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Summary Plan Description (SPD)
United Concordia Schedule of Benefits - Plan 501
For complete schedule of benefits, including limitations and exclusions, please click here.
IMPORTANT INFORMATION ABOUT YOUR PLAN
- This Schedule of Benefits provides a listing of procedures covered by Your Plan. For procedures that require a Copayment, the amount to be paid is shown in the column titled “Member Pays $.” You pay these Copayments to the dental office at the time of service.
- You must select a United Concordia Primary Dental Office (PDO) to receive Covered Services. Your PDO will perform the below procedures or refer You to a Specialty Care Dentist for further care. Treatment by an Out of Network Dentist is not covered, except as described in the Evidence of Coverage.
- Only procedures listed on this Schedule of Benefits are Covered Services. For services not listed (not covered), You are responsible for the full fee charged by the dentist. Procedure codes and member Copayments may be updated to meet American Dental Association (ADA) Current Dental Terminology (CDT) in accordance with national standards.
- In-Network Dentists will charge an additional $125 for the use of precious (high noble) or semi precious (noble) metal.
- For a complete description of Your Plan, please refer to the Evidence of Coverage and the Exclusions and Limitations in addition to this Schedule of Benefits.
- If You have any questions about Your United Concordia Dental Plan, please call Our Customer Service Department toll free at 1-866-357-3304 or access Our Website at www.unitedconcordia.com.
| ADA CODE | ADA DESCRIPTION | MEMBER PAYS $ |
| CLINICAL ORAL EVALUATIONS | ||
| D0120 | Periodic oral evaluation | 0 |
| D0140 | Limited oral evaluation - problem focused | 0 |
| D0150 | Comprehensive oral evaluation - new or established patient |
0 |
| D0160 | Detailed and extensive oral evaluation - problem focused, by report |
0 |
| D0170 | Re-evaluation - limited, problem focused (established patient; not post-operative visit) |
0 |
| D0180 | Comprehensive periodontal evaluation - new or established patient |
0 |
| RADIOGRAPHS/DIAGNOSTIC IMAGING (including interpretation) |
||
| D0210 | Intraoral - complete series (including bitewings) | 0 |
| D0220 | Intraoral - periapical first film | 0 |
| D0230 | Intraoral - periapical each additional film | 0 |
| D0240 | Intraoral - occlusal film | 0 |
| D0270 | Bitewing - single film | 0 |
| D0272 | Bitewings - two films | 0 |
| D0274 | Bitewings - four films | 0 |
| D0277 | Vertical bitewings - 7 to 8 films | 0 |
| D0330 | Panoramic film | 0 |
| D0340 | Cephalometric film | 0 |
| TESTS AND EXAMINATIONS | ||
| D0460 | Pulp vitality tests | 0 |
| D0470 | Diagnostic casts | 0 |
| DENTAL PROPHYLAXIS | ||
| D1110 | Prophylaxis - adult | 0 |
| D1120 | Prophylaxis - child | 0 |
| TOPICAL FLUORIDE TREATMENT (office procedure) |
||
| D1201 | Topical application of fluoride (including prophylaxis) - child |
0 |
| D1203 | Topical application of fluoride (prophylaxis not included) - child |
0 |
| D1204 | Topical application of fluoride (prophylaxis not included) - adult |
0 |
| D1205 | Topical appliction of fluoride (including prophylaxis) - adult |
0 |
| OTHER PREVENTIVE SERVICES | ||
| D1330 | Oral hygiene instructions | 0 |
| D1351 | Sealant - per tooth | 0 |
| SPACE MAINTENANCE (passive appliances) |
||
| D1510 | Space maintainer - fixed - unilateral | 0 |
| D1515 | Space maintainer - fixed - bilateral | 0 |
| D1520 | Space maintainer - removable - unilateral | 0 |
| D1525 | Space maintainer - removable - bilateral | 0 |
| D1550 | Re-cementation of space maintainer | 0 |
| AMALGAM RESTORATIONS (including polishing) |
||
| D2140 | Amalgam - one surface, primary or permanent | 0 |
| D2150 | Amalgam - two surfaces, primary or permanent | 0 |
| D2160 | Amalgam - three surfaces, primary or permanent | 0 |
| D2161 | Amalgam - four or more surfaces, primary or permanent | 0 |
| RESIN-BASED COMPOSITE RESTORATIONS - DIRECT | ||
| D2330 | Resin-based composite - one surface, anterior | 0 |
| D2331 | Resin-based composite - two surfaces, anterior | 0 |
| D2332 | Resin-based composite - three surfaces, anterior | 0 |
| D2335 | Resin-based composite - four or more surfaces or involving incisal angle (anterior) |
0 |
| D2390 | Resin-based composite crown, anterior | 0 |
| D2391 | Resin-based composite - one surface, posterior | 85 |
| D2392 | Resin-based composite - two surfaces, posterior | 109 |
| D2393 | Resin-based composite - three surfaces, posterior | 133 |
| D2394 | Resin-based composite - four or more surfaces, posterior |
140 |
| INLAY/ONLAY RESTORATIONS | ||
| D2510 | Inlay - metallic - one surface | 0 |
| D2520 | Inlay - metallic - two surfaces | 0 |
| D2530 | Inlay - metallic - three or more surfaces | 0 |
| D2542 | Onlay - metallic - two surfaces | 0 |
| D2543 | Onlay - metallic - three surfaces | 0 |
| D2544 | Onlay - metallic - four or more surfaces | 0 |
| CROWNS - SINGLE RESTORATIONS ONLY | ||
| D2710 | Crown - resin-based composite (indirect) | 0 |
| D2712 | Crown - 3/4 resin-based composite (indirect) | 0 |
| D2740 | Crown - porcelain/ceramic substrate | 0 |
| D2750 | Crown - porcelain fused to high noble metal | 0 |
| D2751 | Crown - porcelain fused to predominantly base metal | 0 |
| D2752 | Crown - porcelain fused to noble metal | 0 |
| D2780 | Crown - 3/4 cast high noble metal | 0 |
| D2781 | Crown - 3/4 cast predominantly base metal | 0 |
| D2782 | Crown - 3/4 cast noble metal | 0 |
| D2783 | Crown - 3/4 porcelain/ceramic | 0 |
| D2790 | Crown - full cast high noble metal | 0 |
| D2791 | Crown - full cast predominantly base metal | 0 |
| D2792 | Crown - full cast noble metal | 0 |
| D2794 | Crown - titanium | 0 |
| D2794 | Provisional crown | 0 |
| OTHER RESTORATIVE SERVICES | ||
| D2910 | Recement inlay, onlay, or partial coverage restoration |
0 |
| D2915 | Recement cast or prefabricated post and core | 0 |
| D2920 | Recement crown | 0 |
| D2930 | Prefabricated stainless steel crown - primary tooth |
0 |
| D2931 | Prefabricated stainless steel crown - permanent tooth |
0 |
| D2932 | Prefabricated resin crown | 0 |
| D2933 | Prefabricated stainless steel crown with resin window |
0 |
| D2934 | Prefabricated esthetic coated stainles steel crown - primary tooth |
0 |
| D2940 | Sedative filling | 0 |
| D2950 | Core buildup, involving and including any pins | 0 |
| D2951 | Pin retention - per tooth, in addition to restoration |
0 |
| D2952 | Cast post and core in addition to crown | 0 |
| D2953 | Each additional cast post - same tooth | 10 |
| D2954 | Prefabricated post and core in addition to crown | 0 |
| D2955 | Post removal (not in conjunction with endodontic therapy) |
0 |
| D2957 | Each additional prefabricated post - same tooth | 10 |
| D2971 | Additional procedures to construct new crown under existing partial denture framework |
25 |
| D2980 | Crown repair, by report | 0 |
| PULP CAPPING | ||
| D3110 | Pulp cap - direct (excluding final restoration) | 0 |
| D3120 | Pulp cap - indirect (excluding final restoration) | 0 |
| PULPOTOMY | ||
| D3220 | Therapeutic pulpotomy (excluding final restoration) |
0 |
| D3221 | Pulpal debridement, primary and permanent teeth |
0 |
| ENDODONTIC THERAPY ON PRIMARY TEETH | ||
| D3230 | Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) |
0 |
| D3240 | Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) |
0 |
| ENDODONTIC THERAPY (including treatment plan, clinical procedures and follow-up care) |
||
| D3310 | Anterior (excluding final restoration) | 0 |
| D3320 | Bicuspid (excluding final restoration) | 0 |
| D3330 | Molar (excluding final restoration) | 0 |
| ENDODONTIC RETREATMENT | ||
| D3346 | Retreatment of previous root canal therapy - anterior |
0 |
| D3347 | Retreatment of previous root canal therapy - bicuspid |
0 |
| D3348 | Retreatment of previous root canal therapy - molar |
0 |
| APICOECTOMY/PERIRADICULAR SERVICES | ||
| D3410 | Apicoectomy/periradicular surgery - anterior | 0 |
| D3421 | Apicoectomy/periradicular surgery - bicuspid (first root) |
0 |
| D3425 | Apicoectomy/periradicular surgery - molar (first root) | 0 |
| D3426 | Apicoectomy/periradicular surgery (each additional root) | 0 |
| D3430 | Retrograde filling - per root | 0 |
| D3450 | Root amputation - per root | 0 |
| OTHER ENDODONTIC PROCEDURES | ||
| D3910 | Surgical procedure for isolation of tooth with rubber dam |
0 |
| D3920 | Hemisection (including any root removal), not including root canal therapy |
0 |
| D3950 | Canal preparation and fitting of preformed dowel or post |
0 |
| SURGICAL SERVICES (including usual postoperative care) |
||
| D4210 | Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant |
0 |
| D4211 | Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant |
0 |
| D4240 | Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spaces per quadrant |
0 |
| D4241 | Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth spaces per quadrant |
0 |
| D4245 | Apically positioned flap | 0 |
| D4249 | Clinical crown lengthening - hard tissue | 0 |
| D4260 | Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant |
0 |
| D4261 | Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant |
0 |
| D4263 | Bone replacement graft - first site in quadrant | 120 |
| D4264 | Bone replacement graft - each additional site in quadrant |
92 |
| D4274 | Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) |
0 |
| NON-SURGICAL PERIODONTAL SERVICES | ||
| D4341 | Periodontal scaling and root planing - four or more teeth per quadrant |
0 |
| D4342 | Periodontal scaling and root planing - one to three teeth per quadrant |
0 |
| D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis |
0 |
| D4381 | Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, per report |
43 |
| OTHER PERIODONTAL SERVICES | ||
| D4910 | Periodontal maintenance | 0 |
| COMPLETE DENTURES (including routine post-delivery care) |
||
| D5110 | Complete denture - maxillary | 0 |
| D5120 | Complete denture - mandibular | 0 |
| D5130 | Immediate denture - maxillary | 0 |
| D5140 | Immediate denture - mandibular | 0 |
| PARTIAL DENTURES (including routine post-delivery care) |
||
| D5211 | Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) |
0 |
| D5212 | Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) |
0 |
| D5213 | Maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) |
0 |
| D5214 | Mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) |
0 |
| D5225 | Maxillary partial denture - flexible base (including any clasps, rests and teeth) |
0 |
| D5226 | Mandibular partial denture - flexible base (including any clasps, rests and teeth) |
0 |
| D5281 | Removable unilateral partial denture - one piece cast metal (including clasps and teeth) |
0 |
| ADJUSTMENTS TO DENTURES | ||
| D5410 | Adjust complete denture - maxillary | 0 |
| D5411 | Adjust complete denture - mandibular | 0 |
| D5421 | Adjust partial denture - maxillary | 0 |
| D5422 | Adjust partial denture - mandibular | 0 |
| REPAIRS TO COMPLETE DENTURES | ||
| D5510 | Repair broken complete denture base | 0 |
| D5520 | Replace missing or broken teeth - complete denture (each tooth) |
0 |
| REPAIRS TO PARTIAL DENTURES | ||
| D5610 | Repair resin denture base | 0 |
| D5620 | Repair cast framework | 0 |
| D5630 | Repair or replace broken clasp | 0 |
| D5640 | Replace broken teeth - per tooth | 0 |
| D5650 | Add tooth to existing partial denture | 0 |
| D5660 | Add clasp to existing partial denture | 0 |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary) |
0 |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular) |
0 |
| DENTURE REBASE PROCEDURES | ||
| D5710 | Rebase complete maxillary denture | 0 |
| D5711 | Rebase complete mandibular denture | 0 |
| D5720 | Rebase maxillary partial denture | 0 |
| D5721 | Rebase mandibular partial denture | 0 |
| DENTURE RELINE PROCEDURES | ||
| D5730 | Reline complete maxillary denture (chairside) | 0 |
| D5731 | Reline complete mandibular denture (chairside) |
0 |
| D5740 | Reline maxillary partial denture (chairside) | 0 |
| D5741 | Reline mandibular partial denture (chairside) | 0 |
| D5750 | Reline complete maxillary denture (laboratory) | 0 |
| D5751 | Reline complete mandibular denture (laboratory) |
0 |
| D5760 | Reline maxillary partial denture (laboratory) | 0 |
| D5761 | Reline mandibular partial denture (laboratory) | 0 |
| OTHER REMOVABLE PROSTHETIC SERVICES | ||
| D5850 | Tissue conditioning, maxillary | 0 |
| D5851 | Tissue conditioning, mandibular | 0 |
| FIXED PARTIAL DENTURE PONTICS | ||
| D6205 | Pontic - indirect resin based composite not to be used as a temporary or provisional prosthesis |
0 |
| D6210 | Pontic - cast high noble metal | 0 |
| D6211 | Pontic - cast predominantly base metal | 0 |
| D6212 | Pontic - cast noble metal | 0 |
| D6214 | Pontic - titanium | 0 |
| D6240 | Pontic - porcelain fused to high noble metal | 0 |
| D6241 | Pontic - porcelain fused to predominantly base metal |
0 |
| D6242 | Pontic - porcelain fused to noble metal | 0 |
| D6245 | Pontic - porcelain/ceramic | 0 |
| FIXED PARTIAL DENTURE RETAINERS - INLAYS/ONLAYS | ||
| D6545 | Retainer - cast metal for resin bonded fixed prosthesis |
0 |
| FIXED PARTIAL DENTURE RETAINERS - CROWNS | ||
| D6710 | Crown - indirect resin based composite | 0 |
| D6740 | Crown - porcelain/ceramic | 0 |
| D6750 | Crown - porcelain fused to high noble metal | 0 |
| D6751 | Crown - porcelain fused to predominantly base metal | 0 |
| D6752 | Crown - porcelain fused to noble metal | 0 |
| D6780 | Crown - 3/4 cast high noble metal | 0 |
| D6781 | Crown - 3/4 cast predominantly base metal | 0 |
| D6782 | Crown - 3/4 cast noble metal | 0 |
| D6783 | Crown - 3/4 porcelain/ceramic | 0 |
| D6790 | Crown - full cast high noble metal | 0 |
| D6791 | Crown - full cast predominantly base metal | 0 |
| D6792 | Crown - full cast noble metal | 0 |
| D6794 | Crown - titanium | 0 |
| OTHER FIXED PARTIAL DENTURE SERVICES | ||
| D6930 | Recement fixed partial denture | 0 |
| D6970 | Cast post and core in addition to fixed partial denture retainer |
0 |
| D6971 | Cast post as part of fixed partial denture retainer |
0 |
| D6972 | Prefabricated post and core in addition to fixed partial denture retainer |
0 |
| D6973 | Core build up for retainer, including any pins | 0 |
| D6976 | Each additional cast post - same tooth | 10 |
| D6977 | Each additional prefabricated post - same tooth | 10 |
| D6980 | Fixed partial denture repair, by report | 0 |
| EXTRACTIONS (includes local anesthesia, suturing, if needed, and routine postoperative care) |
||
| D7111 | Coronal remnants - deciduous tooth | 0 |
| D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
0 |
| SURGICAL EXTRACTIONS (includes local anesthesia, suturing, if needed, and routine postoperative care) |
||
| D7210 | Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth |
0 |
| D7220 | Removal of impacted tooth - soft tissue | 0 |
| D7230 | Removal of impacted tooth - partially bony | 0 |
| D7240 | Removal of impacted tooth - completely bony | 0 |
| D7241 | Removal of impacted tooth - completely bony, with unusual surgical complications |
0 |
| D7250 | Surgical removal of residual tooth roots (cutting procedure) |
0 |
| OTHER SURGICAL PROCEDURES | ||
| D7280 | Surgical access of an unerupted tooth | 0 |
| D7283 | Placement of device to facilitate eruption of impacted tooth |
0 |
| D7285 | Biopsy of oral tissue - hard (bone, tooth) | 0 |
| D7286 | Biopsy of oral tissue - soft (all others) | 0 |
| D7288 | Brush biopsy - transepithelial sample collection | 45 |
| ALVEOLOPLASTY (surgical preparation of ridge for dentures) |
||
| D7310 | Alveoloplasty in conjunction with extractions - per quadrant |
0 |
| D7320 | Alveoloplasty not in conjunction with extractions - per quadrant |
0 |
| D7321 | Alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant |
0 |
| SURGICAL EXCISION OF INTRA-OSSEOUS LESIONS | ||
| D7450 | Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25cm | 0 |
| SURGICAL INCISION | ||
| D7510 | Incision and drainage of abscess - intraoral soft tissue | 0 |
| D7520 | Incision and drainage of abscess - extraoral soft tissue | 0 |
| OTHER REPAIR PROCEDURES | ||
| D7960 | Frenulectomy (frenectomy or frenotomy) - separate procedure | 0 |
| D7963 | Frenuloplasty | 0 |
| D7970 | Excision of hyperplastic tissue - per arch | 0 |
| D7971 | Excision of pericoronal gingiva | 0 |
| COMPREHENSIVE ORTHODONTIC TREATMENT | ||
| D8070 | Comprehensive orthodontic treatment of the transitional dentition |
1,500 |
| D8080 | Comprehensive orthodontic treatment of the adolescent dentition |
1,500 |
| D8090 | Comprehensive orthodontic treatment of the adult dentition |
2,000 |
| OTHER ORTHODONTIC SERVICES | ||
| D8680 | Orthodontic retention (removal of appliances, construction and placement of retainer(s)) |
240 |
| + | Orthodontic records fee | 265 |
| UNCLASSIFIED TREATMENT | ||
| D9110 | Palliative (emergency) treatment of dental pain - minor procedure | 0 |
| ANESTHESIA | ||
| D9210 | Local anesthesia not in conjunction with operative or surgical procedures | 0 |
| D9211 | Regional block anesthesia | 0 |
| D9212 | Trigeminal division block anesthesia | 0 |
| D9215 | Local anesthesia | 0 |
| D9220 | Deep sedation/general anesthesia - first 30 minutes | 160 |
| D9221 | Deep sedation/general anesthesia - each additional 15 minutes | 68 |
| D9241 | Intravenous conscious sedation/analgesia - first 30 minutes | 170 |
| D9242 | Intravenous conscious sedation/analgesia - each additional 15 minutes | 42 |
| PROFESSIONAL CONSULTATION | ||
| D9310 | Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) | 0 |
| PROFESSIONAL VISITS | ||
| D9440 | Office visit, after regularly scheduled hours | 40 |
| MISCELLANEOUS SERVICES | ||
| D9951 | Occlusal adjustment - limited | 0 |
| D9952 | Occlusal adjustment - complete | 0 |
| * | Broken appointment per 30 minutes (without 24-hour notice) | 20 |
+ Please report under code D8999 “Unspecified orthodontic procedure, by report.” Records include all diagnostic procedures, such as cephalometric films, full mouth x-rays, models, and treatment plans. * Please report under code D9999 “Unspecified adjunctive procedure, by report.” # Charges for the use of precious (high noble) or semi
precious (noble) metal are not included in the copayment for
crowns, bridges, pontics, inlays and onlays. The decision to
use these materials is a cooperative effort between the
provider and the patient, based on the professional advice of
the provider. Providers are expected to charge no more than
an additional $125 for these materials. |
||