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Summary Plan Description (SPD)
This section replaced by: Amendment 9. View Previous Language
DeltaCare USA Dental Health Plan – DeltaCare Plan CA10A
SCHEDULE A
DESCRIPTION OF BENEFITS AND COPAYMENTS
PLAN CA10A
The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program. Please refer to Schedule B for further clarification of benefits. Enrollees should discuss all treatment options with their Contract Dentist prior to services being rendered.
Codes and/or text that appear in italics below are specifically intended to clarify the delivery of benefits under the DeltaCare USA program and are not to be interpreted as CDT 2007-2008 procedure codes, descriptors or nomenclature which are under copyright by the American Dental Association. The American Dental Association may periodically change CDT codes or definitions. Such updated codes, descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation.
| Code | Description | ENROLLEE PAYS |
| D0100-D0999 I. DIAGNOSTIC | ||
| D0120 | Periodic oral evaluation – established patient | No Cost |
| D0140 | Limited oral evaluation - problem focused | No Cost |
| D0145 | Oral evaluation for a patient under three years of age and counseling with primary caregiver | No Cost |
| D0150 | Comprehensive oral evaluation - new or established patient | No Cost |
| D0160 | Detailed and extensive oral evaluation - problem focused, by report | No Cost |
| D0170 | Re-evaluation - limited, problem focused (established patient; not post-operative visit) | No Cost |
| D0180 | Comprehensive periodontal evaluation - new or established patient | No Cost |
| D0210 | Intraoral radiographs - complete series (including bitewings) - limited to 1 series every 24 months | No Cost |
| D0220 | Intraoral - periapical first film | No Cost |
| D0230 | Intraoral - periapical, each additional film | No Cost |
| D0240 | Intraoral - occlusal film | No Cost |
| D0260 | Extraoral – each additional film | No Cost |
| D0270 | Bitewing radiograph - single film | No Cost |
| D0272 | Bitewings radiographs - two films | |
| D0273 | Bitewings radiographs – three films | No Cost |
| D0274 | Bitewings radiographs - four films - limited to 1 series every 6 months | No Cost |
| D0277 | Vertical bitewings – 7 to 8 films | No Cost |
| D0330 | Panoramic film | No Cost |
| D0415 | Collection of microorganisms for culture and sensitivity | No Cost |
| D0425 | Caries susceptibility tests | No Cost |
| D0460 | Pulp vitality tests | No Cost |
| D0470 | Diagnostic casts | No Cost |
| D0472 | Accession of tissue, gross examination, preparation and transmission of written report | No Cost |
| D0473 | Accession of tissue, gross and microscopic examination, preparation and transmission of written report | No Cost |
| D0474 | Accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report | No Cost |
| D0999 | Unspecified diagnostic procedure, by report -includes office visit, per visit (in addition to other services) | No Cost |
| D1000-D1999 II. PREVENTIVE | ||
| D1110 | Prophylaxis cleaning - adult - 1 per 6month period | No Cost |
| D1110 | Additional prophylaxis cleaning – adult(within the 6 month period) | $ 45.00 |
| D1120 | Prophylaxis cleaning - child - 1 per 6-month period | No Cost |
| D1120 | Additional prophylaxis cleaning – child(within the 6 month period) | $ 35.00 |
| D1203 | Topical application of fluoride (prophylaxis not included) - child - to age 19; 1 per 6 month period | No Cost |
| D1206 | Topical fluoride varnish; therapeutic application for moderate to high caries risk patients – child to age 19; 1 per 6 month period | No Cost |
| D1310 | Nutritional counseling for control of dental disease | No Cost |
| D1330 | Oral hygiene instructions | No Cost |
| D1351 | Sealant - per tooth - limited to permanent molars through age 15 | $ 5.00 |
| D1510 | Space maintainer - fixed - unilateral | $ 10.00 |
| D1515 | Space maintainer - fixed - bilateral | $ 10.00 |
| D1520 | Space maintainer - removable - unilateral | $ 10.00 |
| D1525 | Space maintainer - removable - bilateral | $ 10.00 |
| D1550 | Recementation of space maintainer | No Cost |
| D1555 | Removal of fixed space maintainer | No Cost |
| D2000-D2999 III. RESTORATIVE Includes polishing, all adhesives and bonding agents, indirect pulp capping, bases, liners and acid etch procedures. - When there are more than six crowns in the same treatment plan, an Enrollee may be charged an additional $100 per crown, beyond the 6 th unit. - Replacement of crowns, inlays and onlays requires the existing restoration to be 5+ years old. |
||
| D2140 | Amalgam - one surface, primary or permanent | No Cost |
| D2150 | Amalgam - two surfaces, primary or permanent | No Cost |
| D2160 | Amalgam - three surfaces, primary or permanent | No Cost |
| D2161 | Amalgam - four or more surfaces, primary orpermanent | No Cost |
| D2330 | Resin-based composite - one surface, anterior | No Cost |
| D2331 | Resin-based composite - two surfaces, anterior | No Cost |
| D2332 | Resin-based composite - three surfaces, anterior | No Cost |
| D2335 | Resin-based composite - four or more surfaces or involving incisal angle (anterior) | No Cost |
| D2390 | Resin-based composite crown, anterior | No Cost |
| D2391 | Resin-based composite - one surface, posterior | $ 45.00 |
| D2392 | Resin-based composite - two surfaces, posterior | $ 55.00 |
| D2393 | Resin-based composite - three surfaces, posterior | $ 65.00 |
| D2394 | Resin-based composite - four or more surfaces, posterior | $ 75.00 |
| D2510 | Inlay - metallic - one surface | No Cost |
| D2520 | Inlay - metallic - two surfaces | No Cost |
| D2530 | Inlay - metallic - three or more surfaces | No Cost |
| D2542 | Onlay - metallic - two surfaces | No Cost |
| D2543 | Onlay - metallic - three surfaces | No Cost |
| D2544 | Onlay - metallic - four or more surfaces | No Cost |
| D2610 | Inlay - porcelain/ceramic - one surface | $135.00 |
| D2620 | Inlay - porcelain/ceramic - two surfaces | $150.00 |
| D2630 | Inlay - porcelain/ceramic - three or more surfaces | $160.00 |
| D2642 | Onlay - porcelain/ceramic - two surfaces | $150.00 |
| D2643 | Onlay - porcelain/ceramic - three surfaces | $165.00 |
| D2644 | Onlay - porcelain/ceramic - four or more surfaces | $175.00 |
| D2650 | Inlay - resin-based composite - one surface | $ 85.00 |
| D2651 | Inlay - resin-based composite - two surfaces | $ 95.00 |
| D2652 | Inlay - resin-based composite - three or more surfaces | $115.00 |
| D2662 | Onlay - resin-based composite - two surfaces | $110.00 |
| D2663 | Onlay - resin-based composite - three surfaces | $120.00 |
| D2664 | Onlay - resin-based composite - four or more surfaces | $145.00 |
| D2710 | Crown - resin –based composite (indirect) | $ 35.00 |
| D2710 | Crown - resin –based composite (indirect) – (molars) | $ 35.00 |
| D2712 | Crown - ¾ resin-based composite (indirect) | $ 35.00 |
| D2712 | Crown - ¾ resin-based composite (indirect) – (molars) | $ 35.00 |
| D2720 | Crown - resin with high noble metal | $155.00 |
| D2720 | Crown - resin with high noble metal - (molars) | $155.00 |
| D2721 | Crown - resin with predominantly base metal | $ 55.00 |
| D2721 | Crown - resin with predominantly base metal - (molars) | $ 55.00 |
| D2722 | Crown - resin with noble metal | $ 95.00 |
| D2722 | Crown - resin with noble metal - (molars) | $ 95.00 |
| D2740 | Crown - porcelain/ceramic substrate | $195.00 |
| D2740 | Crown - porcelain/ceramic substrate - (molars) | $195.00 |
| D2750 | Crown - porcelain fused to high noble metal | $195.00 |
| D2750 | Crown - porcelain fused to high noble metal - (molars) | $195.00 |
| D2751 | Crown - porcelain fused to predominantly base metal | $ 95.00 |
| D2751 | Crown - porcelain fused to predominantly base metal - (molars) | $ 95.00 |
| D2752 | Crown - porcelain fused to noble metal | $135.00 |
| D2752 | Crown - porcelain fused to noble metal - (molars) | $135.00 |
| D2780 | Crown - ¾ cast high noble metal | $170.00 |
| D2781 | Crown - ¾ cast predominantly base metal | $ 70.00 |
| D2782 | Crown - ¾ cast noble metal | $110.00 |
| D2783 | Crown - ¾ porcelain/ceramic | $195.00 |
| D2783 | Crown - ¾ porcelain/ceramic - (molars) | $195.00 |
| D2790 | Crown - full cast high noble metal | $170.00 |
| D2791 | Crown - full cast predominantly base metal | $ 70.00 |
| D2792 | Crown - full cast noble metal | $110.00 |
| D2794 | Crown - titanium | $195.00 |
| D2910 | Recement inlay, onlay or partial coverage restoration | No Cost |
| D2915 | Recement cast or prefabricated post and core | No Cost |
| D2920 | Recement crown | No Cost |
| D2930 | Prefabricated stainless steel crown - primary tooth | No Cost |
| D2931 | Prefabricated stainless steel crown - permanent tooth | No Cost |
| D2932 | Prefabricated resin crown - anterior primary tooth | $ 15.00 |
| D2933 | Prefabricated stainless steel crown with resin window - anterior primary tooth | $ 10.00 |
| D2940 | Sedative filling | No Cost |
| D2950 | Core buildup, including any pins | No Cost |
| D2951 | Pin retention - per tooth, in addition to restoration | No Cost |
| D2952 | Post and core in addition to crown, indirectly fabricated - includes canal preparation | No Cost |
| D2953 | Each additional indirectly fabricated post - same tooth - includes canal preparation | No Cost |
| D2954 | Prefabricated post and core in addition to crown - base metal post; includes canal preparation | No Cost |
| D2957 | Each additional prefabricated post - same tooth - base metal post; includes canal preparation | No Cost |
| D2970 | Temporary crown (fractured tooth) - palliative treatment only | $5.00 |
| D2971 | Additional procedures to construct new crown under existing partial denture framework | $ 19.00 |
| D2980 | Crown repair, by report | $ 10.00 |
| D3000-D3999 IV. ENDODONTICS | ||
| D3110 | Pulp cap - direct (excluding final restoration) | No Cost |
| D3120 | Pulp cap - indirect (excluding final restoration) | No Cost |
| D3220 | Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament | No Cost |
| D3221 | Pulpal debridement, primary and permanent teeth | $ 5.00 |
| D3230 | Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) | $ 5.00 |
| D3240 | Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) | $ 5.00 |
| D3310 | Root canal - anterior (excluding final restoration) | $ 45.00 |
| D3320 | Root canal - bicuspid (excluding final restoration) | $ 90.00 |
| D3330 | Root canal - molar (excluding final restoration) | $205.00 |
| D3331 | Treatment of root canal obstruction; non-surgical access | $ 45.00 |
| D3332 | Incomplete endodontic therapy; inoperable, unrestorable or Fractured tooth | $ 45.00 |
| D3333 | Internal root repair of perforation defects | $ 45.00 |
| D3346 | Retreatment of previous root canal therapy - anterior | $ 60.00 |
| D3347 | Retreatment of previous root canal therapy - bicuspid | $105.00 |
| D3348 | Retreatment of previous root canal therapy - molar | $220.00 |
| D3351 | Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) | $ 70.00 |
| D3352 | Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) | $ 45.00 |
| D3353 | Apexification/recalcification – final visit (includes completed root canal therapy – apical closure/calcific repair of perforations, root resorption, etc.) | $ 45.00 |
| D3410 | Apicoectomy/periradicular surgery - anterior | No Cost |
| D3421 | Apicoectomy/periradicular surgery - bicuspid (first root) | No Cost |
| D3425 | Apicoectomy/periradicular surgery - molar (first root) | No Cost |
| D3426 | Apicoectomy/periradicular surgery (each additional root) | No Cost |
| D3430 | Retrograde filling - per root | No Cost |
| D3450 | Root amputation, per root - not covered in conjunction with procedure D3920 | No Cost |
| D3920 | Hemisection (including any root removal), not including root canal therapy | No Cost |
| D4000-D4999 V. PERIODONTICS Includes preoperative and postoperative evaluations and treatment under a local anesthetic. |
||
| D4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant | $ 80.00 |
| D4211 | Gingivectomy or gingivoplasty - one to three contiguous teeth or bonded teeth spaces per quadrant | $ 50.00 |
| D4240 | Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant | $ 80.00 |
| D4241 | Gingival flap procedure, including root planing – one to three contiguous or bonded teeth spaces per quadrant | $ 50.00 |
| D4245 | Apically positioned flap | $ 75.00 |
| D4249 | Clinical crown lengthening – hard tissue | $ 75.00 |
| D4260 | Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant | $175.00 |
| D4261 | Osseous surgery (including flap entry and closure) - one to three contiguous or bonded teeth spaces per quadrant | $140.00 |
| D4263 | Bone replacement graft – first site in quadrant | $195.00 |
| D4263 | Bone replacement graft – each additional site in quadrant | $ 60.00 |
| D4270 | Pedicle soft tissue graft procedure | $195.00 |
| D4271 | Free soft tissue graft procedure (including donor site surgery) | $195.00 |
| D4274 | Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) | $ 45.00 |
| D4341 | Periodontal scaling and root planing - four or more teeth per quadrant - limited to 4 quadrants during any 12 consecutive months | No Cost |
| D4342 | Periodontal scaling and root planing, one to three teeth per quadrant - limited to 4 quadrants during any 12 consecutive months | No Cost |
| D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis - limited to 1 treatment in any 12 consecutive months | No Cost |
| D4910 | Periodontal maintenance - limited to 1 treatment each 6 month period | No Cost |
| D4910 | Additional periodontal maintenance (within the 6 month period) | $ 55.00 |
| D5000-D5899 VI. PROSTHODONTICS (removable) - For all listed dentures and partial dentures, Copayment includes after delivery adjustments and tissue conditioning, if needed, for the first six months after placement, if the Enrollee continues to be eligible and the service is provided at the Contract Dentist’s facility where the denture was originally delivered. - Rebases, relines and tissue conditioning arelimited to 1 per denture during any 12 consecutive months. - Replacement of a denture or partial denture requires the existing denture to be 5+ years old. |
||
| D5110 | Complete denture - maxillary | $100.00 |
| D5120 | Complete denture - mandibular | $100.00 |
| D5130 | Immediate denture - maxillary | $120.00 |
| D5140 | Immediate denture - mandibular | $120.00 |
| D5211 | Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) | $ 80.00 |
| D5212 | Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) | $ 80.00 |
| D5213 | Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $120.00 |
| D5214 | Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) | $120.00 |
| D5225 | Maxillary partial denture – flexible base (including any clasps, rests and teeth) | $170.00 |
| D5226 | Mandibular partial denture – flexible base (including any clasps, rests and teeth) | $170.00 |
| D5410 | Adjust complete denture - maxillary | No Cost |
| D5411 | Adjust complete denture - mandibular | No Cost |
| D5421 | Adjust partial denture - maxillary | No Cost |
| D5422 | Adjust partial denture - mandibular | No Cost |
| D5510 | Repair broken complete denture base | $ 15.00 |
| D5520 | Replace missing or broken teeth - complete denture (each tooth) | $ 5.00 |
| D5610 | Repair resin denture base | $ 15.00 |
| D5620 | Repair cast framework | $ 15.00 |
| D5630 | Repair or replace broken clasp | $ 15.00 |
| D5640 | Replace broken teeth - per tooth | $ 5.00 |
| D5650 | Add tooth to existing partial denture | $ 5.00 |
| D5660 | Add clasp to existing partial denture | $ 5.00 |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) | $ 75.00 |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) | $ 75.00 |
| D5710 | Rebase complete maxillary denture | $ 35.00 |
| D5711 | Rebase complete mandibular denture | $ 35.00 |
| D5720 | Rebase maxillary partial denture | $ 35.00 |
| D5721 | Rebase mandibular partial denture | $ 35.00 |
| D5730 | Reline complete maxillary denture (chairside) | No Cost |
| D5731 | Reline complete mandibular denture (chairside) | No Cost |
| D5740 | Reline maxillary partial denture (chairside) | No Cost |
| D5741 | Reline mandibular partial denture (chairside) | No Cost |
| D5750 | Reline complete maxillary denture (laboratory) | $ 35.00 |
| D5751 | Reline complete mandibular denture (laboratory) | $ 35.00 |
| D5760 | Reline maxillary partial denture (laboratory) | $ 35.00 |
| D5761 | Reline mandibular partial denture (laboratory) | $ 35.00 |
| D5820 | Interim partial denture (maxillary) - limited to 1 in any 12 consecutive months | $ 45.00 |
| D5821 | Interim partial denture (mandibular) - limited to 1 in any 12 consecutive months | $ 45.00 |
| D5850 | Tissue conditioning, maxillary | No Cost |
| D5851 | Tissue conditioning, mandibular | No Cost |
| D5900-D5999VII. MAXILLOFACIAL PROSTHETICS - Not Covered | ||
| D6000-D6199VIII. IMPLANT SERVICES - Not Covered | ||
D6200-D6999 IX. PROSTHODONTICS, FIXED (each retainer and each pontic constitutes a unit in a fixed partial denture [bridge]).
|
||
| D6210 | Pontic - cast high noble metal | $170.00 |
| D6211 | Pontic - cast predominantly base metal | $ 70.00 |
| D6212 | Pontic - cast noble metal | $110.00 |
| D6240 | Pontic - porcelain fused to high noble metal | $195.00 |
| D6240 | Pontic - porcelain fused to high noble metal – (molars) | $195.00 |
| D6241 | Pontic - porcelain fused to predominantly base metal | $ 95.00 |
| D6241 | Pontic - porcelain fused to predominantly base metal – (molars) | $ 95.00 |
| D6242 | Pontic - porcelain fused to noble metal | $135.00 |
| D6242 | Pontic - porcelain fused to noble metal - (molars) | $135.00 |
| D6245 | Pontic - porcelain/ceramic | $195.00 |
| D6245 | Pontic - porcelain/ceramic – (molars) | $195.00 |
| D6250 | Pontic - resin with high noble metal | $155.00 |
| D6250 | Pontic - resin with high noble metal – (molars) | $155.00 |
| D6251 | Pontic - resin with predominantly base metal | $ 55.00 |
| D6251 | Pontic - resin with predominantly base metal – (molars) | $ 55.00 |
| D6252 | Pontic - resin with noble metal | $ 95.00 |
| D6252 | Pontic - resin with noble metal – (molars) | $ 95.00 |
| D6600 | Inlay - porcelain/ceramic, two surfaces | $150.00 |
| D6601 | Inlay - porcelain/ceramic, three or more surfaces | $160.00 |
| D6602 | Inlay - cast high noble metal, two surfaces | $100.00 |
| D6603 | Inlay - cast high noble metal, three or more surfaces | $100.00 |
| D6604 | Inlay - cast predominantly base metal, two surfaces | No Cost |
| D6605 | Inlay - cast predominantly base metal, three or more surfaces | No Cost |
| D6606 | Inlay - cast noble metal, two surfaces | $ 40.00 |
| D6607 | Inlay - cast noble metal, three or more surfaces | $ 40.00 |
| D6608 | Onlay - porcelain/ceramic, two surfaces | $150.00 |
| D6609 | Onlay - porcelain/ceramic, three or more surfaces | $165.00 |
| D6610 | Onlay - cast high noble metal, two surfaces | $100.00 |
| D6611 | Onlay - cast high noble metal, three or more surfaces | $100.00 |
| D6612 | Onlay - cast predominantly base metal, two surfaces | No Cost |
| D6613 | Onlay - cast predominantly base metal, three or more surfaces | No Cost |
| D6614 | Onlay - cast noble metal, two surfaces | $ 40.00 |
| D6615 | Onlay - cast noble metal, three or more surfaces | $ 40.00 |
| D6720 | Crown - resin with high noble metal | $155.00 |
| D6720 | Crown - resin with high noble metal – (molars) | $155.00 |
| D6721 | Crown - resin with predominantly base metal | $ 55.00 |
| D6721 | Crown - resin with predominantly base metal – (molars) | $ 55.00 |
| D6722 | Crown - resin with noble metal | $ 95.00 |
| D6722 | Crown - resin with noble metal – (molars) | $ 95.00 |
| D6740 | Crown - porcelain/ceramic | $195.00 |
| D6740 | Crown - porcelain/ceramic – (molars) | $195.00 |
| D6750 | Crown - porcelain fused to high noble metal | $195.00 |
| D6750 | Crown - porcelain fused to high noble metal – (molars) | $195.00 |
| D6751 | Crown - porcelain fused to predominantly base metal | $ 95.00 |
| D6751 | Crown - porcelain fused to predominantly base metal – (molars) | $ 95.00 |
| D6752 | Crown - porcelain fused to noble metal | $135.00 |
| D6752 | Crown - porcelain fused to noble metal – (molars) | $135.00 |
| D6780 | Crown - ¾ cast high noble metal | $170.00 |
| D6781 | Crown - ¾ cast predominantly base metal | $ 70.00 |
| D6782 | Crown - ¾ cast noble metal | $110.00 |
| D6783 | Crown - ¾ porcelain/ceramic | $195.00 |
| D6783 | Crown - ¾ porcelain/ceramic – (molars) | $195.00 |
| D6790 | Crown - full cast high noble metal | $170.00 |
| D6791 | Crown - full cast predominantly base metal | $ 70.00 |
| D6792 | Crown - full cast noble metal | $110.00 |
| D6930 | Recement fixed partial denture | No Cost |
| D6940 | Stress breaker | No Cost |
| D6970 | Cast post and core in addition to fixed partial denture retainer - includes canal preparation | No Cost |
| D6972 | Prefabricated post and core in addition to fixed partial denture retainer–base metal post; includes canal preparation | No Cost |
| D6973 | Core buildup for retainer, including any pins | No Cost |
| D6976 | Each additional cast post - same tooth - includes canal preparation | No Cost |
| D6977 | Each additional prefabricated post - same tooth – base metal post; includes canal preparation | No Cost |
| D6980 | Fixed partial denture repair, by report | $ 10.00 |
| D7000-D7999 X. Oral and Maxillofacial Surgery Includes preoperative and postoperative evaluations and treatment under a local anesthetic. |
||
| D7111 | Extraction, coronal remnants - deciduous tooth | No Cost |
| D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | No Cost |
| D7210 | Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth | $ 15.00 |
| D7220 | Removal of impacted tooth - soft tissue | $ 25.00 |
| D7230 | Removal of impacted tooth - partially bony | $ 50.00 |
| D7240 | Removal of impacted tooth - completely bony | $ 70.00 |
| D7241 | Removal of impacted tooth - completely bony, with unusual surgical complications | $ 90.00 |
| D7250 | Surgical removal of residual tooth roots (cutting procedure) | No Cost |
| D7270 | Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth | $ 50.00 |
| D7280 | Surgical access of an unerupted tooth | $ 85.00 |
| D7282 | Mobilization of erupted or malpositioned tooth to aid eruption | $ 85.00 |
| D7283 | Placement of device to facilitate eruption of impacted tooth | No Cost |
| D7286 | Biopsy of oral tissue - soft (all others) - does not include pathology laboratory procedures | No Cost |
| D7310 | Alveoloplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant | No Cost |
| D7311 | Alveoloplasty in conjunction with extractions –one to three teeth or tooth spaces, per quadrant | No Cost |
| D7320 | Alveoloplasty not in conjunction with extractions – for our more teeth or tooth spaces, per quadrant | No Cost |
| D7321 | Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant | No Cost |
| D7450 | Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm | No Cost |
| D7451 | Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm | No Cost |
| D7471 | Removal of lateral exostosis - (maxilla or mandible) | No Cost |
| D7472 | Removal of torus palatinus | No Cost |
| D7473 | Removal of torus mandibularis | No Cost |
| D7510 | Incision and drainage of abscess - intraoral soft tissue | No Cost |
| D7960 | Frenulectomy (frenectomy or frenotomy) - separate procedure | No Cost |
| D7970 | Excision hyperplastic tissue – per arch | $ 50.00 |
| D7971 | Excision of pericoronal gingiva | $ 50.00 |
| D8000-D8999XI. Orthodontics - The listed Copayment for each phase of orthodontic treatment (limited, interceptive or comprehensive) covers up to 24 months of active treatment. Beyond 24 months, an additional monthly fee, not to exceed $125.00, may apply. - The Retention Copayment includes adjustments and/or office visits up to 24 months. Pre- and post-orthodontic records The benefit for pre-treatment records and diagnostic services includes: $200.00 |
||
| D0210 | Intraoral – complete series (including bitewings) | |
| D0322 | Tomographic survey | |
| D0330 | Panoramic film | |
| D0340 | Cephalometric film | |
| D0350 | Oral/facial photographic images | |
| D0470 | Diagnostic casts | |
| The benefit for post-treatment records includes:$ 70.00 | ||
| D0210 | Intraoral – complete series (including bitewings) | |
| D0470 | Diagnostic casts | |
| D8010 | Limited orthodontic treatment of the primary dentition | $950.00 |
| D8020 | Limited orthodontic treatment of the transitional dentition- child or adolescent to age 19 | $950.00 |
| D8030 | Limited orthodontic treatment of the adolescent dentition- adolescent to age 19 | $950.00 |
| D8040 | Limited orthodontic treatment of the adult dentition – adults, including covered dependent adult children | $1,150.00 |
| D8050 | Interceptive orthodontic treatment of the primary dentition | $950.00 |
| D8060 | Interceptive orthodontic treatment of the transitional dentition | $950.00 |
| D8070 | Comprehensive orthodontic treatment of the transitional dentition - child or adolescent to age 19 | $1,700.00 |
| D8080 | Comprehensive orthodontic treatment of the adolescent dentition - adolescent to age 19 | $1,700.00 |
| D8090 | Comprehensive orthodontic treatment of the adult dentition – adults, including covered dependent adult children | $1,900.00 |
| D8660 | Pre-orthodontic treatment visit - not to be charged with any other consultation procedure(s) | $ 25.00 |
| D8680 | Orthodontic retention (removal of appliances, construction and placement of removable retainers) | $275.00 |
| D8999 | Unspecified orthodontic procedure, by report -includes treatment planning session | $100.00 |
| D9000-D9999 XII. Adjunctive General Services | ||
| D9110 | Palliative (emergency) treatment of dental pain - minor procedure | $ 5.00 |
| D9211 | Regional block anesthesia | No Cost |
| D9212 | Trigeminal division block anesthesia | No Cost |
| D9215 | Local anesthesia | No Cost |
| D9220 | Deep sedation/general anesthesia – first 30 minutes | $165.00 |
| D9221 | Deep sedation/general anesthesia – each additional 15 minutes | $ 80.00 |
| D9241 | Intravenous conscious sedation/ analgesia – first 30 minutes | $165.00 |
| D9242 | Intravenous conscious sedation/ analgesia– each additional 15 minutes | $ 80.00 |
| D9310 | Consultation (diagnostic services provided by a dentist or physician other than requesting dentist or physician) | No Cost |
| D9430 | Office visit for observation (during regularly scheduled hours) - no other services performed | $ 5.00 |
| D9440 | Office visit - after regularly scheduled hours | $ 20.00 |
| D9450 | Case presentation, detailed and extensive treatment planning | No Cost |
| D9940 | Occlusal guard, by report – limited to 1 in 3 years | $ 95.00 |
| D9951 | Occlusal adjustment, limited | $ 20.00 |
| D9952 | Occlusal adjustment, complete | $ 40.00 |
| D9972 | External bleaching, per arch – limited to one bleaching tray and gel for two weeks of self treatment | $ 125 .00 |
| D9999 | Unspecified adjunctive procedure, by report - includes failed appointment without 24 hour notice - per 15 minutes of appointment time – up to an overall maximum of $4000 |
$ 10.00 |
If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the specified Copayment. Listed procedures which require a Dentist to provide specialized services, and are referred by the assigned Contract Dentist, must be preauthorized in writing by Delta Dental. The Enrollee pays the Copayment specified for such services.
Procedures not listed above are not covered, however, may be available at the Contract Dentist’s “filed fees.” “Filed fees” means the Contract Dentist’s fees on file with Delta Dental. Questions regarding these fees should be directed to Delta Dental’s Customer Service department at (800) 422-4234.