Download copay schedule

Schedule A Description of Benefits and Copayments
D0100
D0120
D0140
D0140
D0150
D0150
D0160
D0160
D0170
D0180
D0180
D0210
D0220
D0230
D0240
D0270
D0272
D0274
D0277
D0330
D0460
D0470
D0100-D0999 I. DIAGNOSTIC
Periodic oral evaluation
Limited oral evaluation - problem focused (GP)
Limited oral evaluation - problem focused (Specialist)
Comprehensive oral evaluation - new or established patient (GP)
Comprehensive oral evaluation - new or established patient (Specialist)
Detailed and extensive oral evaluation - problem focused, by report (GP)
Detailed and extensive oral evaluation - problem focused, by report (Specialist)
Re-evaluation - limited, problem focused (established patient; not post-operative visit)
Comprehensive periodontal evaluation - new or established patient (GP)
Comprehensive periodontal evaluation - new or established patient (Specialist)
Intraoral radiographs - complete series (including bitewings)
Intraoral - periapical first film
Intraoral - periapical each additional film
Intraoral - occlusal film
Bitewing - single film
Bitewings - two films
Bitewings - four films
Vertical bitewings - 7 to 8 films
Panoramic film
Pulp vitality tests
Diagnostic casts
D0999 Unspecified diagnostic procedure, by report - includes office visit, per visit (in addition to other services)
Member Co-Payment
$0.00
$0.00
$12.00
$0.00
$12.00
$0.00
$0.00
$0.00
$0.00
$12.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
D1000
D1110
D1120
D1201
D1203
D1330
D1351
D1510
D1515
D1520
D1525
D1550
D1000-D1999 II. PREVENTIVE
Prophylaxis cleaning - adult - 1 per 6 month period
Prophylaxis cleaning - child - 1 per 6 month period
Topical application of fluoride (including prophylaxis) - child - to age 19; 1 per 6 month period
Topical application of fluoride (prophylaxis not included) - child - to age 19; 1 per 6 month period
Oral hygiene instructions
Sealant - per tooth
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
Space maintainer - removable - unilateral
Space maintainer - removable - bilateral
Re-cementation of space maintainer
Member Co-Payment
$0.00
$0.00
$0.00
$0.00
$0.00
$10.00
$40.00
$40.00
$40.00
$40.00
$10.00
D2000
D2000-D2999 III. RESTORATIVE
Includes indirect pulp capping, bases, liners and acid etch procedures.
Amalgam - one surface, primary or permanent
Amalgam - two surfaces, primary or permanent
Amalgam - three surfaces, primary or permanent
Amalgam - four or more surfaces, primary or permanent
Resin-based composite - one surface, anterior
Resin-based composite - two surfaces, anterior
Member Co-Payment
D2140
D2150
D2160
D2161
D2330
D2331
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2410
D2420
D2430
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
D2910
D2915
D2920
D2930
Resin-based composite - three surfaces, anterior
Resin-based composite - four or more surfaces or involving incisal angle (anterior)
Resin-based composite crown, anterior
Resin-based composite - one surface, posterior
Resin-based composite - two surfaces, posterior
Resin-based composite - three surfaces, posterior
Resin-based composite - four or more surfaces, posterior
Gold foil - one surface
Gold foil - two surfaces
Gold foil - three surfaces
Inlay - metallic - one surface (1)
Inlay - metallic - two surfaces (1)
Inlay - metallic - three or more surfaces (1)
Onlay - metallic - two surfaces (1)
Onlay - metallic - three surfaces (1)
Onlay - metallic - four or more surfaces (1)
Inlay - porcelain/ceramic - one surface
Inlay - porcelain/ceramic - two surfaces
Inlay - porcelain/ceramic - three or more surfaces
Onlay - porcelain/ceramic - two surfaces
Onlay - porcelain/ceramic - three surfaces
Onlay - porcelain/ceramic - four or more surfaces
Inlay - resin-based composite - one surface
Inlay - resin-based composite - two surfaces
Inlay - resin-based composite - three or more surfaces
Onlay - resin-based composite - two surfaces
Onlay - resin-based composite - three surfaces
Onlay - resin-based composite - four or more surfaces
Crown - resin-based composite (indirect) (2)
Crown - resin with high noble metal (1,2)
Crown - resin with predominantly base metal (2)
Crown - resin with noble metal (2)
Crown - porcelain/ceramic substrate (2)
Crown - porcelain fused to high noble metal (1,2)
Crown - porcelain fused to predominantly base metal (2)
Crown - porcelain fused to noble metal (2)
Crown - 3/4 cast high noble metal (1)
Crown - 3/4 cast predominantly base metal
Crown - 3/4 cast noble metal
Crown - 3/4 porcelain / ceramic (2)
Crown - full cast high noble metal (1)
Crown - full cast predominantly base metal
Crown - full cast noble metal
Crown - titanium (1)
Recement inlay, onlay or partial coverage restoration
Recement cast or prefabricated post and core
Recement crown
Prefabricated stainless steel crown - primary tooth
$0.00
$0.00
$0.00
Optional
Optional
Optional
Optional
Optional
Optional
Optional
$130.00
$140.00
$150.00
$146.00
$156.00
$162.00
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Optional
Optional
$110.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$10.00
$10.00
$10.00
$35.00
D2931
D2932
D2933
D2940
D2950
D2951
D2952
D2953
D2954
D2957
D2971
D2980
Prefabricated stainless steel crown - permanent tooth
Prefabricated resin crown - anterior teeth only
Prefabricated stainless steel crown with resin window
Sedative filling
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Cast post and core in addition to crown (1)
Each additional cast post - same tooth (1)
Prefabricated post and core in addition to crown
Each additional prefabricated post - same tooth
Additional procedures to construct new crown under existing partial denture framework
Crown repair, by report
$35.00
$35.00
Optional
plus Lab
$0.00
$15.00
$15.00
$15.00
$15.00
$15.00
$15.00
$40.00
$20.00
D3000
D3999 IV. ENDODONTICS
D3110 Pulp cap - direct (excluding final restoration)
D3120 Pulp cap - indirect (excluding final restoration)
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental
D3220
junction and application of medicament
D3221 Pulpal debridement, primary and permanent teeth
D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration)
D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration)
D3310 Root canal - anterior (excluding final restoration)
D3320 Root canal - bicuspid (excluding final restoration)
D3330 Root canal - molar (excluding fmal restoration)
D3346 Retreatment of previous root canal therapy - anterior
D3347 Retreatment of previous root canal therapy - bicuspid
D3348 Retreatment of previous root canal therapy - molar
D3410 Apicoectomy/periradicular surgery - anterior
D3421 Apicoectomy/periradicular surgery - bicuspid (first root)
D3425 Apicoectomy/periradicular surgery - molar (first root)
D3426 Apicoectomy/periradicular surgery (each additional root)
D3430 Retrograde filling - per root
Member Co-Payment
$0.00
$0.00
D4000
Member Co-Payment
D4210
D4211
D4240
D4241
D4245
D4249
D4260
D4261
D4341
D4342
D4000-D4999 V. PERIODONTICS
Includes preoperative and postoperative evaluations and treatment under a local anesthetic.
Gingivectomy or gingivoplasty - 4 or more contiguous teeth or bounded teeth spaces per quadrant
Gingivectomy or gingivoplasty - 1 to 3 contiguous teeth or bounded teeth spaces per quadrant
Gingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth
spaces per quadrant
Gingival flap procedure, including root planing - one to three contiguous teeth or bounded teeth
spaces per quadrant
Apically positional flap
Clinical crown lengthening - hard tissue
Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth
spaces per quadrant
Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth
spaces per quadrant
Periodontal scaling and root planing - four or more teeth per quadrant
Periodontal scaling and root planing - one to three teeth per quadrant
$5.00
$10.00
$5.00
$5.00
$75.00
$120.00
$180.00
$90.00
$144.00
$215.00
$85.00
$85.00
$85.00
$85.00
$50.00
$125.00
$125.00
$135.00
$135.00
$135.00
$150.00
$250.00
$250.00
$45.00
$45.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis
D4910 Periodontal maintenance
D5000
D5110
D5120
D5130
D5140
D5211
D5212
D5225
D5226
D5281
D5410
D5411
D5421
D5422
D5000-D5899 VI. PROSTHODONTICS (removable)
Complete denture - maxillary (3)
Complete denture - mandibular (3)
Immediate denture - maxillary (3)
Immediate denture - mandibular (3)
Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) (3)
Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) (3)
Maxillary partial denture - cast metal framework with resin denture bases (including any conventional
clasps, rests and teeth) (3)
Mandibular partial denture - cast metal framework with resin denture bases(including any
conventional clasps, rests and teeth) 3
Maxillary partial denture - flexible base (including any clasps, rests and teeth) (3)
Mandibular partial denture - flexible base (including any clasps, rests and teeth) (3)
Removable unilateral partial denture - one piece cast metal (including clasps and teeth)
Adjust complete denture - maxillary
Adjust complete denture - mandibular
Adjust partial denture - maxillary
Adjust partial denture - mandibular
D5510
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5820
D5821
D5850
D5851
D5860
D5861
Repair broken complete denture base
Reline complete maxillary denture (chairside)
Reline complete mandibular denture (chairside)
Reline maxillary partial denture (chairside)
Reline mandibular partial denture (chairside)
Reline complete maxillary denture (laboratory)
Reline complete mandibular denture (laboratory)
Reline maxillary partial denture (laboratory)
Reline mandibular partial denture (laboratory)
Interim partial denture (maxillary)
Interim partial denture (mandibular)
Tissue conditioning, maxillary
Tissue conditioning, mandibular
Overdenture - complete, by report
Overdenture - partial, by report
D5213
D5214
D5900
D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered
D6000
D6000-D6199 VIII. IMPLANT SERVICES - Not Covered
D6200
D6210
D6211
D6212
D6240
D6241
D6242
D6200-D6999 IX. PROSTHODONTICS ( fixed)
Pontic - cast high noble metal (1)
Pontic - cast predominantly base metal
Pontic - cast noble metal
Pontic - porcelain fused to high noble metal (1,2)
Pontic - porcelain fused to predominantly base metal (2)
Pontic - porcelain fused to noble metal (2)
$45.00
$36.00
Member Co-Payment
$225.00
$225.00
$300.00
$300.00
$250.00
$250.00
$275.00
$275.00
Optional
Optional
plus Lab
$250.00
$10.00
$10.00
$10.00
$10.00
$20.00
$30.00
$30.00
$30.00
$30.00
$50.00
$50.00
$50.00
$50.00
$0.00
$0.00
$10.00
$10.00
Optional
Optional
Member Co-Payment
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
D6250
D6251
D6252
D6545
D6548
D6600
D6601
D6602
D6603
D6604
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6720
D6721
D6722
D6750
D6751
D6752
D6780
D6781
D6782
D6790
D6791
D6792
D6930
D6940
D6970
D6971
D6972
D6973
D6976
D6977
Pontic - resin with high noble metal (1,2)
Pontic - resin with predominantly base metal (2)
Pontic - resin with noble metal (2)
Retainer - cast metal for resin bonded fixed prosthesis
Retainer - porcelain/ceramic for resin bonded fixed prosthesis
Inlay - porcelain/ceramic, two surfaces
Inlay - porcelain/ceramic, three or more surfaces
Inlay - cast high noble metals, two surfaces
Inlay - cast high noble metals, three or more surfaces
Inlay - cast predominantly base metal, two surfaces
Inlay - cast predominantly base metal, three or more surfaces
Inlay - cast noble metal, two surfaces
Inlay - cast noble metal, three or more surfaces
Onlay - porcelain/ceramic, two surfaces
Onlay - porcelain/ceramic, three or more surfaces
Onlay - cast high noble metal, two surfaces (1)
Onlay - cast high noble metal, three or more surfaces (1)
Onlay - cast predominantly base metal, two surfaces
Onlay - cast predominantly base metal, three or more surfaces
Onlay - cast noble metal, two surfaces
Onlay - cast noble metal, three or more surfaces
Crown - resin with high noble metal (1,2)
Crown - resin with predominantly base metal (2)
Crown - resin with noble metal (2)
Crown - porcelain fused to high noble metal (1,2)
Crown - porcelain fused to predominantly base metal (2)
Crown - porcelain fused to noble metal (2)
Crown - 3/4 cast high noble metal (1)
Crown - 3/4 cast predominantly base metal
Crown - 3/4 cast noble metal
Crown - full cast high noble metal (1)
Crown - full cast predominantly base metal
Crown - full cast noble metal
Recement fixed partial denture
Stress breaker
Cast post and core in addition to fixed partial denture retainer (1)
Cast post as part of fixed partial denture retainer (1)
Prefabricated post and core in addition to fixed partial denture retainer
Core buildup for retainer, including any pins
Each additional cast post - same tooth (1)
Each additional prefabricated post - same tooth
D7000
D7000-D7900 XI. Oral and Maxofacillary Surgery
d7001
Includes per-operative and post-operative evaluations and treatments under local anesthesia
D7111 Coronal remnants - deciduous teeth
D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)
Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or
D7210
section of tooth
$195.00
$195.00
$195.00
Optional
Optional
Optional
Optional
$150.00
$150.00
$130.00
$140.00
$140.00
$150.00
Optional
Optional
$156.00
$162.00
$146.00
$152.00
$156.00
$162.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$195.00
$15.00
$25.00
$15.00
$15.00
$15.00
$15.00
$15.00
$15.00
Member Co-Payment
$6.00
$6.00
$15.00
D7220
D7230
D7240
D7241
D7250
D7286
D7310
D7320
D7471
D7472
D7473
D7510
D7960
Removal of impacted tooth - soft tissue
Removal of impacted tooth - partially bony
Removal of impacted tooth - completely bony
Removal of impacted tooth - completely bony, with unusual surgical complications
Surgical removal of residual tooth roots (cutting procedure)
Biopsy of oral tissue - soft (all others)
Alveoloplasty in conjunction with extractions - per quadrant
Alveoloplasty not in conjunction with extractions - per quadrant
Removal of lateral exostosis - (maxilla or mandible)
Removal of torus palatinus
Removal of torus mandibularis
Incision and drainage of abscess - intraoral soft tissue
Frenulectomy (frenectomy or frenotomy) - separate procedure
$40.00
$60.00
$80.00
$80.00
$0.00
$20.00
$40.00
$60.00
$50.00
$50.00
$50.00
$0.00
$40.00
D7999
D8000
d8001
d8002
d8003
d8004
d8005
d8006
d8007
d8008
d8009
d8010
d8011
d8012
d8013
D8020
D8030
D8040
D8070
D8080
D8090
D8660
D8670
D8680
D9000
D9110
D9211
D9212
D9215
D9310
D9440
D9450
D9999
D8000-D8999 XI. Orthodontics
Records solely for the purpose of Orthodontics include pre- and post- records as follows:
Pre-records include the following:
Intraoral - complete series (including bitewings) D0210
Tomographic survey D0322
Panoramic film D0330
Cephalometric film D0340
Oral/facial images (includes intra and extraoral images) D0350
Diagnostic casts D0470
Post-records include the following:
Intraoral - complete series (including bitewings) D0210
Diagnostic casts D0470
Limited orthodontic treatment of the transitional dentition (4)
Limited orthodontic treatment of the adolescent dentition (4)
Limited orthodontic treatment of the adult dentition (4)
Comprehensive orthodontic treatment of the transitional dentition (4)
Comprehensive orthodontic treatment of the adolescent dentition (4)
Comprehensive orthodontic treatment of the adult dentition (4)
Pre-orthodontic treatment visit (applied to treatment fee if patient proceeds with treatment)
Periodic orthodontic treatment visit (as part of contract) Inclusive of treatment fee
Orthodontic retention (removal of appliances, construction and placement of retainer(s)) (4)
D9000-D9999 X. Adjunctive General Services
Palliative (emergency) treatment of dental pain - minor procedure
Regional block anesthesia
Trigeminal division block anesthesia
Local anesthesia
Consultation (diagnostic service provided by a dentist or physician other than practitioner providing
treatment)
Office visit - after regularly scheduled hours
Case presentation, detailed and extensive treatment planning
Unspecified adjunctive procedure, by report - includes failed appointment w/o 24-hour notice - per 15 min.
of appointment time
Member Co-Payment
$200.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$70.00
$0.00
$0.00
$1,950.00
$1,950.00
$2,150.00
$1,950.00
$1,950.00
$2,150.00
$25.00
$0.00
$0.00
Member Co-Payment
$10.00
$0.00
$0.00
$0.00
$20.00
$20.00
$0.00
$10.00
Footnotes
(1) Base or noble metal is the benefit. If high noble metal (preciuous) is used for a crown,bridge, cast post or
core, inlay or only, the Enrollee will be charged the additional laboratory cost of the high noble metal.
Additional laboratory costs also apply to a titanium crown.
(2) Porcelain on molars is considered optional treatment
(3) Includes any adjustments for 6 months.
(4) Services include initial examination, diagnosis, consultation, intial banding, 24 months of active treatment,
debanding and the retention phase of treatment. The retention phase includes the initial construction,
placemenet and adjustments to retainers and office visits for a maximum of 24 months. For treatment
plans extending beyond 24 months of active treatment, the Enrollee will be subject to a monthly office fee,
not to exceed $75.00 per month.
Listed Procedures
If services for a listed procedure are performed by the assigned Contract Dentist, the Enrollee pays the
specified Copayment. Listed procedures which require a Dentist to provide specialized services, and are
referred by the assigned Contract Dentist, must be pre-authorized in writing by Delta. The Enrollee pays
the Copayment specified for such services
Optional Procedures
Optional is defined as any alternative procedure presented by the Contract Dentist that satisfies the same
dental need as a covered procedure, is chosen by the Enrollee, and is subject to the limitations and
exclusions of the program. The applicable charge to the Enrollee is the difference between the Contract
Dentist's "filed fee" for the Optional procedure and the "filed fee" for the covered procedure, plus any
applicable Copayment for the covered procedure. Optional treatment does not apply when alternative
choices are benefits. "Filed fees"mean the Contract Dentist's fees on file with Delta. Questions regarding
the DeltaCare program should be directed to the Customer Service department at (800) 422-4234.
Emergency Dental Coverage
The Contract Dentist shall provide emergency dental care for a covered procedure which is required while
an Enrollee is within 35 miles of the facility of the Contract Dentist. If an Enrollee requires emergency
dental care and is more than 35 miles from the facility of the Contract Dentist, then Delta shall reimburse
the Enrollee for the cost of such emergency dental care which exceeds the Enrollee's Copayment up to a
$100.00 maximum per any 12 month period. Emergency dental care shall be limited to listed procedures,
and as described in code D9I10 above: "Palliative (emergency) treatment of dental pain:' Any further
treatment of the cause of such emergency dental care must be pre-authorized by Delta or provided by the
assigned Contract Dentist.
Unlisted Procedures
Procedures not listed above are not covered, but may be available at the Contract Dentist's "filed fees".