...42 ORAL SURGERY1

D7111 Extraction, coronal remnants - primary tooth ..................28D7140 Extraction, erupted tooth or exposed root .......................35D7210 Extraction, erupted tooth req. bone cut ...........................67D7220 Removal of impacted tooth - soft tissue ..........................76D7230 Removal of impacted tooth - partially bony .....................98D7240 Removal of impacted tooth - completely bony ..............121D7241 Removal of imp. tooth - completely bony, with unusual surg. complications .............................109D7250 Removal of residual tooth roots ......................................71D7251 Coronectomy-intentional partial tooth removal ..............109D7260 Oroantralfistulaclosure ................................................289D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth ..113D7272 Tooth transplantation .....................................................308D7280 Exposure of an unerupted tooth ......................................77D7285 Biopsyoforaltissue-hard(bone,tooth) ......................194D7286 Biopsyoforaltissue-soft(allothers) ...........................148D7290 Surgical repositioning of teeth .......................................204D7291 Transseptalfiberotomy/supracrestalfiberotomy, by report .....................................................................30D7310/20 Alveoloplasty, >=4 per quad. ............................................71D7311/21 Alveoloplasty in conj. with/out extractions, 1-3 per quad. .71D7340 Vestibuloplasty - ridge ext. sec. epithel. ........................462D7350 Vestibuloplasty - ridge ext. inc. grafts, etc .....................888D7410 Excision of benign lesion up to 1.25 cm ........................139D7440 Exc. of malignant tumor- lesion diam. <=1.25cm ..........304D7450 Removal of benign odon cyst/tumor - diam <=1.25cm ..177D7451 Removal of benign odon cyst/tumor - diam >1.25cm ....272D7460 Removal of benign nonodon cyst/tumor-diam <=1.25cm ..258D7461 Removal of benign nonodon cyst/tumor-diam >1.25cm .359D7471 Removal of lateral exostosis .........................................176D7472/73 Removal of torus palatinus/mandibulD7510 Incision and drainage of abscess - intraoral soft tissue ..48D7520 Incision/drainage of abscess - extra. soft tissue .............58D7550 Partial ostect/sequestrect non-vital bone rem. .............168D7960 Frenulectomy(frenectomy/frenotomy)-separateproc. 132D7970 Excision of hyperplastic tissue - per arch ...................... 117D7971 Excision of pericoronal gingiva ........................................66D7979 Non-surgical sialolithotomy .............................................22



ORTHODONTICS2 - PRE-AUTHORIZATION REQUIREDD8070 Comp. ortho. treatment - transitional dentition ............3304D8080 Comp. ortho. treatment - adolescent dentition ............3422D8090 Comp. ortho. treatment - adult dentition ......................3658D8660 Pre-orthodontic treatment visit ......................................413D8670 Periodicortho.treatmentvisit(aspartofcontract) ....... 118D8680 Orthodonticret.(rem.ofappl./placementofretainer(s)) 413D8692 Replacement of lost or broken retainer .........................179D8693 Rebondingorrecementingfixeddentures ....................174D8694 Repairoffixedretainers,includesreattachment ...........174

Plan Exclusions1. Services which are covered under worker’s compensation or employer’s liability laws.2. Services which are not necessary for the patient’s dental health as determined by the Plan.3. Surgery or related services for cosmetic purposes to improve appearance, but not to restore bodily function or correct deformity resulting from disease, trauma, or congenital or developmental anomalies.4. Oral surgery requiring the setting of fractures or dislocations.5. Dispensing of drugs.6. Hospitalizationforthefollowing:theoperationortreatmentforthefittingorwearingofdentures;orthodonticcareormalocclusion, operations on or for treatment of or to the teeth or supporting tissues of the teeth, except for the removal of tumors and cysts or treatment of injury to natural teeth due to an accident if the treatment is received within 6 months of the accident; and dental implants. 7. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation.8. ProceduresnotlistedascoveredbenefitsunderthisPlan.9. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpreauthorizedbysuchofficeorthePlan,(withthe exceptionofout-of-areaemergencydentalservices).10. Any bill, or demand for payment, for a dental service that the appropriate regulatory board determines was provided as a result of a prohibited referral. “Prohibited referral” means a referral prohibited by Section 1-302 of the Maryland Health Occupations Article.11. Non-medicallynecessaryorthodontiaisnotacoveredbenefitunderthispolicy.Orthodontiaservicesareonlyprovidedforsevere, dysfunctional, handicapping malocclusion. The provider agreements create no liability for payment by the Plan, and payments by the member for these services do not contribute to the Out-of-Pocket Maximum. The Invisalign system and similar specialized braces are not acoveredbenefit.Seelimitation#24concerningmedicallynecessaryorthodontia.

Plan Limitations1. One(1)evaluation(D0120,D0145,D0150,D0160)iscoveredtwo(2)timespercalendaryear,perpatient,perprovider/location.2. One(1)teethcleaning(D1110orD1120)iscoveredtwo(2)timespercalendaryear,perpatient.3. One(1)topicalfluorideapplication(D1206orD1208)iscoveredtwo(2)timespercalendaryear,perpatient;four(4)fluoridevarnish treatmentsarecoveredpercalendaryear,perpatientforchildrenagethree(3)andabove;eight(8)topicalfluoridevarnishesarecovered percalendaryear,perpatientuptoagetwo(2).4. Two(2)bitewingx-raysarecoveredperplanyear,perpatient,perprovider/location(D0270doesnothaveafrequencylimitation).5. One(1)setoffullmouthx-raysorpanoramicfilmiscoveredeverythree(3)years.Panoramicx-raysarelimitedtoagessix(6)andabove. Nomorethanone(1)setofx-raysarecoveredperprovider/location.6. One(1)sealantpertoothiscoveredperlifetime,perpatient(limitedtoocclusalsurfacesofposteriorpermanentteethwithoutrestorations ordecay).7. One(1)spacemaintainerper24months,perquadrant(D1510orD1520)orperarch(D1515orD1525),perpatienttopreservespace betweenteethforprematurelossofaprimarytooth(doesnotincludeusefororthodontictreatment);D1575limitedtoonceper24months. 8. Replacementofafillingiscoveredifitismorethanthree(3)yearsfromthedateoforiginalplacement.9. Replacementofacrownordentureiscoveredifitismorethanfive(5)yearsfromthedateoforiginalplacement.10. Replacementofaprefabricatedresinandstainlesssteelcrown(D2930,D2932,D2933,D2934)iscoveredifitismorethanthree(3)years from the date of original placement, per tooth, per patient.11. Crownandbridgefeesapplytotreatmentinvolvingfive(5)orfewerunitswhenpresentedinasingletreatmentplan.12. Reliningandrebasingofdenturesiscoveredonceper24months,perpatient,onlyaftersix(6)monthsofinitialplacement.13. Root canal treatment and retreatment of previous root canal are covered once per lifetime, per tooth.14. Periodontalscalingandrootplaning(D4341orD4342),osseoussurgery(D4260orD4261)andgingivectomyorgingivoplasy(D4210or D4211)arelimitedtoone(1)per24months,perpatient,perquadrant.15. Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation-fullmouth,afteroralevaluationandinlieuoracovered D1110/D1120, limited to once per two years.16. Full mouth debridement is covered once per 24 months, per patient.17. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthreeteethperquadrant;oratotalof12teethforallfour(4)quadrantsper 12months.Musthavepocketdepthsoffive(5)millimetersorgreater.18. Periodontal surgery of any type, including any associated material, is covered once every 24 months, per quadrant or surgical site.19. Periodontalmaintenanceafteractivetherapyiscoveredtwo(2)timespercalendaryear.20. One(1)scalinganddebridementinthepresenceofinflammationormucositisofasingleimplant,includingcleaningoftheimplant surfaces,withoutflapentryandclosure,pertwo(2)years. 21. Coronectomy,intentionalpartialtoothremoval,one(1)perlifetime.22. All dental services that are to be rendered in a hospital setting require coordination and approval from both the dental insurer and the medical insurer before services can be rendered. Services delivered to the patient on the date of service are documented separately using applicable procedure codes.23. Anesthesia requires a narrative of medical necessity be maintained in patient records. A maximum of 60 minutes of services are allowed for general anesthesia and intravenous or non-intravenous conscious sedation. General anesthesia is not covered with procedure codes D9230, D9239 or D9243. Intravenous conscious sedation is not covered with procedure codes D9222, D9223 or D9230. Nonintravenous conscioussedationisnotcoveredwithprocedurecodesD9222,D9223orD9230.Analgesia(nitrousoxide)isnotcoveredwithprocedure codes D9222, D9223, D9239 or D9243.24. Orthodontics is only covered if medically necessary as determined by the Plan. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility. 25.Teledentistry,synchronous(D9995)orasynchronous(D9996),limitedtotwopercalendaryear(whenavailable).


D9439 Officevisit ........................................................................................................... 0 .............................................................0 DIAGNOSTIC/PREVENTIVED0120 Periodicoraleval-establishedpatient ............................................................... 0 .............................................................0D0140 Limitedoraleval-problemfocused .................................................................... 0 .............................................................0D0145 Oralevalforapatientunder3yearsofage ........................................................ 0 .............................................................0D0150 Comprehensiveoraleval-neworestablishedpatient ....................................... 0 .............................................................0D0160 Detailedandextensiveoraleval-problemfocused ........................................... 0 .............................................................0D0170 Re-evaluation-limited,problemfocused ............................................................ 0 .............................................................0D0171 Re-evaluation-post-operativeofficevisit .......................................................... 41 ...........................................................41D0180 Comp.periodontaleval-neworestablishedpatient .......................................... 0 .............................................................0D0210 Intraoral-completeseries(includingbitewings) ................................................. 0 .............................................................0D0220 Intraoral-periapicalfirstradiographicimage ...................................................... 0 .............................................................0D0230 Intraoral-periapicaleachadd.radiographicimage ............................................ 0 .............................................................0D0240 Intraoral-occlusalradiographicimage ............................................................... 0 .............................................................0D0250 Extra-oral-2Dprojectionradiographicimage ................................................... 0 .............................................................0D0251 Extra-oralposteriordentalradiographicimage .................................................. 44 ...........................................................44D0270 Bitewing-singleradiographicimage .................................................................. 0 .............................................................0D0272 Bitewings-tworadiographicimages .................................................................. 0 .............................................................0D0273 Bitewings-threeradiographicimages ................................................................ 0 .............................................................0D0274 Bitewings-fourradiographicimages .................................................................. 0 .............................................................0D0277 Verticalbitewings-7to8radiographicimages ................................................... 0 .............................................................0D0310 Sialography ......................................................................................................... 0 .............................................................0D0320 Temporomandibularjointarthrogram,incl.injection ........................................... 0 .............................................................0D0321 Othertemporomandibularjointradiographicimages,byreport .......................... 0 .............................................................0D0322 Tomographicsurvey ............................................................................................ 0 .............................................................0D0330 Panoramicradiographicimage ........................................................................... 0 .............................................................0D0340 2Dcephalometricradiographicimage ................................................................ 0 .............................................................0D0350 2Doral/facialphotographicimages(intraoral/extraoral) ..................................... 0 .............................................................0D0351 3Dphotographicimage ....................................................................................... 0 .............................................................0D0364 ConeBeamCTlimitedview-lessthanonejaw ................................................... 0 .............................................................0D0365 ConeBeamCTonefulldentalarch(mandibular/maxillary) ............................... 0 .............................................................0D0366 ConeBeamCTonefulldentalarch(mandibular/maxillary) ............................... 0 .............................................................0D0367 ConeBeamCTbothjaws ................................................................................... 0 .............................................................0D0368 ConeBeamCT-TMJ .......................................................................................... 0 .............................................................0D0369 MaxillofacialMRI/ultrasound ............................................................................... 0 .............................................................0D0370 MaxillofacialMRI/ultrasound ............................................................................... 0 .............................................................0D0380 ConebeamCTimagecapture-lessthanonejaw ............................................... 0 .............................................................0D0381 ConebeanCTimagecaptureonearch(mandibular/maxillary) ......................... 0 .............................................................0D0382 ConebeanCTimagecaptureonearch(mandibular/maxillary) ......................... 0 .............................................................0D0383 ConebeamCTimagecapturebothjaws ............................................................ 0 .............................................................0D0384 ConebeamCTimagecapture-TMJ ................................................................... 0 .............................................................0D0385 MaxillofacialMRI/ultrasoundimagecapture ....................................................... 0 .............................................................0D0386 MaxillofacialMRI/ultrasoundimagecapture ....................................................... 0 .............................................................0D0391 Interpretationofdiagnosticimageonly ............................................................... 0 .............................................................0D0414 Labprocessingofmicrobialspecimentoincludeculture&sensitivitystudies .. 50 ...........................................................50D0415 Collectionofmicroorganismsforcultureandsensitivity .................................... 29 ...........................................................29D0416 Viralculture ......................................................................................................... 0 .............................................................0D0417 Collection/Prepofsalivasampleforlab .............................................................. 0 .............................................................0D0418 Analysisofsalivasample ................................................................................... 32 ...........................................................32D0422 Collectionandpreparationofgeneticsamplematerialforlabanalysisandreport ... 50 ...........................................................50D0423 Genetictestforsusceptibilitytodiseases ......................................................... 75 ...........................................................75D0425 Cariessusceptibilitytests ................................................................................... 27 ...........................................................27D0431 Adjunctivepre-diagonostic ................................................................................. 49 ...........................................................49D0460 Pulpvitalitytests ................................................................................................. 0 .............................................................0D0470 Diagnosticcasts .................................................................................................. 0 .............................................................0D0472 Accessionoftissue,grossexam,prep,transm .................................................. 0 .............................................................0

DMNNJ19DBHINDPEDEHB

AnnualOut-of-PocketMaximum:$350perchildpercalendaryearformedicallynecessarytreatment(maximumof$700forpolicycoveringtwoormorechildren).ThemembershallonlyberesponsibleforthecopaymentlistedinMemberCopaymentcolumn.AnyprocedurelistedthathasaMemberCopaymentabovetheannualout-of-pocketmaximummayapplyastheseproceduresarenotconsideredmedicallynecessaryandareincludedasadditionalbenefits.ThePlanisresponsibleforthedifferencebetweentheActualCopaymentandtheMemberCopaymentforallmedicallynecessarytreatment.

ADA COVERED MEMBER ACTUAL CODE SERVICES COPAYMENT(S) COPAYMENT(S)

Select Plan Premium Pediatric 706s (NJ)Description of Covered Services, Member Copayments, Exclusions and Limitations

for Pediatric Services (under age 19)

Dominion National Insurance Company


D0473 Accessionoftissue,grossandmicro.exam.,prep,transm ................................ 0 .............................................................0D0474 Accessionoftissue,grossandmicro.exam.,prep,transm ................................ 0 .............................................................0D0480 Accessionofexfoliativecytologicsmears,micro.exam.,prep,transm .............. 0 .............................................................0D0486 Labaccessiontranscytologicsample,micro.exam.,prep,transm .................... 0 .............................................................0D0502 Otheroralpathologyprocedures,byreport ........................................................ 0 .............................................................0D0600 Non-ionizingdiagnosticprocedurecapableofquantifying,monitoring abnormalitiesinclpremalignantandmalignantlesions ................................... 0 .............................................................0D0601 Cariesriskassessment&documentation,withafindingoflowrisk ................... 0 .............................................................0D0602 Cariesriskassessment&documentation,withafindingofmoderaterisk ......... 0 .............................................................0D0603 Cariesriskassessment&documentation,withafindingofhighrisk ................. 0 .............................................................0D1110 Prophylaxis(cleaning)-adult .............................................................................. 0 .............................................................0D1120 Prophylaxis(cleaning)-child .............................................................................. 0 .............................................................0D1206 Topicalfluoridevarnishformod/highriskcariespatients .................................... 0 .............................................................0D1208 Topicalapplicationoffluoride .............................................................................. 0 .............................................................0D1310 Nutritionalcounselingforcontrolofdentaldisease ............................................ 0 .............................................................0D1320 Tobaccocounselingforcontrolofprev.oraldisease .......................................... 0 .............................................................0D1330 Oralhygieneinstructions .................................................................................... 0 .............................................................0D1351 Sealant-pertooth .............................................................................................. 0 .............................................................0D1352 Prevresinrest.mod/highcariesrisk–perm.tooth ............................................. 0 .............................................................0 SPACEMAINTAINERS D1510 Spacemaintainer-fixed-unilateral ................................................................... 0 .............................................................0D1515 Spacemaintainer-fixed-bilateral ..................................................................... 0 .............................................................0D1520 Spacemaintainer-removable-unilateral .......................................................... 0 .............................................................0D1525 Spacemaintainer-removable-bilateral ............................................................ 0 .............................................................0D1550 Re-cementationofspacemaintainer .................................................................. 0 .............................................................0D1555 Removaloffixedspacemaintainer,bynon-originatingdentist .......................... 0 .............................................................0D1575 Distalshoespacemaintainer-fixed-unilateral ................................................. 0 .............................................................0 RESTORATIVE DENTISTRY (FILLINGS) D2140 Amalgam-onesurface,prim.orperm. ............................................................. 21 ...........................................................21D2150 Amalgam-twosurfaces,prim.orperm. ............................................................ 26 ...........................................................26D2160 Amalgam-threesurfaces,prim.orperm. ......................................................... 32 ...........................................................32D2161 Amalgam->=4surfaces,prim.orperm. ........................................................... 39 ...........................................................39D2330 Resin-basedcomposite-onesurface,anterior ................................................. 35 ...........................................................35D2331 Resin-basedcomposite-twosurfaces,anterior ................................................ 42 ...........................................................42D2332 Resin-basedcomposite-threesurfaces,anterior ............................................. 50 ...........................................................50D2335 Resin-basedcomposite->=4surfaces,anterior ............................................... 60 ...........................................................60D2390 Resin-basedcompositecrown,anterior ............................................................. 96 ...........................................................96D2391 Resin-basedcomposite-onesurface,posterior ............................................... 37 ...........................................................37D2392 Resin-basedcomposite-twosurfaces,posterior .............................................. 44 ...........................................................44D2393 Resin-basedcomposite-threesurfaces,posterior ........................................... 51 ...........................................................51D2394 Resin-basedcomposite->=4surfaces,posterior ............................................. 62 ...........................................................62D2410 Goldfoil-onesurface ........................................................................................ 84 ...........................................................84D2420 Goldfoil-twosurfaces ...................................................................................... 99 ...........................................................99D2430 Goldfoil-threesurfaces ................................................................................... 134 .........................................................134 CROWNS & BRIDGES D2510 Inlay-metallic-onesurface .............................................................................. 204 .........................................................204D2520 Inlay-metallic-twosurfaces ............................................................................. 204 .........................................................204D2530 Inlay-metallic-threeormoresurfaces ............................................................ 213 .........................................................213D2542 Onlay-metallic-twosurfaces ............................................................................ 229 .........................................................229D2543 Onlay-metallic-threesurfaces ....................................................................... 262 .........................................................262D2544 Onlay-metallic-fourormoresurfaces ............................................................ 262 .........................................................262D2610 Inlay-porcelain/ceramic-onesurface ............................................................. 214 .........................................................214D2620 Inlay-porcelain/ceramic-twosurfaces ............................................................ 214 .........................................................214D2630 Inlay-porcelain/ceramic->=3surfaces ........................................................... 223 .........................................................223D2642 Onlay-porcelain/ceramic-twosurfaces .......................................................... 240 .........................................................240D2643 Onlay-porcelain/ceramic-threesurfaces ....................................................... 250 .........................................................250D2644 Onlay-porcelain/ceramic->=4surfaces ......................................................... 250 .........................................................250D2650 Inlay-resin-basedcomposite-onesurface ..................................................... 220 .........................................................220D2651 Inlay-resin-basedcomposite-twosurfaces .................................................... 220 .........................................................220D2652 Inlay-resin-basedcomposite->=3surfaces ................................................... 220 .........................................................220D2662 Onlay-resin-basedcomposite-twosurfaces .................................................. 222 .........................................................222D2663 Onlay-resin-basedcomposite-threesurfaces ............................................... 222 .........................................................222D2664 Onlay-resin-basedcomposite->=4surfaces ................................................. 222 .........................................................222D2710 Crown-resinbasedcomposite(indirect) ......................................................... 136 .........................................................136D2712 Crown-3/4resin-basedcomposite(indirect) ................................................... 243 .........................................................243D2720 Crown-resinwithhighnoblemetal .................................................................. 248 .........................................................248D2721 Crown-resinwithpredominantlybasemetal ................................................... 248 .........................................................248


D2722 Crown-resinwithnoblemetal .......................................................................... 248 .........................................................248D2740 Crown-porcelain/ceramic ................................................................................ 280 .........................................................280D2750 Crown-porcelainfusedtohighnoblemetal ..................................................... 262 .........................................................262D2751 Crown-porcelainfusedtopredominantlybasemetal ...................................... 262 .........................................................262D2752 Crown-porcelainfusedtonoblemetal ............................................................ 262 .........................................................262D2780 Crown-3/4casthighnoblemetal .................................................................... 239 .........................................................239D2781 Crown-3/4castpredominantlybasemetal ...................................................... 239 .........................................................239D2782 Crown-3/4castnoblemetal ............................................................................ 239 .........................................................239D2783 Crown-3/4porcelain/ceramic .......................................................................... 256 .........................................................256D2790 Crown-fullcasthighnoblemetal ..................................................................... 248 .........................................................248D2791 Crown-fullcastpredominatelybasemetal ...................................................... 248 .........................................................248D2792 Crown-fullcastnoblemetal ............................................................................. 248 .........................................................248D2910 Recementinlay .................................................................................................. 22 ...........................................................22D2915 Recementcastorprefab.postandcore ............................................................ 41 ...........................................................41D2920 Recementcrown ................................................................................................ 22 ...........................................................22D2929 Porcelain/ceramiccrown-prim.tooth ............................................................... 280 .........................................................280D2930 Prefab.stainlesssteelcrown-prim.tooth ......................................................... 55 ...........................................................55D2931 Prefab.stainlesssteelcrown-perm.tooth ........................................................ 61 ...........................................................61D2932 Prefabricatedresincrown .................................................................................. 70 ...........................................................70D2933 Prefab.stainlesssteelcrownw/resinwindow .................................................. 136 .........................................................136D2934 Prefab.estheticcoatedprimarytooth ............................................................... 148 .........................................................148D2940 Protectiverestoration ........................................................................................ 20 ...........................................................20D2950 Corebuildup,includinganypins ........................................................................ 63 ...........................................................63D2951 Pinretention-pertooth,inadditiontorestoration ..............................................11 ...........................................................11D2952 Castpostandcoreinadditiontocrown ............................................................. 93 ...........................................................93D2953 Eachadd.indirectlyfabricatedpost-sametooth .............................................. 25 ...........................................................25D2954 Prefab.postandcoreinadditiontocrown ......................................................... 77 ...........................................................77D2955 Postremoval(notinconj.withendo.therapy) ................................................... 53 ...........................................................53D2957 Eachadd.prefabpost-sametooth ................................................................... 20 ...........................................................20D2970 Temporarycrown(fracturedtooth) ...................................................................... 0 .............................................................0D2971 Newcrownunderpartialdentureframework ..................................................... 37 ...........................................................37D2975 Coping ................................................................................................................113 .........................................................113D2980 Crownrepair,byreport ...................................................................................... 51 ...........................................................51 PROSTHETICS (DENTURES) D5110 Completedenture-maxillary ............................................................................ 349 .........................................................349D5120 Completedenture-mandibular ........................................................................ 349 .........................................................349D5130 Immediatedenture-maxillary ........................................................................... 350 .........................................................361D5140 Immediatedenture-mandibular ....................................................................... 350 .........................................................361D5211 Maxillarypartialdenture-resinbase ................................................................ 325 .........................................................325D5212 Mandibularpartialdenture-resinbase ............................................................ 325 .........................................................325D5213 Maxillarypartialdenture-castmetal ................................................................ 350 .........................................................375D5214 Mandibularpartialdenture-castmetal ............................................................. 350 .........................................................375D5221 Immediatemaxillarypartialdenture-resinbase .............................................. 325 .........................................................325D5222 Immediatemandibularpartialdenture-resinbase ........................................... 325 .........................................................325D5223 Immediatemaxillarypartialdenture-castmetal .............................................. 350 .........................................................375D5224 Immediatemandibularpartialdenture-castmetal ........................................... 350 .........................................................375D5225 Maxillarypartialdenture-flexiblebase ............................................................. 350 .........................................................375D5226 Mandibularpartialdenture-flexiblebase ......................................................... 350 .........................................................375D5281 Rem.unilateralpartialdenture-onepiececastmetal ...................................... 210 .........................................................210D5410 Adjustcompletedenture-maxillary ................................................................... 19 ...........................................................19D5411 Adjustcompletedenture-mandibular ............................................................... 19 ...........................................................19D5421 Adjustpartialdenture-maxillary ........................................................................ 19 ...........................................................19D5422 Adjustpartialdenture-mandibular .................................................................... 19 ...........................................................19D5511 Repairbrokencompletedenturebase-mandibular .......................................... 44 ...........................................................44 D5512 Repairbrokencompletedenturebase-maxillary ............................................. 44 ...........................................................44D5520 Replacemissingorbrokenteeth-completedenture ........................................ 44 ...........................................................44D5611 Repairresinpartialdenturebase-mandibular .................................................. 44 ...........................................................44 D5612 Repairresinpartialdenturebase-maxillary ..................................................... 44 ...........................................................44 D5621 Repaircastpartialframework-mandibular ....................................................... 44 ...........................................................44D5622 Repaircastpartialframework-maxillary ........................................................... 44 ...........................................................44D5630 Repairorreplacebrokenclasp .......................................................................... 58 ...........................................................58D5640 Replacebrokenteeth-pertooth ....................................................................... 44 ...........................................................44D5650 Addtoothtoexistingpartialdenture .................................................................. 44 ...........................................................44D5660 Addclasptoexistingpartialdenture .................................................................. 58 ...........................................................58D5670 Replaceallteethandacryliconcastmetalframework(maxillary) ................... 144 .........................................................144D5671 Replaceallteethandacryliconcastmetalframework(mandibular) ................ 144 .........................................................144D5710 Rebasecompletemaxillarydenture .................................................................. 130 .........................................................130D5711 Rebasecompletemandibulardenture .............................................................. 130 .........................................................130D5720 Rebasemaxillarypartialdenture ...................................................................... 130 .........................................................130D5721 Rebasemandibularpartialdenture ................................................................... 130 .........................................................130


D5730 Relinecompletemaxillarydenture(chairside) ................................................... 80 ...........................................................80D5731 Relinecompletemandibulardenture(chairside) ............................................... 80 ...........................................................80D5740 Relinemaxillarypartialdenture(chairside) ........................................................ 78 ...........................................................78D5741 Relinemandibularpartialdenture(chairside) .................................................... 78 ...........................................................78D5750 Relinecompletemaxillarydenture(lab) .............................................................112 .........................................................112D5751 Relinecompletemandibulardenture(lab) .........................................................112 .........................................................112D5760 Relinemaxillarypartialdenture(lab) .................................................................112 .........................................................112D5761 Relinemandibularpartialdenture(lab) ..............................................................112 .........................................................112D5810 Interimcompletedenture-maxillary ................................................................. 181 .........................................................181D5811 Interimcompletedenture-mandibular ............................................................. 181 .........................................................181D5820 Interimpartialdenture-maxillary ...................................................................... 181 .........................................................181D5821 Interimpartialdenture-mandibular .................................................................. 181 .........................................................181D5850 Tissueconditioning-maxillary ........................................................................... 40 ...........................................................40D5851 Tissueconditioning-mandibular ....................................................................... 40 ...........................................................40D5862 Precisionattachment,byreport ........................................................................ 194 .........................................................194D5863 Overdenture-completemaxillary ..................................................................... 350 .........................................................847D5864 Overdenture-partialmaxillary .......................................................................... 350 .........................................................834D5865 Overdenture-completemandibular ................................................................. 350 .........................................................847D5866 Overdenture-partialmandibular ...................................................................... 350 .........................................................834D5875 Mod.ofremovprosthesispostimplantsurgery ................................................. 41 ...........................................................41D5911 Facialmoulage(sectional) ................................................................................. 74 ...........................................................74D5912 Facialmoulage(complete) ................................................................................. 74 ...........................................................74D5913 Nasalprosthesis ............................................................................................... 350 .........................................................774D5914 Auricularprosthesis .......................................................................................... 350 .........................................................836D5915 Orbitalprosthesis .............................................................................................. 350 ........................................................1102D5916 Ocularprosthesis .............................................................................................. 350 .........................................................969D5919 Facialprosthesis ............................................................................................... 194 .........................................................194D5922 Nasalseptalprosthesis ..................................................................................... 194 .........................................................194D5923 Ocularprosthesis,interim ................................................................................. 350 .........................................................886D5924 Cranialprosthesis ............................................................................................. 350 ........................................................2204D5925 Facialaugmentationimplantprosthesis ............................................................ 350 .........................................................500D5926 Nasalprosthesis,replacement .......................................................................... 169 .........................................................169D5927 Auricularprosthesis,replacement ..................................................................... 350 ........................................................1948D5928 Orbitalprosthesis,replacement ........................................................................ 350 ........................................................2632D5929 Facialprosthesis,replacement ......................................................................... 255 .........................................................255D5931 Obturatorprosthesis,surgical ........................................................................... 350 .........................................................402D5932 Obturatorprosthesis,definitive ......................................................................... 350 ........................................................2400D5933 Obturatorprosthesis,modification .................................................................... 350 .........................................................355D5934 Mandibularresectionprosthesisw/guideflange .............................................. 350 ........................................................2021D5935 Mandibularresectionprosthesisw/oguideflange ............................................ 350 ........................................................1885D5936 Obturatorprosthesis,interim ............................................................................. 350 ........................................................1025D5951 Feedingaid ....................................................................................................... 350 .........................................................698D5952 Speechaidprosthesis ....................................................................................... 350 .........................................................577D5953 Speechaidprosthesis,adult ............................................................................. 350 .........................................................928D5954 Palatalaugmentationprosthesis ....................................................................... 350 .........................................................867D5955 Palatalliftprosthesis,definitive ......................................................................... 350 .........................................................834D5958 Palatalliftprosthesis,interim ............................................................................ 350 .........................................................834D5959 Palatalliftprosthesis,modification .................................................................... 350 .........................................................834D5960 Speechaidprosthesis,modification ................................................................. 278 .........................................................278D5982 Surgicalstent ..................................................................................................... 44 ...........................................................44D5983 Radiationcarrier ................................................................................................ 350 .........................................................368D5984 Radiationshield ................................................................................................ 350 .........................................................400D5985 Radiationconelocator ...................................................................................... 350 .........................................................400D5986 Fluoridegelcarrier ............................................................................................. 63 ...........................................................63D5987 Commissuresplint ............................................................................................ 350 .........................................................450D5988 Surgicalsplint ..................................................................................................... 63 ...........................................................63D5991 Topicalmedicamentcarrier ................................................................................ 63 ...........................................................63D5992 Adjustmentofprostheticappliance,byreport .................................................... 12 ...........................................................12D5993 Cleaningandmaintenanceprostheticappliance ................................................ 9 .............................................................9D5994 Periodontalmedicamentcarrier ........................................................................ 150 .........................................................150 BRIDGES & PONTICS D6010 Surgicalplacementofimplantbody,endosteal ................................................. 350 .........................................................858D6011 Secondstageimplantsurgery .......................................................................... 100 .........................................................100D6012 Surgicalplacementofinterimimplantbody ...................................................... 350 .........................................................891D6013 Surgicalplacementofminiimplant ................................................................... 286 .........................................................286D6040 Surgicalplacement,epostealimplant ............................................................... 350 ........................................................1782D6050 Surgicalplacement,transostealimplant ........................................................... 350 ........................................................2228D6051 Interimabutment ............................................................................................... 197 .........................................................197D6055 Dentalimplantsupportedconnectingbar ......................................................... 350 .........................................................806



D6056 Prefabricatedabutment ..................................................................................... 228 .........................................................228D6057 Customfabricatedabutment ............................................................................. 350 .........................................................563D6058 Abutmentsupportedporcelain/ceramiccrown .................................................. 280 .........................................................280D6059 Abutmentsupportedporcelainfusedtometalcrown-highnoblemetal .......... 262 .........................................................262D6060 Abutmentsupportedporcelainfusedtometalcrown-predominantlybasedmetal 262 .........................................................262D6061 Abutmentsupportedporcelainfusedtometalcrown-noblemetal .................. 262 .........................................................262D6062 Abutmentsupportedcastmetalcrown-highnoblemetal ................................ 248 .........................................................248D6063 Abutmentsupportedcastmetalcrown-predominantlybasedmetal ............... 248 .........................................................248D6064 Abutmentsupportedcastmetalcrown-noblemetal ........................................ 248 .........................................................248D6065 Implantsupportedporcelain/ceramiccrown ..................................................... 280 .........................................................280D6066 Implantsupportedporcelainfusedtometalcrown-titanium,titanium allow,highnoblemetal .................................................................................. 262 .........................................................262D6067 Implantsupportedmetalcrown-titanium,titaniumalloy,highnoblemetal ...... 262 .........................................................262D6068 Abutmentsupportedretainerforporc/ceramic .................................................. 350 .........................................................394D6069 Abutmentsupp.retainerforporc/highnoble ..................................................... 350 .........................................................422D6070 Abutmentsupp.retainerforporc/pred.base .................................................... 348 .........................................................348D6071 Abutmentsupp.retainerforporc/noble ............................................................. 350 .........................................................352D6072 Abutmentsuppretainerforcasthighnoble ...................................................... 350 .........................................................394D6073 Abutmentsupp.retainerforcasthighnoble ..................................................... 350 .........................................................375D6074 Abutmentsupp.retainerforcastnoblemetal ................................................... 350 .........................................................379D6080 Implantmaintenanceprocedures ....................................................................... 31 ...........................................................31D6081 Scalinganddebridementinthepresenceofinflammationormucositisofa singleimplant,includingcleaningoftheimplantsurfaces,withoutflap entryandclosure ............................................................................................. 32 ...........................................................32D6090 Repairimplantsupportedprosthesis ................................................................ 181 .........................................................181D6091 ReplacementofPrecisionAttachment ............................................................... 17 ...........................................................17D6092 Re-cementimplant/abutmentsupp.crown ........................................................ 56 ...........................................................56D6093 Re-cementimpl/abutmentsupp.fixedpar ......................................................... 86 ...........................................................86D6095 Repairimplantabutment,byreport ................................................................... 196 .........................................................196D6110 Implant/abutsuppremdentforedentulousarch-maxillary ........................... 350 ........................................................1517D6111 Implant/abutsuppremdentforedentulousarch-mandibular ....................... 350 ........................................................1517D6112 Implant/abutsuppremdentforpartiallyedentulousarch-maxillary .............. 350 ........................................................1517D6113 Implant/abutsuppremdentforpartiallyedentulousarch-mandibular .......... 350 ........................................................1517D6114 Implant/abutsuppfixeddentforedentulousarch-maxillary .......................... 350 ........................................................2606D6115 Implant/abutsuppfixeddentforedentulousarch-mandibular ...................... 350 ........................................................2606D6116 Implant/abutsuppfixeddentforpartiallyedentulousarch-maxillary ............ 350 ........................................................1610D6117 Implant/abutsuppfixeddentforpartiallyedentulousarch-mandibular ......... 350 ........................................................1610D6194 Abutmentsupportedretainercrown .................................................................. 350 .........................................................986D6205 Pontic-indirectresinbasedcomposite ............................................................ 223 .........................................................223D6210 Pontic-casthighnoblemetal ........................................................................... 248 .........................................................248D6211 Pontic-castpredominatelybasemetal ............................................................ 248 .........................................................248D6212 Pontic-castnoblemetal ................................................................................... 248 .........................................................248D6240 Pontic-porcelainfusedtohighnoblemetal ..................................................... 262 .........................................................262D6241 Pontic-porcelainfusedtopredominatelybasemetal ...................................... 262 .........................................................262D6242 Pontic-porcelainfusedtonoblemetal ............................................................. 262 .........................................................262D6245 Pontic-porcelain/ceramic ................................................................................. 280 .........................................................280D6250 Pontic-resinwithhighnoblemetal .................................................................. 248 .........................................................248D6251 Pontic-resinwithpredominatelybasemetal ................................................... 248 .........................................................248D6252 Pontic-resinwithnoblemetal .......................................................................... 248 .........................................................248D6545 Ret.-castmetalforresinbondedfixedprosthesis ........................................... 126 .........................................................126D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis ...................................... 197 .........................................................197D6549 Resinretainer-forresinbondedfixedprost ..................................................... 126 .........................................................126D6600 Inlay-porc./ceramic,twosurfaces ................................................................... 214 .........................................................214D6601 Inlay-porc./ceramic,>=3surfaces ................................................................... 223 .........................................................223D6602 Inlay-casthighnoblemetal,twosurfaces ....................................................... 204 .........................................................204D6603 Inlay-casthighnoblemetal,>=3surfaces ...................................................... 213 .........................................................213D6604 Inlay-castpredominantlybasemetal,twosurfaces ........................................ 204 .........................................................204D6605 Inlay-castpredominantlybasemetal,>=3surfaces ........................................ 213 .........................................................213D6606 Inlay-castnoblemetal,twosurfaces ............................................................... 204 .........................................................204D6607 Inlay-castnoblemetal,>=3surfaces .............................................................. 213 .........................................................213D6608 Onlay-porc./ceramic,twosurfaces ................................................................... 240 .........................................................240D6609 Onlay-porc./ceramic,threeormoresurfaces .................................................. 250 .........................................................250D6610 Onlay-casthighnoblemetal,twosurfaces ..................................................... 229 .........................................................229D6611 Onlay-casthighnoblemetal,>=3surfaces ..................................................... 262 .........................................................262D6612 Onlay-castpredominantlybasemetal,twosurfaces ...................................... 229 .........................................................229D6613 Onlay-castpredominantlybasemetal,>=3surfaces ...................................... 262 .........................................................262D6614 Onlay-castnoblemetal,twosurfaces ............................................................. 229 .........................................................229D6615 Onlay-castnoblemetal,>=3surfaces ............................................................ 262 .........................................................262D6710 Crown-indirectresinbasedcomposite ............................................................ 223 .........................................................223D6720 Crown-resinwithhighnoblemetal .................................................................. 248 .........................................................248


D6721 Crown-resinwithpredominantlybasemetal ................................................... 248 .........................................................248D6722 Crown-resinwithnoblemetal .......................................................................... 248 .........................................................248D6740 Crown-porcelain/ceramic ................................................................................ 280 .........................................................280D6750 Crown-porcelainfusedtohighnoblemetal ..................................................... 262 .........................................................262D6751 Crown-porcelainfusedtopredominatelybasemetal ...................................... 262 .........................................................262D6752 Crown-porcelainfusedtonoblemetal ............................................................ 262 .........................................................262D6780 Crown-3/4casthighnoblemetal .................................................................... 235 .........................................................235D6781 Crown-3/4castpredominantlybasemetal ...................................................... 235 .........................................................235D6782 Crown-3/4castnoblemetal ............................................................................ 235 .........................................................235D6783 Crown-3/4porc./ceramic ................................................................................. 256 .........................................................256D6790 Crown-fullcasthighnoblemetal ..................................................................... 248 .........................................................248D6791 Crown-fullcastpredominatelybasemetal ...................................................... 248 .........................................................248D6792 Crown-fullcastnoblemetal ............................................................................. 248 .........................................................248D6930 Recementfixedpartialdenture .......................................................................... 35 ...........................................................35D6950 Precisionattachment ........................................................................................ 189 .........................................................189D6980 Fixedpartialdenturerepair,byreport ................................................................ 86 ...........................................................86D6985 Pediatricpartialdenture,fixed .......................................................................... 280 .........................................................280 ENDODONTICS1 D3110 Pulpcap-direct(excl.finalrestoration) ............................................................. 16 ...........................................................16D3120 Pulpcap-indirect(excl.finalrestoration) .......................................................... 16 ...........................................................16D3220 Therapeuticpulpotomy(excl.finalrestor.) ......................................................... 41 ...........................................................41D3221 Pulpaldebridement,prim.andperm.teeth ........................................................ 47 ...........................................................47D3222 Partialpulpotomyforapexogenesis ................................................................... 80 ...........................................................80D3230 Pulpaltherapy-resorbablefilling,anterior ........................................................ 80 ...........................................................80D3240 Pulpaltherapy-resorbablefilling,posterior ....................................................... 82 ...........................................................82D3310 Endodontictherapy,anteriortooth(excludingfinalrestoration) ........................ 171 .........................................................171D3320 Endodontictherapy,premolartooth(excludingfinalrestoration) ...................... 209 .........................................................209D3330 Endodontictherapy,molartooth(excludingfinalrestoration) ........................... 256 .........................................................256D3331 Treatmentofrootcanalobstr.non-surgical....................................................... 104 .........................................................104D3332 Incomp.endo.therapy-inop.orfracturedtooth .................................................. 92 ...........................................................92D3333 Internalrootrepairofperforationdefects ........................................................... 53 ...........................................................53D3346 Retreatofprev.rootcanaltherapy,anterior ...................................................... 194 .........................................................194D3347 Retreatofprev.rootcanaltherapy,premolar .................................................... 233 .........................................................233D3348 Retreatofprev.rootcanaltherapy,molar ......................................................... 279 .........................................................279D3351 Apexification/recalcification-initialvisit ............................................................ 101 .........................................................101D3352 Apexification/recalcification-interimmed.repl. ................................................ 295 .........................................................295D3353 Apexification/recalcification-finalvisit .............................................................. 225 .........................................................225D3355 Pulpalregeneration-initialvisit ........................................................................ 101 .........................................................101D3356 Pulpalregeneration-interimmedicationreplacement ...................................... 295 .........................................................295D3357 Pulpalregeneration-completionoftreatment .................................................. 225 .........................................................225D3410 Apicoectomy-anterior ...................................................................................... 162 .........................................................162D3421 Apicoectomy-premolar(firstroot) .................................................................... 182 .........................................................182D3425 Apicoectomy-molar(firstroot) ......................................................................... 209 .........................................................209D3426 Apicoectomy/periradicularsurgery(eachadd.root) .......................................... 76 ...........................................................76D3427 Periradicularsurgeryw/oapicoectomy ............................................................. 133 .........................................................133D3428 Bonegraftinconj.w/periradicularsurg.,pertooth,singlesite ........................ 350 .........................................................372D3429 Bonegraftinconj.w/periradicularsurg.,add.contiguoustooth,samesite ..... 291 .........................................................291D3430 Retrogradefilling-perroot ................................................................................ 60 ...........................................................60D3431 Biologicmaterialstoaidsoft/osseoustissueregen.inconj.w/periradicularsurg. 204 ........................................................204D3432 Guidedtissueregen.,resorbablebarrier,persite,inconj.w/periradicularsurg. . 350 .........................................................408D3450 Rootamputation-perroot .................................................................................117 .........................................................117D3910 Surg.proc.forisol.oftoothw/rubberdam ........................................................ 29 ...........................................................29D3920 Hemisection,notinc.rootcanaltherapy ............................................................117 .........................................................117D3950 Canalprep/fittingofpreformeddowelorpost .................................................... 68 ...........................................................68 PERIODONTICS1 D4210 Gingivectomyorgingivoplasty->3cont.teeth,perquad. ................................ 140 .........................................................140D4211 Gingivectomyorgingivoplasty-<=3teeth,perquad. ........................................ 50 ...........................................................50D4212 Gingivectomyorgingivoplasty,rest.,pertooth .................................................. 20 ...........................................................20D4240 Gingivalflapproc.,inc.rootplaning->3cont.teeth,perquad ........................ 173 .........................................................173D4241 Gingivalflapproc,inc.rootplaning-<=3cont.teeth,perquad ........................ 53 ...........................................................53D4245 Apicallypositionedflap ...................................................................................... 93 ...........................................................93D4249 Clinicalcrownlengthening-hardtissue ........................................................... 288 .........................................................288D4260 Osseoussurgery->3cont.teeth,perquad ..................................................... 250 .........................................................250D4261 Osseoussurgery-<=3cont.teeth,perquad ................................................... 196 .........................................................196D4263 Bonereplacementgraft-retainednaturaltooth-firstsiteinquad. .................. 350 .........................................................372D4264 Bonereplacementgraft-retainednaturaltooth-eachadd.siteinquad. ........ 291 .........................................................291D4265 Biologicmaterials .............................................................................................. 204 .........................................................204D4266 Guidedtissueregen.-resorb.barrier,persite ................................................. 350 .........................................................408D4267 Guidedtissueregen.-non-resorb.barrier,persite .......................................... 350 .........................................................399D4268 Surgicalrevisionproc.,pertooth ...................................................................... 179 .........................................................179D4270 Pediclesofttissuegraftprocedure .................................................................... 322 .........................................................322


D4273 Subepithelialconnectivetissuegraftproc. ........................................................ 350 .........................................................400D4274 Mesial/distalwedgeprocedure,singletooth ..................................................... 154 .........................................................154D4275 Softtissueallograft ........................................................................................... 350 .........................................................427D4276 Comb.connec.tissue/doublepediclegraft,pertooth ....................................... 350 .........................................................510D4277 Freesofttissuegraft,pertooth ......................................................................... 327 .........................................................327D4278 Freesofttissuegraft,eachadd.tooth ............................................................... 50 ...........................................................50D4320 Provisionalsplinting-intracoronal .................................................................... 214 .........................................................214D4321 Provisionalsplinting-extracoronal ................................................................... 189 .........................................................189D4341 Perioscalingandrootplaning->3contteeth,perquad. .................................. 55 ...........................................................55D4342 Perioscalingandrootplaning-<=3teeth,perquad ........................................ 32 ...........................................................32D4346 Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation -fullmouth,afteroralevaluation ....................................................................... 23 ...........................................................23D4355 Fullmouthdebridement ..................................................................................... 45 ...........................................................45D4381 Localizeddeliveryofchemotherapeuticagents ................................................. 49 ...........................................................49D4910 Periodontalmaintenance ................................................................................... 37 ...........................................................37 ORAL SURGERY1 D7111 Extraction,coronalremnants-primarytooth ..................................................... 28 ...........................................................28D7140 Extraction,eruptedtoothorexposedroot .......................................................... 35 ...........................................................35D7210 Extraction,eruptedtoothreqelev,etc .............................................................. 67 ...........................................................67D7220 Removalofimpactedtooth-softtissue ............................................................. 76 ...........................................................76D7230 Removalofimpactedtooth-partiallybony ........................................................ 98 ...........................................................98D7240 Removalofimpactedtooth-completelybony .................................................. 121 .........................................................121D7241 Removalofimp.tooth-completelybony,withunusualsurg.complications .... 109 .........................................................109D7250 Removalofresidualtoothroots ......................................................................... 71 ...........................................................71D7251 Coronectomy-intentionalpartialtoothremoval ................................................. 109 .........................................................109D7260 Oroantralfistulaclosure .................................................................................... 289 .........................................................289D7261 Primaryclosureofasinusperforation .............................................................. 233 .........................................................233D7270 Toothreimplant./stabiliz.ofacc.evulsed/displacedtooth ..................................113 .........................................................113D7272 Toothtransplantation ......................................................................................... 308 .........................................................308D7280 Exposureofanuneruptedtooth ......................................................................... 77 ...........................................................77D7282 Mobil.oferupted/malpositionedtoothtoaideruption ........................................116 .........................................................116D7283 Place.ofdevicetofacilitateerupt.ofimpactedtooth ......................................... 72 ...........................................................72D7285 Biopsyoforaltissue-hard(bone,tooth) .......................................................... 194 .........................................................194D7286 Biopsyoforaltissue-soft(allothers) ............................................................... 148 .........................................................148D7287 Exfoliativecytologicalsamplecollection ............................................................ 14 ...........................................................14D7288 Brushbiopsy-transepithelialsamplecollect ..................................................... 47 ...........................................................47D7290 Surgicalrepositioningofteeth ........................................................................... 204 .........................................................204D7291 Transseptalfiberotomy/supracrestalfiberotomy,byreport ............................... 30 ...........................................................30D7292 Surgicalplacementoftempanchdevice .......................................................... 273 .........................................................273D7293 Surgicalplacementoftempanchreqflap ......................................................... 283 .........................................................283D7294 Surgicalplacement:w/oflap .............................................................................. 66 ...........................................................66D7295 Boneharvesting-autogenousgraftingprocedure ............................................... 87 ...........................................................87D7310 Alveoloplastyinconj.w/extractions,>=4perquad. .......................................... 71 ...........................................................71D7311 Alveoloplastyinconj.w/extractions,1-3perquad. ........................................... 71 ...........................................................71D7320 Alveoloplastynotinconj.w/extractions,>=4perquad. .................................... 71 ...........................................................71D7321 Alveoloplastynotinconj.w/extractions,1-3perquad. ..................................... 71 ...........................................................71D7340 Vestibuloplasty-ridgeext.sec.epithel. ............................................................ 350 .........................................................462D7350 Vestibuloplasty-ridgeext.inc.grafts,etc ......................................................... 350 .........................................................888D7410 Excisionofbenignlesionupto1.25cm ............................................................ 139 .........................................................139D7411 Excisionofbenignlesion>1.25cm ..................................................................113 .........................................................113D7412 Excisionofbenignlesion,complicated ............................................................. 157 .........................................................157D7413 Excisionofmalignantlesionupto1.25cm ....................................................... 286 .........................................................286D7414 Excisionofmalignantlesion>1.25cm ............................................................. 252 .........................................................252D7415 Excisionofmalignantlesion,complicated ........................................................ 350 .........................................................407D7440 Exc.ofmalignanttumor-lesiondiam.<=1.25cm .............................................. 304 .........................................................304D7441 Exc.ofmalignanttumor-lesiondiam.>1.25cm ................................................ 350 .........................................................367D7450 Removalofbenignodoncyst/tumor-diam<=1.25cm ..................................... 177 .........................................................177D7451 Removalofbenignodoncyst/tumor-diam>1.25cm........................................ 272 .........................................................272D7460 Removalofbenignnonodoncyst/tumor-diam<=1.25cm ................................. 258 .........................................................258D7461 Removalofbenignnonodoncyst/tumor-diam>1.25cm.................................... 350 .........................................................359D7465 Destruct.oflesion(s)byphysorchemmethod ................................................. 150 .........................................................150D7471 Removaloflateralexostosis ............................................................................. 176 .........................................................176D7472 Removaloftoruspalatinus ............................................................................... 240 .........................................................240D7473 Removaloftorusmandibularis ......................................................................... 240 .........................................................240D7485 Surgicalreductionofosseoustuberosity .......................................................... 284 .........................................................284D7490 Radicalresectionofmaxillaormandible .......................................................... 350 ........................................................2204D7510 Incisionanddrainageofabscess-intraoralsofttissue ..................................... 48 ...........................................................48D7511 Incision/drainageofabscess-intra.softtissue,comp. ..................................... 56 ...........................................................56D7520 Incision/drainageofabscess-extra.softtissue ................................................ 58 ...........................................................58D7521 Incision/drainageofabscess-extra.softtissue,comp. .................................... 60 ...........................................................60D7530 Foreignbodyremfrommuc./skin/subcuttissue ................................................ 44 ...........................................................44


D7540 Reactionproducingforeignbodiesremoval ...................................................... 350 .........................................................584D7550 Partialostect/sequestrectnon-vitalbonerem. .................................................. 168 .........................................................168D7560 Max.sinusotomyfortoothfragmentremoval .................................................... 350 .........................................................373D7610 Maxillary-openreduction(teethimmobilized) ................................................. 350 ........................................................1098D7620 Maxillary-closedreduction(teethimmobilized) ............................................... 350 .........................................................829D7630 Mandible-openreduction(teethimmobilized) ................................................. 350 ........................................................1199D7640 Mandible-closedreduction(teethimmobilize) ................................................. 350 .........................................................809D7650 Malarand/orzygomaticarch-openreduction .................................................. 350 .........................................................849D7660 Malarand/orzygomaticarch-closedreduction ................................................ 350 .........................................................665D7670 Alveolus-closedreduction ............................................................................... 265 .........................................................265D7671 Alveolus-openreduction(incl.teethstabil.) ...................................................... 267 .........................................................267D7680 Facialbones-complicatedreduction ............................................................... 350 ........................................................1883D7710 Maxillary-openreduction ................................................................................. 350 ........................................................1217D7720 Maxillary-closedreduction .............................................................................. 350 ........................................................1269D7730 Mandible-openreduction ................................................................................ 350 ........................................................1200D7740 Mandible-closedreduction .............................................................................. 350 .........................................................864D7750 Malarand/orzygomaticarch-openreduction .................................................. 350 ........................................................1058D7760 Malarand/orzygomaticarch-closedreduction ................................................ 350 .........................................................801D7770 Alveolus-openreductionstabiliz.ofteeth ....................................................... 350 .........................................................599D7771 Alveolus,closedreductionstabiliz.ofteeth ...................................................... 104 .........................................................104D7780 Facialbones-complicatedreduction ............................................................... 350 ........................................................2356D7810 Openreductionofdislocation ........................................................................... 350 ........................................................1175D7820 Closedreductionofdislocation ......................................................................... 171 .........................................................171D7830 Manipulationunderanesthesia ......................................................................... 142 .........................................................142D7840 Condylectomy ................................................................................................... 350 ........................................................1591D7850 Surgicaldiscectomy,with/withoutimplant ......................................................... 350 ........................................................1489D7854 Synovectomy .................................................................................................... 350 ........................................................1669D7858 Jointreconstruction ........................................................................................... 350 ........................................................3231D7860 Arthrotomy ........................................................................................................ 350 .........................................................866D7865 Arthroplasty ....................................................................................................... 350 ........................................................2423D7870 Arthrocentesis .................................................................................................... 79 ...........................................................79D7871 Non-arthroscopiclysisandlavage .................................................................... 276 .........................................................276D7872 Arthroscopy-diagnosis,w/orw/outbiopsy ...................................................... 350 .........................................................750D7873 Arthroscopy-surgical-lavage/lysisofadhesion .................................................. 350 .........................................................822D7874 Arthroscopy-surgical:discreposit/stabiliz ....................................................... 350 ........................................................1039D7875 Arthroscopy-surgical:synovectomy ................................................................ 350 ........................................................1111D7876 Arthroscopy-surgical:discectomy ................................................................... 350 ........................................................1154D7877 Arthroscopy-surgical:debridement ................................................................. 350 ........................................................1068D7880 Occlusalorthoticdevice,“byreport” ................................................................. 136 .........................................................136D7910 Sutureofrecentsmallwoundsupto5cm ......................................................... 30 ...........................................................30D7911 Complicatedsuture,<=5cm ............................................................................. 35 ...........................................................35D7912 Complicatedsuture,>5cm ............................................................................... 40 ...........................................................40D7920 Skingraft-identifydefect ................................................................................. 350 .........................................................742D7921 Collectionapplicationofbloodconcentrate ....................................................... 20 ...........................................................20D7940 Osteoplasty-fororthognathicdeformities ........................................................ 350 .........................................................596D7941 Osteotomy-mandibularrami ............................................................................ 350 ........................................................2341D7943 Osteotomy-mandibularramiwithbonegraft ................................................... 350 ........................................................2112D7944 Osteotomy-segmented/subapical-persext/quad ............................................ 350 ........................................................1851D7945 Osteotomy-bodyofmandible .......................................................................... 350 ........................................................2164D7946 LeFortI(maxillary-total) .................................................................................. 350 ........................................................2622D7947 LeFortI(maxillary-segmented) ....................................................................... 350 ........................................................2399D7948 LeFortIIorLeFortIII ......................................................................................... 350 ........................................................2970D7949 LeFortIIorLeFortIII-withbonegraft .............................................................. 350 ........................................................3634D7950 Osseous,osteoperiosteal,orcartilagegraft ..................................................... 157 .........................................................157D7951 SinusAugmentationvialateralapproach .......................................................... 309 .........................................................309D7952 Sinusaugmentationviaverticalapproach ........................................................ 160 .........................................................160D7955 Repairofmaxillofacialsoftandhardtissue ...................................................... 161 .........................................................161D7960 Frenulectomy(frenectomy/frenotomy)-separateproc. .................................... 132 .........................................................132D7963 Frenuloplasty .................................................................................................... 147 .........................................................147D7970 Excisionofhyperplastictissue-perarch ...........................................................117 .........................................................117D7971 Excisionofpericoronalgingiva .......................................................................... 66 ...........................................................66D7972 Surgicalreductionoffibroustuberosity ............................................................. 261 .........................................................261D7979 Non-surgicalsialolithotomy ................................................................................ 22 ...........................................................22 D7980 Surgicalsialolithotomy .......................................................................................114 .........................................................114D7981 Excisionofsalivarygland,byreport ................................................................. 350 .........................................................470D7982 Sialodochoplasty ............................................................................................... 350 .........................................................470D7983 Closureofsalivaryfistula .................................................................................. 350 .........................................................370D7990 Emergencytracheotomy ................................................................................... 350 .........................................................379D7991 Coronoidectomy ................................................................................................ 350 ........................................................1060D7995 Syntheticgraft-mandibleorfacialbones ......................................................... 270 .........................................................270D7996 Implant-mandibleforaugmentationpurposes ................................................... 350 .........................................................596D7997 Applianceremoval(notbyoriginaldentist) ....................................................... 135 .........................................................135



ORTHODONTICS2 - PRE-AUTHORIZATION REQUIRED D8010 Limitedortho.treatmentoftheprimarydentition .............................................. 350 ........................................................3304D8020 Limitedortho.treatmentofthetransitionaldentition ......................................... 350 ........................................................3304D8030 Limitedorthotreatment-adolescentdentition .................................................. 350 ........................................................3422D8040 Limitedorthotreatment-adultdentition ........................................................... 350 ........................................................3658D8050 Interceptiveortho.treatmentoftheprimarydentition ....................................... 350 ........................................................3304D8060 Interceptiveortho.treatment-transitionaldentition .......................................... 350 ........................................................3304D8070 Comp.ortho.treatment-transitionaldentition .................................................. 350 ........................................................3304D8080 Comp.ortho.treatment-adolescentdentition .................................................. 350 ........................................................3422D8090 Comp.ortho.treatment-adultdentition ........................................................... 350 ........................................................3658D8660 Pre-orthodontictreatmentvisit .......................................................................... 350 .........................................................413D8670 Periodicortho.treatmentvisit(aspartofcontract) ............................................118 .........................................................118D8680 Orthodonticretainer(rem.ofappl./placementofretainer(s)) ............................ 413 .........................................................413D8681 Removableorthodonticretaineradjustment ...................................................... 31 ...........................................................31D8691 Repairoforthodonticappliance ........................................................................ 100 .........................................................100D8692 Replacementoflostorbrokenretainer ............................................................. 179 .........................................................179D8693 Rebondingorrecementingfixeddentures ........................................................ 174 .........................................................174D8694 Repairoffixedretainers,includesreattachment ............................................... 174 .........................................................174 ADJUNCTIVE GENERAL SERVICES D9110 Palliative(emergency)treatmentofdentalpain ................................................. 22 ...........................................................22D9210 Localanesthesianotinconj.w/operative/surg.procedures .............................. 0 .............................................................0D9211 Regionalblockanesthesia .................................................................................. 0 .............................................................0D9212 Trigeminaldivisionblockanesthesia................................................................... 0 .............................................................0D9215 Localanesthesiainconj.w/operative/surg.procedures .................................... 0 .............................................................0D9222 Deepsedation/generalanesthesia-first15minutes ......................................... 52 ...........................................................52 D9223 Deepsedation/generalanesthesia-eachsubsequent15minuteincrement .... 52 ...........................................................52D9230 Analgesia,anxiolysis,inhalationofnitrousoxide ............................................... 19 ...........................................................19D9239 Intravenousmoderate(conscious)sedation/analgesia–first15minutes ......... 52 ...........................................................52 D9243 Intravenousmoderate(conscious)sedation/analgesia-each subsequent15minuteincrement ................................................................... 52 ...........................................................52D9248 Non-intravenousconscioussedation ................................................................. 73 ...........................................................73D9310 Consultation(diagnosticservicebynontreatingdentist) .................................... 22 ...........................................................22D9410 House/extendedcarefacilitycall ...................................................................... 100 .........................................................100D9420 Hospitalcall ....................................................................................................... 175 .........................................................175D9430 Officevisitforobservation(duringregularlyscheduledhours)-no otherservicesperformed ................................................................................ 0 .............................................................0D9440 Officevisitafterregularlyscheduledhours ........................................................ 45 ...........................................................45D9450 Casepres,detailed/exttreatmentplanning ....................................................... 22 ...........................................................22D9610 Therapeuticparenteraldrug,singleadmin. ....................................................... 13 ...........................................................13D9612 Therapeuticparenteraldrug,2ormoreadmin.,diff.med. ................................. 35 ...........................................................35D9630 Drugsormedicamentsdispensedintheofficeforhomeuse ............................ 21 ...........................................................21D9910 Applicationofdesensitizingmedicament ........................................................... 16 ...........................................................16D9911 Appl.ofdesen.resinforcervical/rootsurf. ......................................................... 38 ...........................................................38D9920 Behaviormanagement,byreport ....................................................................... 34 ...........................................................34D9930 Treatmentofcomplications(post-surgical) ........................................................ 22 ...........................................................22D9940 Occlusalguard,byreport .................................................................................. 136 .........................................................136D9941 Fabricationofathleticmouthguard ..................................................................... 51 ...........................................................51D9942 Repairand/orrelineofocclusalguard .............................................................. 105 .........................................................105D9943 Occlusalguardadjustment ................................................................................ 46 ...........................................................46D9950 Occlusionanalysis-mountedcase ................................................................... 52 ...........................................................52D9951 Occlusaladjustment-limited ............................................................................. 33 ...........................................................33D9952 Occlusaladjustment-complete ........................................................................ 133 .........................................................133D9971 Odontoplasty1-2teeth ..................................................................................... 24 ...........................................................24D9974 Internalbleaching-pertooth ............................................................................. 82 ...........................................................82D9986 Missedappointment ........................................................................................... 50 ...........................................................50D9995 Teledentistry-synchronous;real-timeencounter(whenavailable) ................... 20 ...........................................................20D9996 Teledentistry-asynchronous;informationstoredandforwardedtodentist forsubsequentreview(whenavailable) ......................................................... 20 ...........................................................20

1 Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Plan Specialist. 2 See exclusion #9 and limitation #14 for additional coverage information.

OnlycurrentADACDTcodesareconsideredvalidbyDominionNational.Current Dental Terminology © American Dental Association.

Plan Exclusions1. Serviceswhicharecoveredunderworker’scompensationoremployer’sliabilitylaws. 2. Serviceswhicharenotnecessaryforthepatient’sdentalhealthasdeterminedbythePlan. 3. Cosmetic,electiveoraestheticdentistryexceptasrequiredduetoaccidentalbodilyinjurytosoundnaturalteethasdeterminedbythePlan.4. Serviceswithrespecttomalignancies,cystsorneoplasms,hereditary,congenital,mandibularprognathismordevelopmentmalformations where,intheopinionofthePlan,suchservicesshouldnotbeperformedinadentaloffice. 5. Hospitalizationforanydentalprocedure. 6. Treatmentrequiredforconditionsresultingfrommajordisaster,epidemic,war,actsofwar,whetherdeclaredorundeclared,orwhileon activedutyasamemberofthearmedforcesofanynation. 7. ProceduresnotlistedasCoveredServicesunderthisPlan. 8. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpredeterminedbysuchofficeorthePlan(withthe exceptionofout-of-areaemergencydentalservices). 9. Non-medicallynecessaryorthodontiaisnotacoveredserviceunderthispolicy.TheInvisalignsystemandsimilarspecializedbracesare notacoveredservice.Seelimitation#14concerningmedicallynecessaryorthodontia. 10.Noservicewillbepaidforanysurgical,adjunctiveorprostheticservicenotlistedaboveunlesstheCoveredChildhadNewJersey BenchmarkMedicalCoverageineffectonthedatetheservicewasrendered,andtheCoveredChildorResponsiblePartyhassubmitted tothePlanacopyofthemedicalcarrier’sexplanationofservicesshowingthattheservicewasnotcoveredundertheBenchmarkMedical Coverage.“BenchmarkMedicalCoverage”meansmedicalcoveragethatisprovidedbyacarrierthatisaqualifiedhealthplanintheState ofNewJerseyandsatisfiesthebenchmarkplanrequirementformedicalessentialhealthservicesinNewJersey.

Plan Limitations1. One(1)evaluation(D0120,D0145,D0150orD0160)persix(6)months,perpatient.2. One(1)teethcleaning(D1110orD1120)persix(6)months,perpatient. 3. Onefluoridetreatmentperthree(3)months,perpatient. 4. Bitewingx-rayfilms. 5. One(1)setoffullmouthx-raysorpanoramicfilmiscoveredeverythree(3)years. 6. Onesealantpertooth,perpatientuptoage19(limitedtoocclusalsurfacesofposteriorpermanentteethwithoutrestorationsordecay).7. Spacemaintainerstopreservespacebetweenteethforprematurelossofaprimarytooth(doesnotincludeusefororthodontictreatment).8. Crownandbridgefeesapplytotreatmentinvolvingfive(5)orfewerunitswhenpresentedinasingletreatmentplan. 9. Reliningandrebasingofdenturesiscoveredonceper12months,perpatient,onlyaftersix(6)monthsofinitialplacement. 10.Onerootscalingandplaning(D4341,D4342orD4346)perquadrantofmouthpersix(6)months. 11.Periodontalmaintenancefollowingsurgery(D4341isnotconsideredsurgery). 12.Alldentalservicesthataretoberenderedinahospitalsettingrequirecoordinationandapprovalfromboththedentalinsurerandthe medicalinsurerbeforeservicescanberendered.Servicesdeliveredtothepatientonthedateofservicearedocumentedseparatelyusing applicableprocedurecodes. 13.Anesthesiarequiresanarrativeofmedicalnecessitybemaintainedinpatientrecords.Amaximumof60minutesofservicesisallowedfor generalanesthesiaandintravenousornon-intravenousconscioussedation.Generalanesthesiaisnotcoveredwithprocedurecodes D9230,D9239orD9243.IntravenousconscioussedationisnotcoveredwithprocedurecodesD9222,D9223orD9230.Non-intravenous conscioussedationisnotcoveredwithprocedurecodesD9222,D9223orD9230.Analgesia(nitrousoxide)isnotcoveredwithprocedure codeD9222,D9223,D9239orD9243.14.OrthodonticsisonlycoveredifmedicallynecessaryasdeterminedbythePlan.Medicalnecessitymustbemetbydemonstratingsevere functionaldifficulties,developmentalanomaliesoffacialbonesand/ororalstructures,facialtraumaresultinginfunctionaldifficultiesor documentationofapsychological/psychiatricdiagnosisfromamentalhealthproviderthatorthodontictreatmentwillimprovethemental/ psychologicalconditionofthechild.Patientcopaymentswillapplytotheroutineorthodonticapplianceportionofservicesonly.Additional costsincurredwillbecomethepatient’sresponsibility. 15. Teledentistry,synchronous(D9995)orasynchronous(D9996),limitedtotwopercalendaryear(whenavailable).


CROWNS & BRIDGES

D2510/20 Inlay- metallic - 1-2 surfaces ................................................204D2530 Inlay - metallic - three or more surfaces ...............................213D2542 Onlay - metallic-two surfaces ...............................................229D2543/44 Onlay - metallic - three or more surfaces .............................262D2610/20 Inlay - porcelain/ceramic - 1-2 surfaces ...............................214D2630 Inlay - porcelain/ceramic - >=3 surfaces ..............................223D2642 Onlay - porcelain/ceramic - two surfaces .............................240D2643/44 Onlay - porcelain/ceramic - >=3 surfaces ............................250D2650/51/52 Inlay - resin-based composite - >=1 surface(s) ....................220D2662/63/64 Onlay - resin-based composite - >=2 surfaces ....................222D2710 Crown - resin based composite (indirect) ............................136D2712 Crown - 3/4 resin-based composite (indirect) ......................243D2720/21/22 Crown - resin with metal ......................................................248D2740 Crown - porcelain/ceramic ...................................................280D2750/51/52 Crown - porcelain fused metal .............................................262D2780/81/82 Crown - 3/4 cast with metal ..................................................239D2783 Crown - 3/4 porcelain/ceramic .............................................256D2790/91/92 Crown - full cast metal .........................................................248D2794 Crown - titanium ...................................................................248D2910/20 Recement inlay/crown ............................................................22D2929 Procelain/cermaic crown - prim. tooth ..................................280D2930 Prefab. stainless steel crown - prim. tooth .............................55D2931 Prefab. stainless steel crown - perm. tooth ............................61D2932 Prefabricated resin crown ......................................................70D2941 Interim therapeutic restoration, primary dentition ...................16D2952 Cast post and core in addition to crown .................................93D2954 Prefab. post and core in addition to crown .............................77D2955 Post removal (not in conj. with endo. therapy) .......................53D2970 Temporary crown (fractured tooth) ...........................................0D2980 Crown repair, by report ..........................................................51D2981/82/83 Inlay, only or veneer repair .....................................................51D2990 Resininfitrationlesion ............................................................21 PROSTHETICS (DENTURES)D5110/20 Complete denture - maxillary/mandibular ............................349D5130/40 Immediate denture - maxillary/mandibular ...........................361D5211/12 Maxillary/mandibular partial denture - resin base ................325D5213/14 Maxillary/mandibular partial denture - cast metal ................375D5221/22 Immediate maxillary/mandibular partial denture - resin base ......................................................................325D5223/24 Immediate maxillary/mandibular partial denture - cast metal ......................................................................375D5225/26 Maxillary/mandibularpartialdenture-flexiblebase .............375D5281 Rem. unilateral partial denture - one piece cast metal .........210D5410/11 Adjust complete denture - maxillary/mandibular ....................19D5421/22 Adjust partial denture - maxillary/mandibular .........................19D5511/12 Repair broken complete denture base - maxillary/mandibular ........................................................44D5520 Replace missing or broken teeth - complete denture ............44D5611/12 Repair resin partial denture base - maxillary/mandibular .......44 D5621/22 Repair cast partial framework - maxillary/mandibular ............44 D5620 Repair cast framework ...........................................................44D5630/60 Clasp repaired, replaced or added .........................................58D5640 Replace broken teeth - per tooth ...........................................44D5650 Add tooth to existing partial denture ......................................44D5670/71 Replace all teeth and acrylic on cast metal framework (maxillary/mandibular) ......................................................144D5710/11 Rebase complete maxillary/mandibular denture ..................130D5720/21 Rebase maxillary/mandibular partial denture .......................130D5730/31 Reline complete maxillary/mandibular denture (chairside) ....80D5740/41 Reline maxillary/mandibular partial denture (chairside) .........78D5750/51 Reline complete maxillary/mandibular denture (lab) ............ 112

D9439 Officevisit ................................................................................0

DIAGNOSTIC/PREVENTIVED0120 Periodic oral eval - established patient ....................................0D0140 Limited oral eval - problem focused .........................................0D0145 Oral eval for a patient under 3 years of age .............................0D0150 Comprehensive oral eval - new or established patient ............0D0160 Detailed and extensive oral eval - problem focused ................0D0170 Re-evaluation - limited, problem focused .................................0D0210 Intraoral - complete series (including bitewings) ......................0D0220/30 Intraoral-periapicalfirstfilmandeachadditional ....................0D0240 Intraoral-occlusalfilm .............................................................0D0250 Extraoralfilm ............................................................................0D0270-74 Bitewingx-rays-1-4films ........................................................0D0277 Verticalbitewings-7to8films .................................................0D0330 Panoramicfilm .........................................................................0D0340 2D cephalometric radiographic image .....................................0D0350 Oral/facial photographic images (intraoral/extraoral) ...............0D0351 3D photographic image ............................................................0D0391 Interpretation of diagnostic image only ....................................0D0460 Pulp vitality tests ......................................................................0D0470 Diagnostic casts .......................................................................0D0601/02/03 Caries risk assessment/documentation, withafindingoflow/moderate/highrisk ...............................0D1110 Prophylaxis (cleaning) - adult ...................................................0D1120 Prophylaxis (cleaning) - child ...................................................0D1206 Topicalfluoridevarnishformod/highriskcariespatients .........0D1208 Topicalapplicationoffluoride ...................................................0D1310 Nutritional counseling for control of dental disease .................0D1320 Tobacco counseling for control of prev. oral disease ...............0D1330 Oral hygiene instructions .........................................................0D1351 Sealant - per tooth ...................................................................0D1352 Prev resin rest. mod/high caries risk – perm. tooth ..................0 SPACE MAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral .......................0D1515/25 Spacemaintainer-fixed/removable-bilateral .........................0D1550 Re-cementation of space maintainer .......................................0 D1575 Distalshoespacemaintainer-fixed-unilateral ......................0 RESTORATIVE DENTISTRY (FILLINGS) AMALGAM RESTORATIONS (SILVER) D2140 Amalgam - one surface, prim. or perm. .................................21D2150 Amalgam - two surfaces, prim. or perm. ................................26D2160 Amalgam - three surfaces, prim. or perm. .............................32D2161 Amalgam - >=4 surfaces, prim. or perm. ...............................39

RESIN/COMPOSITE RESTORATIONS (TOOTH COLORED)D2330 Resin-based composite - one surface, anterior .....................35D2331 Resin-based composite - two surfaces, anterior ....................42D2332 Resin-based composite - three surfaces, anterior .................50D2335 Resin-based composite - >=4 surfaces, anterior ...................60D2390 Resin-based composite crown, anterior .................................96D2391 Resin-based composite - one surface, posterior ...................37D2392 Resin-based composite - two surfaces, posterior ..................44D2393 Resin-based composite - three surfaces, posterior ...............51D2394 Resin-based composite - >=4 surfaces, posterior .................62 D2940 Protective restoration ............................................................20D2949 Restorative foundation for an indirect restoration ....................0D2950 Core buildup, including any pins ............................................63D2951 Pin retention - per tooth, in addition to restoration ................. 11D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) ....................16

DMNPA19DBHINDPEDEHB All fees exclude the cost of noble and precious metals. An additional fee will be charged if these materials are used.





Select Plan Premium Kids 706s (PA)Description of Benefits & Member Copayments for Pediatric Services (under age 19)


D5760/61 Reline maxillary/mandibular partial denture (lab) ................. 112D5810/11 Interim complete denture - maxillary/mandibular .................181D5820/21 Interim partial denture - maxillary/mandibular ......................181D5850/51 Tissue conditioning - maxillary/mandibular ............................40 BRIDGES & PONTICS

D6010 Surgical placement of implant body, endosteal ....................858D6011 Second stage implant surgery .............................................100D6012 Surgical placement of interim implant body .........................891D6013 Surgical placement of mini implant ......................................286D6040 Surgical placement, eposteal implant ................................1782D6050 Surgical placement, transosteal implant ............................2228D6055 Dental implant supported connecting bar ............................806D6056 Prefabricated abutment ........................................................228D6058 Abutment supported porcelain/ceramic crown .....................280D6059/60/61 Abutment supported porcelain fused to metal crown - metal ...... 262D6062/63/64 Abutment supported cast metal crown - metal .....................248D6065 Implant supported porcelain/ceramic crown ........................280D6066 Implant supported porcelain fused to metal crown - titanium, titanium allow, high noble metal ......................262D6067 Implant supported metal crown - titanium, titanium alloy, high noble metal .......................262D6068 Abutment supported retainer for porc/ceramic .....................394D6069 Abutment supp. retainer for porc/high noble ........................422D6070 Abutment supp. retainer for porc/pred. base .......................348D6071 Abutment supp. retainer for porc/noble ................................352D6072 Abutment supp retainer for cast high noble .........................394D6073 Abutment supp. retainer for cast high noble ........................375D6074 Abutment supp. retainer for cast noble metal ......................379D6075 Implant supported retainer for ceramic FPD ........................437D6076 Implant supported retainer for porc/metal FPD ....................412D6077 Implant supported retainer for cast metal FPD ....................436D6080 Implant maintenance procedures ...........................................31D6081 Scalinganddebridementinthepresenceofinflammation or mucositis of a single implant, including cleaning of theimplantsurfaces,withoutflapentryandclosure ..........32 D6090 Repair implant supported prosthesis ...................................181D6091 Replacement of Precision Attachment ...................................17D6095 Repair implant abutment, by report ......................................196D6100 Implant removal, by report ...................................................121D6101 Debribement periimplant defect .............................................45D6102 Deridement and osseous contouring periimplant defect ........90D6103 Bone graft repair perrimplant defect ....................................300D6104 Bone graft at time of implant placement ..............................300D6190 Radiographic surgical implant index, by report ........................0D6210/11/12 Pontic - cast metal ...............................................................248D6214 Pontic - titanium ...................................................................248D6240/41/42 Pontic - porcelain fused to metal ..........................................262D6245 Pontic - porcelain/ceramic ....................................................280D6250/51/52 Pontic - resin with metal .......................................................248D6545 Ret.-castmetalforresinbondedfixedprosthesis ..............126D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis .........197D6549 Resinretainer-forresinbondedfixedprosthesis ...............126D6600 Inlay - porc./ceramic, two surfaces ......................................214D6601 Inlay - porc./ceramic, >=3 surfaces ......................................223D6602 Inlay - cast high noble metal, two surfaces ..........................204D6603 Inlay - cast high noble metal, >=3 surfaces .........................213D6604 Inlay - cast predominantly base metal, two surfaces ...........204D6605 Inlay - cast predominantly base metal, >=3 surfaces ...........213D6606 Inlay - cast noble metal, two surfaces ..................................204D6607 Inlay - cast noble metal, >=3 surfaces .................................213D6608 Onlay -porc./ceramic, two surfaces ......................................240D6609 Onlay - porc./ceramic, three or more surfaces .....................250D6610 Onlay - cast high noble metal, two surfaces ........................229D6611 Onlay - cast high noble metal, >=3 surfaces ........................262D6612 Onlay - cast predominantly base metal, two surfaces .........229D6613 Onlay - cast predominantly base metal, >=3 surfaces .........262D6614 Onlay - cast noble metal, two surfaces ................................229D6615 Onlay - cast noble metal, >=3 surfaces ...............................262D6720/21/22 Crown - resin with metal ......................................................248D6740 Crown - porcelain/ceramic ...................................................280D6750/51/52 Crown - porcelain fused to metal .........................................262D6780/81/82 Crown - 3/4 cast metal .........................................................235

D6783 Crown - 3/4 porc./ceramic ....................................................256D6790/91/92 Crown - full cast metal .........................................................248D6930 Recementfixedpartialdenture ..............................................35D6980 Fixed partial denture repair, by report ....................................86 ADJUNCTIVE GENERAL SERVICESD9110 Palliative (emergency) treatment of dental pain .....................22D9210/15 Local anesthesia ......................................................................0D9211/12 Regional block anesthesia .......................................................0D9222 Deepsedation/generalanesthesia-first15min. ...................52D9223 Deep sedation/general anesthesia - each subsequent 15 min. ................................................................52D9230 Analgesia, anxiolysis, inhalation of nitrous oxide ...................19D9239 Intravenous moderate (conscious) sedation/analgesia–first15min. ......................................52 D9243 Intravenous (conscious) sedation/analgesia - each subsequent 15 min. ............................................................52D9310 Consultation (diagnostic service by nontreating dentist) ........22D9610 Therapeutic parenteral drug, single admin. ...........................13D9910 Application of desensitizing medicament ...............................16D9930 Treatment of complications (post-surgical) ............................22D9940 Occlusal guard, by report .....................................................136D9950 Occlusion analysis - mounted case .......................................52D9951 Occlusal adjustment - limited .................................................33D9952 Occlusal adjustment - complete ...........................................133D9986 Missed appointment ...............................................................50 D9995 Teledentistry – synchronous; real-time encounter (when available) .................................................................20 D9996 Teledentistry – asynchronous; information stored and forwarded to dentist for subsequent review (when available) .................................................................20 ENDODONTICS1

D3220 Therapeuticpulpotomy(excl.finalrestor.) .............................41D3221 Pulpal debridement, prim. and perm. teeth ............................47D3222 Partial pulpotomy for apexogenesis .......................................80D3230 Pulpaltherapy-resorbablefilling,anterior ............................80D3240 Pulpaltherapy-resorbablefilling,posterior ...........................82D3310 Endodontic therapy, anterior tooth (excluding finalrestoration) ...............................................................171D3320 Endodontic therapy, premolar tooth (excluding finalrestoration) ...............................................................209D3330 Endodontic therapy, molar tooth (excluding finalrestoration) ...............................................................256D3333 Internal root repair of perforation defects ...............................53D3346 Retreat of prev. root canal therapy, anterior .........................194D3347 Retreat of prev. root canal therapy, premolar .......................233D3348 Retreat of prev. root canal therapy, molar ............................279D3351 Apexification/recalcification-initialvisit ...............................101D3352 Apexification/recalcification-interimmed.repl. ...................295D3353 Apexification/recalcification-finalvisit .................................225D3355 Pulpal regeneration - initial visit ...........................................101D3356 Pulpal regeneration - interim medication replacement .........295D3357 Pulpal regeneration - completion of treatment .....................225D3410 Apicoectomy - anterior .........................................................162D3421 Apicoectomy-premolar(firstroot) .......................................182D3425 Apicoectomy-molar(firstroot) ............................................209D3426 Apicoectomy - (each add. root) ..............................................76D3427 Periradicular surgery w/o apicoectomy ................................133D3430 Retrogradefilling-perroot ....................................................60D3450 Root amputation - per root ................................................... 117D3920 Hemisection, not inc. root canal therapy .............................. 117D3950 Canalprep/fittingofpreformeddowelorpost ........................68 PERIODONTICS1

D0180 Comp. periodontal eval - new or established patient ...............0D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad. ...140D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad. ............50D4212 Gingivectomy or gingivoplasty, rest., per tooth ......................20D4240 Gingivalflapproc.,inc.rootplaning->3cont.teeth,perquad ... 173D4241 Gingivalflapproc,inc.rootplaning-<=3cont.teeth,perquad ... 53D4249 Clinical crown lengthening - hard tissue ..............................288D4260 Osseous surgery - >3 cont. teeth, per quad.........................250





1 Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. 2 See exclusion #14 and limitation #23 for additional coverage information.

Only current ADA CDT codes are considered valid by Dominion National Current Dental Terminology © American Dental Association.

D4261 Osseous surgery - <=3 cont. teeth, per quad ......................196D4268 Surgical revision proc., per tooth .........................................179D4270 Pedicle soft tissue graft procedure .......................................322D4273 Subepithelial connective tissue graft proc. ...........................400D4274 Mesial/distal wedge procedure, single tooth ........................154D4277 Free soft tissue graft, per tooth ............................................327D4278 Free soft tissue graft, each add. tooth ...................................50D4341 Perio scaling and root planing - >3 cont teeth, per quad. ......55D4342 Perio scaling and root planing - <= 3 teeth, per quad ............32D4346 Scaling in presence of generalized moderate or severe gingivalinflammation-fullmouth,afteroralevaluation .....23 D4355 Full mouth debridement .........................................................45D4381 Localized delivery of chemotherapeutic agents .....................49D4910 Periodontal maintenance .......................................................37D4921 Gingival irrigation - per quadrant ..............................................0 ORAL SURGERY1

D7111 Extraction, coronal remnants - primary tooth .........................28D7140 Extraction, erupted tooth or exposed root ..............................35D7210 Extraction, erupted tooth req. bone cut ..................................67D7220 Removal of impacted tooth - soft tissue .................................76D7230 Removal of impacted tooth - partially bony ............................98D7240 Removal of impacted tooth - completely bony .....................121D7241 Removal of imp. tooth - completely bony, with unusual surg. complications .....................................109D7250 Removal of residual tooth roots .............................................71D7251 Coronectomy-intentional partial tooth removal ....................109D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth .... 113D7280 Exposure of an unerupted tooth .............................................77D7291 Transseptalfiberotomy/supracrestalfiberotomy,byreport ...30D7310/20 Alveoloplasty, >=4 per quad. ..................................................71D7311/21 Alveoloplasty not in conj. w/ extractions, 1-3 per quad. .........71D7471 Removal of lateral exostosis ................................................176D7510 Incision and drainage of abscess - intraoral soft tissue .........48D7910 Suture of recent small wounds up to 5 cm .............................30D7921 Collection application of blood concentrate ...........................20D7960 Frenulectomy (frenectomy/frenotomy) - separate proc. .......132D7971 Excision of pericoronal gingiva ..............................................66D7979 Non-surgical sialolithotomy ....................................................22

ORTHODONTICS2 - PRE-AUTHORIZATION REQUIREDD8010 Limited ortho. treatment of the primary dentition ...............3304D8020 Limited ortho. treatment of the transitional dentition ............3304D8030 Limited ortho treatment - adolescent dentition ...................3422D8050 Interceptive ortho. treatment of the primary dentition ...........3304D8060 Interceptive ortho. treatment - transitional dentition ...........3304D8070 Comp. ortho. treatment - transitional dentition ...................3304D8080 Comp. ortho. treatment - adolescent dentition ...................3422D8090 Comp. ortho. treatment - adult dentition ............................3658D8210 Removable appliance therapy .............................................770D8220 Fixed appliance therapy .......................................................783D8660 Pre-orthodontic treatment visit .............................................413D8670 Periodic ortho. treatment visit (as part of contract) .............. 118D8680 Orthodontic ret. (rem. of appl./placement of retainer(s)) ............413

Exclusions & LimitationsPlan Exclusions1. Services which are covered under worker’s compensation, employer’s liability laws or the Pennsylvania Motor Vehicle Financial Responsibility Law.2. Services which are not necessary for the patient’s dental health as determined by the Plan.3. Cosmetic, elective or aesthetic dentistry except as required due to accidental bodily injury to sound natural teeth as determined by the Plan.4. Oral surgery requiring the setting of fractures or dislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformations where,intheopinionofthePlan,suchservicesshouldnotbeperformedinadentaloffice.6. Dispensing of drugs.7. Hospitalization for any dental procedure.8. Treatment required for conditions resulting from major disaster, epidemic, war, acts of war, whether declared or undeclared, or while on active duty as a member of the armed forces of any nation.9. Replacement due to loss or theft of prosthetic appliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpreauthorizedbysuchofficeorthePlan(withtheexception of out-of-area emergency dental services).12. Services related to the treatment of TMD (Temporomandibular Disorder) except if TMD is caused by severe, dysfunctional, handicapping malocclusion that requires medically necessary orthodontia services.13. Elective surgery including, but not limited to, extraction of non-pathologic, asymptomatic impacted teeth as determined by the Plan. The prophylactic removal of these teeth for medically necessary orthodontia services may be covered subject to review.14. Non-medically necessary orthodontia and Phase I Treatment codes D8010 and D8050 for medically necessary orthodontia are not coveredbenefitsunderthispolicy.DiscountsareprovidedtomembersthroughthePlan’sagreementswithitsparticipatingorthodontists. The provider agreements create no liability for payment by the Plan, and payments by the member for these services do not contribute totheOut-of-PocketMaximum.TheInvisalignsystemandsimilarspecializedbracesarenotacoveredbenefit.Seelimitation#23 concerning medically necessary orthodontia.

Plan Limitations1. One (1) evaluation (D0120, D0140, D0145, D0150, D0180) is covered per six (6) months, per patient. 2. One (1) teeth cleaning (D1110 or D1120) per six (6) months, per patient.3. One(1)fluorideapplicationeverysix(6)months,perpatient.4. One (1) set of bitewing x-rays are covered per six (6) months.5. One(1)setoffullmouthx-raysorpanoramicfilmiscoveredeveryfive(5)years.Panoramicx-raysarelimitedtoagessix(6)andabove. No more than one (1) set of x-rays are covered per visit. 6. One (1) sealant per tooth is covered per 36 months, per patient (limited to occlusal surfaces of posterior permanent teeth without restorations or decay). 7. Replacement of a primary stainless steel crown (under age 15), crown, denture or other prosthodontic appliance is covered if it is more thanfive(5)yearsfromthedateoforiginalplacement.8. Crownandbridgefeesapplytotreatmentinvolvingfive(5)orfewerunitswhenpresentedinasingletreatmentplan.Additionalcrownor bridge units, beginning with the sixth unit, are available at the provider’s Usual, Customary and Reasonable (UCR) fee, minus 25%.9. One (1) relining and rebasing of dentures is covered per 24 months, per patient.10. Periodontal scaling and root planing (D4341 or D4342), limited to one (1) per 24 months, per patient, per quadrant.11. Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation-fullmouth,afteroralevaluationandinlieuofacovered D1110/D1120, limited to once per two years. 12. Osseoussurgery(D4260orD4261),gingivalflapprocedure(D4240)andgingivectomyorgingivoplasy(D4210-D4212)arelimitedtoone (1) per 36 months.13. One (1) full mouth debridement is covered per lifetime, per patient.14. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthree(3)teethperquadrant;oratotalof12teethforallfour(4)quadrants pertwelve(12)months.Musthavepocketdepthsoffive(5)millimetersorgreater.15. One (1) periodontal surgery of any type, including any associated material, is covered every 24 months, per quadrant or surgical site.16. Periodontalmaintenanceiscoveredfour(4)timespercalendaryearinadditiontoadultprophylaxis,within24monthsafterdefinitive periodontal therapy.17. One(1)scalinganddebridementinthepresenceofinflammationormucositisofasingleimplant,includingcleaningoftheimplant surfaces,withoutflapentryandclosure,pertwo(2)years. 18. Coronectomy, intentional partial tooth removal, one (1) per lifetime. 19. General anesthesia and analgesic (only when provided in connection with a covered procedure(s) when determined to be medically or dentallynecessaryfordocumentedhandicappedoruncontrollablepatientsorjustifiablemedicalordentalconditions),including intravenous and non-intravenous sedation with a maximum of 60 minutes of services allowed (general anesthesia is not covered with procedure codes D9230, D9239 or D9243; intravenous conscious sedation is not covered with procedure code D9222, D9223 or D9230; non-intravenous conscious sedation is not covered with procedure code D9222, D9223 or D9230; requires a narrative of medical necessity be maintained in patient records.20. Occlusal guards are covered by report for patients 13 years of age or older when the purpose of the occlusal guard is for the treatment of bruxism or diagnoses other than temporomandibular dysfunction (TMD). Occlusal guards are limited to one (1) per 12 consecutive month period. 21. Fixed partial dentures, buildups, and posts and cores for members under 16 years of age are only covered if deemed necessary by the Plan.22. Onlays, crowns, and posts and cores for members 12 years of age or younger are only covered if deemed necessary by the Plan. Cast postsandcores(D2952)areprocessedasanalternatebenefitofaprefabricatedpostandcore.Postsareeligibleonlywhenprovidedas part of a crown buildup or implant and are considered integral to the buildup or implant. 23. Orthodontics is only covered if medically necessary as determined by the Plan. Patient copayments will apply to the routine orthodontic appliance portion of services only. Additional costs incurred will become the patient’s responsibility. 24. Teledentistry, synchronous (D9995) or asynchronous (D9996), limited to two per calendar year (when available).

D9439 Officevisit ........................................................................................................... 0 .............................................................0

DIAGNOSTIC/PREVENTIVED0120 Periodicoraleval-establishedpatient ............................................................... 0 .............................................................0D0140 Limitedoraleval-problemfocused .................................................................... 0 .............................................................0D0145 Oralevalforapatientunder3yearsofage ........................................................ 0 .............................................................0D0150 Comprehensiveoraleval-neworestablishedpatient ....................................... 0 .............................................................0D0160 Detailedandextensiveoraleval-problemfocused ........................................... 0 .............................................................0D0170 Re-evaluation-limited,problemfocused ............................................................ 0 .............................................................0D0210 Intraoral-completeseries(includingbitewings) ................................................. 0 .............................................................0D0220/30 Intraoral-periapicalfirstfilmandeachadditional ............................................... 0 .............................................................0D0240 Intraoral-occlusalfilm ........................................................................................ 0 .............................................................0D0250 Extraoral .............................................................................................................. 0 .............................................................0D0270-74 Bitewingx-rays-1-4films ................................................................................... 0 .............................................................0D0277 Verticalbitewings-7to8films ............................................................................ 0 .............................................................0D0330 Panoramicfilm .................................................................................................... 0 .............................................................0D0340 Cephalometricfilm .............................................................................................. 0 .............................................................0D0350 Oral/facialphotographicimages ......................................................................... 0 .............................................................0D0351 3Dphotographicimage ....................................................................................... 0 .............................................................0 D0460 Pulpvitalitytests ................................................................................................. 0 .............................................................0D0470 Diagnosticcasts .................................................................................................. 0 .............................................................0D1110 Prophylaxis(cleaning)-adult .............................................................................. 0 .............................................................0D1120 Prophylaxis(cleaning)-child .............................................................................. 0 .............................................................0D1206 Topicalfluoridevarnishformod/highriskcariespatients .................................... 0 .............................................................0D1208 Topicalapplicationoffluoride .............................................................................. 0 .............................................................0D1310 Nutritionalcounselingforcontrolofdentaldisease ............................................ 0 .............................................................0D1320/30 Oralhygieneinstructions .................................................................................... 0 .............................................................0D1351 Sealant-pertooth .............................................................................................. 0 .............................................................0D1352 Prevresinrest.mod/highcariesrisk–perm.tooth ............................................. 0 .............................................................0

SPACE MAINTAINERSD1510/20 Spacemaintainer-fixed/removable-unilateral .................................................. 0 .............................................................0D1515/25 Spacemaintainer-fixed/removable-bilateral .................................................... 0 .............................................................0D1550 Re-cementationofspacemaintainer .................................................................. 0 .............................................................0D1555 Removaloffixedspacemaintainer,bynon-originatingdentist .......................... 0 .............................................................0D1575 Distalshoespacemaintainer-fixed-unilateral ................................................. 0 .............................................................0

RESTORATIVE DENTISTRY (FILLINGS) AMALGAMRESTORATIONS(SILVER)D2140 Amalgam-onesurface,prim.orperm. ............................................................. 21 ...........................................................21D2150 Amalgam-twosurfaces,prim.orperm. ............................................................ 26 ...........................................................26D2160 Amalgam-threesurfaces,prim.orperm. ......................................................... 32 ...........................................................32D2161 Amalgam->=4surfaces,prim.orperm. ........................................................... 39 ...........................................................39

RESIN/COMPOSITERESTORATIONS(TOOTHCOLORED)D2330 Resin-basedcomposite-onesurface,anterior ................................................. 35 ...........................................................35D2331 Resin-basedcomposite-twosurfaces,anterior ................................................ 42 ...........................................................42D2332 Resin-basedcomposite-threesurfaces,anterior ............................................. 50 ...........................................................50D2335 Resin-basedcomposite->=4surfaces,anterior ............................................... 60 ...........................................................60D2390 Resin-basedcompositecrown,anterior ............................................................. 96 ...........................................................96D2391 Resin-basedcomposite-onesurface,posterior ............................................... 37 ...........................................................37D2392 Resin-basedcomposite-twosurfaces,posterior .............................................. 44 ...........................................................44

DMNVA19DBHINDPEDEHB

Select Plan Premium Kids 706s (VA)Description of Benefits & Member Copayments for Pediatric Services (under age 19)

CoveragecontinuesthroughendofmonthinwhichtheMemberturns19.

Underwritten by: Dominion Dental Services, Inc. d/b/a Dominion National

AnnualOut-of-PocketMaximum:$350perchildpercalendaryearformedicallynecessarytreatment(maximumof$700forpolicycoveringtwoormorechildren).ThemembershallonlyberesponsibleforthecopaymentlistedinMemberCopaymentcolumn.AnyprocedurelistedthathasaMemberCopaymentabovetheannualout-of-pocketmaximummayapplyastheseproceduresarenotconsideredmedicallynecessaryandareincludedasadditionalbenefits.ThePlanisresponsibleforthedifferencebetweentheActualCopaymentandtheMemberCopaymentforallmedicallynecessarytreatment.ADA MEMBER ACTUAL CODE BENEFIT COPAYMENT(S) COPAYMENT(S)

ADA MEMBER ACTUAL CODE BENEFIT COPAYMENT(S) COPAYMENT(S)

D2393 Resin-basedcomposite-threesurfaces,posterior ........................................... 51 ...........................................................51D2394 Resin-basedcomposite->=4surfaces,posterior ............................................. 62 ...........................................................62 D2940 Protectiverestoration ......................................................................................... 20 ...........................................................20D2950 Corebuildup,includinganypins ........................................................................ 63 ...........................................................63D2951 Pinretention-pertooth,inadditiontorestoration ..............................................11 ...........................................................11D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) ................................................ 16 ...........................................................16 CROWNS & BRIDGES♦

D2510/20 Inlay-metallic-1-2surfaces ............................................................................. 204 .........................................................204D2530 Inlay-metallic-threeormoresurfaces ............................................................ 213 .........................................................213D2542 Onlay-metallic-twosurfaces ............................................................................ 229 .........................................................229D2543/44 Onlay-metallic-threeormoresurfaces .......................................................... 262 .........................................................262D2610/20 Inlay-porcelain/ceramic-1-2surfaces ............................................................ 214 .........................................................214D2630 Inlay-porcelain/ceramic->=3surfaces ........................................................... 223 .........................................................223D2642 Onlay-porcelain/ceramic-twosurfaces .......................................................... 240 .........................................................240D2643/44 Onlay-porcelain/ceramic->=3surfaces ......................................................... 250 .........................................................250D2650/51/52 Inlay-resin-basedcomposite->=1surface(s) ................................................. 220 .........................................................220D2662/63/64 Onlay-resin-basedcomposite->=2surfaces ................................................. 222 .........................................................222D2710 Crown-resinbasedcomposite(indirect) ......................................................... 136 .........................................................136D2712 Crown-3/4resin-basedcomposite(indirect) ................................................... 243 .........................................................243D2720/21/22 Crown-resinwithmetal ................................................................................... 248 .........................................................248D2740 Crown-porcelain/ceramic ................................................................................ 280 .........................................................280D2750/51/52 Crown-porcelainfusedmetal .......................................................................... 262 .........................................................262D2780/81/82 Crown-3/4castwithmetal ............................................................................... 239 .........................................................239D2783 Crown-3/4porcelain/ceramic .......................................................................... 256 .........................................................256D2790-94 Crown-fullcastmetal ...................................................................................... 248 .........................................................248D2910/20 Recementinlay/crown ........................................................................................ 22 ...........................................................22D2915 Recementcastorprefab.postandcore ............................................................ 41 ...........................................................41D2929 Procelain/ceramiccrown-prim.tooth ............................................................... 280 .........................................................280D2930 Prefab.stainlesssteelcrown-prim.tooth ......................................................... 55 ...........................................................55D2931 Prefab.stainlesssteelcrown-perm.tooth ........................................................ 61 ...........................................................61D2932 Prefabricatedresincrown .................................................................................. 70 ...........................................................70D2933 Prefab.stainlesssteelcrownw/resinwindow .................................................. 136 .........................................................136D2934 Prefab.estheticcoatedprimarytooth ............................................................... 148 .........................................................148D2941 Interimtherapeuticrestoration,primarydentition ............................................... 16 ...........................................................16D2952 Castpostandcoreinadditiontocrown ............................................................. 93 ...........................................................93D2954 Prefab.postandcoreinadditiontocrown ......................................................... 77 ...........................................................77D2955 Postremoval(notinconj.withendo.therapy) ................................................... 53 ...........................................................53D2962 Labialveneer(porcelainlaminate)-laboratory ................................................. 225 .........................................................225D2970 Temporarycrown(fracturedtooth) ...................................................................... 0 .............................................................0D2980 Crownrepair,byreport ...................................................................................... 51 ...........................................................51 PROSTHETICS (DENTURES)D5110/20 Completedenture-maxillary/mandibular ......................................................... 349 .........................................................349D5130/40 Immediatedenture-maxillary/mandibular ........................................................ 350 .........................................................361D5211/12 Maxillary/mandibularpartialdenture-resinbase ................................................... 325 .........................................................325D5213/14 Maxillary/mandibularpartialdenture-castmetal ............................................. 350 .........................................................375D5221/22 Immediatemaxillary/mandibularpartialdenture ............................................... 325 .........................................................325D5223/24 Immediatemaxillary/mandibularpartialdenture ............................................... 375 .........................................................375 D5225/26 Maxillary/mandibularpartialdenture-flexiblebase .......................................... 350 .........................................................375D5281 Rem.unilateralpartialdenture-onepiececastmetal ...................................... 210 .........................................................210D5410/11 Adjustcompletedenture-maxillary/mandibular ................................................ 19 ...........................................................19D5421/22 Adjustpartialdenture-maxillary/mandibular ..................................................... 19 ...........................................................19D5511/12 Repairbrokencompletedenturebase-maxillary/mandibular ........................... 44 ...........................................................44D5520 Replacemissingorbrokenteeth-completedenture ........................................ 44 ...........................................................44D5611/12 Repairresinpartialdenturebase-maxillary/mandibular ................................... 44 ...........................................................44 D5621/22 Repaircastpartialframework-maxillary/mandibular ........................................ 44 ...........................................................44D5620 Repaircastframework ....................................................................................... 44 ...........................................................44D5630/60 Clasprepaired,replacedoradded ..................................................................... 58 ...........................................................58D5640 Replacebrokenteeth-pertooth ....................................................................... 44 ...........................................................44D5650 Addtoothtoexistingpartialdenture .................................................................. 44 ...........................................................44D5670/71 Replaceallteethandacryliconcastmetalframework(maxillary/mandibular) ...... 144 .........................................................144D5710/11 Rebasecompletemaxillary/mandibulardenture ............................................... 130 .........................................................130D5720/21 Rebasemaxillary/mandibularpartialdenture .................................................... 130 .........................................................130

♦Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused.

D5730/31 Relinecompletemaxillary/mandibulardenture(chairside) ..................................... 80 ...........................................................80D5740/41 Relinemaxillary/mandibularpartialdenture(chairside) ..................................... 78 ...........................................................78D5750/51 Relinecompletemaxillary/mandibulardenture(lab) ..........................................112 .........................................................112D5760/61 Relinemaxillary/mandibularpartialdenture(lab) ...............................................112 .........................................................112D5810/11 Interimcompletedenture-maxillary/mandibular .............................................. 181 .........................................................181D5820/21 Interimpartialdenture-maxillary/mandibular ................................................... 181 .........................................................181D5850/51 Tissueconditioning-maxillary/mandibular ........................................................ 40 ...........................................................40D5951 Feedingaid ....................................................................................................... 350 .........................................................698

BRIDGES & PONTICS♦

D6205 Pontic-indirectresinbasedcomposite ............................................................ 223 .........................................................223D6210-14 Pontic-metal .................................................................................................... 248 .........................................................248D6240/41/42 Pontic-porcelainfusedtometal ....................................................................... 262 .........................................................262D6245 Pontic-porcelain/ceramic ................................................................................. 280 .........................................................280D6250/51/52 Pontic-resinwithmetal .................................................................................... 248 .........................................................248D6545 Ret.-castmetalforresinbondedfixedprosthesis ........................................... 126 .........................................................126D6548 Ret.-porc./ceramicforresinbondedfixedprosthesis ...................................... 197 .........................................................197D6549 Resinret.forresinbondedfixedprosthesis ...................................................... 126 .........................................................126D6600 Inlay-porc./ceramic,twosurfaces ................................................................... 214 .........................................................214D6601 Inlay-porc./ceramic,>=3surfaces ................................................................... 223 .........................................................223D6602 Inlay-casthighnoblemetal,twosurfaces ....................................................... 204 .........................................................204D6603 Inlay-casthighnoblemetal,>=3surfaces ...................................................... 213 .........................................................213D6604 Inlay-castpredominantlybasemetal,twosurfaces ........................................ 204 .........................................................204D6605 Inlay-castpredominantlybasemetal,>=3surfaces ........................................ 213 .........................................................213D6606 Inlay-castnoblemetal,twosurfaces ............................................................... 204 .........................................................204D6607 Inlay-castnoblemetal,>=3surfaces .............................................................. 213 .........................................................213D6608 Onlay-porc./ceramic,twosurfaces ................................................................... 240 .........................................................240D6609 Onlay-porc./ceramic,threeormoresurfaces .................................................. 250 .........................................................250D6610 Onlay-casthighnoblemetal,twosurfaces ..................................................... 229 .........................................................229D6611 Onlay-casthighnoblemetal,>=3surfaces ..................................................... 262 .........................................................262D6612 Onlay-castpredominantlybasemetal,twosurfaces ...................................... 229 .........................................................229D6613 Onlay-castpredominantlybasemetal,>=3surfaces ...................................... 262 .........................................................262D6614 Onlay-castnoblemetal,twosurfaces ............................................................. 229 .........................................................229D6615 Onlay-castnoblemetal,>=3surfaces ............................................................ 262 .........................................................262D6710 Crown-indirectresinbasedcomposite ............................................................ 223 .........................................................223D6720/21/22 Crown-resinwithmetal ................................................................................... 248 .........................................................248D6740 Crown-porcelain/ceramic ................................................................................ 280 .........................................................280D6750/51/52 Crown-porcelainfusedtometal ...................................................................... 262 .........................................................262D6780/81/82 Crown-3/4castmetal ...................................................................................... 235 .........................................................235D6783 Crown-3/4porc./ceramic ................................................................................. 256 .........................................................256D6790-94 Crown-fullcastmetal ...................................................................................... 248 .........................................................248D6930 Recementfixedpartialdenture .......................................................................... 35 ...........................................................35D6980 Fixedpartialdenturerepair,byreport ................................................................ 86 ...........................................................86

ADJUNCTIVE GENERAL SERVICESD9110 Palliative(emergency)treatmentofdentalpain ................................................. 22 ...........................................................22D9210/15 Localanesthesia ................................................................................................. 0 .............................................................0D9211/12 Regionalblockanesthesia .................................................................................. 0 .............................................................0D9222 Deepsedation/generalanesthesia-first15min. ............................................... 52 ...........................................................52 D9223 Deepsedation/generalanesthesia-eachsubsequent15min.increment ....................52 ...........................................................52D9230 Analgesia,anxiolysis,inhalationofnitrousoxide ............................................... 19 ...........................................................19D9239 Intravenousmoderateconscioussedation/analgesia–first15min. ................. 52 ...........................................................52 D9243 Intravenousconscioussedation/analgesia-eachsubsequent 15min.increment. ........................................................................................ 52 ...........................................................52D9248 Non-intravenousconscioussedation ................................................................. 73 ...........................................................73D9310 Consultation(diagnosticservicebynontreatingdentist) ...................................... 22 ...........................................................22D9420 Hospitalcall ....................................................................................................... 175 .........................................................175D9440 Officevisitafterregularlyscheduledhours ........................................................ 45 ...........................................................45D9610 Therapeuticparenteraldrug,singleadmin. ....................................................... 13 ...........................................................13D9612 Therapeuticparenteraldrug,2ormoreadmin.,diff.med. ...................................... 35 ...........................................................35D9630 Drugsormedicamentsdispensedintheofficeforhomeuse ............................ 21 ...........................................................21D9910 Applicationofdesensitizingmedicament ........................................................... 16 ...........................................................16D9920 Behaviormanagement,byreport ....................................................................... 34 ...........................................................34D9930 Treatmentofcomplications(post-surgical) ........................................................ 22 ...........................................................22


♦Allfeesexcludethecostofnobleandpreciousmetals.Anadditionalfeewillbechargedifthesematerialsareused.

D9940 Occlusalguard,byreport(forgrindingandclenchingofteeth) ........................ 136 .........................................................136D9950 Occlusionanalysis-mountedcase ................................................................... 52 ...........................................................52D9951 Occlusaladjustment-limited ............................................................................. 33 ...........................................................33D9952 Occlusaladjustment-complete ........................................................................ 133 .........................................................133D9986 Missedappointment ........................................................................................... 50 ...........................................................50 D9995 Teledentistry–synchronous;real-timeencounter(whenavailable) .................. 20 ...........................................................20 D9996 Teledentistry–asynchronous;informationstoredandforwardedto dentistforsubsequentreview(whenavailable) ............................................ 20 ...........................................................20 ENDODONTICS1

D3220 Therapeuticpulpotomy(excl.finalrestor.) ......................................................... 41 ...........................................................41D3221 Pulpaldebridement,prim.andperm.teeth ........................................................ 47 ...........................................................47D3230 Pulpaltherapy-resorbablefilling,anterior ........................................................ 80 ...........................................................80D3240 Pulpaltherapy-resorbablefilling,posterior ....................................................... 82 ...........................................................82D3310 Endodontictherapy,anteriortooth(excludingfinalrestoration) ........................ 171 .........................................................171D3320 Endodontictherapy,premolartooth(excludingfinalrestoration) ...................... 209 .........................................................209D3330 Endodontictherapy,molartooth(excludingfinalrestoration) ........................... 256 .........................................................256D3333 Internalrootrepairofperforationdefects ........................................................... 53 ...........................................................53D3346 Retreatofprev.rootcanaltherapy,anterior ...................................................... 194 .........................................................194D3347 Retreatofprev.rootcanaltherapy,premolar .................................................... 233 .........................................................233D3348 Retreatofprev.rootcanaltherapy,molartooth(excludingfinalrestoration) ........279 .........................................................279D3351 Apexification/recalcification-initialvisit ............................................................ 101 .........................................................101D3352 Apexification/recalcification-interimmed.repl. ................................................ 295 .........................................................295D3353 Apexification/recalcification-finalvisit .............................................................. 225 .........................................................225D3355 Pulpalregeneration-initialvisit ........................................................................ 101 .........................................................101D3356 Pulpalregeneration-interimmedication .......................................................... 295 .........................................................295D3357 Pulpalregeneration-completionoftreatment .................................................. 225 .........................................................225D3410 Apicoectomy-anterior ...................................................................................... 162 .........................................................162D3421 Apicoectomy-premolar(firstroot) .................................................................... 182 .........................................................182D3425 Apicoectomy-molar(firstroot) ......................................................................... 209 .........................................................209D3426 Apicoectomy-(eachadd.root) .......................................................................... 76 ...........................................................76D3427 Periradicularsurgeryw/oapicoectomy ............................................................. 133 .........................................................133D3428 Bonegraftinconj.w/periradicularsurg.,pertooth,singlesite .......................................372..................................................................372 D3429 Bonegraftinconj.w/periradicularsurg.,add.contiguoustooth,samesite ..... 291 .........................................................291D3430 Retrogradefilling-perroot ................................................................................ 60 ...........................................................60D3450 Rootamputation-perroot .................................................................................117 .........................................................117D3920 Hemisection,notinc.rootcanaltherapy ............................................................117 .........................................................117D3950 Canalprep/fittingofpreformeddowelorpost .................................................... 68 ...........................................................68 PERIODONTICS1

D0180 Comp.periodontaleval-neworestablishedpatient .......................................... 0 .............................................................0D4210 Gingivectomyorgingivoplasty->3cont.teeth,perquad. ...................................... 140 .........................................................140D4211 Gingivectomyorgingivoplasty-<=3teeth,perquad. ........................................ 50 ...........................................................50D4240 Gingivalflapproc.,inc.rootplaning->3cont.teeth,perquad ........................ 173 .........................................................173D4241 Gingivalflapproc,inc.rootplaning-<=3cont.teeth,perquad ........................ 53 ...........................................................53D4249 Clinicalcrownlengthening-hardtissue ........................................................... 288 .........................................................288D4260 Osseoussurgery->3cont.teeth,perquad ..................................................... 250 .........................................................250D4261 Osseoussurgery-<=3cont.teeth,perquad ................................................... 196 .........................................................196D4263 Bonereplacementgraft,firstsiteinquad. ........................................................ 350 .........................................................372D4264 Bonereplacementgraft,eachadd.siteinquad. .............................................. 291 .........................................................291D4268 Surgicalrevisionproc.,pertooth ...................................................................... 179 .........................................................179D4270 Pediclesofttissuegraftprocedure .................................................................... 322 .........................................................322D4273 Subepithelialconnectivetissuegraftproc. ........................................................ 350 .........................................................400D4274 Mesial/distalwedgeprocedure,singletooth ..................................................... 154 .........................................................154D4277 Freesofttissuegraft,pertooth ......................................................................... 327 .........................................................327D4278 Freesofttissuegraft,eachadd.tooth ............................................................... 50 ...........................................................50D4320 Provisionalsplinting-intracoronal .................................................................... 214 .........................................................214D4321 Provisionalsplinting-extracoronal ................................................................... 189 .........................................................189D4341 Perioscalingandrootplaning->3contteeth,perquad. .................................. 55 ...........................................................55D4342 Perioscalingandrootplaning-<=3teeth,perquad ........................................ 32 ...........................................................32D4346 Scalinginpresenceofgeneralizedmoderateorseveregingival inflammation-fullmouth,afteroralevaluation ............................................. 23 ...........................................................23 D4355 Fullmouthdebridement ..................................................................................... 45 ...........................................................45D4381 Localizeddeliveryofchemotherapeuticagents ................................................. 49 ...........................................................49D4910 Periodontalmaintenance ................................................................................... 37 ...........................................................37


ORAL SURGERY1

D7111 Extraction,coronalremnants-primarytooth ..................................................... 28 ...........................................................28D7140 Extraction,eruptedtoothorexposedroot .......................................................... 35 ...........................................................35D7210 Extraction,eruptedtoothreq.bonecut .............................................................. 67 ...........................................................67D7220 Removalofimpactedtooth-softtissue ............................................................. 76 ...........................................................76D7230 Removalofimpactedtooth-partiallybony ........................................................ 98 ...........................................................98D7240 Removalofimpactedtooth-completelybony .................................................. 121 .........................................................121D7241 Removalofimp.tooth-completelybony,withunusualsurg.complications .... 109 .........................................................109D7250 Removalofresidualtoothroots ......................................................................... 71 ...........................................................71D7251 Coronectomy-intentionalpartialtoothremoval ................................................. 109 .........................................................109 D7260 Oroantralfistulaclosure .................................................................................... 289 .........................................................289D7261 Primaryclosureofasinusperforation .............................................................. 233 .........................................................233D7270 Toothreimplant./stabiliz.ofacc.evulsed/displacedtooth .......................................113 .........................................................113D7280 Exposureofanuneruptedtooth ......................................................................... 77 ...........................................................77D7282 Mobil.oferupted/malpositionedtoothtoaideruption ........................................116 .........................................................116D7283 Place.ofdevicetofacilitateerupt.ofimpactedtooth ......................................... 72 ...........................................................72D7285 Biopsyoforaltissue-hard(bone,tooth) .......................................................... 194 .........................................................194D7286 Biopsyoforaltissue-soft(allothers) ............................................................... 148 .........................................................148D7288 Brushbiopsy-transepithelialsamplecollect ..................................................... 47 ...........................................................47D7291 Transseptalfiberotomy/supracrestalfiberotomy,byreport ............................... 30 ...........................................................30D7310/20 Alveoloplasty,>=4perquad. .............................................................................. 71 ...........................................................71D7311/21 Alveoloplastyinconj.with/outextractions .......................................................... 71 ...........................................................71D7450 Removalofbenignodoncyst/tumor-diam<=1.25cm ..................................... 177 .........................................................177D7451 Removalofbenignodoncyst/tumor-diam>1.25cm........................................ 272 .........................................................272D7471 Removaloflateralexostosis ............................................................................. 176 .........................................................176D7472/73 Removaloftoruspalatinus/mandibularis .......................................................... 240 .........................................................240D7485 Surgicalreductionofosseoustuberosity .......................................................... 284 .........................................................284D7510 Incisionanddrainageofabscess-intraoralsofttissue ..................................... 48 ...........................................................48D7511 Incision/drainageofabscess-intra.softtissue,comp. ..................................... 56 ...........................................................56D7880 OcclusalorthoticdeviceforTMJ,“byreport” .................................................... 136 .........................................................136D7960 Frenulectomy(frenectomy/frenotomy)-separateproc. .................................... 132 .........................................................132D7963 Frenuloplasty .................................................................................................... 147 .........................................................147D7970 Excisionofhyperplastictissue-perarch ...........................................................117 .........................................................117D7971 Excisionofpericoronalgingiva .......................................................................... 66 ...........................................................66D7972 Surgicalreductionoffibroustuberosity ............................................................. 261 .........................................................261D7979 Non-surgicalsialolithotomy ................................................................................ 22 ...........................................................22 ORTHODONTICS2 - PRE-AUTHORIZATION REQUIREDD8020 Limitedortho.treatmentofthetransitionaldentition ........................................... 350 ........................................................3304D8030 Lim.orthotreatment-adolescentdentition ....................................................... 350 ........................................................3422D8040 Lim.orthotreatment-adultdentition ............................................................... 3658 .......................................................3658D8070 Comp.ortho.treatment-transitionaldentition ................................................. 3304 .......................................................3304D8080 Comp.ortho.treatment-adolescentdentition .................................................. 350 ........................................................3422D8090 Comp.ortho.treatment-adultdentition .......................................................... 3658 .......................................................3658D8210 Removableappliancetherapy(includingappliancesforthumbsucking andtonguethrusting) ................................................................................... 350 .........................................................770D8220 Fixedappliancetherapy(includingappliancesforthumbsucking andtonguethrusting) ................................................................................... 350 .........................................................783D8660 Pre-orthodontictreatmentvisit .......................................................................... 350 .........................................................413D8670 Periodicortho.treatmentvisit(aspartofcontract) ............................................118 .........................................................118D8680 Orthodonticret.(rem.ofappl./placementofretainer(s)) ............................................ 413 .........................................................413D8692 Replacementoflostorbrokenretainer ............................................................. 179 .........................................................179D8694 Repairoffixedretainers,includesreattachment ............................................... 174 .........................................................174D8999 Unspecifiedorthodonticprocedure,byreport ..................................................... 0 .............................................................0


1 Specialty care is provided at the listed copayment whether performed by a Participating General Dentist or a Participating Specialist. See Plan Exclusion #13.

2 Phase I Treatment codes D8010 and D8050 are provided at a 15% reduction from the orthodontist’s UCR fees. See exclusion #14 and limitation #23 for additional coverage information.

OnlycurrentADACDTcodesareconsideredvalidbyDominionNational.Current Dental Terminology © American Dental Association.

Exclusions & LimitationsPlan Exclusions1. Serviceswhicharecoveredunderworker’scompensationoremployer’sliabilitylaws.2. Serviceswhicharenotnecessaryforthepatient’sdentalhealthasdeterminedbythePlan.3. Cosmetic,electiveoraestheticdentistryexceptasrequiredduetoaccidentalbodilyinjurytosoundnaturalteethasdeterminedbythe Plan.4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Serviceswithrespecttomalignancies,cystsorneoplasms,hereditary,congenital,mandibularprognathismordevelopmentmalformations where,intheopinionofthePlan,suchservicesshouldnotbeperformedinadentaloffice.6. Dispensingofdrugs.7. Hospitalizationforanydentalprocedure.8. Treatmentrequiredforconditionsresultingfrommajordisaster,epidemic,war,actsofwar,whetherdeclaredorundeclared,orwhileon activedutyasamemberofthearmedforcesofanynation.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. ServicesobtainedoutsideofthedentalofficeinwhichenrolledandthatarenotpreauthorizedbysuchofficeorthePlan(withtheexception ofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(TemporomandibularDisorder)exceptifTMDiscausedbysevere,dysfunctional,handicapping malocclusionthatrequiresmedicallynecessaryorthodontiaservices.13. Electivesurgeryincluding,butnotlimitedto,extractionofnon-pathologic,asymptomaticimpactedteethasdeterminedbythePlan.The prophylacticremovaloftheseteethformedicallynecessaryorthodontiaservicesmaybecoveredsubjecttoreview.14. Non-medicallynecessaryorthodontiaandPhaseITreatmentcodesD8010andD8050formedicallynecessaryorthodontiaarenot coveredbenefitsunderthispolicy.DiscountsareprovidedtomembersthroughthePlan’sagreementswithitsparticipatingorthodontists. TheprovideragreementscreatenoliabilityforpaymentbythePlan,andpaymentsbythememberfortheseservicesdonotcontribute totheOut-of-PocketMaximum.TheInvisalignsystemandsimilarspecializedbracesarenotacoveredbenefit.Seelimitation#23 concerningmedicallynecessaryorthodontia.

Plan Limitations1. One(1)evaluation(D0120,D0145orD0150)persix(6)months,perpatient.2. One(1)teethcleaning(D1110orD1120)persix(6)months,perpatient.3. One(1)fluoridetreatmentiscoveredpersix(6)months,perpatient.4. One(1)sealantpertooth,perlifetime,perpatient(limitedtoocclusalsurfacesofposteriorpermanentteethwithoutrestorationsordecay).5. One(1)spacemaintainer(D1510,D1520,D1515orD1525)iscoveredper12months,perquadrant(unilateral)orperarch(bilateral),per patient;one(1)distalshoespacemaintainer(D1575),fixed,unilateralper24months.6. Replacementofafillingiscoveredifitismorethan12monthsfromthedateoforiginalplacement.7. Replacementofacrown,dentureorlabialveneeriscoveredifitismorethanfive(5)yearsfromthedateoforiginalplacement.8. Replacementofaprimarystainlesssteelcrowniscoveredifitismorethanthree(3)yearsfromthedateoforiginalplacement,pertooth, perpatient.9. Crownandbridgefeesapplytotreatmentinvolvingfiveorfewerunitswhenpresentedinasingletreatmentplan.Additionalcrownor bridgeunits,beginningwiththesixthunit,areavailableattheprovider’sUsual,Customary,andReasonable(UCR)fee,minus25%.10. Reliningandrebasingofdenturesiscoveredonceper24months,perpatient,onlyaftersix(6)monthsofinitialplacement.11. Rootcanaltreatmentiscoveredoncepertooth,perlifetime,perpatient.Retreatmentofpreviousrootcanaltherapyiscoveredonceper tooth,perlifetime,perpatient.12. Periodontalscalingandrootplaning(D4341orD4342),osseoussurgery(D4260orD4261)andgingivectomyorgingivoplasy(D4210or D4211)arelimitedtoone(1)per24months,perquadrant,perpatient.13. Scalinginpresenceofgeneralizedmoderateorseveregingivalinflammation-fullmouth,afteroralevaluationandinlieuofacovered D1110/D1120,limitedtooncepertwoyears.14. Fullmouthdebridementiscoveredonceper12months,perpatient.15. ProcedureCodeD4381islimitedtoone(1)benefitpertoothforthree(3)teethperquadrant;oratotalof12teethforallfour(4)quadrants pertwelve(12)months,perpatient.Musthavepocketdepthsoffive(5)millimetersorgreater.16. Periodontalsurgeryofanytype,includinganyassociatedmaterial,iscoveredonceevery24months,perquadrantorsurgicalsite,per patient.17. Periodontalmaintenanceafteractivetherapyiscoveredfour(4)timesper12months,perpatient.18. Coronectomy,intentionalpartialtoothremoval,one(1)perlifetime.19. Alldentalservicesthataretoberenderedinahospitalsettingrequirecoordinationandapprovalfromboththedentalinsurerandthe medicalinsurerbeforeservicescanberendered.Servicesdeliveredtothepatientonthedateofservicearedocumentedseparatelyusing applicableprocedurecodes.20. Anesthesiarequiresanarrativeofmedicalnecessitybemaintainedinpatientrecords.Amaximumof60minutesofservicesareallowed forgeneralanesthesiaandintravenousornon-intravenousconscioussedation.Theroutineadministrationofinhalationanalgesiaororal sedationisgenerallyconsideredpartofthetreatmentprocedure,unlessitsuseisdocumentedinthepatientrecordasnecessaryto completetreatment.21. Occlusalguard,byreport(forgrindingandclenchingofteeth).22. Apexification,apicoectomyandclinicalcrownlengtheningareeachcoveredoncepertooth,perprovider,perlifetime.23. OrthodonticsisonlycoveredifmedicallynecessaryasdeterminedbythePlanandislimitedtoonceperlifetime.Patientcopaymentswillapply totheroutineorthodonticapplianceportionofservicesonly.Additionalcostsincurredwillbecomethepatient’sresponsibility. 24. Teledentistry,synchronous(D9995)orasynchronous(D9996),limitedtotwopercalendaryear(whenavailable).

Documents

Select Plan Premium Kids 706s (DC) - Dominion National · Select Plan Premium Kids 706s (DC) Description of Benefits & Member Copayments for Pediatric Services (under age 19) Coverage