Select Plan Premium 705xa (DC) Description of …...D2951 Pin retention - per tooth, in addition to...

D2391 Resin-based composite - one surface, posterior ....68D2392 Resin-based composite - two surfaces, posterior ..................................................................80D2393 Resin-based composite - three surfaces, posterior ..................................................................93D2394 Resin-based composite - >=4 surfaces, posterior ................................................................112 Crown & Bridge D2510 Inlay - metallic - one surface .................................390D2520 Inlay - metallic - two surfaces ...............................390D2530 Inlay - metallic - three or more surfaces ...............407D2542 Onlay - metallic-two surfaces ...............................423D2543 Onlay - metallic-three surfaces .............................511D2544 Onlay - metallic-four or more surfaces .................511D2610 Inlay - porcelain/ceramic - one surface ................410D2620 Inlay - porcelain/ceramic - two surfaces ...............410D2630 Inlay - porcelain/ceramic - >=3 surfaces ...............427D2642 Onlay - porcelain/ceramic - two surfaces .............439D2643 Onlay - porcelain/ceramic - three surfaces ..........459D2644 Onlay - porcelain/ceramic - >=4 surfaces .............459D2650 Inlay - resin-based composite - one surface .........425D2651 Inlay - resin-based composite - two surfaces .......425D2652 Inlay - resin-based composite - >=3 surfaces .......425D2662 Onlay - resin-based composite - two surfaces......429D2663 Onlay - resin-based composite - three surfaces ...429D2664 Onlay - resin-based composite - >=4 surfaces ......429D2710 Crown - resin based composite (indirect).............259D2712 Crown - 3/4 resin-based composite (indirect) ......450D2720/21/22 Crown - resin with metal.......................................470D2740 Crown - porcelain/ceramic ...................................531D2750/51/52 Crown - porcelain fused metal..............................495D2780/81/82 Crown - 3/4 cast with metal .................................457D2783 Crown - 3/4 porcelain/ceramic .............................469D2790/91/92 Crown - full cast metal ..........................................481D2910/20 Recementinlay,onlay/crownorpartial coverage rest. ..........................................................41D2931 Prefab. stainless steel crown.................................119D2932 Prefabricated resin crown .....................................135D2940 Protectiverestoration ............................................37D2950 Core buildup, including any pins ...........................120D2951 Pinretention-pertooth,inadditionto restoration...............................................................22D2952 Postandcoreinadditiontocrown .......................181D2954 Prefab.postandcoreinadditiontocrown ..........148D2955 Post removal (not in conj. with endo. therapy) ....101D2980 Crownrepairnecessitatedbyrestorative material failure ........................................................93

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 ....................................0D1110* Additionalcleaning(expectingmothersor Diabetics) ................................................................40D1206 Topicalapplicationoffluoridevarnish ......................0D1208 Topicalapplicationoffluoride-excludingvarnish ...0D1310 Nutritionalcounselingforcontrolofdental disease ......................................................................0D1320/30 Oralhygieneinstructions ..........................................0

Restorative (Fillings) D2140 Amalgam - one surface, prim. or perm. .................37D2150 Amalgam - two surfaces, prim. or perm. ................46D2160 Amalgam - three surfaces, prim. or perm. .............58D2161 Amalgam - >=4 surfaces, prim. or perm. ................69D2330 Resin-based composite - one surface, anterior ......64D2331 Resin-based composite - two surfaces, anterior ....76D2332 Resin-based composite - three surfaces, anterior ...................................................................90D2335 Resin-based composite - >=4 surfaces, anterior .................................................................109D2390 Resin-based composite crown, anterior ...............175

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 Premium 705xa (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 pid26791

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



D2981 Inlayrepairnecessitatedbyrestorative material failure ........................................................93D2982 Onlayrepairnecessitatedbyrestorative material failure ........................................................93 Endodontics1 D3110/20 Pulpcap-direct/indirect(excl.finalrestoration) ...28D3220 Therapeuticpulpotomy(excl.finalrestor.).............81D3221 Pulpal debridement ................................................87D3310 Endodontictherapy,anteriortooth(excl. finalrestor.) ...........................................................325D3320 Endodontictherapy,premolartooth(excl. finalrestor.) ...........................................................395D3330 Endodontictherapy,molartooth(excl. finalrestor.) ...........................................................488D3333 Internalrootrepairofperforationdefects .............96D3346 Retreat of prev. root canal therapy, anterior ........356D3347 Retreat of prev. root canal therapy, premolar ......418D3348 Retreat of prev. root canal therapy, molar ...........527D3410 Apicoectomy - anterior ........................................310D3421 Apicoectomy-premolar(firstroot) .....................333D3425 Apicoectomy-molar(firstroot) ..........................379D3426 Apicoectomy - (each add. root) ............................148D3430 Retrogradefilling-perroot ..................................113D3450 Rootamputation-perroot ..................................202D3920 Hemisection,notinc.rootcanaltherapy .............202D3950 Canalprep/fittingofpreformeddowelorpost ....125 Periodontics1 D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad. ....................................................265D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad. ......................................................94D4240 Gingivalflapproc.,inc.rootplaning->3 cont. teeth, per quad ............................................324D4241 Gingivalflapproc,inc.rootplaning-<=3 cont. teeth, per quad ..............................................90D4260 Osseous surgery - >3 cont. teeth, per quad .........485D4261 Osseous surgery - <=3 cont. teeth, per quad .......360D4263 Bonereplacementgraft-retainednatural tooth-firstsiteinquad ........................................502D4264 Bonereplacementgraft-retainednatural tooth-eachadditionalsiteinquad ......................393D4265 Biologicalmaterialstoaidinsoftand osseoustissueregeneration .................................275D4268 Surgical revision proc., per tooth ..........................329D4270 Pediclesofttissuegraftprocedure .......................434D4273 Autogenousconnectivetissuegraft procedure,firsttooth............................................540D4274 Mesial/distalwedgeprocedure,singletooth .......308D4275 Non-autogenousconnectivetissuegraft (including recipient site and donor material) firsttooth,implant,oredentuloustooth positioningraft .....................................................576D4277 Freesofttissuegraftprocedure,firsttooth .........441D4278 Freesofttissuegraftprocedure,each add. tooth ...............................................................68D4341 Perio scaling and root planing - >3 cont teeth, per quad. ....................................................105D4342 Perio scaling and root planing - <= 3 teeth, per quad .......................................................57D4346 Scaling in presence of generalized moderate orseveregingivalinflammation-fullmouth, afteroralevaluation ................................................39D4355 Fullmouthdebridement .........................................77D4381 Localizeddeliveryofantimicrobialagents .............90D4910 Periodontal maintenance .......................................66

Prosthetics (Dentures) D5110/20 Complete denture - maxillary/mandibular ...........664D5130/40 Immediate denture - maxillary/mandibular .........708D5211/12 Maxillary/mandibularpartialdenture- resin base ..............................................................613D5213/14 Maxillary/mandibularpartialdenture- cast metal ..............................................................722D5221 Immediatemaxillarypartialdenture- resin base ..............................................................613D5222 Immediatemandibularpartialdenture- resin base ..............................................................613D5223 Immediatemaxillarypartialdenture- cast metal framework ...........................................722D5224 Immediatemandibularpartialdenture- cast metal framework ...........................................722D5225/26 Maxillary/mandibularpartialdenture- flexiblebase ..........................................................722D5282/83 Rem.unilateralpartialdenture- one piece cast metal, maxillary/mandibular ........397D5410/11 Adjust complete denture - maxillary/mandibular .............................................35D5421/22 Adjustpartialdenture- maxillary/mandibular .............................................35D5511 Repair broken complete denture base, mandibular ..............................................................84D5512 Repair broken complete denture base, maxillary ..................................................................84D5520 Replace missing or broken teeth - complete denture ...................................................84D5611 Repairresinpartialdenturebase,mandibular .......84D5612 Repairresinpartialdenturebase,maxillary ...........84D5621 Repaircastpartialframework,mandibular ............84D5622 Repaircastpartialframework,maxillary ................84D5630/60 Clasp repaired, replaced or added .......................112D5640 Replace broken teeth - per tooth ...........................84D5650 Addtoothtoexistingpartialdenture .....................84D5670/71 Replace all teeth and acrylic on cast metal framework .............................................................263D5710/11 Rebase complete maxillary/mandibular denture..................................................................253D5720/21 Rebasemaxillary/mandibularpartialdenture .....253D5730/31 Reline complete maxillary/mandibular denture (chairside) ................................................152D5740/41 Relinemaxillary/mandibularpartial denture (chairside) ................................................152D5750/51 Reline complete maxillary/mandibular denture (lab) .........................................................214D5760/61 Relinemaxillary/mandibularpartial denture (lab) .........................................................214D5810/11 Interim complete denture - maxillary/mandibular ...........................................333D5820/21 Interimpartialdenture- maxillary/mandibular ...........................................333D5850/51 Tissueconditioning-maxillary/mandibular ...........75 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 ................57D6210/11/12 Pontic-metal ........................................................481D6240/41/42 Pontic-porcelainfusedmetal ..............................495D6245 Pontic-porcelain/ceramic ....................................531D6250/51/52 Pontic-resinwithmetal .......................................470D6545 Retainer-castmetalforresinbondedfixed prosthesis ..............................................................233

pid26792DMN20MADOBINFAM-DCDEPAVA



D6548 Ret.-porc./ceramicforresinbondedfixed prosthesis ..............................................................364D6549 Resinretainer-forresinbondedfixed prosthesis ..............................................................233D6600 Retainer inlay - porc./ceramic, two surfaces ........410D6601 Retainer inlay - porc./ceramic, >=3 surfaces ........427D6602 Retainer inlay - cast high noble metal, two surfaces .................................................................390D6603 Retainer inlay - cast high noble metal, >=3 surfaces .................................................................407D6604 Retainer inlay - cast predominantly base metal, two surfaces ...............................................390D6605 Retainer inlay - cast predominantly base metal, >=3 surfaces ...............................................407D6606 Retainer inlay - cast noble metal, two surfaces ....390D6607 Retainer inlay - cast noble metal, >=3 surfaces ....407D6608 Retainer onlay - porc./ceramic, two surfaces .......439D6609 Retainer onlay - porc./ceramic, three or more surfaces .......................................................459D6610 Retainer onlay - cast high noble metal, two surfaces ..........................................................423D6611 Retainer onlay - cast high noble metal, >=3 surfaces ..........................................................511D6612 Retainer onlay - cast predominantly base metal, two surfaces ...............................................423D6613 Retainer onlay - cast predominantly base metal, >=3 surfaces ...............................................511D6614 Retainer onlay - cast noble metal, two surfaces .................................................................423D6615 Retainer onlay - cast noble metal, >=3 surfaces .................................................................511D6720/21/22 Retainer crown - resin with metal ........................470D6740 Retainer crown - porcelain/ceramic .....................531D6750/51/52 Retainer crown - porcelain fused metal ...............495D6780 Retainer crown - 3/4 cast high noble metal .........457D6781 Retainer crown - 3/4 cast predominantly base metal .............................................................457D6782 Retainer crown - 3/4 cast noble metal .................457D6783 Retainer crown - 3/4 porc./ceramic ......................469D6790/91/92 Retainer crown - full cast metal ............................481D6930 Recementorrebondfixedpartialdenture .............66D6980 Fixedpartialdenturerepair,byreport .................157 Oral Surgery1 D7111 Extraction,coronalremnants-primarytooth ........45D7140 Extraction,eruptedtoothorexposedroot ............63D7210 Extraction,eruptedtoothreqelev,etc ................127D7220 Removalofimpactedtooth-softtissue ..............144D7230 Removalofimpactedtooth-partiallybony .........189D7240 Removal of impacted tooth - completely bony ....227D7241 Removal of imp. tooth - completely bony, withunusualsurg.complications .........................181D7250 Removal of residual tooth roots .......................136D7251 Coronectomy-intentionalpartialtooth removal .................................................................181D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth .......................................211D7280 Exposure of an unerupted tooth ..........................111D7291 Transseptalfiberotomy/supracrestal fiberotomy,byreport ..............................................41D7310/20 Alveoloplasty, per quad ........................................135D7510 Incision and drainage of abscess - intraoralsofttissue .................................................91D7960 Frenulectomy(frenectomy/frenotomy)- separate proc. .......................................................256D7979 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 ServicesD9110 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) ................................................42D9613 Infiltrationofsustainedreleasetherapeutic drug–singleormultiplesites ...............................190D9910 Applicationofdesensitizingmedicament ..............31D9930 Treatmentofcomplications(post-surgical) ............43D9944 Occlusalguard–hardappliance,fullarch ............298D9945 Occlusalguard–softappliance,fullarch .............298D9946 Occlusalguard–hardappliance,partialarch ......298D9950 Occlusion analysis - mounted case .........................81D9951 Occlusal adjustment - limited .................................62D9952 Occlusal adjustment - complete ...........................255D9986 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.


pid26795

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 Premium 705xa (DE)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-





pid26985




D2391 Resin-based composite - one surface, posterior ... 68D2392 Resin-based composite - two surfaces, posterior ................................................................. 80D2393 Resin-based composite - three surfaces, posterior ................................................................. 93D2394 Resin-based composite - >=4 surfaces, posterior ............................................................... 112 Crown & Bridge D2510 Inlay - metallic - one surface ................................ 390D2520 Inlay - metallic - two surfaces .............................. 390D2530 Inlay - metallic - three or more surfaces .............. 407D2542 Onlay - metallic-two surfaces .............................. 423D2543 Onlay - metallic-three surfaces ............................ 511D2544 Onlay - metallic-four or more surfaces ................ 511D2610 Inlay - porcelain/ceramic - one surface ............... 410D2620 Inlay - porcelain/ceramic - two surfaces .............. 410D2630 Inlay - porcelain/ceramic - >=3 surfaces .............. 427D2642 Onlay - porcelain/ceramic - two surfaces ............ 439D2643 Onlay - porcelain/ceramic - three surfaces ......... 459D2644 Onlay - porcelain/ceramic - >=4 surfaces ............ 459D2650 Inlay - resin-based composite - one surface ........ 425D2651 Inlay - resin-based composite - two surfaces ...... 425D2652 Inlay - resin-based composite - >=3 surfaces ....... 425D2662 Onlay - resin-based composite - two surfaces ..... 429D2663 Onlay - resin-based composite - three surfaces .. 429D2664 Onlay - resin-based composite - >=4 surfaces ..... 429D2710 Crown - resin based composite (indirect) ............ 259D2712 Crown - 3/4 resin-based composite (indirect) ..... 450D2720/21/22 Crown - resin with metal ...................................... 470D2740 Crown - porcelain/ceramic ................................... 531D2750/51/52 Crown - porcelain fused metal ............................. 495D2780/81/82 Crown - 3/4 cast with metal ................................. 457D2783 Crown - 3/4 porcelain/ceramic ............................ 469D2790/91/92 Crown - full cast metal ......................................... 481D2910/20 Recementinlay,onlay/crownorpartial coverage rest. ......................................................... 41D2931 Prefab. stainless steel crown - perm. tooth ......... 119D2932 Prefabricated resin crown .................................... 135D2940 Protectiverestoration ............................................ 37D2950 Core buildup, including any pins .......................... 120D2951 Pinretention-pertooth,inadditionto restoration .............................................................. 22D2952 Postandcoreinadditiontocrown ...................... 181D2954 Prefab.postandcoreinadditiontocrown ......... 148D2955 Post removal (not in conj. with endo. therapy) ... 101D2980 Crownrepairnecessitatedbyrestorative material failure ....................................................... 93

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 ................................... 0D1110* Additionalcleaning(expectingmothersor Diabetics) ................................................................ 40D1206 Topicalapplicationoffluoridevarnish..................... 0D1208 Topicalapplicationoffluoride-excludingvarnish .. 0D1310 Nutritionalcounselingforcontrolofdental disease ...................................................................... 0D1320/30 Oralhygieneinstructions ......................................... 0

Restorative (Fillings)D2140 Amalgam - one surface, prim. or perm. ................. 37D2150 Amalgam - two surfaces, prim. or perm. ............... 46D2160 Amalgam - three surfaces, prim. or perm. ............ 58D2161 Amalgam - >=4 surfaces, prim. or perm. ............... 69D2330 Resin-based composite - one surface, anterior ..... 64D2331 Resin-based composite - two surfaces, anterior ... 76D2332 Resin-based composite - three surfaces, anterior ................................................................... 90D2335 Resin-based composite - >=4 surfaces, anterior ................................................................. 109D2390 Resin-based composite crown, anterior .............. 175




Select Plan Premium 705xa (MD)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-



DMN20MDDBHINFAM pid27571




D2981 Inlayrepairnecessitatedbyrestorative material failure ....................................................... 93D2982 Onlayrepairnecessitatedbyrestorative material failure ....................................................... 93 Endodontics1 D3110/20 Pulpcap-direct/indirect(excl.final restoration) ............................................................ 28D3220 Therapeuticpulpotomy(excl.finalrestor.) ........... 81D3221 Pulpal debridement ................................................ 87D3310 Endodontictherapy,anteriortooth(excl. finalrestor.) .......................................................... 325D3320 Endodontictherapy,premolartooth(excl. finalrestor.) .......................................................... 395D3330 Endodontictherapy,molartooth(excl. finalrestor.) .......................................................... 488D3333 Internalrootrepairofperforationdefects ............ 96D3346 Retreat of prev. root canal therapy, anterior ...... 356D3347 Retreat of prev. root canal therapy, premolar .... 418D3348 Retreat of prev. root canal therapy, molar .......... 527D3410 Apicoectomy - anterior ........................................ 310D3421 Apicoectomy-premolar(firstroot) .................... 333D3425 Apicoectomy-molar(firstroot) ......................... 379D3426 Apicoectomy - (each add. root) ........................... 148D3430 Retrogradefilling-perroot ................................. 113D3450 Rootamputation(resection)-perroot ............... 202D3920 Hemisection,notinc.rootcanaltherapy ............ 202D3950 Canalprep/fittingofpreformeddowelorpost ... 125 Periodontics1 D4210 Gingivectomy or gingivoplasty - >3 cont. teeth, per quad..................................................... 265D4211 Gingivectomy or gingivoplasty - <=3 teeth, per quad....................................................... 94D4240 Gingivalflapproc.,inc.rootplaning->3 cont. teeth, per quad ........................................... 324D4241 Gingivalflapproc,inc.rootplaning-<=3 cont. teeth, per quad ............................................. 90D4260 Osseous surgery - >3 cont. teeth, per quad ......... 485D4261 Osseous surgery - <=3 cont. teeth, per quad ....... 360D4263 Bonereplacementgraft-retainednatural tooth-firstsiteinquad ........................................ 502D4264 Bonereplacementgraft-retainednatural tooth-eachadditionalsiteinquad ..................... 393D4265 Biologicalmaterialstoaidinsoftand osseoustissueregeneration ................................ 275D4268 Surgical revision proc., per tooth ......................... 329D4270 Pediclesofttissuegraftprocedure ...................... 434D4273 Autogenousconnectivetissuegraftprocedure, firsttooth .............................................................. 540D4274 Mesial/distalwedgeprocedure,singletooth ...... 308D4275 Non-autogenousconnectivetissuegraft (including recipient site and donor material) firsttooth,implant,oredentuloustooth positioningraft .................................................... 576D4277 Freesofttissuegraftprocedure,firsttooth ........ 441D4278 Freesofttissuegraftprocedure,each add. tooth ............................................................... 68D4341 Perio scaling and root planing - >3 cont teeth, per quad..................................................... 105D4342 Perio scaling and root planing - <= 3 teeth, per quad....................................................... 57D4346 Scaling in presence of generalized moderate orseveregingivalinflammation-fullmouth, afteroralevaluation ............................................... 39D4355 Fullmouthdebridement ........................................ 77D4381 Localizeddeliveryofantimicrobialagents ............. 90D4910 Periodontal maintenance....................................... 66

Prosthetics (Dentures) D5110/20 Complete denture - maxillary/mandibular .......... 664D5130/40 Immediate denture - maxillary/mandibular ........ 708D5211/12 Maxillary/mandibularpartialdenture- resin base ............................................................. 613D5213/14 Maxillary/mandibularpartialdenture- cast metal ............................................................. 722D5221 Immediatemaxillarypartialdenture- resin base ............................................................. 613D5222 Immediatemandibularpartialdenture- resin base ............................................................. 613D5223 Immediatemaxillarypartialdenture- cast metal framework .......................................... 722D5224 Immediatemandibularpartialdenture- cast metal framework .......................................... 722D5225/26 Maxillary/mandibularpartialdenture- flexiblebase .......................................................... 722D5282/83 Rem.unilateralpartialdenture- one piece cast metal, maxillary/mandibular ....... 397D5410/11 Adjust complete denture - maxillary/mandibular ............................................. 35D5421/22 Adjustpartialdenture-maxillary/mandibular ...... 35D5511 Repair broken complete denture base, mandibular ............................................................. 84D5512 Repair broken complete denture base, maxillary . 84D5520 Replace missing or broken teeth - complete denture .................................................. 84D5611 Repairresinpartialdenturebase,mandibular ...... 84D5612 Repairresinpartialdenturebase,maxillary .......... 84D5621 Repaircastpartialframework,mandibular ........... 84D5622 Repaircastpartialframework,maxillary ............... 84D5630/60 Clasp repaired, replaced or added ....................... 112D5640 Replace broken teeth - per tooth .......................... 84D5650 Addtoothtoexistingpartialdenture .................... 84D5670/71 Replace all teeth and acrylic on cast metal framework ............................................................ 263D5710/11 Rebase complete maxillary/mandibular denture ................................................................. 253D5720/21 Rebasemaxillary/mandibularpartialdenture ..... 253D5730/31 Reline complete maxillary/mandibular denture (chairside) ............................................... 152D5740/41 Relinemaxillary/mandibularpartial denture (chairside) ............................................... 152D5750/51 Reline complete maxillary/mandibular denture (lab) ......................................................... 214D5760/61 Relinemaxillary/mandibularpartial denture (lab) ......................................................... 214D5810/11 Interim complete denture - maxillary/mandibular ........................................... 333D5820/21 Interimpartialdenture- maxillary/mandibular ........................................... 333D5850/51 Tissueconditioning-maxillary/mandibular .......... 75 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 ............... 57D6210/11/12 Pontic-metal ....................................................... 481D6240/41/42 Pontic-porcelainfusedmetal ............................. 495D6245 Pontic-porcelain/ceramic ................................... 531D6250/51/52 Pontic-resinwithmetal ...................................... 470D6545 Retainer-castmetalforresinbondedfixed prosthesis ............................................................. 233

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D6548 Ret.-porc./ceramicforresinbondedfixed prosthesis ............................................................. 364D6549 Resinretainer-forresinbondedfixed prosthesis ............................................................. 233D6600 Retainer inlay - porc./ceramic, two surfaces ....... 410D6601 Retainer inlay - porc./ceramic, >=3 surfaces ....... 427D6602 Retainer inlay - cast high noble metal, two surfaces ......................................................... 390D6603 Retainer inlay - cast high noble metal, >=3 surfaces ......................................................... 407D6604 Retainer inlay - cast predominantly base metal, two surfaces .............................................. 390D6605 Retainer inlay - cast predominantly base metal, >=3 surfaces .............................................. 407D6606 Retainer inlay - cast noble metal, two surfaces ... 390D6607 Retainer inlay - cast noble metal, >=3 surfaces ... 407D6608 Retainer onlay - porc./ceramic, two surfaces ...... 439D6609 Retainer onlay - porc./ceramic, three or more surfaces ....................................................... 459D6610 Retainer onlay - cast high noble metal, two surfaces ......................................................... 423D6611 Retainer onlay - cast high noble metal, >=3 surfaces ......................................................... 511D6612 Retainer onlay - cast predominantly base metal, two surfaces .............................................. 423D6613 Retainer onlay - cast predominantly base metal, >=3 surfaces .............................................. 511D6614 Retainer onlay - cast noble metal, two surfaces ................................................................ 423D6615 Retainer onlay - cast noble metal, >=3 surfaces ................................................................ 511D6720/21/22 Retainer crown - resin with metal ....................... 470D6740 Retainer crown - porcelain/ceramic .................... 531D6750/51/52 Retainer crown - porcelain fused metal .............. 495D6780 Retainer crown - 3/4 cast high noble metal ........ 457D6781 Retainer crown - 3/4 cast predominantly base metal ............................................................ 457D6782 Retainer crown - 3/4 cast noble metal ................ 457D6783 Retainer crown - 3/4 porc./ceramic..................... 469D6790/91/92 Retainer crown - full cast metal ........................... 481D6930 Recementorrebondfixedpartialdenture ............ 66D6980 Fixedpartialdenturerepair,byreport ................ 157 Oral Surgery1 D7111 Extraction,coronalremnants-primarytooth ....... 45D7140 Extraction,eruptedtoothorexposedroot ........... 63D7210 Extraction,eruptedtoothreqelev,etc ............... 127D7220 Removalofimpactedtooth-softtissue .............. 144D7230 Removalofimpactedtooth-partiallybony ........ 189D7240 Removal of impacted tooth - completely bony ... 227D7241 Removal of imp. tooth - completely bony, withunusualsurg.complications ........................ 181D7250 Removal of residual tooth roots .......................... 136D7251 Coronectomy-intentionalpartialtooth removal................................................................. 181D7270 Tooth reimplant./stabiliz. of acc. evulsed/displaced tooth ...................................... 211D7280 Exposure of an unerupted tooth ......................... 111D7291 Transseptalfiberotomy/supracrestal fiberotomy,byreport ............................................ 41D7310/20 Alveoloplasty, per quad ....................................... 135D7510 Incision and drainage of abscess - intraoral softtissue ............................................................... 91D7960 Frenulectomy(frenectomy/frenotomy)- separate proc. ...................................................... 256D7979 Non-surgical sialolithotomy ................................... 43

Orthodontics2 D8660 Pre-orthodontictreatmentvisit ........................... 413D8090 Comp.ortho.treatment-adultdentition ......... 3658D8670 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 Intravenous moderate conscious sedation/analgesia–first15minutes .................. 103D9243 Intravenous moderate conscious sedation/analgesia-eachsubsequent15min .... 103D9310 Consultation(diagnosticserviceby nontreatingdentist) ............................................... 42D9613 Infiltrationofsustainedreleasetherapeutic drug–singleormultiplesites .............................. 190D9910 Applicationofdesensitizingmedicament .............. 31D9930 Treatmentofcomplications(post-surgical) ........... 43D9944 Occlusalguard–hardappliance,fullarch ........... 298D9945 Occlusalguard–softappliance,fullarch ............ 298D9946 Occlusalguard–hardappliance,partialarch...... 298D9950 Occlusion analysis - mounted case ........................ 81D9951 Occlusal adjustment - limited ................................ 62D9952 Occlusal adjustment - complete .......................... 255D9986 Missedappointment .............................................. 50D9995 Teledentistry–synchronous;real-time encounter ............................................................... 20D9996 Teledentistry–asynchronous;information storedandforwardedtodentistfor subsequent review ................................................. 20



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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.

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Select Plan Premium 705xa (PA)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-





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Select Plan Premium 705xa (VA)Description of Services, Member Copayments, Exclusions and Limitations for Adult Services (age 19 and over) -Coveragebeginsthefirstdayofthemonthfollowingthemonthinwhichthe Memberturns19-





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Select Plan Premium 705xa (DC) Description of …...D2951 Pin retention - per tooth, in addition to...

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Transcript of Select Plan Premium 705xa (DC) Description of …...D2951 Pin retention - per tooth, in addition to...