select plan basic 703xa (dc) description of services ... · d5221 immediate maxillary partial...

D2391 Resin-based composite - one surface, posterior ....73D2392 Resin-based composite - two surfaces, posterior ..................................................................87D2393 Resin-based composite - three surfaces, posterior ................................................................102D2394 Resin-based composite - >=4 surfaces, posterior ................................................................123

Crown & BridgeD2510 Inlay - metallic - one surface .................................407D2520 Inlay - metallic - two surfaces ...............................407D2530 Inlay - metallic - three or more surfaces ...............425D2542 Onlay - metallic-two surfaces ...............................458D2543 Onlay - metallic-three surfaces .............................524D2544 Onlay - metallic-four or more surfaces .................524D2610 Inlay - porcelain/ceramic - one surface ................427D2620 Inlay - porcelain/ceramic - two surfaces ...............427D2630 Inlay - porcelain/ceramic - >=3 surfaces ...............445D2642 Onlay - porcelain/ceramic - two surfaces .............479D2643 Onlay - porcelain/ceramic - three surfaces ..........499D2644 Onlay - porcelain/ceramic - >=4 surfaces .............499D2650 Inlay - resin-based composite - one surface .........440D2651 Inlay - resin-based composite - two surfaces .......440D2652 Inlay - resin-based composite - >=3 surfaces .......440D2662 Onlay - resin-based composite - two surfaces......444D2663 Onlay - resin-based composite - three surfaces ...444D2664 Onlay - resin-based composite - >=4 surfaces ......444D2710 Crown - resin based composite (indirect).............272D2712 Crown - 3/4 resin-based composite (indirect) ......485D2720/21/22 Crown - resin with metal.......................................495D2740 Crown - porcelain/ceramic ...................................560D2750/51/52 Crown - porcelain fused metal..............................523D2780/81/82 Crown - 3/4 cast with metal .................................478D2783 Crown - 3/4 porcelain/ceramic .............................511D2790/91/92 Crown - full cast metal ..........................................495D2910/20 Recementinlay,onlay/crownorpartial coverage rest. ..........................................................43D2931 Prefab. stainless steel crown.................................121D2932 Prefabricated resin crown .....................................140D2940 Protectiverestoration ............................................39D2950 Core buildup, including any pins ...........................125D2951 Pinretention-pertooth,inadditionto restoration...............................................................22D2952 Postandcoreinadditiontocrown .......................186D2954 Prefab.postandcoreinadditiontocrown ..........154D2955 Post removal (not in conj. with endo. therapy) ....105D2980 Crownrepairnecessitatedbyrestorative material failure ......................................................102

Diagnostic/Preventive D9439 Officevisit ...............................................................10D0120 Periodicoraleval-establishedpatient .....................0D0140 Limited oral eval - problem focused .........................0D0150 Comprehensive oral eval - new or established patient .......................................................................0D0160 Detailed and extensive oral eval - problem focused ......................................................................0D0170 Re-evaluation-limited,problemfocused ................0D0180 Comp. periodontal eval - new or established patient .....................................................................36D0210 Intraoral - complete series of radiographic images .....................................................................26D0220 Intraoral-periapicalfirstradiographicimage ..........0D0230 Intraoral - periapical each add. radiographic image .........................................................................0D0240 Intraoral - occlusal radiographic image ....................0D0250 Extra-oral-2Dprojectionradiographicimage ........0D0270-74 Bitewing x-rays - 1 to 4 radiographic images ............0D0277 Verticalbitewings-7to8radiographicimages ........0D0330 Panoramic radiographic image ...............................30D0340 2D cephalometric radiographic image .....................0D0350 2D oral/facial photographic image obtained intra-orally or extra-orally .........................................0D0351 3D photographic image ............................................0D0460 Pulp vitality tests .......................................................0D0470 Diagnosticcasts .........................................................0D1110 Prophylaxis (cleaning) - adult ..................................13D1110* Additionalcleaning(expectingmothersor Diabetics) ................................................................40D1206 Topicalapplicationoffluoridevarnish ......................0D1208 Topicalapplicationoffluoride-excludingvarnish ...0D1310 Nutritionalcounselingforcontrolofdental disease ......................................................................0D1320/30 Oralhygieneinstructions ..........................................0

Restorative (Fillings)D2140 Amalgam - one surface, prim. or perm. .................41D2150 Amalgam - two surfaces, prim. or perm. ................51D2160 Amalgam - three surfaces, prim. or perm. .............64D2161 Amalgam - >=4 surfaces, prim. or perm. ................78D2330 Resin-based composite - one surface, anterior ......69D2331 Resin-based composite - two surfaces, anterior ....83D2332 Resin-based composite - three surfaces, anterior ...................................................................99D2335 Resin-based composite - >=4 surfaces, anterior .................................................................119D2390 Resin-based composite crown, anterior ...............192

Dominion National; 251 18th Street South, Suite 900; Arlington, VA 22202888.518.5338; DominionNational.com

Plan Highlights• Thisplanhasfixedcopayments.• Thereisnoout-of-networkcoverage(withtheexceptionofout-of-areaemergencydentalservicesand/orforservicesprovidedwhenaMember

is referred to an out-of-network specialist). See exclusion 11.• Therearenoannualmaximumdollarlimits,nowaitingperiodsandnodeductibles.• If course of treatment is to exceed $300, prior review is recommended.

Select Plan Basic 703xa (DC)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-

ADA MEMBERCODE DESCRIPTION COPAYMENT(S)


DMN20MADOBINFAM-DCDEPAVA pid26771

The dental plan is underwritten by Dominion Dental Services, Inc. d/b/a Dominion National (hereinafter referred to as “Dominion”).



D2981 Inlayrepairnecessitatedbyrestorative material failure ......................................................102D2982 Onlayrepairnecessitatedbyrestorative material failure ......................................................102 Endodontics1 D3110/20 Pulpcap-direct/indirect(excl.final restoration) .............................................................32D3220 Therapeuticpulpotomy(excl.finalrestor.).............81D3221 Pulpal debridement ................................................94D3310 Endodontictherapy,anteriortooth(excl. finalrestor.) ...........................................................341D3320 Endodontictherapy,premolartooth(excl. finalrestor.) ...........................................................418D3330 Endodontictherapy,molartooth(excl. finalrestor.) ...........................................................512D3333 Internalrootrepairofperforationdefects ...........105D3346 Retreat of prev. root canal therapy, anterior ........387D3347 Retreat of prev. root canal therapy, premolar ......465D3348 Retreat of prev. root canal therapy, molar ...........558D3410 Apicoectomy - anterior ........................................323D3421 Apicoectomy-premolar(firstroot) .....................364D3425 Apicoectomy-molar(firstroot) ..........................418D3426 Apicoectomy - (each add. root) ............................152D3430 Retrogradefilling-perroot ..................................119D3450 Rootamputation-perroot ..................................234D3920 Hemisection,notinc.rootcanaltherapy .............234D3950 Canalprep/fittingofpreformeddowelorpost ....136

Periodontics1

D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad. ....................................................279D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad. ....................................................100D4240 Gingivalflapproc.,inc.rootplaning->3 cont. teeth, per quad ............................................345D4241 Gingivalflapproc,inc.rootplaning-<=3 cont. teeth, per quad ............................................106D4260 Osseous surgery - >3 cont. teeth, per quad .........499D4261 Osseous surgery - <=3 cont. teeth, per quad .......392D4263 Bonereplacementgraft-retainednatural tooth-firstsiteinquad ........................................613D4264 Bonereplacementgraft-retainednatural tooth-eachadditionalsiteinquad ......................480D4265 Biologicalmaterialstoaidinsoftand osseoustissueregeneration .................................336D4268 Surgical revision proc., per tooth ..........................358D4270 Pediclesofttissuegraftprocedure .......................530D4273 Autogenousconnectivetissuegraft procedure,firsttooth............................................660D4274 Mesial/distalwedgeprocedure,singletooth .......308D4275 Non-autogenousconnectivetissuegraft (including recipient site and donor material) firsttooth,implant,oredentuloustooth positioningraft .....................................................705D4277 Freesofttissuegraftprocedure,firsttooth .........540D4278 Freesofttissuegraftprocedure,each add. tooth ...............................................................83D4341 Perio scaling and root planing - >3 cont teeth, per quad. ....................................................109D4342 Perio scaling and root planing - <= 3 teeth, per quad .......................................................63D4346 Scaling in presence of generalized moderate orseveregingivalinflammation-fullmouth, afteroralevaluation ................................................51D4355 Fullmouthdebridement .........................................89D4381 Localizeddeliveryofantimicrobialagents .............98D4910 Periodontal maintenance .......................................74

Prosthetics (Dentures)D5110/20 Complete denture - maxillary/mandibular ...........697D5130/40 Immediate denture - maxillary/mandibular .........722D5211/12 Maxillary/mandibularpartialdenture- resin base ..............................................................649D5213/14 Maxillary/mandibularpartialdenture- cast metal ..............................................................750D5221 Immediatemaxillarypartialdenture- resin base ..............................................................649D5222 Immediatemandibularpartialdenture- resin base ..............................................................649D5223 Immediatemaxillarypartialdenture- cast metal framework ...........................................750D5224 Immediatemandibularpartialdenture- cast metal framework ...........................................750D5225/26 Maxillary/mandibularpartialdenture- flexiblebase ..........................................................750D5282/83 Rem.unilateralpartialdenture- one piece cast metal, maxillary/mandibular ........419D5410/11 Adjust complete denture - maxillary/mandibular .............................................38D5421/22 Adjustpartialdenture- maxillary/mandibular .............................................38D5511 Repair broken complete denture base, mandibular ..............................................................87D5512 Repair broken complete denture base, maxillary ..................................................................87D5520 Replace missing or broken teeth - complete denture ...................................................87D5611 Repairresinpartialdenturebase,mandibular .......87D5612 Repairresinpartialdenturebase,maxillary ...........87D5621 Repaircastpartialframework,mandibular ............87D5622 Repaircastpartialframework,maxillary ................87D5630/60 Clasp repaired, replaced or added .......................115D5640 Replace broken teeth - per tooth ...........................87D5650 Addtoothtoexistingpartialdenture .....................87D5670/71 Replace all teeth and acrylic on cast metal framework .............................................................287D5710/11 Rebase complete maxillary/mandibular denture..................................................................260D5720/21 Rebasemaxillary/mandibularpartialdenture .....260D5730/31 Reline complete maxillary/mandibular denture (chairside) ................................................159D5740/41 Relinemaxillary/mandibularpartial denture (chairside) ................................................155D5750/51 Reline complete maxillary/mandibular denture (lab) .........................................................224D5760/61 Relinemaxillary/mandibularpartial denture (lab) .........................................................224D5810/11 Interim complete denture - maxillary/mandibular ...........................................362D5820/21 Interimpartialdenture- maxillary/mandibular ...........................................362D5850/51 Tissueconditioning-maxillary/mandibular ...........79 Bridge & PonticsD6000-D6199ALLIMPLANTSERVICES-15%DISCOUNT (incl. D0360-D0363 cone beam imaging w/ implants)D6081 Scaling and debridement in the presence ofinflammationormucositisofasingle implant, including cleaning of the implant surfaces,withoutflapentryandclosure ................63D6210/11/12 Pontic-metal ........................................................495D6240/41/42 Pontic-porcelainfusedmetal ..............................523D6245 Pontic-porcelain/ceramic ....................................560D6250/51/52 Pontic-resinwithmetal .......................................495D6545 Retainer-castmetalforresinbondedfixed prosthesis ..............................................................251

pid26772DMN20MADOBINFAM-DCDEPAVA



D6548 Ret.-porc./ceramicforresinbondedfixed prosthesis ..............................................................393D6549 Resinretainer-forresinbondedfixed prosthesis ..............................................................251D6600 Retainer inlay - porc./ceramic, two surfaces ........427D6601 Retainer inlay - porc./ceramic, >=3 surfaces ........445D6602 Retainer inlay - cast high noble metal, two surfaces .................................................................407D6603 Retainer inlay - cast high noble metal, >=3 surfaces .................................................................425D6604 Retainer inlay - cast predominantly base metal, two surfaces ...............................................407D6605 Retainer inlay - cast predominantly base metal, >=3 surfaces ...............................................425D6606 Retainer inlay - cast noble metal, two surfaces ....407D6607 Retainer inlay - cast noble metal, >=3 surfaces ....425D6608 Retainer onlay - porc./ceramic, two surfaces .......479D6609 Retainer onlay - porc./ceramic, three or more surfaces .......................................................499D6610 Retainer onlay - cast high noble metal, two surfaces ..........................................................458D6611 Retainer onlay - cast high noble metal, >=3 surfaces ..........................................................524D6612 Retainer onlay - cast predominantly base metal, two surfaces ...............................................458D6613 Retainer onlay - cast predominantly base metal, >=3 surfaces ...............................................524D6614 Retainer onlay - cast noble metal, two surfaces .................................................................458D6615 Retainer onlay - cast noble metal, >=3 surfaces .................................................................524D6720/21/22 Retainer crown - resin with metal ........................495D6740 Retainer crown - porcelain/ceramic .....................560D6750/51/52 Retainer crown - porcelain fused metal ...............523D6780 Retainer crown - 3/4 cast high noble metal .........470D6781 Retainer crown - 3/4 cast predominantly base metal .............................................................470D6782 Retainer crown - 3/4 cast noble metal .................470D6783 Retainer crown - 3/4 porc./ceramic ......................511D6790/91/92 Retainer crown - full cast metal ............................495D6930 Recementorrebondfixedpartialdenture .............69D6980 Fixedpartialdenturerepair,byreport .................172 Oral Surgery1 D7111 Extraction,coronalremnants-primarytooth ........56D7140 Extraction,eruptedtoothorexposedroot ............69D7210 Extraction,eruptedtoothreqelev,etc ................133D7220 Removalofimpactedtooth-softtissue ..............151D7230 Removalofimpactedtooth-partiallybony .........196D7240 Removal of impacted tooth - completely bony ......................................................................241D7241 Removal of imp. tooth - completely bony, withunusualsurg.complications .........................217D7250 Removal of residual tooth roots ...........................141D7251 Coronectomy-intentionalpartialtooth removal .................................................................217D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth .......................................226D7280 Exposure of an unerupted tooth ..........................153D7291 Transseptalfiberotomy/supracrestal fiberotomy,byreport ..............................................60D7310/20 Alveoloplasty, per quad ........................................141D7510 Incision and drainage of abscess - intraoralsofttissue .................................................96D7960 Frenulectomy(frenectomy/frenotomy)- separate proc. .......................................................263D7979 Non-surgical sialolithotomy ....................................43

Orthodontics2 D8090 Comp.ortho.treatment-adultdentition ..........3658D8660 Pre-orthodontictreatmentvisit............................413D8670 Periodic ortho. treatment visit (as part of contract) ............................................................118D8680 Orthodonticretention(rem.ofappl. and placement of retainer(s)) ...............................413 Adjunctive General Services D9110 Palliative(emergency)treatmentofdentalpain .....43D9210/15 Local anesthesia ........................................................0D9211 Regional block anesthesia .........................................0D9212 Trigeminal division block anesthesia ........................0D9219 Evaluationfordeepsedationorgeneral anesthesia .................................................................0D9222 Deepsedation/generalanesthesia-first 15 minutes ............................................................103D9223 Deepsedation/generalanesthesia-each subsequent 15 min incr ........................................103D9230 Inhalationofnitrousoxide/analgesia,anxiolysis ....37D9239 Intravenousmoderatesedation/analgesia– first15minutes .....................................................103D9243 Intravenousmoderatesedation/analgesia- each subsequent 15 min ......................................103D9310 Consultation(diagnosticserviceby nontreatingdentist) ................................................43D9613 Infiltrationofsustainedreleasetherapeutic drug–singleormultiplesites ...............................190D9910 Applicationofdesensitizingmedicament ..............31D9930 Treatmentofcomplications(post-surgical) ............43D9944 Occlusalguard–hardappliance,fullarch ............272D9945 Occlusalguard–softappliance,fullarch .............272D9946 Occlusalguard–hardappliance,partialarch ......272D9950 Occlusion analysis - mounted case .......................104D9951 Occlusal adjustment - limited .................................66D9952 Occlusal adjustment - complete ...........................266D9986 Missedappointment ...............................................50D9995 Teledentistry–synchronous;real-time encounter ................................................................20D9996 Teledentistry–asynchronous;information storedandforwardedtodentistfor subsequent review ..................................................20

1 AsperformedbyaParticipatingGeneralDentist.SeePlan Exclusion #13.2 PhaseITreatment(D8010-D8050)isprovidedata15% reductionfromtheorthodontist’sUCRfees.Seeexclusion#15 foradditionalcoverageexclusions.

CurrentDentalTerminology©AmericanDentalAssociation.OnlycurrentADACDTcodesareconsideredvalidbyDominion.Forafulldescriptionofeachcode,pleaseconsulttheADA’sCDTguidelines.


pid26775

Plan Exclusions PleaserefertothesectioninyourIndividualDentalPolicytitled“State-SpecificExclusionsorExceptions”foradditionalexclusions and/orexceptionstothefollowingexclusions,ifapplicable.1. Serviceswhicharecoveredunderworker’scompensationor employer’sliabilitylaws.2. Serviceswhicharemedicallynotnecessaryforthepatient’s dental health as determined by the Plan. 3. Cosmetic,electiveoraestheticdentistryexceptasrequireddue to accidental bodily injury to sound natural teeth as determined by the Plan. 4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformationswhere,intheopinionofthePlan,suchservices shouldnotbeperformedinadentaloffice. 6. Dispensing of drugs. 7. Hospitalizationforanydentalprocedure. 8. Treatmentrequiredforconditionsresultingfrommajordisaster, epidemic, war, acts of war, whether declared or undeclared, or whileonactivedutyasamemberofthearmedforcesofany nation.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. Servicesobtainedoutsideofthedentalofficeinwhichenrolled andthatarenotpreauthorizedbysuchofficeorthePlan(with theexceptionofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(Temporomandibular Disorder). 13. Services related to procedures that are of such a degree of complexityastonotbenormallyperformedbyaparticipating generaldentist.Abovecopaymentsdonotapplywhen performedbyaparticipatingplanspecialist(withtheexception oforthodonticsandpalliativeemergencypaintreatment). Participatingplanspecialists,ifavailable,haveenteredinto anagreementwithDominionNationaltoprovidedentalservices tomembersata25%reductionfromtheirUsual,Customary,and Reasonable(UCR)fees.ThismeansthatMemberwillbe responsiblefor25%ofthelesserofaParticipatingSpecialists UCRfeeortheamounttheproviderhasagreedtoaccept. MembersmustdirectlycontacttheParticipatingSpecialistto obtain fees as the amount varies by provider.14. Electivesurgeryincluding,butnotlimitedto,extractionofnon- pathologic,asymptomaticimpactedteeth,includingthirdmolars, as determined by the Plan. 15. The Invisalign system and similar appliances are not a covered benefit.Patientcopaymentswillapplytotheroutineorthodontic applianceportionofservicesonly.Additionalcostsincurredwill becomethepatient’sresponsibility. Plan Limitations 1. Two(2)evaluationsarecoveredpercalendaryearperpatient includingamaximumofone(1)comprehensiveevaluation.2. One (1) problem focused exam is covered per calendar year perpatient. 3. Two (2) teeth cleanings (prophylaxis) are covered per calendar yearperpatient(oneadditionalcleaningiscoveredduring pregnancyandfordiabeticpatients). 4. One(1)topicalfluorideorfluoridevarnishiscoveredper calendaryearperpatient. 5. Two (2) bitewing x-rays are covered per calendar year per patient.

6. One(1)setoffullmouthx-raysorpanoramicfilmiscovered everythree(3)yearsperpatient. 7. Replacementofafillingiscoveredifitismorethantwo(2)years from the date of original placement. 8. Replacement of a bridge, crown or denture is covered if it is more than seven (7) years from the date of original placement. 9. Crownandbridgefeesapplytotreatmentinvolvingfiveorfewer unitswhenpresentedinasingletreatmentplan.Additional crown or bridge units, beginning with the sixth unit, are available attheprovider’sUsual,Customary,andReasonable(UCR)fee, minus25%. 10. Relining and rebasing of dentures is covered once every 24 monthsperpatient. 11. Retreatment of root canal is covered if it is more than two (2) years from the original treatment. 12. Root planing or scaling is covered once every 24 months per quadrantperpatient. 13. Scaling in presence of generalized moderate or severe gingival inflammation-fullmouth,afteroralevaluationandinlieuofa covered D1110, limited to once per two years. 14. Scalinganddebridementinthepresenceofinflammationor mucositisofasingleimplant,includingcleaningoftheimplant surfaces,withoutflapentryandclosure 15. Fullmouthdebridementiscoveredonceperlifetimeperpatient.16. ProcedureCodeD4381islimitedtoone(1)benefitpertoothfor three teeth per quadrant or a total of 12 teeth for all four quadrantspertwelve(12)monthsperpatient.Musthavepocket depthsoffive(5)millimetersorgreater. 17. Periodontal surgery of any type, including any associated material, is covered once every 36 months per quadrant or surgicalsiteperpatient. 18. Periodontalmaintenanceafteractivetherapyiscoveredtwice percalendaryear,within24monthsafterdefinitiveperiodontal therapy,perpatient. 19. Coronectomy-intentionalpartialtoothremoval,onceper lifetime.20. Teledentistry,synchronous(D9995)orasynchronous(D9996), limited to two per calendar year (when available).21. Orthodontiatreatmentislimitedtoonceperlifetime.

DMN20MADOBINFAM-DCDEPAVA








Select Plan Basic 703xa (DE)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-








Periodontics1




pid26975











Select Plan Basic 703xa (MD)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-



DMN20MDDBLINFAM pid27551





Periodontics1



pid27552DMN20MDDBLINFAM



D6548 Ret.-porc./ceramicforresinbondedfixed prosthesis ..............................................................393D6549 Resinretainer-forresinbondedfixed prosthesis ..............................................................251D6600 Retainer inlay - porc./ceramic, two surfaces ........427D6601 Retainer inlay - porc./ceramic, >=3 surfaces ........445D6602 Retainer inlay - cast high noble metal, two surfaces .................................................................407D6603 Retainer inlay - cast high noble metal, >=3 surfaces .................................................................425D6604 Retainer inlay - cast predominantly base metal, two surfaces ...............................................407D6605 Retainer inlay - cast predominantly base metal, >=3 surfaces ...............................................425D6606 Retainer inlay - cast noble metal, two surfaces ....407D6607 Retainer Inlay - cast noble metal, >=3 surfaces ....425D6608 Retainer onlay - porc./ceramic, two surfaces .......479D6609 Retainer onlay - porc./ceramic, three or more surfaces .......................................................499D6610 Retainer onlay - cast high noble metal, two surfaces ..........................................................458D6611 Retainer onlay - cast high noble metal, >=3 surfaces ..........................................................524D6612 Retainer onlay - cast predominantly base metal, two surfaces ...............................................458D6613 Retainer onlay - cast predominantly base metal, >=3 surfaces ...............................................524D6614 Retainer onlay - cast noble metal, two surfaces .................................................................458D6615 Retainer onlay - cast noble metal, >=3 surfaces .................................................................524D6720/21/22 Retainer crown - resin with metal ........................495D6740 Retainer crown - porcelain/ceramic .....................560D6750/51/52 Retainer crown - porcelain fused metal ...............523D6780 Retainer crown - 3/4 cast high noble metal .........470D6781 Retainer crown - 3/4 cast predominantly base metal .............................................................470D6782 Retainer crown - 3/4 cast noble metal .................470D6783 Retainer crown - 3/4 porc./ceramic ......................511D6790/91/92 Retainer crown - full cast metal ............................495D6930 Recementorrebondfixedpartialdenture .............69D6980 Fixedpartialdenturerepair,byreport .................172 Oral Surgery1 D7111 Extraction,coronalremnants-primarytooth ........56D7140 Extraction,eruptedtoothorexposedroot ............69D7210 Extraction,eruptedtoothreqelev,etc ................133D7220 Removalofimpactedtooth-softtissue ..............151D7230 Removalofimpactedtooth-partiallybony .........196D7240 Removal of impacted tooth - completely bony ......................................................................241D7241 Removal of imp. tooth - completely bony, withunusualsurg.complications .........................217D7250 Removal of residual tooth roots ...........................141D7251 Coronectomy-intentionalpartialtooth removal .................................................................217D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth .......................................226D7280 Exposure of an unerupted tooth ..........................153D7291 Transseptalfiberotomy/supracrestal fiberotomy,byreport ..............................................60D7310/20 Alveoloplasty, per quad ........................................141D7510 Incision and drainage of abscess - intraoralsofttissue .................................................96D7960 Frenulectomy(frenectomy/frenotomy)- separate proc. .......................................................263D7979 Non-surgical sialolithotomy ....................................43




pid27553DMN20MDDBLINFAM

pid27554

Plan Exclusions PleaserefertothesectioninyourCertificateofCoveragetitled“State-SpecificExclusions”foradditionalexclusions,ifapplicable.1. Serviceswhicharecoveredunderworker’scompensationor employer’sliabilitylaws.2. Serviceswhicharenotnecessaryforthepatient’sdentalhealth as determined by the Plan. 3. Cosmetic,electiveoraestheticdentistryexceptasrequireddue to accidental bodily injury to sound natural teeth as determined by the Plan. 4. Oralsurgeryrequiringthesettingoffracturesordislocations.5. Services with respect to malignancies, cysts or neoplasms, hereditary, congenital, mandibular prognathism or development malformationswhere,intheopinionofthePlan,suchservices shouldnotbeperformedinadentaloffice. 6. Dispensing of drugs. 7. Hospitalizationforanydentalprocedure. 8. Treatmentrequiredforconditionsresultingfrommajordisaster, epidemic, war, acts of war, whether declared or undeclared, or whileonactivedutyasamemberofthearmedforcesofany nation.9. Replacementduetolossortheftofprostheticappliance.10. ProceduresnotlistedascoveredbenefitsunderthisPlan.11. Servicesobtainedoutsideofthedentalofficeinwhichenrolled andthatarenotpreauthorizedbysuchofficeorthePlan(with theexceptionofout-of-areaemergencydentalservices).12. ServicesrelatedtothetreatmentofTMD(Temporomandibular Disorder). 13. Services related to procedures that are of such a degree of complexityastonotbenormallyperformedbyaparticipating generaldentist.Abovecopaymentsdonotapplywhen performedbyaparticipatingplanspecialist(withtheexception oforthodonticsandpalliativeemergencypaintreatment). Participatingplanspecialists,ifavailable,haveenteredinto anagreementwithDominionNationaltoprovidedentalservices tomembersata25%reductionfromtheirUsual,Customary,and Reasonable(UCR)fees.ThismeansthatMemberwillbe responsiblefor25%ofthelesserofaParticipatingSpecialists UCRfeeortheamounttheproviderhasagreedtoaccept. MembersmustdirectlycontacttheParticipatingSpecialistto obtain fees as the amount varies by provider.14. Electivesurgeryincluding,butnotlimitedto,extractionofnon- pathologic,asymptomaticimpactedteeth,includingthirdmolars, as determined by the Plan. 15. The Invisalign system and similar appliances are not a covered benefit.Patientcopaymentswillapplytotheroutineorthodontic applianceportionofservicesonly.Additionalcostsincurredwill becomethepatient’sresponsibility. Plan Limitations 1. Two(2)evaluationsarecoveredpercalendaryearperpatient includingamaximumofone(1)comprehensiveevaluation.2. One (1) problem focused exam is covered per calendar year perpatient. 3. Two (2) teeth cleanings (prophylaxis) are covered per calendar yearperpatient(oneadditionalcleaningiscoveredduring pregnancyandfordiabeticpatients). 4. One(1)topicalfluorideorfluoridevarnishiscoveredper calendaryearperpatient. 5. Two (2) bitewing x-rays are covered per calendar year per patient. 6. One(1)setoffullmouthx-raysorpanoramicfilmiscovered

everythree(3)yearsperpatient. 7. Replacementofafillingiscoveredifitismorethantwo(2)years from the date of original placement. 8. Replacement of a bridge, crown or denture is covered if it is more than seven (7) years from the date of original placement. 9. Crownandbridgefeesapplytotreatmentinvolvingfiveorfewer unitswhenpresentedinasingletreatmentplan.Additional crown or bridge units, beginning with the sixth unit, are available attheprovider’sUsual,Customary,andReasonable(UCR)fee, minus25%. 10. Relining and rebasing of dentures is covered once every 24 monthsperpatient. 11. Retreatment of root canal is covered if it is more than two (2) years from the original treatment. 12. Root planing or scaling is covered once every 24 months per quadrantperpatient. 13. Scaling in presence of generalized moderate or severe gingival inflammation-fullmouth,afteroralevaluationandinlieuofa covered D1110, limited to once per two years. 14. Scalinganddebridementinthepresenceofinflammationor mucositisofasingleimplant,includingcleaningoftheimplant surfaces,withoutflapentryandclosure 15. Fullmouthdebridementiscoveredonceperlifetimeperpatient.16. ProcedureCodeD4381islimitedtoone(1)benefitpertoothfor three teeth per quadrant or a total of 12 teeth for all four quadrantspertwelve(12)monthsperpatient.Musthavepocket depthsoffive(5)millimetersorgreater. 17. Periodontal surgery of any type, including any associated material, is covered once every 36 months per quadrant or surgicalsiteperpatient. 18. Periodontalmaintenanceafteractivetherapyiscoveredtwice percalendaryear,within24monthsafterdefinitiveperiodontal therapy,perpatient. 19. Coronectomy-intentionalpartialtoothremoval,onceper lifetime.20. Teledentistry,synchronous(D9995)orasynchronous(D9996), limited to two per calendar year (when available).21. Orthodontiatreatmentislimitedtoonceperlifetime.

DMN20MDDBLINFAM








Select Plan Basic 703xa (PA)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-








Periodontics1




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Select Plan Basic 703xa (VA)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-








Periodontics1




pid27305




select plan basic 703xa (dc) description of services ... · d5221 immediate maxillary partial...

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