You can select from several nationwide, and in some areas, regional dental Preferred Provider Organization (PPO) or Health Maintenance Organization (HMO) plans, and high and standard coverage options.  You can also select from several nationwide vision plans.  You may enroll in a dental plan or a vision plan, or both.  Some TRICARE beneficiaries may not be eligible to enroll in both.  Visit www.opm.gov/dental or  
www.opm.gov/vision for more information.

You can enroll online at www.BENEFEDS.gov. Please see Section 2, Enrollment, for more information.

If you sign up for a dental and/or vision plan during the 2024 Open Season, your coverage will begin on January 1, 2025.  Premium deductions will start with the first full pay period beginning on/after January 1, 2025. You may use your benefits as soon as your enrollment is confirmed.

Employees automatically pay premiums through payroll deductions using pre-tax dollars.  Annuitants automatically pay premiums through annuity deductions using post-tax dollars.  TRICARE enrollees automatically pay premiums through payroll deduction or automatic bank withdrawal (ABW) using post-tax dollars.

Each year, an open season will be held, during which you may enroll or change your dental and/or vision plan enrollment. This year, open season runs from November 11, 2024 through midnight EST December 9, 2024. You do not need to re-enroll each open season, unless you wish to change plans or plan options; your coverage will continue from the previous year.  In addition to the annual open season, there are certain events that allow you to make specific types of enrollment changes throughout the year.  Please see Section 2, Enrollment, for more information. 

FEDVIP abides by the Current Dental Terminology (CDT) codification system in accordance with standards set by the American Dental Association (ADA).

Current Dental Terminology (CDT), Copyright © American Dental Association. All rights reserved.

If you are a Federal or U.S. Postal Service employee, you are eligible to enroll in FEDVIP, if you are eligible for the Federal Employees Health Benefits (FEHB) Program, the Postal Service Health Benefits (PSHB) Program, or the Health Insurance Marketplace (Exchange) and your position is not excluded by law or regulation, you are eligible to enroll in FEDVIP. Enrollment in the FEHB Program, PSHB Program, or a Health Insurance Marketplace (Exchange) plan is not required.

Certain temporary, intermittent, and seasonal Federal and U.S. Postal Service employees are now eligible to enroll in FEDVIP. To be eligible, these employees must be expected to work 130 hours per calendar month for at least 90 days. In addition, certain firefighters hired under a temporary appointment and intermittent emergency response personnel are eligible to enroll in FEDVIP. The employing agency must determine and notify these employees of their eligibility.  

You are eligible to enroll if you:

• retired on an immediate annuity under the Civil Service Retirement System (CSRS), the Federal Employees Retirement System (FERS) or another retirement system for employees of the Federal Government;
• retired for disability under CSRS, FERS, or another retirement system for employees of the Federal Government.

Your FEDVIP enrollment will continue into retirement if you retire on an immediate annuity or for disability under CSRS, FERS or another retirement system for employees of the Government, regardless of the length of time you had FEDVIP coverage as an employee.  There is no requirement to have coverage for 5 years of service prior to retirement in order to continue coverage into retirement, as there is with the FEHB/PSHB Program.

Your FEDVIP coverage will end if you retire on a Minimum Retirement Age (MRA) + 10 retirement and postpone receipt of your annuity.  You may enroll in FEDVIP again when you begin to receive your annuity.

Advise BENEFEDS of your new payroll office number.

An individual who is eligible for FEDVIP dental coverage based on the individual's eligibility to previously be covered under the TRICARE Retiree Dental Program or an individual eligible for FEDVIP vision coverage based on the individual's enrollment in a specified TRICARE health plan.

Retired members of the uniformed services and National Guard/Reserve components, including “gray-area” retirees under age 60 and their families are eligible for FEDVIP dental coverage.  These individuals, if enrolled in a TRICARE health plan, are also eligible for FEDVIP vision coverage.  In addition, uniformed services active duty family members who are enrolled in a TRICARE health plan are eligible for FEDVIP vision coverage. 

Except with respect to TRICARE-eligible individuals, family members include your spouse and unmarried dependent children under age 22. This includes legally adopted children and recognized natural children who meet certain dependency requirements. This also includes stepchildren and foster children who live with you in a regular parent- child relationship. Under certain circumstances, you may also continue coverage for a disabled child 22 years of age or older who is incapable of self-support. FEDVIP rules and FEHB/PSHB rules for family member eligibility are NOT the same. For more information on family member eligibility visit the website at www.opm.gov/healthcare-insurance/dental-vision/ or contact your employing agency or retirement system.

With respect to TRICARE-eligible individuals, family members include your spouse, unremarried widow, unremarried widower, unmarried child, an unremarried former spouse who meets the U.S Department of Defense's 20-20-20 or 20-20-15 eligibility requirements, and certain unmarried persons placed in your legal custody by a court.

Children include legally adopted children, stepchildren, and pre-adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

The following persons are not eligible to enroll in FEDVIP, regardless of FEHB/PSHB eligibility or receipt of an annuity or portion of an annuity:

• Deferred annuitants
• Former spouses of employees or annuitants.  Note:  Former spouses of TRICARE-eligible individuals may enroll in a FEDVIP vision plan.
• FEHB/PSHB Temporary Continuation of Coverage (TCC) enrollees
• Anyone receiving an insurable interest annuity who is not also an eligible family member
• Active duty uniformed service members.  Note:  If you are an active duty uniformed service member, your dental and vision coverage will be provided by TRICARE.  Your family members will still be eligible to enroll in the TRICARE Dental Plan (TDP). 
• Temporary/seasonal employees who do not meet the 130 hours per calendar month for 90 days 

You must use BENEFEDS to enroll or change enrollment in a FEDVIP plan.  BENEFEDS is a secure enrollment website (www.BENEFEDS.gov) sponsored by OPM.  If you do not have access to a computer, call 1-877-888-FEDS (1-877-888-3337), TTY number 1-877-889-5680 to enroll or change your enrollment.

If you are currently enrolled in FEDVIP and do not want to change plans, your enrollment will continue automatically. Please Note:  Your plans’ premiums may change for 2025.

Note: You cannot enroll or change enrollment in a FEDVIP plan using the Health Benefits Election Form (SF 2809) or through an agency self-service system, such as Employee Express, PostalEase, EBIS, MyPay, or Employee Personal Page.  However, those sites may provide a link to BENEFEDS.

Self Only: A Self Only enrollment covers only you as the enrolled employee or annuitant.  You may choose a Self Only enrollment even though you have a family; however, your family members will not be covered under FEDVIP.

Self Plus One: A Self Plus One enrollment covers you as the enrolled employee or annuitant plus one eligible family member whom you specify.  You may choose a Self Plus One enrollment even though you have additional eligible family members, but the additional family members will not be covered under FEDVIP.

Self and Family: A Self and Family enrollment covers you as the enrolled employee or annuitant and all of your eligible family members.  You must list all eligible family members when enrolling.

Open Season

If you are an eligible employee, annuitant, or TRICARE-eligible individual, you may enroll in a dental and/or vision plan during the November 11, 2024 through midnight EST December 9, 2024, Open Season.  Coverage is effective January 1, 2025.

During future annual open seasons, you may enroll in a plan, or change or cancel your dental and/or vision coverage.  The effective date of these open season enrollments and changes will be set by OPM.  If you want to continue your current enrollment, do nothing.  Your enrollment carries over from year to year, unless you change it.

New hire/Newly eligible

You may enroll within 60 days after you become eligible as:

• a new employee;
• a previously ineligible employee who transferred to a covered position;
• a survivor annuitant if not already covered under FEDVIP; or
• an employee returning to service following a break in service of at least 31 days.
• a TRICARE-eligible individual

Qualifying Life Event

A qualifying life event (QLE) is an event that allows you to enroll, or if you are already enrolled, allows you to change your enrollment outside of an open season. 

The following chart lists the QLEs and the enrollment actions you may take.

Qualifying Life Event: Marriage
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Acquiring an eligible family member (non-spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing a covered family member
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: Yes
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Losing other dental/vision coverage (eligible or covered person)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: Yes
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Moving out of regional plan's service area
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes

Qualifying Life Event: Going on active military duty, non- pay status (enrollee or spouse)
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from active military duty (enrollee or spouse)
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Returning to pay status from Leave without pay
From Not Enrolled to Enrolled: Yes (if enrollment cancelled during LWOP)
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: Yes (if enrollment cancelled during LWOP)

Qualifying Life Event: Annuity/ compensation restored
From Not Enrolled to Enrolled: Yes
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: No
Change from One Plan to Another: No

Qualifying Life Event: Transferring to an eligible position*
From Not Enrolled to Enrolled: No
Increase Enrollment Type: No
Decrease Enrollment Type: No
Cancel: Yes
Change from One Plan to Another: No

*Position must be in a Federal agency that provides dental and/or vision coverage with 50 percent or more employer-paid premium and you elect to enroll.  

The timeframe for requesting a QLE change is from 31 days before to 60 days after the event. There are two exceptions:  

• There is no time limit for a change based on moving from a regional plan’s service area; and 
• You cannot request a new enrollment based on a QLE before the QLE occurs, except for enrollment because of a loss of dental or vision insurance. You must make the change no later than 60 days after the event. 

Enrollments and enrollment changes made based on a QLE are effective on the first day of the pay period following the one in which BENEFEDS receives the enrollment or change. BENEFEDS will send you confirmation of your new coverage effective date.  

Once you enroll in a plan, your 60-day window for that type of plan ends, even if 60 calendar days have not yet elapsed. That means once you have enrolled in either plan, you cannot change or cancel that particular enrollment until the next open season, unless you experience a QLE that allows such a change or cancellation.  

VA Exception for Cancellation 

Generally, you may cancel your enrollment only during the annual open season. However, if you are a FEDVIP enrollee paying premiums on a post-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may change your enrollment type or cancel your enrollment within 60 days of receiving notification of VA dental or vision eligibility. This 60-day period may fall outside of open season. VA dental or vision eligibility documentation must be submitted to OPM via the BENEFEDS mailbox (benefedsportal@opm.gov) within 60 days of notification to support the FEDVIP enrollment change or cancellation. 

Your cancellation is effective at the end of the day before the date OPM sets as the open season effective date. An eligible family member’s coverage also ends upon the effective date of the cancellation. 

If you are a FEDVIP enrollee paying premiums on a pre-tax basis, and you, your family member, or TEI family member becomes eligible for VA dental or vision benefits, then you may not change or cancel your FEDVIP enrollment until the next open season. 

FEDVIP enrollees can verify if they are paying their premiums on a pre- or post- tax basis by contacting BENEFEDS at 1-877-888-3337, TTY number 1-877-889-5680.

• Coverage ends for active and retired Federal, U.S. Postal employees, and TRICARE-eligible individuals when you:

  • no longer meet the definition of an eligible employee, annuitant, or TRICARE-eligible individual;
  • as a Retired Reservist you begin active duty;
  • as sponsor or primary enrollee leaves active duty;
  • begin a period of non-pay status or pay that is insufficient to have your FEDVIP premiums withheld and you do not make direct premium payments to BENEFEDS;
  • are making direct premium payments to BENEFEDS and you stop making the payments;
  • cancel the enrollment during open season;
  • a Retired Reservist begins active duty; or
  • the sponsor or primary enrollee leaves active duty.

• Coverage for a family member ends when:

  • you as the enrollee lose coverage; or
  • the family member no longer meets the definition of an eligible family member.

NOTE: Coverage ends for a covered individual when UnitedHealthcare Dental does not receive premium payment for that covered individual.

Under FEDVIP, there is no 31-day extension of coverage. The following are also NOT available under the FEDVIP plans:

• Temporary Continuation of Coverage (TCC);
• spouse equity coverage; or
• right to convert to an individual policy (conversion policy).

If you are planning to enroll in an FSAFEDS Health Care Flexible Spending Account (HCFSA) or Limited Expense Health Care Flexible Spending Account (LEX HCFSA), you should consider how coverage under a FEDVIP plan will affect your annual expenses, and thus the amount that you should allot to an FSAFEDS account. Please note that insurance premiums are not eligible expenses for either type of FSA.   

Please review IRS - Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans (https://www.irs.gov/forms-pubs/about-publication-969) for additional information about carryover and contribution amounts for the upcoming tax year. If you have an HCFSA or LEX HCFSA FSAFEDS account and you have not exhausted your funds by December 31st of the plan year, FSAFEDS can automatically carry over a set maximum amount of unspent funds into another health care or limited expense account for the subsequent year. To be eligible for carryover, you must be employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st. You must also actively re-enroll in a health care or limited expense account during the next open season to be carryover eligible. Your re-enrollment must meet the minimum contribution amount for the plan year. If you do not re-enroll, or if you are not employed by an agency that participates in FSAFEDS and actively making allotments from your pay through December 31st, your funds will not be carried over. 

Because of the tax benefits an FSA provides, the IRS requires that you forfeit any money for which you did not incur an eligible expense and file a claim in the time permitted. This is known as the “Use-it-or-Lose-it” rule. Carefully consider the amount you will elect. 

Current FSAFEDS participants must re-enroll to participate in the program next year. See
https://www.fsafeds.gov or call 1-877-FSAFEDS (372-3337) or TTY: 1-866-353-8058. Note: FSAFEDS is not open to retired employees or to TRICARE eligible individuals. 

If you enroll or are enrolled in a high deductible health plan with a health savings account (HSA) or health reimbursement arrangement (HRA), you may use your HSA or HRA to pay for qualified dental/vision costs not covered by your FEHB/PSHB and/or FEDVIP plans. 

Enroll online at www.BENEFEDS.gov. Upon confirmation of your enrollment, you will be sent a welcome packet with a new member checklist. Your UnitedHealthcare Dental Plan identification card is available electronically at www.myuhc.com if you have a UnitedHealthcare Medical Plan or www.myuhcdental.com/fedvip if you do not have a UnitedHealthcare Medical Plan. You may contact customer service at 1-866-315-2321 or TTY 711 for a physical card to mailed to your home address. 

You may visit any provider in the UnitedHealthcare Dental network. Log on to
www.myuhcdental.com/fedvip and select the provider locator option. You may also contact UnitedHealthcare Dental's 24-hour, toll-free Interactive Voice Response (IVR) system dedicated to Federal employees and annuitants at 1-866-315-2321 or TTY 711. You may elect to visit any dental provider to utilize your benefit, even if they are not part of the UnitedHealthcare Dental provider network.

We list plan providers on our Web site at www.myuhcdental.com/fedvip. In addition, you can call UnitedHealthcare Dental Plan’s 24-hour, toll-free Interactive Voice Response (IVR) system dedicated to Federal employees and annuitants at 1-866-315-2321 or TTY 711.

Once you locate an in-network provider, call the provider directly to schedule your appointment. Identify yourself as having UnitedHealthcare Dental coverage and provide the primary insured’s subscriber number and patient’s name and date of birth. You can find participating providers at www.myuhcdental.com/fedvip.

If you use a dentist outside the network, you may need to pay the difference between what the plan covers and what your dentist charges for the services. Plus, you may need to submit your own claims to the following address:

UnitedHealthcare Dental
Attention: Claims Department
P.O. Box 30567
Salt Lake City, UT 84130-0567

You and your dentist may request us to precertify dental procedures that your dentist plans to perform. We will provide an explanation of benefits to both you and your dentist that will indicate if procedures are covered and what we will pay for those specific services.

If more than one service or procedure can be used to treat the covered person’s dental condition, UnitedHealthcare Dental may decide to authorize coverage only for the less costly covered service or procedure when that service is an appropriate method of treatment and the service meets broadly accepted national standards of dental practice. For example, this may apply but not limited to include: an amalgam or composite filling may be the alternate benefit of a crown or; a partial denture may be an alternate benefit for implants. Should the member and the dentist choose the more expensive treatment, the member is responsible for the additional charges beyond the allowance for the alternate service, even if an in-network provider.

UnitedHealthcare Dental Plan's claim review is conducted by licensed dental professionals who review the clinical documentation submitted by your treating dentist.  These licensed dental professionals review the records checking for dental necessity for certain procedures such as crowns, bridges, onlays, implants, periodontal treatments, as well as other services.  The licensed dental professionals may also recommend that an alternate benefit be applied to a service in accordance with the terms of the plan.

When you visit a provider who participates with both your FEHB/PSHB plan and your FEDVIP plan, the FEHB/PSHB plan will pay benefits first. The FEDVIP plan allowance will be the prevailing charge in these cases. You are responsible for the difference between the FEHB/PSHB and FEDVIP benefit payments and the FEDVIP plan allowance. UnitedHealthcare Dental is responsible for facilitating the process with the FEHB/PSHB first payor. It is important to bring your FEDVIP and FEHB/PSHB identification cards to every dental appointment to ensure that you are receiving the maximum allowable benefit under each program.

If you are covered under a non-FEHB/non-PSHB plan, your UnitedHealthcare Dental benefits will be coordinated using traditional COB provisions for determining payment.

We will coordinate benefit payments with the payment of benefits under other group health benefits coverage (non-FEHB/non-PSHB) you may have and the payment of dental costs under no-fault insurance that pays benefits without regard to fault.

Here is an example of how we would coordinate benefits if a non-FEHB/non-PSHB plan was primary. This example assumes all deductibles have been met and annual maximums have not been reached. The amounts listed in the chart below are for example purposes only and do not reflect your non-FEHB/non-PSHB or UnitedHealthcare Dental benefits. The example does not include your copay which you are responsible for paying.

UnitedHealthcare Dental coverage is secondary to non-FEHB/non-PSHB coverage

In-Network Dentist's Fee: $200.00*

Plan Allowance: $150.00

Primary Plan's Scheduled Amount: $125.00

Primary Plan's Payment: $125.00

FEDVIP Payment: $25.00 ($150.00-$125.00)

Member Payment: $0.00

 *You are not responsible for the $50.00 difference between the dentist’s fee and the plan allowance, when you use an in-network dentist. The dentist cannot bill you for this amount.  

If you live in a limited access area* (defined as driving distance greater than 15 miles urban areas/ greater than 35 miles in rural areas) and you receive covered dental services from an out-of-network provider, we will pay the same plan allowances as if you utilized an in-network provider.   It is important to note that you will be responsible for the difference between the billed amount and our payment. If you have any questions about limited access areas or you are having problems locating an in-network dentist in your area, please call us at 1-866-315-2321 or TTY 711

*NOTE: Access Standards

Limited Access does not apply to International Members.

Urban and suburban zip codes: at least 90% of Federal eligibles (employees and annuitants) in a network access area (zip code plus 15 driving-miles) must have access to a dental care preferred provider.

Rural zip codes: at least 80% of Federal eligibles (employees and annuitants) in a network access area (zip code plus 35 driving-miles) must have access to a dental care preferred provider.

A deductible is a fixed amount of expenses you must incur for certain covered services and supplies before we will pay for covered services. Covered charges credited to the deductible are also counted towards the Plan maximum and limitations.

Class A
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $0
Out-of-Network Standard Option: $100 (Self), $200 (Self Plus One), $300(Family)

Class B
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50 (Self), $100 (Self Plus One), $150 (Family)
Out-of-Network Standard Option: $100 (Self), $200 (Self Plus One), $300(Family)

Class C
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $50 (Self), $100 (Self Plus One), $150 (Family)
Out-of-Network Standard Option: $100 (Self), $200 (Self Plus One), $300(Family)

Orthodontics
In-Network High Option: $0
In-Network Standard Option: $0
Out-of-Network High Option: $0
Out-of-Network Standard Option: $0

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you meet your deductible, if applicable.

Class A
In-Network High Option: 0%
In-Network Standard Option: 0%
Out-of-Network High Option: 10%
Out-of-Network Standard Option: 10%

Class B
In-Network High Option: 30%
In-Network Standard Option: 45%
Out-of-Network High Option: 40%
Out-of-Network Standard Option: 60%

Class C
In-Network High Option: 50%
In-Network Standard Option: 65%
Out-of-Network High Option: 60%
Out-of-Network Standard Option: 80%

Orthodontics
In-Network High Option: 50%
In-Network Standard Option: 50%
Out-of-Network High Option: 50%
Out-of-Network Standard Option: 50%

Once you reach this amount, you are responsible for all additional charges.  The Annual Benefit Maximums within each option are combined between in and out-of-network services.  The total Annual Benefit Maximum will never be greater than the In-Network Maximum Annual Benefit.

Maximum Annual Benefits:

In-Network High Option: Unlimited
In-Network Standard Option: $1,500 per person
Out-of-Network High Option: $3,000 per person
Out-of-Network Standard Option: $1,000 per person

The Lifetime Maximum is applicable to Orthodontia benefits only. The Lifetime Maximums within each option are combined between in and out-of-network services. There are no other lifetime maximums under this Plan.

Lifetime Orthodontic Maximum
In-Network High Option: $2,000 per adult / $4,000 per child*
In-Network Standard Option: $2,000 per person
Out-of-Network High Option: $2,000 per adult / $4,000 per child*
Out-of-Network Standard Option: $2,000 person

*Child is defined as ages 18 and under. 

You pay the coinsurance percentage of our network allowance for covered services.  You are not responsible for charges above that allowance. 

If the dentist you use is not part of our network, benefits will be considered at the out-of- network level.  All services provided by an out-of-network dentist will be paid at out-of-network levels, except for limited access benefits.  All benefit payments are based on UnitedHealthcare Dental’s Plan Allowance Amounts, which is a schedule of fixed dollar maximums established by UnitedHealthcare Dental for services by out-of-network providers.  If a member chooses to go out of network, payments will be made directly to the member.

The calendar year refers to the plan year, which is defined as January 1, 2025 to December 31, 2025.

In-progress treatment for dependents of retiring active duty service members who were enrolled in the TRICARE Dental Program (TDP) will be covered for the 2025 plan year; regardless of any current plan exclusion for care initiated prior to the enrollee's effective date.

This requirement includes assumption of payments for covered orthodontia services up to the FEDVIP policy limits, and full payment where applicable up to the terms of FEDVIP policy for covered services completed (but not initiated) in the 2025 plan year such as crowns and implants.

D0120 Periodic oral evaluation - established patient - Limited to 2 times per calendar year

D0140 Limited oral evaluation - problem focused - Limited to 2 times per calendar year

D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver - Limited to 2 times per calendar year

D0150 Comprehensive oral evaluation - new or established patient - Limited to 2 times per calendar year

D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) - Limited to 2 times per calendar year

D0180 Comprehensive periodontal evaluation - new or established patient - Limited to 2 times per calendar year

D0210 Intraoral – comprehensive series of radiographic images – Limited to 1 per 60 months

D0220 Intraoral - periapical first radiographic image - Limited to 8 images per calendar year

D0230 Intraoral - periapical each additional radiographic image - Limited to 8 images per calendar year

D0240 Intraoral - occlusal radiographic image - Limited to 4 images per calendar year

D0250 Extra-oral – 2D projection radiographic image created using a stationary radiation source, and detector - Limited to 2 images per calendar year

D0251 Extra-oral posterior dental radiographic image - Limited to 2 images per calendar year

D0270 Bitewing - single radiographic image – Limited to 1 series of images per calendar year

D0272 Bitewings - two radiographic images - Limited to 1 series of images per calendar year

D0273 Bitewings - three radiographic images - Limited to 1 series of images per calendar year

D0274 Bitewings - four radiographic images - Limited to 1 series of images per calendar year

D0277 Vertical bitewings - 7 to 8 radiographic images - Limited to 1 series of images per calendar year

D0330 Panoramic radiographic image - Limited to 1 complete series or a panoramic radiographic image per 60 months.

D0350 2D oral/facial photographic image obtained intra-orally or extra-orally - Limited to 1 time per consecutive 36 months

D0391 Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report

D0414 Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report

D0415 Collection of microorganisms for culture and sensitivity

D0416 Viral culture

D0422 Collection and preparation of genetic sample material for laboratory analysis and report - Limited to 1 per 60 months

D0423 Genetic test for susceptibility to diseases – specimen analysis - Limited to 1 per 60 months

D0425 Caries susceptibility tests - Limited to 1 per 60 months

D0431 Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures – Limited to 1 time per calendar year for adults

D0460 Pulp vitality tests - Limited to 1 charge per visit, regardless of how many teeth are tested.

D0470 Diagnostic casts - Limited to 1 time per consecutive 24 months

D0486 Laboratory accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report

D0600 Non-ionizing diagnostic procedure capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum - Limited to 1 per 36 months

D0601 Caries risk assessment and documentation, with a finding of low risk - Limited to 2 times per calendar year

D0602 Caries risk assessment and documentation, with a finding of moderate risk - Limited to 2 times per calendar year

D0603 Caries risk assessment and documentation, with a finding of high risk - Limited to 2 times per calendar year

D9995 Teledentistry - synchronous; real-time encounter - Limited to 2 times per calendar year

D9996 Teledentistry - asynchronous; information stored and forwarded to dentist for subsequent review - Limited to 2 times per calendar year

D1110 Prophylaxis - adult - (Age 13 and under will be processed as D1120 Prophylaxis - child) - Limited to 2 times per calendar year

D1120 Prophylaxis - child - (Age 14 and over will be processed as D1110 Prophylaxis - adult) - Limited to 2 times per calendar year

D1206 Topical application of fluoride varnish - Limited to 2 times per calendar year

D1208 Topical application of fluoride – excluding varnish - Limited to 2 times per calendar year

D1351 Sealant - per tooth - Limited to covered persons under the age of 19 years and once per first or second permanent molar every consecutive 36 months

D1352 Preventive resin restoration in a moderate to high caries risk patient – permanent tooth - Limited to covered persons under the age of 19 years and once per first or second permanent molar every consecutive 36 months

D1353 Sealant repair – per tooth - Limited to covered persons under the age of 19 years and once per first or second permanent molar every 36 months

D1354 Application of caries arresting medicament – per tooth - Limited per permanent (molars & premolars) tooth per 36 months, excludes wisdom teeth

D1510 Space maintainer - fixed, unilateral – per quadrant - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation

D1516 Space maintainer – fixed – bilateral, maxillary - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation

D1517 Space maintainer – fixed – bilateral, mandibular - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation

D1520 Space maintainer - removable, unilateral - per quadrant - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation

D1526 Space maintainer – removable – bilateral, maxillary - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation

D1527 Space maintainer – removable – bilateral, mandibular - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation

D1551 Re-cement or re-bond bilateral space maintainer – maxillary - Limited to 1 per consecutive 6 months after initial insertion

D1552 Re-cement or re-bond bilateral space maintainer - mandibular - Limited to 1 per consecutive 6 months after initial insertion

D1553 Re-cement or re-bond unilateral space maintainer – per quadrant - Limited to 1 per consecutive 6 months after initial insertion

D1556 Removal of fixed unilateral space maintainer - per quadrant

D1557 Removal of fixed bilateral space maintainer - maxillary

D1558 Removal of fixed bilateral space maintainer - mandibular

D1575 Distal shoe space maintainer - fixed, unilateral - per quadrant - Limited to covered persons under the age of 19 years, once per consecutive 60 months. Benefit includes all adjustments within 6 months of installation

D9110 Palliative treatment of dental pain – per visit - Covered as a separate benefit only if no other services, other than exam and radiographs were done on the same tooth during the visit

D9440 Office visit - after regularly scheduled hours - Limited to 1 per calendar year. Subject to clinical review and necessity

D2140 Amalgam – one surface, primary or permanent

D2150 Amalgam – two surfaces, primary or permanent

D2160 Amalgam – three surfaces, primary or permanent

D2161 Amalgam – four or more surfaces, primary or permanent

D2330 Resin-based composite – one surface, anterior

D2331 Resin-based composite – two surfaces, anterior

D2332 Resin-based composite – three surfaces, anterior

D2335 Resin-based composite – four or more surfaces (anterior)

D2390 Resin-based composite crown, anterior

D2391 Resin-based composite – one surface, posterior

D2392 Resin-based composite – two surfaces, posterior

D2393 Resin-based composite – three surfaces, posterior

D2394 Resin-based composite – four or more surfaces, posterior

D2610 Inlay - porcelain/ceramic - one surface - Limited to 1 time per tooth per consecutive 60 months

D2620 Inlay - porcelain/ceramic - two surfaces - Limited to 1 time per tooth per consecutive 60 months.

D2630 Inlay - porcelain/ceramic - three or more surfaces - Limited to 1 time per tooth per consecutive 60 months.

D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration - Limited to 1 per consecutive 12 months. Limited to those performed more than 12 months after the initial insertion

D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and core - Limited to 1 per consecutive 12 months. Limited to those performed more than 12 months after the initial insertion

D2920 Re-cement or re-bond crown - Limited to 1 per consecutive 12 months. Limited to those performed more than 12 months after the initial insertion

D2921 Reattachment of tooth fragment, incisal edge or cusp – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.

D2929 Prefabricated porcelain/ceramic crown – primary tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. D2934 Prefabricated esthetic coated stainless steel crown - primary tooth are limited to primary anterior teeth

D2930 Prefabricated stainless steel crown - primary tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. D2934 Prefabricated esthetic coated stainless steel crown - primary tooth are limited to primary anterior teeth.

D2931 Prefabricated stainless steel crown – permanent tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth.

D2940 Placement of interim direct restoration - Covered as a separate benefit only if no other service, other than x-rays and exam, were performed on the same tooth during the visit

D2951 Pin retention – per tooth, in addition to restoration - Limited to 2 pins per tooth; not Covered in addition to cast restoration. Limited to 1 time per consecutive 60 months.

D2989 Excavation of a tooth resulting in the determination of non-restorability 

D3110 Pulp cap - direct (excluding final restoration) - Not Covered if utilized solely as a liner or base underneath a restoration

D3120 Pulp cap - indirect (excluding final restoration) - Not Covered if utilized solely as a liner or base underneath a restoration

D3220 Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament - Limited to 1 time per primary or secondary tooth per lifetime

D3221 Pulpal debridement, primary and permanent teeth - Limited to 1 time per tooth per lifetime. Not covered on the same day as other endodontic services

D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development - Limited to 1 time per primary or secondary tooth per lifetime.

D3230 Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration) - Limited to 1 per tooth per lifetime.

D3240 Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration) - Limited to 1 per tooth per lifetime.

D3331 Treatment of root canal obstruction; non-surgical access - Limited to 1 time per tooth per lifetime

D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth - Limited to 1 time per tooth per lifetime

D3333 Internal root repair of perforation defects - Limited to 1 time per tooth per lifetime

D3355 Pulpal regeneration - initial visit - Limited to 1 time per tooth per lifetime

D3356 Pulpal regeneration - interim medication replacement - Limited to 1 time per tooth per lifetime

D3357 Pulpal regeneration - completion of treatment - Limited to 1 time per tooth per lifetime

D3430 Retrograde filling - per root - Limited to 1 time per tooth per lifetime

D4230 Anatomical crown exposure – four or more contiguous teeth or tooth bounded spaces per quadrant - Limited to 1 per quadrant or site per consecutive 36 months

D4231 Anatomical crown exposure – one to three teeth or tooth bounded spaces per quadrant - Limited to 1 per quadrant or site per consecutive 36 months

D4245 Apically positioned flap - Limited to 1 per quadrant or site per consecutive 36 months

D4264 Bone replacement graft – retained natural tooth – each additional site in quadrant - Limited to 1 per consecutive 36 months. (For D4263 Bone replacement graft – retained natural tooth – first site in quadrant see Class C services.)

D4265 Biologic materials to aid in soft and osseous tissue regeneration, per site - Limited to 1 per consecutive 36 months

D4266 Guided tissue regeneration, natural teeth – resorbable barrier, per site - Limited to 1 per consecutive 36 months

D4267 Guided tissue regeneration, natural teeth – non-resorbable barrier, per site - Limited to 1 per consecutive 36 months

D4268 Surgical revision procedure, per tooth - Limited to 1 per quadrant or site per consecutive 36 months. (For D4263 Bone replacement graft – retained natural tooth – first site in quadrant see Class C services.)

D4274 Mesial/distal wedge procedure, single tooth (when not performed in conjunction with surgical procedures in the same anatomical area)

D4276 Combined connective tissue and pedicle graft, per tooth - Limited to 1 per quadrant or site per consecutive 36 months

D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft - Limited to 1 per quadrant or site per consecutive 36 months

D4341 Periodontal scaling and root planing - four or more teeth per quadrant - Limited to 1 time per quadrant per consecutive 24 months

D4342 Periodontal scaling and root planing - one to three teeth per quadrant – Limited to 1 time per quadrant per consecutive 24 months.

D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation - Limited to 2 times per calendar year in combination with prophylaxis and periodontal maintenance

D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth - Limited to 3 sites per quadrant or 12 sites total for refractory pockets or in conjunction with Periodontal Scaling and Root Planing

D4910 Periodontal maintenance - Limited to the maximum of 4 per calendar year in combination with adult prophylaxis and scaling in presence of generalized moderate or severe gingival inflammation

D4920 Unscheduled dressing change (by someone other than treating dentist or their staff) - Limited to 1 per consecutive 6 months, Limited to 1 per day

D4999 Unspecified periodontal procedure, by report - Subject to clinical review and necessity.

D5410 Adjust complete denture – maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5411 Adjust complete denture – mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5421 Adjust partial denture – maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5422 Adjust partial denture – mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5511 Repair broken complete denture base, mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5512 Repair broken complete denture base, maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5520 Replace missing or broken teeth – complete denture – per tooth - Limit 1 beginning 6 months after the initial installation

D5611 Repair resin partial denture base, mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5612 Repair resin partial denture base, maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5621 Repair cast partial framework, mandibular - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5622 Repair cast partial framework, maxillary - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5630 Repair or replace broken retentive clasping materials - per tooth - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5640 Replace missing or broken teeth – partial denture – per tooth - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5650 Add tooth to existing partial denture – per tooth - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5660 Add clasp to existing partial denture - per tooth - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5670 Replace all teeth and acrylic on cast metal framework (maxillary) – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5671 Replace all teeth and acrylic on cast metal framework (mandibular) – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D5710 Rebase complete maxillary denture – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5711 Rebase complete mandibular denture – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5720 Rebase maxillary partial denture – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5721 Rebase mandibular partial denture - Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5730 Reline complete maxillary denture (direct) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5731 Reline complete mandibular denture (direct) - Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5740 Reline maxillary partial denture (direct) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5741 Reline mandibular partial denture (direct) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5750 Reline complete maxillary denture (indirect) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5751 Reline complete mandibular denture (indirect) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5760 Reline maxillary partial denture (indirect) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5761 Reline mandibular partial denture (indirect) – Limited to relining/rebasing performed more than 6 months after the initial insertion. Limited to 1 time per consecutive 36 months

D5850 Tissue conditioning, maxillary - Limited to 1 time per consecutive 12 months

D5851 Tissue conditioning, mandibular - Limited to 1 time per consecutive 12 months

D6092 Re-cement or re-bond implant/abutment supported crown - Limited to 1 time per consecutive 6 months

D6093 Re-cement or re-bond implant/abutment supported fixed partial denture - Limited to 1 time per consecutive 6 months

D6930 Re-cement or re-bond fixed partial denture - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.

D6980 Fixed partial denture repair necessitated by restorative material failure - Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months.

D7111 Extraction, coronal remnants - primary tooth

D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal)

D7210 Extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated

D7220 Removal of impacted tooth – soft tissue

D7230 Removal of impacted tooth – partially bony

D7240 Removal of impacted tooth – completely bony

D7241 Removal of impacted tooth – completely bony, with unusual surgical complications

D7250 Removal of residual tooth roots (cutting procedure)

D7251 Coronectomy – intentional partial tooth removal, impacted teeth only

D7260 Oroantral fistula closure - Limited to one per site per visit

D7261 Primary closure of a sinus perforation - Limited to 1 time per tooth per lifetime

D7270 Tooth re-implantation and/or stabilization of accidentally evulsed or displaced tooth - Limited to 1 per site per lifetime

D7272 Tooth transplantation (includes re-implantation from one site to another and splinting and/or stabilization) - Limited to 1 per site per lifetime

D7280 Exposure of an unerupted tooth - Limited to 1 per tooth per lifetime

D7282 Mobilization of erupted or malpositioned tooth to aid eruption - Limited to 1 per tooth per lifetime

D7283 Placement of device to facilitate eruption of impacted tooth - Limited to 1 per tooth per lifetime

D7285 Incisional biopsy of oral tissue-hard (bone, tooth) - Limited to 1 per site per visit

D7286 Incisional biopsy of oral tissue-soft - Limited to 1 per site per visit

D7287 Exfoliative cytological sample collection – Limited to 1 per site per visit

D7288 Brush biopsy - transepithelial sample collection - Limited to 1 per site per visit

D7291 Transseptal fiberotomy/supra crestal fiberotomy, by report - Limited to 1 per tooth per lifetime

D7310 Alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

D7311 Alveoloplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

D7320 Alveoloplasty not in conjunction with extractions - four or more teeth or tooth spaces, per quadrant

D7321 Alveoloplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant

D7410 Excision of benign lesion up to 1.25 cm - Limited to 1 per site per visit

D7411 Excision of benign lesion greater than 1.25 cm - Limited to 1 per site per visit

D7412 Excision of benign lesion, complicated - Limited to 1 per site per visit

D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm - Limited to 1 per site per visit

D7451 Removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm - Limited to 1 per site per visit

D7460 Removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm - Limited to 1 per site per visit

D7461 Removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm - Limited to 1 per site per visit

D7471 Removal of lateral exostosis (maxilla or mandible) - Limited to 1 per site per visit

D7510 Incision and drainage of abscess – intraoral soft tissue - Limited to 1 per site per visit

D7511 Incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces) - Limited to 1 per site per visit

D7520 Incision and drainage of abscess - extraoral soft tissue - Limited to 1 per site per visit

D7521 Incision and drainage of abscess - extraoral soft tissue - complicated (includes drainage of multiple fascial spaces) - Limited to 1 per site per visit

D7530 Removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue - Limited to 1 per site per visit

D7540 Removal of reaction producing foreign bodies, musculoskeletal system - Limited to 1 per site per visit

D7550 Partial ostectomy/sequestrectomy for removal of non-vital bone - Limited to 1 per site per visit

D7910 Suture of recent small wounds up to 5 cm - Limited to 1 per site per visit

D7921 Collection and application of autologous blood concentrate product – Limited to 1 per consecutive 36 months

D7953 Bone replacement graft for ridge preservation - per site – Limited to 1 per site per lifetime. Not covered if done in conjunction with other bone graft replacement procedures.

D7963 Frenuloplasty

D7970 Excision of hyperplastic tissue - per arch - Limited to 1 site per consecutive 36 months

D7971 Excision of pericoronal gingiva - Limited to 1 site per consecutive 36 months

D7972 Surgical reduction of fibrous tuberosity – Limited to 1 site per consecutive 36 months

D7997 Appliance removal (not by dentist who placed appliance), includes removal of archbar - Limited to once per appliance per lifetime

D7999 Unspecified oral surgery procedure, by report - Subject to clinical review and necessity.

D9210 Local anesthesia not in conjunction with operative or surgical procedures - Not Covered in conjunction with operative or surgical procedure – Limited to 1 time per tooth per consecutive 60 months

D9219 Evaluation for moderate sedation, deep sedation or general anesthesia - Covered when Necessary in conjunction with covered dental services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically necessary. Covered for patients over age of 6 if it is clinically necessary.

D9230 Inhalation of nitrous oxide/analgesia, anxiolysis - Covered when Necessary in conjunction with covered dental services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically necessary. Covered for patients over age of 6 if it is clinically necessary.

D9248 Non-intravenous conscious sedation - Covered when Necessary in conjunction with covered dental services. If required for patients under 6 years of age or patients with behavioral problems or physical disabilities or if it is clinically necessary. Covered for patients over age of 6 if it is clinically necessary.

D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician - Not covered if done with exams or professional visit

D9612 Therapeutic parenteral drugs, two or more administrations, different medications - Limited to 1 per visit

D9630 Drugs or medicaments dispensed in the office for home use - Limited to 1 per site per 6 months

D9910 Application of desensitizing medicament - Limited to 1 per site per 6 months

D9911 Application of desensitizing resin for cervical and/or root surface, per tooth - Limited to 1 per site per 6 months

D9950 Occlusion analysis - mounted case - Limited to 1 time per consecutive 60 months

D9951 Occlusal adjustment – limited - Limited to 1 per site per 6 months

D9952 Occlusal adjustment – complete - Limited to 1 per site per 6 months

D2410 Gold foil – one surface – Multiple restorations on one surface will be treated as a single filling

D2420 Gold foil – two surfaces – Multiple restorations on one surface will be treated as a single filling

D2430 Gold foil – three surfaces – Multiple restorations on one surface will be treated as a single filling

D2510 Inlay - metallic - one surface - Limited to 1 time per tooth per consecutive 60 months.

D2520 Inlay - metallic - two surfaces - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. Not covered if done in conjunction with any other inlay, onlay and crown codes except post and core buildup codes.

D2530 Inlay - metallic - three or more surfaces – Limited to 1 per tooth per 60 consecutive months.

D2542 Onlay - metallic - two surfaces – Limited to 1 per tooth per consecutive 60 months

D2543 Onlay - metallic - three surfaces – Limited to 1 per tooth per consecutive 60 months

D2544 Onlay - metallic - four or more surfaces – Limited to 1 per tooth per consecutive 60 months

D2642 Onlay - porcelain/ceramic - two surfaces – Limited to 1 per tooth per consecutive 60 months, including crowns, bridges, prosthetics

D2643 Onlay - porcelain/ceramic - three surfaces – Limited to 1 per tooth per consecutive 60 months, including crowns, bridges, prosthetics

D2644 Onlay - porcelain/ceramic - four or more surfaces – Limited to 1 per tooth per consecutive 60 months, including crowns, bridges, prosthetics

D2650 Inlay - resin-based composite - one surface – Limited to 1 per tooth per consecutive 60 months

D2651 Inlay - resin-based composite - two surfaces – Limited to 1 per tooth per consecutive 60 months

D2652 Inlay - resin-based composite - three or more surfaces – Limited to 1 per tooth per consecutive 60 months

D2662 Onlay - resin-based composite - two surfaces – Limited to 1 per tooth per consecutive 60 months

D2663 Onlay - resin-based composite - three surfaces – Limited to 1 per tooth per consecutive 60 months

D2664 Onlay - resin-based composite - four or more surfaces – Limited to 1 per tooth per consecutive 60 months

D2710 Crown - resin-based composite (indirect) – Limited to 1 per tooth per consecutive 60 months

D2712 Crown - ¾ resin-based composite (indirect) – Limited to 1 per tooth per consecutive 60 months

D2720 Crown - resin with high noble metal – Limited to 1 per tooth per consecutive 60 months

D2721 Crown - resin with predominantly base metal – Limited to 1 per tooth per consecutive 60 months

D2722 Crown - resin with noble metal – Limited to 1 per tooth per consecutive 60 months

D2740 Crown - porcelain/ceramic – Limited to 1 per tooth per consecutive 60 months

D2750 Crown - porcelain fused to high noble metal – Limited to 1 per tooth per consecutive 60 months

D2751 Crown - porcelain fused to predominantly base metal – Limited to 1 per tooth per consecutive 60 months

D2752 Crown - porcelain fused to noble metal – Limited to 1 per tooth per consecutive 60 months

D2753 Crown - porcelain fused to titanium and titanium alloys – Limited to 1 time per tooth per consecutive 60 months

D2780 Crown - 3/4 cast high noble metal - Limited to 1 per tooth per consecutive 60 months

D2781 Crown - 3/4 cast predominantly base metal – Limited to 1 per tooth per consecutive 60 months

D2782 Crown - 3/4 cast noble metal – Limited to 1 per tooth per consecutive 60 months

D2783 Crown - 3/4 porcelain/ceramic – Limited to 1 per tooth per consecutive 60 months

D2790 Crown - full cast high noble metal – Limited to 1 per tooth per consecutive 60 months

D2791 Crown - full cast predominantly base metal – Limited to 1 per tooth per consecutive 60 months

D2792 Crown - full cast noble metal – Limited to 1 per tooth per consecutive 60 months

D2794 Crown - titanium and titanium alloys - Limited to 1 per tooth per consecutive 60 months

D2932 Prefabricated resin crown - Limited to 1 per tooth per consecutive 60 months

D2933 Prefabricated stainless steel crown with resin window – Limited to 1 per tooth per consecutive 60 months

D2934 Prefabricated esthetic coated stainless steel crown - primary tooth – Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth. D2934 Prefabricated esthetic coated stainless steel crown - primary tooth are limited to primary anterior teeth

D2950 Core buildup, including any pins when required – Limited to 1 per tooth per consecutive 60 months when there is significant loss of tooth structure and deemed Necessary based on clinical review

D2952 Post and core in addition to crown, indirectly fabricated – Covered only for teeth that have had root canal therapy. Limited to 1 per tooth per consecutive 60 months

D2953 Each additional indirectly fabricated post - same tooth – Covered only for teeth that have had root canal therapy. Limited to 1 per tooth per consecutive 60 months

D2954 Prefabricated post and core in addition to crown – Covered only for teeth that have had root canal therapy. Limited to 1 per tooth per consecutive 60 months

D2957 Each additional prefabricated post - same tooth

D2960 Labial veneer (resin laminate) - direct - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth

D2961 Labial veneer (resin laminate) - indirect - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth

D2962 Labial veneer (porcelain laminate) - indirect - Limited to 1 time per tooth per consecutive 60 months. Covered only when a filling cannot restore the tooth

D2975 Coping - Limited to 1 per tooth per consecutive 60 months

D2980 Crown repair necessitated by restorative material failure – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D2981 Inlay repair necessitated by restorative material failure - Limit 1 every 12 months- Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D2982 Onlay repair necessitated by restorative material failure – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D2983 Veneer repair necessitated by restorative material failure – Limited to repairs or adjustments performed more than 12 months after the initial insertion. Limited to 1 per consecutive 6 months

D2990 Resin infiltration of incipient smooth surface lesions - Limited to 1 per consecutive 36 months

D3310 Endodontic therapy, anterior tooth (excluding final restoration) - Limited to 1 time per tooth per lifetime. Dentist cannot charge retreatment codes on tooth treated for the first 12 months.

D3320 Endodontic therapy, premolar tooth (excluding final restoration) - Limited to 1 time per tooth per lifetime. Dentist cannot charge retreatment codes on tooth treated for the first 12 months.

D3330 Endodontic therapy, molar tooth (excluding final restoration) - Limited to 1 time per tooth per lifetime. Dentist cannot charge retreatment codes on tooth treated for the first 12 months.

D3346 Retreatment of previous root canal therapy – anterior

D3347 Retreatment of previous root canal therapy – premolar

D3348 Retreatment of previous root canal therapy – molar

D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) - Limited to 1 per tooth per lifetime

D3352 Apexification/recalcification – interim medication replacement - Limited to 1 per tooth per lifetime

D3353 Apexification/recalcification – final visit (includes completed root canal therapy - apical closure/calcific repair of perforations, root resorption, etc.) - Limited to 1 per tooth per lifetime

D3410 Apicoectomy - anterior - Limited to 1 per tooth per lifetime

D3421 Apicoectomy - premolar (first root) - Limited to 1 per tooth per lifetime

D3425 Apicoectomy - molar (first root) - Limited to 1 per tooth per lifetime

D3426 Apicoectomy (each additional root) - Limited to 1 per tooth per lifetime

D3450 Root amputation – per root - Limited to 1 per tooth per lifetime

D3920 Hemisection (including any root removal), not including root canal therapy - Limited to 1 per tooth per lifetime

D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant – Limited to 1 per quadrant or site per consecutive 36 months

D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant – Limited to 1 per quadrant or site per consecutive 36 months

D4212 Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth – Limited to 1 per quadrant or site per consecutive 36 months

D4240 Gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quadrant – Limited to 1 per quadrant or site per consecutive 36 months

D4241 Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant – Limited to 1 per quadrant or site consecutive 36 months

D4249 Clinical crown lengthening – hard tissue – Limited to 1 per quadrant or site per consecutive 36 months

D4260 Osseous surgery (including elevation of a full thickness flap and closure) – four or more contiguous teeth or tooth bounded spaces per quadrant – Limited to 1 per consecutive 36 months

D4261 Osseous surgery (including elevation of a full thickness flap and closure) – one to three contiguous teeth or tooth bounded spaces per quadrant – Limited to 1 per consecutive 36 months

D4263 Bone replacement graft – retained natural tooth – first site in quadrant - Limited to 1 per consecutive 36 months. (For D4264 Bone replacement graft – retained natural tooth – each additional site in quadrant and D4268 Surgical revision procedure, per tooth see Class B services.)

D4270 Pedicle soft tissue graft procedure – Limited to 1 per quadrant or site per consecutive 36 months

D4273 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant, or edentulous tooth position in graft – Limited to 1 per quadrant or site per consecutive 36 months

D4275 Non-autogenous connective tissue graft (including recipient site and donor material) first tooth, implant, or edentulous tooth position in graft - Limited to 1 per quadrant or site per consecutive 36 months

D4278 Free soft tissue graft procedure (including recipient and donor surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limited to 1 per quadrant or site per consecutive 36 months. (For D4277 Free soft tissue graft procedure (including recipient and donor surgical sites) first tooth, implant or edentulous tooth position in graft see Class B services.)

D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) – each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limited to 1 per quadrant or site per consecutive 36 months

D4285 Non-autogenous connective tissue graft procedure (including recipient surgical site and donor material) – each additional contiguous tooth, implant or edentulous tooth position in same graft site – Limited to 1 per quadrant or site per consecutive 36 months

D4355 Full mouth debridement to enable a comprehensive periodontal evaluation and diagnosis on a subsequent visit - Limited to 1 per consecutive 36 months

D5110 Complete denture – maxillary – Limited to 1 per consecutive 60 months

D5120 Complete denture - mandibular – Limited to 1 per consecutive 60 months

D5130 Immediate denture – maxillary – Limited to 1 per consecutive 60 months

D5140 Immediate denture - mandibular – Limited to 1 per consecutive 60 months

D5211 Maxillary partial denture – resin base (including, retentive/clasping materials, rests, and teeth) – Limited to 1 per consecutive 60 months

D5212 Mandibular partial denture – resin base (including, retentive/clasping materials, rests, and teeth) – Limited to 1 per consecutive 60 months

D5213 Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months

D5214 Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months

D5221 Immediate maxillary partial denture - resin base (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months

D5222 Immediate mandibular partial denture - resin base (including retentive/clasping materials, rests and teeth) – Limited to 1 per consecutive 60 months

D5223 Immediate maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) - Limited to 1 per consecutive 60 months

D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) - Limited to 1 per consecutive 60 months

D5225 Maxillary partial denture - flexible base (including retentive/clasping materials, rests, and teeth) – Limited to 1 per consecutive 60 months

D5226 Mandibular partial denture - flexible base (including retentive/clasping materials, rests, and teeth) – Limited to 1 per consecutive 60 months

D5282 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), maxillary – Limited to 1 per consecutive 60 months

D5283 Removable unilateral partial denture – one piece cast metal (including retentive/clasping materials, rests, and teeth), mandibular - Limited to 1 per consecutive 60 months

D5284 Removable unilateral partial denture – one piece flexible base (including retentive/clasping materials, rests, and teeth) – per quadrant – Limited to 1 per consecutive 60 months

D5286 Removable unilateral partial denture – one piece resin (including retentive/clasping materials, rests, and teeth) – per quadrant – Limited to 1 per consecutive 60 months

D5810 Interim complete denture (maxillary) - Limited to 1 per consecutive 60 months

D5811 Interim complete denture (mandibular) - Limited to 1 per consecutive 60 months

D5820 Interim partial denture (including retentive/clasping materials, rests, and teeth), maxillary - Limited to 1 per consecutive 60 months

D5821 Interim partial denture (including retentive/clasping materials, rests, and teeth), mandibular - Limited to 1 per consecutive 60 months

D5863 Overdenture – complete maxillary - Limited to 1 per consecutive 60 months

D5864 Overdenture – partial maxillary - Limited to 1 per consecutive 60 months

D5865 Overdenture – complete mandibular - Limited to 1 per consecutive 60 months

D5866 Overdenture – partial mandibular - Limited to 1 per consecutive 60 months

D5876 Add metal substructure to acrylic full denture (per arch) - Limited to 1 per consecutive 60 months

D6010 Surgical placement of implant body: endosteal implant – Limited to 1 per tooth per consecutive 60 months

D6012 Surgical placement of interim implant body for transitional prosthesis: endosteal implant – Limited to 1 per tooth per consecutive 60 months

D6013 Surgical placement of mini implant – Limited to 1 per tooth per consecutive 60 months

D6040 Surgical placement: eposteal implant – Limited to 1 per tooth per consecutive 60 months

D6050 Surgical placement: transosteal implant – Limited to 1 per tooth per consecutive 60 months

D6055 Connecting bar – implant supported or abutment supported - Limited to 1 time per tooth per consecutive 60 months

D6056 Prefabricated abutment - includes modification and placement – Limited to 1 time per tooth per consecutive 60 months

D6057 Custom fabricated abutment – includes placement - Limited to 1 time per tooth per consecutive 60 months

D6058 Abutment supported porcelain/ceramic crown – Limited to 1 time per tooth per consecutive 60 months

D6059 Abutment supported porcelain fused to metal crown (high noble metal) - Limited to 1 time per tooth per consecutive 60 months

D6060 Abutment supported porcelain fused to metal crown (predominantly base metal) - Limited to 1 time per tooth per consecutive 60 months

D6061 Abutment supported porcelain fused to metal crown (noble metal) - Limited to 1 time per tooth per consecutive 60 months

D6062 Abutment supported cast metal crown (high noble metal) - Limited to 1 time per tooth per consecutive 60 months

D6063 Abutment supported cast metal crown (predominantly base metal) – Limited to 1 time per tooth per consecutive 60 months

D6064 Abutment supported cast metal crown (noble metal) – Limited to 1 time per tooth per consecutive 60 months

D6065 Implant supported porcelain/ceramic crown – Limited to 1 time per tooth per consecutive 60 months

D6066 Implant supported crown - porcelain fused to high noble alloys – Limited to 1 time per tooth per consecutive 60 months

D6067 Implant supported crown - high noble alloys – Limited to 1 time per tooth per consecutive 60 months

D6068 Abutment supported retainer for porcelain/ceramic FPD – Limited to 1 time per tooth per consecutive 60 months

D6069 Abutment supported retainer for porcelain fused to metal FPD (high noble metal) – Limited to 1 time per tooth per consecutive 60 months

D6070 Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) – Limited to 1 time per tooth per consecutive 60 months

D6071 Abutment supported retainer for porcelain fused to metal FPD (noble metal) – Limited to 1 time per tooth per consecutive 60 months

D6072 Abutment supported retainer for cast metal FPD (high noble metal) – Limited to 1 time per tooth per consecutive 60 months

D6073 Abutment supported retainer for cast metal FPD (predominantly base metal) - Limited to 1 time per tooth per consecutive 60 months

D6074 Abutment supported retainer for cast metal FPD (noble metal) - Limited to 1 time per tooth per consecutive 60 months

D6075 Implant supported retainer for ceramic FPD – Limited to 1 time per tooth per consecutive 60 months

D6076 Implant supported retainer for FPD - porcelain fused to high noble alloys - Limited to 1 time per tooth per consecutive 60 months

D6077 Implant supported retainer for metal FPD - high noble alloys – Limited to 1 time per tooth per consecutive 60 months

D6080 Implant maintenance procedures when a full arch fixed hybrid prosthesis is removed and reinserted, including cleansing of prosthesis and abutments – Limited to 1 time per tooth per consecutive 60 months

D6081 Scaling and debridement of a single implant in the presence of mucositis, including inflammation, bleeding upon probing and increased pocket depths; includes cleaning of the implant surfaces, without flap entry and closure – Limited to 1 time per tooth per consecutive 60 months

D6082 Implant supported crown – porcelain fused to predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months

D6083 Implant supported crown – porcelain fused to noble alloys - Limited to 1 time per tooth per consecutive 60 months

D6084 Implant supported crown – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6086 Implant supported crown – predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months

D6087 Implant supported crown – noble alloys - Limited to 1 time per tooth per consecutive 60 months

D6088 Implant supported crown – titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6089 Accessing and retorquing loose implant screw - per screw

D6090 Repair of implant/abutment supported prosthesis – Limited to 1 time per tooth per consecutive 60 months

D6091 Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment – Limited to 1 time per tooth per consecutive 60 months

D6094 Abutment supported crown - titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6096 Remove broken implant retaining screw – Limited to 1 time per consecutive 12 months

D6097 Abutment supported crown – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6098 Implant supported retainer – porcelain fused to predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months

D6099 Implant supported retainer for FPD – porcelain fused to noble alloys - Limited to 1 time per tooth per consecutive 60 months

D6100 Surgical removal of implant body – Limited to 1 time per tooth per consecutive 60 months

D6101 Debridement of a peri-implant defect or defects surrounding a single implant, and surface cleaning of the exposed implant surfaces, including flap entry and closure – Limited to 1 time per consecutive 60 months

D6102 Debridement and osseous contouring of a peri-implant defect or defects surrounding a single implant and includes surface cleaning of the exposed implant surfaces, including flap entry and closure – Limited to 1 time per consecutive 60 months

D6103 Bone graft for repair of peri-implant defect – does not include flap entry and closure - Limited to 1 time per consecutive 36 months

D6104 Bone graft at time of implant placement - Limited to 1 time per consecutive 36 months

D6110 Implant /abutment supported removable denture for edentulous arch – maxillary - Limited to 1 time per tooth per consecutive 60 months

D6111 Implant /abutment supported removable denture for edentulous arch – mandibular - Limited to 1 time per tooth per consecutive 60 months

D6112 Implant /abutment supported removable denture for partially edentulous arch – maxillary - Limited to 1 time per tooth per consecutive 60 months

D6113 Implant /abutment supported removable denture for partially edentulous arch – mandibular - Limited to 1 time per tooth per consecutive 60 months

D6114 Implant /abutment supported fixed denture for edentulous arch – maxillary - Limited to 1 time per tooth per consecutive 60 months

D6115 Implant /abutment supported fixed denture for edentulous arch – mandibular - Limited to 1 time per tooth per consecutive 60 months

D6116 Implant /abutment supported fixed denture for partially edentulous arch – maxillary - Limited to 1 time per tooth per consecutive 60 months

D6117 Implant /abutment supported fixed denture for partially edentulous arch – mandibular - Limited to 1 time per tooth per consecutive 60 months

D6120 Implant supported retainer – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6121 Implant supported retainer for metal FPD – predominantly base alloys - Limited to 1 time per tooth per consecutive 60 months

D6122 Implant supported retainer for metal FPD – noble alloys - Limited to 1 time per tooth per consecutive 60 months

D6123 Implant supported retainer for metal FPD – titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6180 Implant maintenance procedures when a full arch fixed hybrid prosthesis is not removed, including cleansing of prosthesis and abutments

D6190 Radiographic/surgical implant index, by report – Limited to 1 time per tooth per consecutive 60 months

D6193 Replacement of an implant screw

D6194 Abutment supported retainer crown for FPD - titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6195 Abutment supported retainer – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6205 Pontic – indirect resin based composite – Limited to 1 time per tooth per consecutive 60 months

D6210 Pontic - cast high noble metal - Limited to 1 time per tooth per consecutive 60 months

D6211 Pontic - cast predominantly base metal - Limited to 1 time per tooth per consecutive 60 months

D6212 Pontic - cast noble metal - Limited to 1 time per tooth per consecutive 60 months

D6214 Pontic - titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6240 Pontic - porcelain fused to high noble metal - Limited to 1 time per tooth per consecutive 60 months

D6241 Pontic - porcelain fused to predominantly base metal - Limited to 1 time per tooth per consecutive 60 months

D6242 Pontic - porcelain fused to noble metal - Limited to 1 time per tooth per consecutive 60 months

D6243 Pontic – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6245 Pontic - porcelain/ceramic - Limited to 1 time per tooth per consecutive 60 months

D6250 Pontic – resin with high noble metal – Limited to 1 time per tooth per consecutive 60 months

D6251 Pontic - resin with predominantly base metal – Limited to 1 time per tooth per consecutive 60 months

D6252 Pontic - resin with noble metal - Limited to 1 time per tooth per consecutive 60 months

D6545 Retainer - cast metal for resin bonded fixed prosthesis - Limited to 1 time per tooth per consecutive 60 months

D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis - Limited to 1 time per tooth per consecutive 60 months

D6549 Retainer – resin bonded fixed prosthesis - Limit 1 every 60 months, including all other crowns, bridges, prosthetics

D6600 Retainer inlay - porcelain/ceramic, two surfaces - Limited to 1 time per tooth per consecutive 60 months

D6601 Retainer inlay - porcelain/ceramic, three or more surfaces - Limited to 1 time per tooth per consecutive 60 months

D6602 Retainer inlay - cast high noble metal, two surfaces – Limited to 1 time per tooth per consecutive 60 months

D6603 Retainer inlay - cast high noble metal, three or more surfaces – Limited to 1 time per tooth per consecutive 60 months

D6604 Retainer inlay - cast predominantly base metal, two surfaces - Limited to 1 time per tooth per consecutive 60 months

D6605 Retainer inlay - cast predominantly base metal, three or more surfaces - Limited to 1 time per tooth per consecutive 60 months

D6606 Retainer inlay - cast noble metal, two surfaces – Limited to 1 time per tooth per consecutive 60 months

D6607 Retainer inlay - cast noble metal, three or more surfaces – Limited to 1 time per tooth per consecutive 60 months

D6608 Retainer onlay - porcelain/ceramic, two surfaces - Limited to 1 time per tooth per consecutive 60 months

D6609 Retainer onlay - porcelain/ceramic, three or more surfaces - Limited to 1 time per tooth per consecutive 60 months including all other crowns, bridges, prosthetics

D6610 Retainer onlay - cast high noble metal, two surfaces – Limited to 1 time per tooth per consecutive 60 months

D6611 Retainer onlay - cast high noble metal, three or more surfaces – Limited to 1 time per tooth per consecutive 60 months

D6612 Retainer onlay - cast predominantly base metal, two surfaces – Limited to 1 time per tooth per consecutive 60 months

D6613 Retainer onlay - cast predominantly base metal, three or more surfaces – Limited to 1 time per tooth per consecutive 60 months

D6614 Retainer onlay - cast noble metal, two surfaces – Limited to 1 time per tooth per consecutive 60 months

D6615 Retainer onlay - cast noble metal, three or more surfaces – Limited to 1 time per tooth per consecutive 60 months

D6624 Retainer inlay - titanium – Limited to 1 time per tooth per consecutive 60 months

D6634 Retainer onlay - titanium – Limited to 1 time per tooth per consecutive 60 months

D6710 Retainer crown - indirect resin based composite - Limited to 1 time per tooth per consecutive 60 months

D6720 Retainer crown - resin with high noble metal - Limited to 1 time per tooth per consecutive 60 months

D6721 Retainer crown - resin with predominantly base metal - Limited to 1 time per tooth per consecutive 60 months

D6722 Retainer crown - resin with noble metal – Limited to 1 time per tooth per consecutive 60 months

D6740 Retainer crown - porcelain/ceramic – Limited to 1 time per tooth per consecutive 60 months

D6750 Retainer crown - porcelain fused to high noble metal - Limited to 1 time per tooth per consecutive 60 months

D6751 Retainer crown - porcelain fused to predominantly base metal – Limited to 1 time per tooth per consecutive 60 months

D6752 Retainer crown - porcelain fused to noble metal - Limited to 1 time per tooth per consecutive 60 months

D6753 Retainer crown – porcelain fused to titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6780 Retainer crown - 3/4 cast high noble metal - Limited to 1 time per tooth per consecutive 60 months

D6781 Retainer crown - 3/4 cast predominantly base metal - Limited to 1 time per tooth per consecutive 60 months

D6782 Retainer crown - 3/4 cast noble metal – Limited to 1 time per tooth per consecutive 60 months

D6783 Retainer crown - 3/4 porcelain/ceramic – Limited to 1 time per tooth per consecutive 60 months

D6784 Retainer crown 3/4 – titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D6790 Retainer crown - full cast high noble metal - Limited to 1 time per tooth per consecutive 60 months

D6791 Retainer crown - full cast predominantly base metal - Limited to 1 time per tooth per consecutive 60 months

D6792 Retainer crown - full cast noble metal - Limited to 1 time per tooth per consecutive 60 months

D6793 Interim retainer crown - further treatment or completion of diagnosis necessary prior to final impression - Limited to 1 time per tooth per consecutive 60 months

D6794 Retainer crown - titanium and titanium alloys - Limited to 1 time per tooth per consecutive 60 months

D9120 Fixed partial denture sectioning – Limited to 1 time per tooth per consecutive 60 months

D9941 Fabrication of athletic mouthguard

D9943 Occlusal guard adjustment - Limit 1 every 24 months

D9944 Occlusal guard – hard appliance, full arch – Limited to 1 per consecutive 36 months

D9945 Occlusal guard – soft appliance, full arch – Limited to 1 per consecutive 36 months

D9946 Occlusal guard – hard appliance, partial arch – Limited to 1 per consecutive 36 months

D9999 Unspecified adjunctive procedure, by report – Covered if Necessary

D0160 Detailed and extensive oral evaluation - problem focused, by report - Limited to 2 times per calendar year

D9222 Deep sedation/general anesthesia – first 15 minutes – Covered when Necessary

D9223 Deep sedation/general anesthesia - each subsequent 15 minute increment - Covered when Necessary

D9239 Intravenous moderate (conscious) sedation/analgesia – first 15 minutes - Covered when Necessary

D9243 Intravenous moderate (conscious) sedation/analgesia - each subsequent 15 minute increment - Covered when Necessary

D9610 Therapeutic parenteral drug, single administration

D9930 Treatment of complications (post-surgical) - unusual circumstances, by report

D9974 Internal bleaching - per tooth

D0340 2D cephalometric radiographic image – acquisition, measurement and analysis – Limited to 1 per consecutive 12 months

D8010 Limited orthodontic treatment of the primary dentition

D8020 Limited orthodontic treatment of the transitional dentition

D8030 Limited orthodontic treatment of the adolescent dentition

D8070 Comprehensive orthodontic treatment of the transitional dentition

D8080 Comprehensive orthodontic treatment of the adolescent dentition

D8090 Comprehensive orthodontic treatment of the adult dentition

D8091 Comprehensive orthodontic treatment with orthognathic surgery

D8210 Removable appliance therapy - Limited to 1 time per consecutive 60 months

D8220 Fixed appliance therapy - Limited to 1 time per consecutive 60 months

D8660 Pre-orthodontic treatment examination to monitor growth and development - Limited to new patients or 2 times per consecutive 12 months

D8670 Periodic orthodontic treatment visit

D8671 Periodic orthodontic treatment visit associated with orthognathic surgery

D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) - Limited to 1 time per consecutive 60 months

D8695 Removal of fixed orthodontic appliances for reasons other than completion of treatment – Limited to 1 time per consecutive 60 months.

D8698 Re-cement or re-bond fixed retainer – maxillary

D8699 Re-cement or re-bond fixed retainer – mandibular

Refer to Section 7 for a list of general exclusions:

• Repair of damaged orthodontic appliances
• Replacement of lost or missing appliances
• Services used exclusively to alter vertical dimension and/or restore or maintain the occlusion.

If you receive dental services while overseas, you will pay the provider in-full at the time of service. You will then need to submit the claim to UnitedHealthcare Dental. Upon receipt of the claim we will translate the claim if necessary and process it. We use the rate of exchange in effect at the time we process the claim. Claims are paid in U.S. currency.

You may use any dentist while overseas.

Submit the itemized paid receipt(s), along with the primary insured's unique identification number and patient's name and date of birth to:

SCS RMO-Lason Inc
4050 South 500 West, Ste 50
Salt Lake City, UT 84123-1358
Attn: 224 - Foreign Claims - DBP

There is one international region. Please see the rate table for the actual premium amount.

To avoid delay in the payment of your dental claims, please have your dental provider submit your claims directly to your FEHB/PSHB plan (Should you be enrolled), then to UnitedHealthcare Dental. Pretreatment estimates can be submitted directly to UnitedHealthcare Dental (exception: If accidental injury occurs, pretreatment estimates should be submitted to your FEHB/PSHB plan).

If you need to send in a paper claim you may download a claim form from UnitedHealthcare Dental's website, www.myuhcdental.com/fedvip.

Mail completed claim form to: 

UnitedHealthcare Dental
Attention: Claims Department
P.O. Box 30567
Salt Lake City, UT 84130-0567

You must submit your claim within 24 months from the date service was rendered.

Step 1:

Ask us in writing to reconsider our initial decision. You must include any pertinent information omitted from the initial claim filing and send your additional proof to us within 180 days from the date of receipt of our decision.

Step 2:

You may mail your request for reconsideration to:

UnitedHealthcare Dental
Attention: Dental Appeals and Grievance
P.O. Box 30569
Salt Lake City, UT 84130-0569

Or go to www.myuhcdental.com/fedvip

We will review your request and provide you with a written or electronic explanation of benefit determination within 30 days of the receipt of your request.

Step 3:

If you disagree with the decision regarding your request for reconsideration, you may request a second review of the denial within 60 days from receipt of our reconsideration. You must submit your request to us in writing to the address shown above along with any additional information you or your dentist can provide to substantiate your claim so that we can reconsider our decision. Failure to do so will disqualify the appeal of your claim. We will provide a decision within 30 days of receipt of your request for second review.

Step 4:

If you do not agree with our final decision, under certain circumstances you may request an independent third party, mutually agreed upon by UnitedHealthcare Dental and OPM, review the decision. To qualify for this independent third party review, the reason for denial must be based on our determination that the rationale for the procedure did not meet our dental necessity criteria or our administration of the plans Alternate Benefit provision, for example, a bridge being given an alternate benefit of a partial denture.

The decision of the independent third party is binding and is the final review of your claim.

Follow this disputed claims process if you disagree with our decision on your claim or request for services.  FEDVIP legislation does not provide a role for OPM to review disputed claims.

If we determine a service less costly than the one performed by your dentist could have been performed by your dentist, we will pay benefits based upon the less costly services. See Section 3, How You Obtain Care.

The maximum annual benefit that you can receive per person.

Federal retirees (who retired on an immediate annuity) and survivors (of those who retired on an immediate annuity or died in service) receiving an annuity.  This also includes those receiving compensation from the Department of Labor’s Office of Workers’ Compensation Programs, who are called compensationers.  Annuitants are sometimes called retirees.

From January 1, 2025 through December 31, 2025. Also referred to as the plan year.

Basic services, which include oral examinations, prophylaxis, diagnostic evaluations, sealants, and X-rays. 

The calendar date on which you visit the dentist's office and services are rendered. 

The Federal employee, annuitant, or TRICARE-eligible individual enrolled in this plan.

Dental services that initiated in 2024 that will be completed in 2025.

The amount we use to determine our payment for services.  If services are provided by an in-network dentist the maximum allowable amount is based on the discounted fee they accept as payment in full for the procedure or procedures.  If services are provided by an out-of- network dentist the maximum allowed amount is based on UnitedHealthcare Dental's determination of charges for the procedure or procedures.

Network Allowance means the allowance per procedure that UnitedHealthcare Dental has negotiated with the provider and they have agreed to accept as payment in full for their services.

UnitedHealthcare Dental

Generally, a sponsor means the individual who is eligible for medical or dental benefits under 10 U.S.C. chapter 55 based on their direct affiliation with the uniformed services (including military members of the National Guard and Reserves).

Under circumstances where a sponsor is not an enrollee, a TEI family member may accept responsibility to self-certify as an enrollee and enroll TEI family members

TEI family members include a sponsor’s spouse, unremarried widow, unremarried widower, unmarried child, and certain unmarried persons placed in a sponsor’s legal custody by a court. Children include legally adopted children, stepchildren, and pre- adoptive children. Children and dependent unmarried persons must be under age 21 if they are not a student, under age 23 if they are a full-time student, or incapable of self-support because of a mental or physical incapacity.

UnitedHealthcare Dental

0%

10%

30%

40%

50%

60%

Class A, B, and C Services do not have an annual maximum benefit amount for in-network services 

Unlimited

$3,000

Class D Services – orthodontic

up to $2,000 per adult and $4,000 per child lifetime maximum combined for in-network or out-of-network

50%

50%

Class A (Basic) Services – preventive and diagnostic

0%

10%

45%

60%

65%

80%

Class A, B, and C Services are subject to a combined $1,500 annual maximum benefit for the in-network benefits or $1,000 for the out-of-network benefits. The Annual Benefit Maximums within each option are combined between in and out-of-network services. The total Annual Benefit Maximum will never be greater than the in-network Maximum Annual Benefit.

$1,500

$1,000

Class D Services – orthodontic

$2,000 lifetime maximum per person combined for in-network or out-of-network

50%

50%