The following is a list of covered services and, if applicable, copayments.
Copayment is defined as what you must pay for the service.

Terms of treatment for Orthodontics can be found at the end of the rate table. Services that are not covered by the DPO are listed at the bottom of this page.
Codes Description of Covered Services Copayments
D0100-D0999 I. DIAGNOSTIC

Clinical Oral Examination - (Oral evaluations are limited to once per 6 month interval)
D0120 Periodic Oral Evaluation $ 0
D0140 Limited Oral Evaluation $ 0
D0150 Comprehensive Oral Evaluation $ 0
D0160 Detailed and Extensive Oral Evaluation $ 0

Radiographs    (Bitewing X-rays are limited to one series of up to 4 films per 6 month interval; set of full mouth X-rays are limited to once per 36 month interval; no more than 18 films per set of mouth X-rays)

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

D0250

 Extraoral-First Film $ 0

D0260

 Extraoral-Each Additional Film $ 0

D0270

 Bitewings-Single Film $ 0

D0272

 Bitewings-Two Films $ 0

D0274

 Bitewings-Four Films $ 0

D0277

 Vertical Bitewings-Eight Films $ 0

D0290

Posterior-Anterior or Lateral Skull and Facial Bone Survey Film

$ 0

D0330

 Panoramic Film $ 0

D0340

 Cephalometric Film $ 0
Tests and Laboratory Examinations
D0415 Bacterial Studies for Determination of Pathologic Agents $ 0
D0425 Caries Susceptibility Tests $ 0
D0460 Pulp Vitality Tests $ 0
D0470 Diagnostic Casts $ 0
D1000-D1999 II. PREVENTIVE

Dental Prophylaxis    (Limited to once per 6 month interval)
D1110 Prophylaxis-Adult $ 0
D1120 Prophylaxis-Child $ 0

Topical Fluoride Treatment (Office Procedure)    (Limited to once per 6 month interval, and only for eligible dependent children under the age of 19 years)

D1201

Application Including Prophylaxis-Child

 $ 0
D1203 Application Excluding Prophylaxis-Child $ 0
D1204 Application Excluding Prophylaxis-Adult $ 0
D1205 Application Including Prophylaxis-Adult $ 0

Other Preventive Services    (Sealants are limited to once per lifetime for permanent molars of eligible dependent children under the age of 19 years)

D1330

Oral Hygiene Instruction

 $ 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-Unilatera $ 0
D1525 Space Maintainer-Removable—Bilateral $ 0
D1550 Recementation of Space Maintainer $ 0
D2000-D2999 III. RESTORATIVE     (The replacement of a crown is covered only after a 5 year period measured from the date on which the crown was previously placed)

Amalgam Restorations (Including Polishing)
D2110

Amalgam-One Surface Primary

 $ 0
D2120 Amalgam-Two Surfaces Primary $ 0
D2130 Amalgam-Three Surfaces Primary $ 0
D2131 Amalgam-Four or More Surfaces Primary $ 0
D2140 Amalgam-One Surface Permanent $ 0
D2150 Amalgam-Two Surfaces Permanent $ 0
D2160 Amalgam-Three Surfaces Permanent $ 0
D2161 Amalgam-Four or More Surfaces Permanent $ 0

Resin Restorations
D2330

D2330 Resin-One Surface Anterior $ 0

 $ 0
D2331 Resin-Two Surfaces Anterior $ 0
D2332 Resin-Three Surfaces Anterior $ 0
D2335 Resin-Four or more Surfaces Anterior, or Involving Incisal Angle $ 0
D2335 Resin-Four or more Surfaces Anterior, or Involving Incisal Angle $ 0
D2336 Composite Resin Crown-Anterior-Primary $ 35
D2337 Composite Resin Crown Anterior-Permanent $ 35
D2380 Resin-One Surface Posterior-Primary $ 15
D2381 Resin-Two Surfaces Posterior-Primary $ 25
D2382 Resin-Three or more Surfaces Posterior-Primary $ 35
D2385 Resin-One Surface Posterior-Permanent $ 15
D2386 Resin-Two Surfaces Posterior-Permanent $ 25
D2387 Resin-Three Surfaces Posterior-Permanent $ 35
D2388 Resin Four or more Surfaces Posterior-Permanent $ 45

Inlay/Onlay Restorations
D2510

Inlay-Metallic-One Surface

 $ 100
D2520 Inlay-Metallic-Two Surfaces $ 100
D2530 Inlay-Metallic-Three or more Surfaces $ 100
D2542 Onlay-Metallic-Two Surfaces $ 100
D2543 Onlay-Metallic-Three Surfaces $ 100
D2544 Onlay-Metallic-Four or More Surfaces $ 100
D2610 Inlay-Porcelain/Ceramic-One Surface $ 115
D2620 Inlay-Porcelain/Ceramic-Two Surfaces $ 115
D2630

Inlay-Porcelain/Ceramic-Three or More Surfaces

 $ 115
D2642 Onlay-Porcelain/Ceramic-Two Surfaces $ 115
D2643 Onlay-Porcelain/Ceramic-Three Surfaces $ 115
D2644 Onlay-Porcelain/Ceramic-Four or More Surfaces $ 115
D2650 Inlay-Composite/Resin-One Surface (Lab Process) $ 115
D2651 Inlay-Composite/Resin-Two Surface (Lab Process) $ 115
D2652 Inlay-Composite/Resin-Three or More Surfaces (Lab Process) $ 115
D2662 Onlay-Composite/Resin-Two Surfaces (Lab Process) $ 115
D2663 Onlay-Composite/Resin-Three Surfaces (Lab Process) $ 115
D2664 Onlay-Composite/Resin-Four or more Surfaces (Lab Process) $ 115

Crowns - Single Restorations Only
D2710

Crown-Resin-Laboratory (see note)

 $ 115
D2720 Crown-Resin with High Noble Metal $ 150
D2721 Crown-Resin with Predominantly Base Metal $ 150
D2722 Crown-Resin with Noble Metal $ 150
D2740 Crown-Porcelain/Ceramic Substrate $ 200
D2750 Crown-Porcelain Fused to High Noble Metal $ 225
D2751

Crown-Porcelain Fused to Predominantly Base Metal

 $ 200
D2752 Crown-Porcelain Fused to Noble Metal $ 200
D2780 Crown ¾ Cast High Noble Metal $ 225
D2781 Crown ¾ Cast Predominantly Base Metal $ 200
D2790 Crown-Full Cast High Noble Metal $ 225
D2791 Crown-Full Cast Predominantly Base Metal $ 200
D2792 Crown-Full Cast Noble Metal $ 200

Other Restorative Services
D2910

Re-cement Inlay

 $ 0
D2920 Re-cement Crown $ 0
D2930 Prefabricated Stainless Steel Crown-Primary Tooth $ 35
D2931 Prefabricated Stainless Steel Crown-Permanent Tooth $ 35
D2932 Prefabricated Resin Crown $ 35
D2933 Prefab Stainless Steel Crown with Resin Window $ 35
D2940 Sedative Fillings $ 0
D2950 Buildup Including Any Pins $ 0
D2951 Pin Retention-Per Tooth in Addition to Restoration $ 0
D2952 Cast Post & Core in Addition to Crown $ 40
D2954 Prefabricated Post & Core in Addition to Crown $ 40
D2955 Post Removal (Not in Conjunction with Endodontic Therapy) $ 0
D2970 Temporary Crown (Fractured Tooth) $ 0
D2980 Crown Repair - By Report $ 0
Note: There is no copayment for procedure D2710 when performed in conjunction with a permanent crown on the same tooth.
D3000-D3999 IV. ENDODONTICS
Pulp Capping
D3110

Pulp Capping-Direct Excluding Final Restoration

 $ 0
D3120 Pulp Capping-Indirect Excluding Final Restoration $ 0
Pulpotomy
D3220 Therapeutic Pulpotomy Excluding Final Restoration $ 25
Endodontic Therapy on Primary Teeth
D3230

Pulpal Therapy (Resorbable Filling)-Anterior-Primary Tooth

 $ 20
D3240 Pulpal Therapy (Resorbable Filling)-Posterior-Primary Tooth $ 20

Endodontic Therapy
D3310

Anterior (Excluding Final Restoration)

 $100
D3320 Bicuspid (Excluding Final Restoration) $125
D3330 Molar (Excluding Final Restoration) $150
Endodontic Retreatment
D3346

Retreat Previous Root Canal-Anterior

 $125
D3347 Retreat Previous Root Canal-Bicuspid $150
D3348 Retreat Previous Root Canal-Molar $175
Apexification/Recalcification Procedures
D3351

Apexification/Recalcification-Initial Visit

 $ 35
D3352 Apexification/Recalcification-Interim Medication Replacement $ 35
D3353 Apexification/Recalcification-Final Visit $ 35
Apicoectomy/Periapical Services
D3410

Apicoectomy/Periradicular Surgical-Anterior

 $ 90
D3421 Apicoectomy/Periradicular Surgical-Bicus First Root $ 90
D3425 Apicoectomy/Periradicular Surgical-Molar First Root $ 90
D3426 Apicoectomy/Periradicular Surgical-Each Add Root $ 40
D3430 Retrograde Filling-Per Root $ 20
D3450 Root Amputation-Per Root $ 40
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 $ 60

D4000-D4999 V. PERIODONTICS
(Coverage for surgical periodontal procedures, excluding scaling and root planing, is limited to one surgical periodontal treatment per quadrant every 36 months; coverage for scaling and root planing is limited to one nonsurgical periodontal treatment per quadrant every 12 months)

Surgical Services
D4210

Gingivectomy/Gingivoplasty-Per Quadrant&

 $ 85
D4211 Gingivectomy/Gingivoplasty-Per Tooth $ 30
D4240 Gingival Flap Procedure Including Root Planing- Per Quadrant $ 90
D4245 Apically Positioned Flap $ 90
D4249 Crown Lengthening-Hard Tissue $ 90
D4260

Osseous Surgery (Including Flap Entry & Closure)-Per Quadrant

 $ 175
D4263 Bone Replacement Graft-First Site in Quadrant $ 100
D4264 Bone Replacement Graft-Each Addition Site in Quadrant $  50
D4266 Guided Tissue Regeneration-Resorbable Barrier $  90
D4267 Guided Tissue Regeneration-Non-resorbable Barrier $  90
D4270 Pedicle Soft Tissue Graft Procedure $ 175
D4271

Free Soft Tissue Graft Procedure (Including Donor Site)

 $ 175
D4273 Subepithelial Connective Tissue Graft Procedure $ 175
D4274 Distal or Proximal Wedge Procedure $  40

Adjunctive Periodontal Services
D4320

Provisional Splinting-Intracoronal

 $ 0
D4321 Provisional Splinting-Extracoronal $ 0
D4341 Periodontal Root Planing-Per Quadrant $ 55
D4355 Full Debridement, Enable Complete Periodontal Evaluation $ 55
Other Periodontal Services
D4910

Periodontal Maintenance Procedures After Active Therapy

 $ 30
D4920 Unscheduled Dressing Change (By Someone Other than Treating Dentist) $ 0

D5000-D5999 VI. PROSTHODONTICS (REMOVABLE)
(The replacement of an existing removable prosthetic appliance is covered only after a 5 year period measured from the date on which the appliance was previously placed)

Complete Dentures (Including Routine Post Delivery Care)
D5110

Complete Denture-Maxillary

 $250
D5120 Complete Denture-Mandibular $250
D5130 Immediate Denture-Maxillary $275
D5140 Immediate Denture-Mandibular $275

Partial Dentures (Including Routine Post Delivery Care)
D5211

Maxillary Partial Denture-Resin Base (Including any Conventional Clasps, Rests and Teeth)

 $250
D5212 Mandibular Partial Denture-Resin Base (Including any Conventional Clasps, Rests and Teeth) $250
D5213 Maximum Partial Denture-Cast Metal Framework w/Resin Denture Bases (Including any Conventional Clasps, Rests & Teeth) $275
D5214 Mandibular Partial Denture-Cast Metal Framework w/Resin Denture Bases (Including any Conventional Clasps, Rests & Teeth) $275
D5281 Removable Unilateral Partial Denture-One Piece Cast Metal (Including Clasps & Teeth) $125
Adjustments to Removable Prostheses
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

 $ 35
D5520 Replace Missing or Broken Teeth-Complete Denture-Each Tooth $ 35
Repairs to Partial Dentures
D5610

Repair Resin Denture Base

 $ 35
D5620 Repair Cast Framework $ 35
D5630 Repair or Replace Broken Clasp $ 35
D5640 Replace Broken Teeth-Per Tooth $ 35
D5650 Add Tooth to Existing Partial Denture $ 35
D5660 Add Clasp to Existing Partial Denture $ 35

Denture Rebase Procedures
D5710

Rebase Complete Maxilary Denture

$ 85
D5711 Rebase Complete Mandibular Denture $ 85
D5720 Rebase Maxillary Partial Denture $ 85
D5721 Rebase Mandibular Partial Denture $ 85
Denture Reline Procedures
D5730

Reline Complete Maxillary Denture-Chairside

 $ 40
D5731 Reline Complete Mandibular Denture-Chairside $ 40
D5740 Reline Maxillary Partial Denture-Chairside $ 40
D5741 Reline Mandibular Partial Denture-Chairside $ 40
D5750 Reline Complete Maxillary Denture-(Lab Process) $ 40
D5751 Reline Complete Mandibular Denture-(Lab Process) $ 40
D5760 Reline Maxillary Partial Denture-(Lab Process) $ 40
D5761 Reline Mandibular Partial Denture-(Lab Process) $ 40
Other Removable Prosthetic Services
D5810

Interim Complete Denture (Maxillary)

 $ 95
D5811 Interim Complete Denture (Mandibular) $ 95
D5820 Interim Partial Denture (Maxillary) $ 65
D5821 Interim Partial Denture (Mandibular) $ 65
D5850 Tissue Conditioning (Maxillary) $ 15
D5851 Tissue Conditioning (Mandibular) $ 15
D6200-D6999 IX. PROSTHODONTICS, FIXED

Fixed Partial Denture Pontics
D6210

Pontic-Cast High Noble Metal

 $225
D6211 Pontic-Cast Predominantly Base Metal $200
D6212 Pontic-Cast Noble Metal $200
D6240 Pontic-Porcelain Fused to High Noble Metal $225
D6241 Pontic-Porcelain Fused to Predominantly Base Metal $200
D6242 Pontic-Porcelain Fused to Noble Metal $200
D6245 Pontic Porcelain/Ceramic $200
D6250 Pontic-Resin with High Noble Metal $150
D6251 Pontic-Resin with Predominantly Base Metal $150
D6252 Pontic-Resin with Noble Metal $150
Fixed Partial Denture Retainers-Inlays/Onlays
D6520

Inlay-Metallic-Two Surfaces

 $100
D6530 Inlay-Metallic-Three or More Surfaces $100
D6543 Onlay-Metallic-Four or More Surfaces $100
D6544 Onlay-Metallic-Four or More Surfaces $100
D6545 Retainer-Cast Metal for Resin Bonded Fixed Prosthesis $100
Fixed Partial Denture Retainers-Crown
D6720

Crown-Resin with High Noble Metal

 $150
D6721 Crown-Resin with Predominantly Base Metal $150
D6722 Crown-Resin with Noble Metal $150
D6740 Crown Porcelain/Ceramic $200
D6750 Crown-Porcelain Fused to High Noble Metal $225
D6751

Crown-Porcelain Fused to Predominately Base Metal

 $200
D6752 Crown-Porcelain Fused to Noble Metal $200
D6780 Crown-3/4 Cast High Noble Metal $225
D6781 Crown 3/4 Cast Predominately Base Metal $200
D6782 Crown 3/4 Cast Noble Metal $200
D6783

Crown 3/4 Porcelain/Ceramic

 $200
D6790 Crown-Full Cast High Noble Metal $225
D6791 Crown-Full Cast Predominantly Base Metal $200
D6792 Crown-Full Cast Noble Metal $200
Other Fixed Partial Denture Services
D6930

Recement Fixed Partial Denture

 $ 15
D6970 Cast Post & Core in Addition to Bridge Retainer $ 40
D6971 Cast Post as Part of Fixed Partial Denture $ 40
D6972 Prefabricated Post & Core in Addition to Bridge Retainer $ 40
D6973 Core Buildup for Retainer Including Pins $ 0
D6980 Fixed Partial Denture Repair-By Report $ 25
D7000-D7999 X. ORAL AND MAXILLOFACIAL SURGERY
Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Post-Operative Care
D7110

Single Tooth

 $ 20
D7120 Each Additional Tooth $ 15
D7130 Root Removal-Exposed Roots $ 20

Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Post-Operative Care
D7210

Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap & Removal of Bone and/or Section of Tooth

 $ 30
D7220 Removal of Impacted Tooth-Soft Tissue $ 55
D7230 Removal of Impacted Tooth-Partially Bony $ 55
D7240 Removal of Impacted Tooth-Completely Bony $ 65
D7241 Removal of Impacted Tooth-Completely Bony with Complications $ 65
D7250 Surgical Removal of Residual Tooth Roots-Cutting Procedure $ 30
Other Surgical Procedures
D7260

Oroantral Fistula Closure

 $100
D7270 Tooth Reimplantation/Stabilization $ 60
D7280 Surgical Exposure of Impacted/Unerupted Tooth-for Orthodontic Reasons $ 60
D7281 Surgical Exposure of Impacted/Unerupted Tooth-to Aid Eruption $ 60
D7285 Biopsy of Oral Tissue-Hard $ 60
D7286 Biopsy of Oral Tissue-Soft $ 25
D7291 Transseptal Fiberotomy-By Report $ 20

Alveoloplasty-Surgical Preparation of the Ridge for Dentures
D7310

Alveoloplasty in Conjunction with Extraction-Per Quad

 $ 30
D7320 Alveoloplasty Not in Conjunction with Extractions-Per Quadrant $ 35

Removal of Cysts, Tumors and Neoplasms
D7430

Excision of Benign Tumor-Lesion Up to 1.25cm Diameter

 $ 60
D7431 Excision of Benign Tumor-Lesion Greater than 1.25cm Diameter $ 60
D7450 Excision of Odontogenic Cyst or Tumor-Lesion Up to 1.25cm Diameter $ 60
D7451 Excision of Odontogenic Cyst or Tumor-Lesion Greater than 1.25cm Diameter $ 60
D7460 Excision of Non-Odontogenic Cyst or Tumor-Lesion Up to 1.25cm Diameter $ 60
D7461 Excision of Non-Odontogenic Cyst or Tumor-Lesion Greater than 1.25cm Diameter $ 60

Excision of Bone Tissue
D7471

Removal of Exostosis-Maxilla or Mandible

 $ 90

Surgical Incision
D7510

Incision & Drainage of Abscess-Intraoral Soft Tissue

 $ 25
D7520 Incision & Drainage of Abscess-Extraoral Soft Tissue $ 35

Other Repair Procedures
D7960

Frenulectomy-Separate Procedure

 $ 60
D7970 Excision of Hyperplastic Tissue-Per Arch $ 60
D7971 Excision of Pericoronal Gingiva $ 30
Miscellaneous Services
D9110

Palliative (Emergency) Treatment of Dental Pain-Minor Procedure

 $ 0
D9211 Regional Block Anesthesia $ 0
D9212 Trigeminal Division Block Anesthesia $ 0
D9215

Local Anesthesia

 $ 0
D9220 General Anesthesia - First 30 Minutes $ 40
D9221 General Anesthesia - Each Additional 15 Minutes $ 20
D9230 Analgesia $ 0
D9241

Intravenous Sedation, First 30 Minutes

 $ 40
D9242 Intravenous Sedation, Each Additional 15 Minutes $ 20
D9310 Consultation $ 0
D9430 Office Visit Observation $ 0
D9440 Office Visit After Hours $ 0
D9610

Therapeutic Drug Injection By Report

 $ 0
D9630 Other Drugs and/or Medications By Report $ 0
D9910 Application of Desensitizing Medication $ 0
D9930 Treat Complications By Report $ 0
D9940 Occlusal Guard-By Report $ 40
D9951 Occlusal Adjustment-Limited $ 0
D9952 Occlusal Adjustment-Complete $ 60



Orthodontics

(Treatment plan maximum of 24 months)

1. Patient under 18 years of age at the start of treatment — Class I, II, and III malocclusion (copayment required of $1,000 or 50% of bill, whichever is less).

2. Patient 18 years of age or over at the start of treatment — Class I, II, and III malocclusion (copayment required of $1,750 or 50% of bill, whichever is less).


Services That Are Not Covered By the DPO

· A service started before the person became a covered individual under the plan.

· A service covered under any medical or surgical or major medical plan (including a health maintenance organization) provided by the employer.

· Replacement of lost, stolen, or damaged prosthodontic devices within two years of the date of initial installation.

· A service not reasonably necessary for the dental care of a covered individual or provided solely for cosmetic purposes.

· Providing supplies of a type normally intended for home use, such as toothpaste, toothbrushes, waterpicks, and mouthwash.

· A service required because of war or an act of war.

· A service made available to a covered individual or financed by the federal government or a state or local government. This includes the federal Medicare program and any similar federal program, any Workers’ Compensation law or similar law, any automobile no-fault law, or any other program or law under which the covered individual is, or could be, covered. The exclusion is applicable whether or not the covered individual receives the service, makes a claim or receives compensation for the service, or receives a recovery from a third party for damages.

· A service not furnished by a dentist. This is not applicable to a service performed by a licensed dental hygienist under   the supervision of a dentist.

· General anesthesia, except when medically necessary in connection with covered oral and periodontal surgery   procedures.

· Hospitalization.

· Any dental implant including any devices or appliances attached to implants.

· Experimental procedures.

· Appliances, restorations, and procedures to alter vertical dimension and/or restore occlusion, including temporomandibular joint dysfunction, except oral splints.

· Procedures not listed.


More Expensive Services

A covered individual may elect a more expensive procedure than an appropriate procedure recommended by the DPO. The covered individual shall pay any copayment required for the less expensive procedure plus the difference in cost between the two procedures on the basis of the reasonable and customary dental charges for the procedures.

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