Aflac Dental Insurance
Reliable dental coverage is something to smile about.
With Aflac, you can feel confident in your dental health. Aflac dental coverage allows you to visit dental professionals of your choice and receive the care you need—without pesky precertification requirements and annual deductibles.
Reliable dental coverage is something to smile about.
With Aflac, you can feel confident in your dental health. Aflac dental coverage allows you to visit dental professionals of your choice and receive the care you need—without pesky precertification requirements and annual deductibles.
Over 25% of adults
only choose to visit
the dentist once they
have a problem.*
only choose to visit
the dentist once they
have a problem.*
Over 25% of adults
only choose to visit the dentist
once they have a problem.*
only choose to visit the dentist
once they have a problem.*
*Facts and Figures. National Smile Month. 07 June 2016.
http://www.nationalsmilemonth.org/facts-figures/.
Accessed: July 17, 2017.
http://www.nationalsmilemonth.org/facts-figures/.
Accessed: July 17, 2017.
738,000 Americans
visit emergency rooms
annually for
dental treatment.**
visit emergency rooms
annually for
dental treatment.**
738,000 Americans
visit emergency rooms annually
for dental treatment.**
visit emergency rooms annually
for dental treatment.**
**Who has dental benefits? National Association of Dental Plans.
http://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx.
Accessed: July 17, 2017.
http://www.nadp.org/Dental_Benefits_Basics/Dental_BB_1.aspx.
Accessed: July 17, 2017.
Why Aflac dental coverage?
You brush your teeth twice a day. You floss regularly. You avoid sweets and buy dentist-recommended toothpaste. You go to the dentist twice a year for cleanings. So, why purchase Aflac dental coverage? No matter how well you take care of your pearly whites, sometimes dental assistance is needed for the unexpected. Whether you find yourself in need of a crown or cleaning, Aflac is always ready to help with quality coverage.
Time for a cleaning.
You go to the dentist of your choice for your bi-annual exam, cleaning, and X-rays.
Looks like you need a crown.
Turns out, you have a large cavity that requires a crown. Luckily, with Aflac dental coverage that's nothing to grind your teeth over.
Aflac steps in with reliable coverage.
Aflac pays benefits directly to you, unless assigned, so there's always a reason to smile.
Basic
$510
Benefits Payable
Standard
$700
Benefits Payable
Premier
$785
Benefits Payable
Expand to view important benefit scenario details.
The Aflac Dental – Basic scenario includes the following benefit conditions: Dental Wellness Benefit $45, X-Ray Benefit of $25, Crowns and Other Major Restorative Benefit - ADA Code: D2722 (waiting period met) of $440.
The Aflac Dental – Standard scenario includes the following benefit conditions: Dental Wellness Benefit $90, X-Ray Benefit of $45, Crowns and Other Major Restorative Benefit - ADA Code: D2722 (waiting period met) of $565.
The Aflac Dental – Premier scenario includes the following benefit conditions: Dental Wellness Benefit $90, X-Ray Benefit of $45, Crowns and Other Major Restorative Benefit - ADA Code: D2722 (waiting period met) of $650.
Benefits and/or premiums may vary by state and level of coverage selected. The policy has limitations and exclusions that may affect benefits payable. The policy may contain a waiting period. For costs and complete details of the coverage, contact your Aflac insurance agent/producer. This brochure is for illustrative purposes only. Refer to the outline of coverage and policy for complete benefit details, definitions, limitations and exclusions.
Collapse to close important benefit scenario details.
Benefits go even further
with Aflac riders.
Cosmetic Benefit Rider
When you smile, you should feel confident. With the Aflac Cosmetic Benefit Rider, you can receive benefits for cosmetic treatments. Whether you’re interested in veneers, teeth bleaching or enamel microabrasion, Aflac can help with your out-of-pocket expenses.
Orthodontic Benefit Rider
Let’s get it straight: when you need orthodontic assistance, Aflac is there to help. From adolescents to adults, the Orthodontic Benefit Rider, provides benefits for orthodontic treatment for a beautiful smile.
No benefits will be paid for replacement of teeth missing before the effective date of coverage.
Aflac Dental
Benefits Overview
Policy Series A81000
| Benefit | Waiting Period | Basic | Standard | Premier |
|---|---|---|---|---|
| Dental Wellness Benefit | None | $45 | $90 | $90 |
| X-Ray Benefit | None | $25 | $45 | $45 |
| Other Preventative Benefits | 6 months | $30 - $175 | $40 - $195 | $40 - $215 |
| Other Diagnostic Benefits | 3 months | $25 - $275 | $30 - $300 | $30 - $330 |
| Fillings and Other Basic Restorative Benefits | 3 months | $50 - $390 | $80 - $440 | $100 - $480 |
| Crowns and Other Major Restorative Benefits | 12 months | $30 - $605 | $30 - $650 | $45 - $740 |
| Root Canals and Other Endodontic Benefits | 12 months | $30 - $520 | $40 - $565 | $40 - $690 |
| Gum Treatments / Periodontic Benefits | 6 months | $45 - $520 | $45 - $565 | $45 - $650 |
| Dentures and Other Prosthetic Benefits | 24 months | $75 - $780 | $80 - $950 | $80 - $1,125 |
| Repairs and Adjustments to Prosthetics Benefit | 6 months | $40 - $440 | $50 - $565 | $50 - $650 |
| Extractions and Other Oral Surgery Benefits | 6 months | $70 - $1,300 | $80 - $1,470 | $90 - $1,690 |
| Pain Relief and Adjunctive Services Benefits | 3 months | $45 - $215 | $50 - $225 | $70 - $250 |
| Policy Year Maximum | $2,100 | $2,475 | $2,850 | |
| Outline of Coverage |
View the Outline of Coverage
|
View the Outline of Coverage
|
View the Outline of Coverage
|
Aflac Dental
Terms You Need to Know
Policy Series A81000
Covered Person:
Any person insured under the coverage type you applied for: individual (named insured listed in the Policy Schedule), named insured/spouse only (named insured and spouse), one-parent family (named insured and dependent children), or two-parent family (named insured, spouse, and dependent children). Dependent children are your natural children, stepchildren, or legally adopted children who are under age 26. Newborn children are automatically covered from the moment of birth. Coverage provided under any one-parent family or two-parent family policy will include any other dependent child, regardless of age, who is incapable of self-sustaining employment by reason of mental retardation or physical handicap, and who became so incapacitated prior to age 26. Please see the policy for additional details.
Dental Hygienist:
A legally qualified person, other than a member of your immediate family, who is licensed by the state to treat the type of condition for which a claim is made.
Dentist:
A legally qualified person, other than a member of your immediate family, who is licensed by the state to treat the type of condition for which a claim is made.
Effective Date:
The effective date of the policy will be the date shown in the Policy Schedule, not the date the application is signed.
Waiting Period:
The period after the effective date of coverage for which benefits are not payable for each covered person. If a dependent is added by endorsement, the waiting period will begin from the effective date of the addition. In the event of reinstatement, all covered persons will be subject to new waiting periods beginning with the effective date of reinstatement.
Aflac Dental
ADA Codes
Policy Series A81000
If a covered ADA code* is revised or replaced by the American Dental Association, Aflac will pay an amount comparable to the amount shown in the Schedule of Dental Procedures for the procedure or code shown below.
Policy Benefits
Dental Wellness Benefit
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D0110 | Initial Oral Evaluation | $45 | $90 | $90 |
| D0120 | Periodic Oral Evaluation | $45 | $90 | $90 |
| D0145 | Oral Evaluation (for a patient under three years of age and counseling with primary caregiver) | $45 | $90 | $90 |
| D0150 | Comprehensive Oral Evaluation (new or established patient) | $45 | $90 | $90 |
| D0160 | Detailed and Extensive Oral Evaluation (problem focused, by report) | $45 | $90 | $90 |
| D0170 | Re-evaluation — Limited, Problem (established patient; not postoperative visit) | $45 | $90 | $90 |
| D0171 | Re-evaluation – Post-Operative Office Visit | $45 | $90 | $90 |
| D0180 | Comprehensive Periodontal Evaluation (new or established patient) | $45 | $90 | $90 |
| D0425 | Caries Susceptibility Tests | $45 | $90 | $90 |
| D0600 | Non-ionizing Diagnostic Procedure (capable of quantifying, monitoring, and recording changes in structure of enamel, dentin, and cementum) | $45 | $90 | $90 |
| D1110 | Prophylaxis (adult) | $45 | $90 | $90 |
| D1120 | Prophylaxis (child) | $45 | $90 | $90 |
| D1201 | Topical Application of Fluoride (child, including prophylaxis) | $45 | $90 | $90 |
| D1203 | Topical Application of Fluoride (child, prophylaxis not included) | $45 | $90 | $90 |
| D1204 | Topical Application of Fluoride (adult, prophylaxis not included) | $45 | $90 | $90 |
| D1205 | Topical Application of Fluoride (adult, including prophylaxis) | $45 | $90 | $90 |
| D1206 | Topical Fluoride Varnish (therapeutic application for moderate to high caries risk patients) | $45 | $90 | $90 |
| D1208 | Topical Application of Fluoride | $45 | $90 | $90 |
| D1310 | Nutritional Counseling for Control of Dental Disease | $45 | $90 | $90 |
| D1320 | Tobacco Counseling for the Control and Prevention of Oral Disease | $45 | $90 | $90 |
| D1330 | Oral Hygiene Instructions | $45 | $90 | $90 |
| D4910 | Periodontal Maintenance | $45 | $90 | $90 |
| D7881 | Occlusal Orthotic Device Adjustment | $45 | $90 | $90 |
| D9430 | Office Visit for Observation (during regularly scheduled hours, no other services performed) | $45 | $90 | $90 |
| D9910 | Application of Desensitizing Medicament | $45 | $90 | $90 |
| D9932 | Cleaning and Inspection of Removable Complete Denture (maxillary) | $45 | $90 | $90 |
| D9933 | Cleaning and Inspection of Removable Complete Denture (mandibular) | $45 | $90 | $90 |
| D9934 | Cleaning and Inspection of Removable Partial Denture (maxillary) | $45 | $90 | $90 |
| D9935 | Cleaning and Inspection of Removable Partial Denture (mandibular) | $45 | $90 | $90 |
| D9943 | Occlusal Guard Adjustment | $45 | $90 | $90 |
X-Ray Benefit
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D0210 | Intraoral (complete series, including bitewings) | $25 | $45 | $45 |
| D0220 | Intraoral (periapical, first film) | $25 | $45 | $45 |
| D0230 | Intraoral (periapical, each additional film) | $25 | $45 | $45 |
| D0240 | Intraoral (occlusal film) | $25 | $45 | $45 |
| D0250 | Extraoral (first film) | $25 | $45 | $45 |
| D0251 | Extraoral (posterior dental radiographic image) | $25 | $45 | $45 |
| D0260 | Extraoral (each additional film) | $25 | $45 | $45 |
| D0270 | Bitewing (single film) | $25 | $45 | $45 |
| D0272 | Bitewings (two films) | $25 | $45 | $45 |
| D0273 | Bitewings (three films) | $25 | $45 | $45 |
| D0274 | Bitewings (four films) | $25 | $45 | $45 |
| D0277 | Vertical Bitewings (seven to eight films) | $25 | $45 | $45 |
| D0330 | Panoramic Film | $25 | $45 | $45 |
| D0340 | Cephalometric Film | $25 | $45 | $45 |
| D0364 | Cone beam CT capture and interpretation with limited field of view (less than one whole jaw) | $25 | $45 | $45 |
| D0365 | Cone beam CT capture and interpretation with field of view of one full dental arch (mandible) | $25 | $45 | $45 |
| D0366 | Cone beam CT capture and interpretation with field of view of one full dental arch (maxilla, with or without cranium) | $25 | $45 | $45 |
| D0367 | Cone beam CT capture and interpretation with field of view of both jaws, with or without cranium | $25 | $45 | $45 |
| D0368 | Cone beam CT capture and interpretation for TMJ series including two or more exposures | $25 | $45 | $45 |
| D0369 | Maxillofacial MRI capture and interpretation | $25 | $45 | $45 |
| D0370 | Maxillofacial ultrasound capture and interpretation | $25 | $45 | $45 |
| D0371 | Sialoendoscopy capture and interpretation | $25 | $45 | $45 |
| D0380 | Cone beam CT image capture with limited field of view (less than one whole jaw) | $25 | $45 | $45 |
| D0381 | Cone beam CT image capture with field of view of one full dental arch (mandible) | $25 | $45 | $45 |
| D0382 | Cone beam CT image capture with field of view of one full dental arch (maxilla, with or without cranium) | $25 | $45 | $45 |
| D0383 | Cone beam CT image capture with field of view of both jaws, with or without cranium | $25 | $45 | $45 |
| D0384 | Cone beam CT image capture for TMJ series including two or more exposures | $25 | $45 | $45 |
| D0385 | Maxillofacial MRI image capture | $25 | $45 | $45 |
| D0386 | Maxillofacial ultrasound image capture | $25 | $45 | $45 |
| D0391 | Interpretation of diagnostic image by a practitioner not associated with capture of the image, including report | $25 | $45 | $45 |
| D0393 | Treatment simulation using 3D image volume | $25 | $45 | $45 |
| D0394 | Digital subtraction of two or more images or image volumes of the same modality | $25 | $45 | $45 |
| D0395 | Fusion of two or more 3D image volumes of one or more modalities | $25 | $45 | $45 |
Other Preventive Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D1351 | Sealant (per tooth) | $30 | $40 | $40 |
| D1352 | Preventive Resin Restoration (in a moderate to high caries risk patient, permanent tooth) | $30 | $40 | $40 |
| D1353 | Sealant Repair (per tooth) | $30 | $40 | $40 |
| D1354 | Interim caries arresting medicament application | $30 | $40 | $40 |
| D1510 | Space Maintainer (fixed, unilateral) | $145 | $150 | $165 |
| D1515 | Space Maintainer (fixed, bilateral) | $175 | $195 | $215 |
| D1520 | Space Maintainer (removable, unilateral) | $145 | $150 | $165 |
| D1525 | Space Maintainer (removable, bilateral) | $175 | $195 | $215 |
| D1550 | Recementation of Space Maintainer | $70 | $75 | $80 |
| D1555 | Removal of fixed Space Maintainer | $145 | $150 | $165 |
| D1575 | Distal Shoe Space Maintainer (fixed, unilateral) | $145 | $150 | $165 |
Other Diagnostic Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| Benefits D0130 and D0140 are payable only for visits where no other covered services are performed. | ||||
| D0130 | Emergency Oral Evaluation | $40 | $45 | $50 |
| D0140 | Limited Oral Evaluation | $40 | $45 | $50 |
| D0290 | Posterior-Anterior or Lateral Skull and Facial Bone Survey Film | $105 | $115 | $140 |
| D0310 | Sialography | $275 | $300 | $330 |
| D0411 | Hba1c in-office point of service testing | $25 | $30 | $30 |
| D0414 | Laboratory processing of microbial specimen to include culture and sensitivity studies, preparation and transmission of written report | $25 | $30 | $30 |
| D0415 | Bacteriologic Studies for Determination of Pathologic Agents | $25 | $30 | $30 |
| D0416 | Viral Culture | $25 | $30 | $30 |
| D0422 | Collection and preparation of genetic sample material for laboratory analysis and report | $25 | $30 | $30 |
| D0423 | Genetic test for susceptibility to diseases (specimen analysis) | $25 | $30 | $30 |
| D0431 | Adjunctive pre-diagnostic test that aids in detection of mucosal abnormalities including premalignant and malignant lesions, not to include cytology or biopsy procedures | $25 | $30 | $30 |
| D0460 | Pulp Vitality Tests | $30 | $30 | $30 |
| D0470 | Diagnostic Casts | $40 | $50 | $50 |
| D0471 | Diagnostic Photographs | $25 | $30 | $30 |
| D0501 | Histopathologic Exam | $75 | $80 | $90 |
Fillings and Other Basic Restorative Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
|
D2140
|
Amalgam (one surface)
Primary Permanent |
$50 $80 |
$80 $105 |
$100 $140 |
|
D2150
|
Amalgam (two surfaces)
Primary Permanent |
$50 $90 |
$90 $115 |
$115 $145 |
|
D2160
|
Amalgam (three surfaces)
Primary Permanent |
$75 $100 |
$100 $125 |
$115 $150 |
|
D2161
|
Amalgam (four or more surfaces)
Primary Permanent |
$80 $105 |
$105 $140 |
$140 $165 |
| D2330 | Resin-Based Composite (one surface, anterior) | $75 | $100 | $125 |
| D2331 | Resin-Based Composite (two surfaces, anterior) | $90 | $115 | $150 |
| D2332 | Resin-Based Composite (three surfaces, anterior) | $100 | $140 | $175 |
| D2335 | Resin-Based Composite (four or more surfaces or involving incisal angle, anterior) | $105 | $150 | $215 |
| D2390 | Resin-Based Composite Crown (anterior) | $105 | $150 | $215 |
|
D2391
|
Resin-Based Composite (one surface, posterior)
Primary Permanent |
$50 $75 |
$90 $100 |
$115 $125 |
|
D2392
|
Resin-Based Composite (two surfaces, posterior)
Primary Permanent |
$80 $90 |
$105 $115 |
$145 $150 |
|
D2393
|
Resin-Based Composite (three surfaces, posterior)
Primary Permanent |
$90 $100 |
$125 $140 |
$165 $175 |
|
D2394
|
Resin-Based Composite (four or more surfaces, posterior)
Primary Permanent |
$90 $100 |
$125 $140 |
$165 $175 |
| D2410 | Gold Foil (one surface) | $345 | $390 | $440 |
| D2420 | Gold Foil (two surfaces) | $390 | $440 | $480 |
Crowns and Other Major Restorative Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D2510 | Inlay (metallic, one surface) | $330 | $345 | $390 |
| D2520 | Inlay (metallic, two surfaces) | $390 | $440 | $440 |
| D2530 | Inlay (metallic, three or more surfaces) | $605 | $650 | $690 |
| D2542 | Onlay (metallic, two surfaces) | $390 | $440 | $520 |
| D2543 | Onlay (metallic, three surfaces) | $440 | $480 | $565 |
| D2544 | Onlay (metallic, four or more surfaces) | $480 | $565 | $605 |
| D2610 | Inlay (porcelain/ceramic, one surface) | $345 | $390 | $440 |
| D2620 | Inlay (porcelain/ceramic, two surfaces) | $390 | $440 | $480 |
| D2630 | Inlay (porcelain/ceramic, three or more surfaces) | $605 | $650 | $740 |
| D2642 | Onlay (porcelain/ceramic, two surfaces) | $440 | $480 | $565 |
| D2643 | Onlay (porcelain/ceramic, three surfaces) | $480 | $565 | $605 |
| D2644 | Onlay (porcelain/ceramic, four or more surfaces) | $565 | $605 | $650 |
| D2650 | Inlay (resin-based composite, one surface) | $315 | $345 | $390 |
| D2651 | Inlay(resin-based composite, two surfaces) | $345 | $390 | $440 |
| D2652 | Inlay (resin-based composite, three or more surfaces) | $440 | $480 | $565 |
| D2662 | Onlay (resin-based composite, two surfaces) | $390 | $440 | $480 |
| D2663 | Onlay (resin-based composite, three surfaces) | $440 | $480 | $565 |
| D2664 | Onlay (resin-based composite, four or more surfaces) | $440 | $480 | $565 |
| D2710 | Crown (resin, indirect) | $265 | $300 | $330 |
| D2712 | Crown (3/4 resin-based composite, indirect) | $265 | $300 | $330 |
| D2720 | Crown (resin with high noble metal) | $440 | $565 | $650 |
| D2721 | Crown (resin with predominantly base metal) | $440 | $565 | $650 |
| D2722 | Crown (resin with noble metal) | $440 | $565 | $650 |
| D2740 | Crown (porcelain/ceramic substrate) | $440 | $565 | $650 |
| D2750 | Crown (porcelain fused to high noble metal) | $440 | $565 | $650 |
| D2751 | Crown (porcelain fused to predominantly base metal) | $440 | $565 | $650 |
| D2752 | Crown (porcelain fused to noble metal) | $440 | $565 | $650 |
| D2780 | Crown (3/4-cast high noble metal) | $440 | $565 | $650 |
| D2781 | Crown (3/4-cast predominantly base metal) | $440 | $565 | $650 |
| D2782 | Crown (3/4-cast noble metal) | $440 | $565 | $650 |
| D2783 | Crown (3/4-porcelain/ceramic) | $440 | $565 | $650 |
| D2790 | Crown (full-cast high noble metal) | $440 | $565 | $650 |
| D2791 | Crown (full-cast predominantly base metal) | $440 | $565 | $650 |
| D2792 | Crown (full-cast noble metal) | $440 | $565 | $650 |
| D2794 | Crown (titanium) | $440 | $565 | $650 |
| D2910 | Recement Inlay | $50 | $70 | $70 |
| D2915 | Recement cast or prefabricated post and core | $50 | $70 | $70 |
| D2920 | Recement Crown | $50 | $70 | $70 |
| D2921 | Reattachment of tooth fragment, incisal edge or cusp | $50 | $70 | $70 |
| D2929 | Prefabricated Porcelain/Ceramic Crown (primary tooth) | $115 | $140 | $145 |
| D2930 | Prefabricated Stainless Steel Crown (primary tooth) | $115 | $140 | $145 |
| D2931 | Prefabricated Stainless Steel Crown (permanent tooth) | $140 | $145 | $155 |
| D2932 | Prefabricated Resin Crown | $175 | $195 | $225 |
| D2933 | Prefabricated Stainless Steel Crown with Resin Window | $195 | $225 | $250 |
| D2934 | Prefabricated Esthetic Coated Stainless Steel Crown (primary tooth) | $115 | $140 | $145 |
| D2940 | Sedative Filling | $45 | $50 | $50 |
| D2941 | Interim Therapeutic Restoration (primary dentition) | $45 | $50 | $50 |
| D2949 | Restorative Foundation for an Indirect Restoration | $45 | $50 | $50 |
| D2950 | Core Buildup (including any pins) | $115 | $140 | $145 |
| D2951 | Pin Retention (per tooth, in addition to restoration) | $30 | $30 | $45 |
| D2952 | Cast Post and Core (in addition to crown) | $165 | $195 | $195 |
| D2954 | Prefabricated Post and Core (in addition to crown) | $175 | $195 | $225 |
| D2955 | Post Removal (not in conjunction with endodontic therapy) | $140 | $150 | $155 |
| D2970 | Temporary Crown (fractured tooth) | $140 | $145 | $150 |
| D2980 | Crown Repairs, by Report | $220 | $275 | $330 |
| D2981 | Inlay Repair necessitated by restorative material failure | $220 | $275 | $330 |
| D2982 | Onlay Repair necessitated by restorative material failure | $220 | $275 | $330 |
| D2983 | Veneer Repair necessitated by restorative material failure | $220 | $275 | $330 |
Root Canals and Other Endodontic Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D3110 | Pulp Cap (direct, excluding final restoration) | $30 | $40 | $40 |
| D3120 | Pulp Cap (indirect, excluding final restoration) | $30 | $40 | $40 |
| D3220 | Therapeutic Pulpotomy (excluding final restoration) Removal of Pulp Coronal to the Dentinocemental Junction and Application of Medicament | $75 | $80 | $90 |
| D3230 | Pulpal Therapy (resorbable filling; anterior, primary tooth, excluding final restoration) | $80 | $90 | $90 |
| D3240 | Pulpal Therapy (resorbable filling; posterior, primary tooth, excluding final restoration) | $80 | $90 | $90 |
| D3310 | Anterior (excluding final restoration, root canal) | $265 | $345 | $390 |
| D3320 | Bicuspid (excluding final restoration, root canal) | $345 | $440 | $480 |
| D3330 | Molar (excluding final restoration, root canal) | $440 | $565 | $650 |
| D3340 | Root Canal (four or more) | $440 | $565 | $650 |
| D3346 | Retreatment of Previous Root Canal Therapy (anterior) | $225 | $315 | $345 |
| D3347 | Retreatment of Previous Root Canal Therapy (bicuspid) | $315 | $390 | $440 |
| D3348 | Retreatment of Previous Root Canal Therapy (molar) | $390 | $520 | $565 |
| D3351 | Apexification/Recalcification (intial visit; apical closure/calcific repair of perforations, root resorptions, etc.) | $225 | $250 | $275 |
| D3352 | Apexification/Recalcification (interim medication replacement; apical closure/calcific repair of perforations, root resorption, etc.) | $50 | $70 | $75 |
| D3353 | Apexification/Recalcification (final visit; includes completed root canal therapy; apical closure/calcific repair of perforations, root resorption, etc.) | $115 | $140 | $145 |
| D3355 | Pulpal Regeneration (initial visit) | $225 | $250 | $275 |
| D3356 | Pulpal Regeneration (interim medication replacement) | $50 | $70 | $75 |
| D3357 | Pulpal Regeneration (completion of treatment) | $115 | $140 | $145 |
| D3410 | Apicoectomy/Periradicular Surgery (anterior) | $250 | $275 | $300 |
| D3421 | Apicoectomy/Periradicular Surgery (bicuspid, first root) | $480 | $520 | $565 |
| D3425 | Apicoectomy/Periradicular Surgery (molar; first root) | $520 | $565 | $690 |
| D3426 | Apicoectomy/Periradicular Surgery (each additional root) | $195 | $215 | $225 |
| D3427 | Periradicular Surgery (without apicoectomy) | $480 | $520 | $565 |
| D3428 | Bone graft in conjunction with Periradicular Surgery (per tooth, single site) | $480 | $520 | $565 |
| D3429 | Bone graft in conjunction with Periradicular Surgery (each additional contiguous tooth in the same surgical site) | $480 | $520 | $565 |
| D3430 | Retrograde Filling (per root) | $145 | $150 | $165 |
| D3431 | Biologic materials to aid in soft and osseous tissue regeneration in conjunction with Periradicular Surgery | $480 | $520 | $565 |
| D3432 | Guided tissue regeneration, resorbable barrier, per site, in conjunction with Periradicular Surgery | $480 | $520 | $565 |
| D3450 | Root Amputation (per root) | $275 | $300 | $330 |
| D3920 | Hemisection (including any root removal; not including root canal therapy) | $215 | $225 | $265 |
| D3950 | Canal Preparation and Fitting of Preformed Dowel or Post | $100 | $105 | $115 |
Gum Treatments/Periodontic Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D4210 | Gingivectomy or Gingivoplasty (four or more contiguous teeth or bounded teeth spaces per quadrant) | $225 | $265 | $275 |
| D4211 | Gingivectomy or Gingivoplasty (one to three teeth per quadrant) | $80 | $90 | $90 |
| D4230 | Anatomical Crown Exposure (four or more contiguous teeth per quadrant) | $225 | $265 | $275 |
| D4231 | Anatomical Crown Exposure (one to three teeth per quadrant) | $80 | $90 | $90 |
| D4240 | Gingival Flap Procedure, Including Root Planing (four or more contiguous teeth or bounded teeth spaces per quadrant) | $390 | $440 | $480 |
| D4241 | Gingival Flap Procedure, Including Root Planing (one to three teeth per quadrant) | $390 | $440 | $480 |
| D4249 | Clinical Crown Lengthening (hard tissue) | $440 | $480 | $520 |
| D4250 | Mucogingival Surgery (per quadrant) | $440 | $480 | $520 |
| D4260 | Osseous Surgery (including flap entry and closure; four or more contiguous teeth or bounded teeth spaces per quadrant) | $440 | $480 | $520 |
| D4261 | Osseous Surgery (including flap entry and closure; one to three teeth per quadrant) | $440 | $480 | $520 |
| D4263 | Bone Replacement Graft (first site in quadrant) | $480 | $520 | $565 |
| D4264 | Bone Replacement Graft (each additional site in quadrant) | $390 | $390 | $440 |
| D4270 | Pedicle Soft Tissue Graft Procedure | $480 | $520 | $565 |
| D4271 | Free Soft Tissue Graft Procedure (including donor site surgery) | $480 | $520 | $565 |
| D4273 | Subepithelial Connective Tissue Graft Procedures | $520 | $565 | $650 |
| D4275 | Soft Tissue Allograft | $480 | $520 | $565 |
| D4277 | Free Soft Tissue Graft Procedure (including donor site surgery), first tooth or edentulous tooth position in graft | $480 | $520 | $565 |
| D4278 | Free Soft Tissue Graft Procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site | $480 | $520 | $565 |
| 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 | $390 | $425 | $490 |
| 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 | $365 | $390 | $425 |
| D4320 | Provisional Splinting (intracoronal) | $265 | $275 | $315 |
| D4321 | Provisional Splinting (extracoronal) | $195 | $225 | $265 |
| D4341 | Periodontal Scaling and Root Planing (four or more contiguous teeth or bounded teeth spaces per quadrant) | $105 | $115 | $145 |
| D4342 | Periodontal Scaling and Root Planing (one to three teeth per quadrant) | $105 | $115 | $145 |
| D4346 | Scaling in presence of generalized moderate or severe gingival inflammation (full mouth, after oral evaluation) | $105 | $115 | $145 |
| D4355 | Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis | $100 | $105 | $115 |
| D4921 | Gingival Irrigation (per quadrant) | $45 | $45 | $45 |
| D6103 | Bone graft for repair of periimplant defect (not including flap entry and closure or, when indicated, placement of a barrier membrane or biologic materials to aid in osseous regeneration) | $480 | $520 | $565 |
| D6104 | Bone graft at time of implant placement | $390 | $390 | $440 |
Dentures and Other Prosthetic Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D5110 | Complete Denture (maxillary) | $605 | $740 | $905 |
| D5120 | Complete Denture (mandibular) | $605 | $740 | $905 |
| D5130 | Immediate Denture (maxillary) | $605 | $740 | $905 |
| D5140 | Immediate Denture (mandibular) | $605 | $740 | $905 |
| D5211 | Maxillary Partial Denture (resin base; including any conventional clasps, rests, and teeth) | $440 | $565 | $650 |
| D5212 | Mandibular Partial Denture (resin base; including any conventional clasps, rests, and teeth) | $440 | $565 | $650 |
| D5213 | Maxillary Partial Denture (cast metal framework with resin denture bases; including any conventional clasps, rests, and teeth) | $650 | $780 | $950 |
| D5214 | Mandibular Partial Denture (cast metal framework with resin denture bases; including any conventional clasps, rests, and teeth) | $650 | $780 | $950 |
| D5221 | Immediate Maxillary Partial Denture (resin base; including any conventional clasps, rests, and teeth) | $440 | $565 | $650 |
| D5222 | Immediate Mandibular Partial Denture (resin base; including any conventional clasps, rests, and teeth) | $440 | $565 | $650 |
| D5223 | Immediate Maxillary Partial Denture (cast metal framework with resin denture bases; including any conventional clasps, rests, and teeth) | $650 | $780 | $950 |
| D5224 | Immediate Mandibular Partial Denture (cast metal framework with resin denture bases; including any conventional clasps, rests, and teeth) | $650 | $780 | $950 |
| D5225 | Maxillary Partial Denture (flexible base; including any clasps, rests, and teeth) | $650 | $780 | $950 |
| D5226 | Mandibular Partial Denture (flexible base; including any clasps, rests, and teeth) | $650 | $780 | $950 |
| D5281 | Removable Unilateral Partial Denture (one-piece cast metal; including clasps and teeth) | $520 | $565 | $605 |
| D5670 | Replace All Teeth and Acrylic on Cast Metal Framework (maxillary) | $75 | $80 | $80 |
| D5671 | Replace All Teeth and Acrylic on Cast Metal Framework (mandibular) | $75 | $80 | $80 |
| D5810 | Interim Complete Denture (maxillary) | $390 | $390 | $440 |
| D5811 | Interim Complete Denture (mandibular) | $390 | $440 | $520 |
| D5820 | Interim Partial Denture (maxillary) | $300 | $315 | $345 |
| D5821 | Interim Partial Denture (mandibular) | $315 | $345 | $390 |
| D5863 | Overdenture (complete maxillary) | $605 | $740 | $905 |
| D5864 | Overdenture (partial maxillary) | $440 | $565 | $650 |
| D5865 | Overdenture (complete mandibular) | $605 | $740 | $905 |
| D5866 | Overdenture (partial mandibular) | $440 | $565 | $650 |
| D6010 | Surgical Placement of Implant Body: Endosteal Implant | $780 | $950 | $1,125 |
| D6011 | Second Stage Implant Surgery | $195 | $240 | $290 |
| D6013 | Surgical Placement of Mini Implant | $390 | $480 | $565 |
| D6020 | Abutment Placement or Substitution: Endosteal Implant | $780 | $950 | $1,125 |
| D6040 | Surgical Placement: Eposteal Implant | $780 | $950 | $1,125 |
| D6050 | Surgical Placement: Transosteal Implant | $780 | $950 | $1,125 |
| D6052 | Semi-Precision Attachment Abutment | $440 | $565 | $650 |
| D6056 | Prefabricated Abutment (includes placement) | $780 | $950 | $1,125 |
| D6080 | Implant Maintenance Procedures, Including Removal of Prosthesis, Cleansing of Prosthesis and Abutments, and Reinsertion of Prosthesis | $265 | $305 | $390 |
| D6081 | Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure | $265 | $305 | $390 |
| D6085 | Provisional Implant Crown | $265 | $305 | $390 |
| D6205 | Pontic (indirect resin based composite) | $440 | $565 | $650 |
| D6210 | Pontic (cast high noble metal) | $440 | $565 | $650 |
| D6211 | Pontic (cast predominantly base metal) | $440 | $565 | $650 |
| D6212 | Pontic (cast noble metal) | $440 | $565 | $650 |
| D6214 | Pontic (titanium) | $440 | $565 | $650 |
| D6240 | Pontic (porcelain fused to high noble metal) | $440 | $565 | $650 |
| D6241 | Pontic (porcelain fused to predominantly base metal) | $440 | $565 | $650 |
| D6242 | Pontic (porcelain fused to noble metal) | $440 | $565 | $650 |
| D6245 | Pontic (porcelain/ceramic) | $440 | $565 | $650 |
| D6250 | Pontic (resin with high noble metal) | $440 | $565 | $650 |
| D6251 | Pontic (resin with predominantly base metal) | $440 | $565 | $650 |
| D6252 | Pontic (resin with noble metal) | $440 | $565 | $650 |
| D6253 | Provisional Pontic | $440 | $565 | $650 |
| D6545 | Retainer (cast metal for resin-bonded fixed prosthesis) | $250 | $275 | $300 |
| D6548 | Retainer (porcelain/ceramic for resin-bonded fixed prosthesis) | $250 | $275 | $300 |
| D6549 | Resin Retainer (for resin bonded fixed prosthesis) | $250 | $275 | $300 |
| D6600 | Inlay (porcelain/ceramic, two surfaces) | $390 | $440 | $480 |
| D6601 | Inlay (porcelain/ceramic, three or more surfaces) | $605 | $650 | $740 |
| D6602 | Inlay (cast high noble metal, two surfaces) | $520 | $605 | $650 |
| D6603 | Inlay (cast high noble metal, three or more surfaces) | $565 | $650 | $690 |
| D6604 | Inlay (cast predominantly base metal, two surfaces) | $520 | $605 | $650 |
| D6605 | Inlay (cast predominantly base metal, three or more surfaces) | $565 | $650 | $690 |
| D6606 | Inlay (cast noble metal, two surfaces) | $520 | $605 | $650 |
| D6607 | Inlay (cast noble metal, three or more surfaces) | $565 | $650 | $690 |
| D6608 | Onlay (porcelain/ceramic, two surfaces) | $440 | $480 | $565 |
| D6609 | Onlay (porcelain/ceramic, three or more surfaces) | $480 | $565 | $605 |
| D6610 | Onlay (cast high noble metal, two surfaces) | $565 | $650 | $690 |
| D6611 | Onlay (cast high noble metal, three or more surfaces) | $605 | $690 | $740 |
| D6612 | Onlay (cast predominantly base metal, two surfaces) | $565 | $650 | $690 |
| D6613 | Onlay (cast predominantly base metal, three or more surfaces) | $605 | $690 | $740 |
| D6614 | Onlay (cast noble metal, two surfaces) | $565 | $650 | $690 |
| D6615 | Onlay (cast noble metal, three or more surfaces) | $605 | $690 | $740 |
| D6624 | Inlay (titanium) | $565 | $650 | $690 |
| D6634 | Onlay (titanium) | $605 | $690 | $740 |
| D6710 | Crown (indirect Resin-Based Composite) | $440 | $565 | $650 |
| D6720 | Crown (resin with high noble metal) | $440 | $565 | $650 |
| D6721 | Crown (resin with predominantly base metal) | $440 | $565 | $650 |
| D6722 | Crown (resin with noble metal) | $440 | $565 | $650 |
| D6740 | Crown (porcelain/ceramic) | $440 | $565 | $650 |
| D6750 | Crown (porcelain fused to high noble metal) | $440 | $565 | $650 |
| D6751 | Crown (porcelain fused to predominantly base metal) | $440 | $565 | $650 |
| D6752 | Crown (porcelain fused to noble metal) | $440 | $565 | $650 |
| D6780 | Crown (3/4-cast high noble metal) | $440 | $565 | $650 |
| D6781 | Crown (3/4-cast predominantly base metal) | $440 | $565 | $650 |
| D6782 | Crown (3/4-cast noble metal) | $440 | $565 | $650 |
| D6783 | Crown (3/4-porcelain/ceramic) | $440 | $565 | $650 |
| D6790 | Crown (full-cast high noble metal) | $440 | $565 | $650 |
| D6791 | Crown (full-cast predominantly base metal) | $440 | $565 | $650 |
| D6792 | Crown (full-cast noble metal) | $440 | $565 | $650 |
| D6793 | Provisional Retainer Crown | $440 | $565 | $650 |
| D6794 | Crown (titanium) | $440 | $565 | $650 |
| D6970 | Cast Post and Core (in addition to fixed partial denture retainer) | $225 | $250 | $275 |
| D6971 | Cast Post (as part of fixed partial denture retainer) | $215 | $225 | $250 |
| D6972 | Prefabricated Post and Core (in addition to fixed partial denture retainer) | $175 | $215 | $225 |
| D6973 | Core Buildup for Retainer (including any pins) | $150 | $155 | $175 |
| D6975 | Coping (metal) | $390 | $440 | $520 |
Repairs and Adjustments to Prosthetic Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D5410 | Adjust Complete Denture (maxillary) | $40 | $50 | $50 |
| D5411 | Adjust Complete Denture (mandibular) | $40 | $50 | $50 |
| D5421 | Adjust Partial Denture (maxillary) | $40 | $50 | $50 |
| D5422 | Adjust Partial Denture (mandibular) | $40 | $50 | $50 |
| D5510 | Repair Broken Complete Denture Base | $80 | $90 | $90 |
| D5511 | Repair Broken Complete Denture Base (mandibular) | $80 | $90 | $90 |
| D5512 | Repair Broken Complete Denture Base (maxillary) | $80 | $90 | $90 |
| D5520 | Replace Missing or Broken Teeth (complete denture; each tooth) | $75 | $80 | $80 |
| D5610 | Repair Resin Denture Base | $80 | $90 | $90 |
| D5611 | Repair Resin Partial Denture Base (mandibular) | $80 | $90 | $90 |
| D5612 | Repair Resin Partial Denture Base (maxillary) | $80 | $90 | $90 |
| D5620 | Repair Cast Framework | $105 | $115 | $140 |
| D5621 | Repair Cast Partial Framework (mandibular) | $105 | $115 | $140 |
| D5622 | Repair Cast Partial Framework (maxillary) | $105 | $115 | $140 |
| D5630 | Repair or Replace Broken Clasp | $90 | $100 | $105 |
| D5640 | Replace Broken Teeth (per tooth) | $75 | $80 | $80 |
| D5650 | Add Tooth to Existing Partial Denture | $80 | $90 | $100 |
| D5660 | Add Clasp to Existing Partial Denture | $105 | $115 | $140 |
| D5710 | Rebase Complete Maxillary Denture | $225 | $250 | $275 |
| D5711 | Rebase Complete Mandibular Denture | $300 | $315 | $345 |
| D5720 | Rebase Maxillary Partial Denture | $300 | $315 | $345 |
| D5721 | Rebase Mandibular Partial Denture | $300 | $315 | $345 |
| D5730 | Reline Complete Maxillary Denture (chairside) | $145 | $150 | $165 |
| D5731 | Reline Complete Mandibular Denture (chairside) | $145 | $150 | $165 |
| D5740 | Reline Maxillary Partial Denture (chairside) | $155 | $175 | $195 |
| D5741 | Reline Mandibular Partial Denture (chairside) | $155 | $175 | $195 |
| D5750 | Reline Complete Maxillary Denture (laboratory) | $195 | $215 | $225 |
| D5751 | Reline Complete Mandibular Denture (laboratory) | $195 | $215 | $225 |
| D5760 | Reline Maxillary Partial Denture (laboratory) | $225 | $265 | $275 |
| D5761 | Reline Mandibular Partial Denture (laboratory) | $225 | $265 | $275 |
| D5850 | Tissue Conditioning (maxillary) | $75 | $80 | $90 |
| D5851 | Tissue Conditioning (mandibular) | $75 | $80 | $90 |
| D6090 | Repair of Implanted Supported Prosthetic, by Report | $195 | $215 | $225 |
| D6091 | Replacement of semi-precision or precision attachment (male or female component) of implant/abutment supported prosthesis, per attachment | $195 | $215 | $225 |
| D6092 | Recement implant/abutment supported crown | $195 | $215 | $225 |
| D6093 | Recement implant/abutment supported fixed partial denture | $195 | $215 | $225 |
| D6095 | Repair of Implanted Abutment, by Report | $195 | $215 | $225 |
| D6100 | Implant Removal, By Report | $70 | $75 | $75 |
| D6101 | Debridement of a Periimplant Defect and surface cleaning of exposed implant surfaces, including flap entry and closure | $70 | $75 | $75 |
| D6102 | Debridement and Osseous Contouring of a Periimplant Defect (includes surface cleaning of exposed implant surfaces and flap entry and closure) | $70 | $75 | $75 |
| D6110 | Implant/abutment supported removable denture for edentulous arch (maxillary) | $440 | $565 | $650 |
| D6111 | Implant/abutment supported removable denture for edentulous arch (mandibular) | $440 | $565 | $650 |
| D6112 | Implant/abutment supported removable denture for partially edentulous arch (maxillary) | $440 | $565 | $650 |
| D6113 | Implant/abutment supported removable denture for partially edentulous arch (mandibular) | $440 | $565 | $650 |
| D6114 | Implant/abutment supported fixed denture for edentulous arch (maxillary) | $440 | $565 | $650 |
| D6115 | Implant/abutment supported fixed denture for edentulous arch (mandibular) | $440 | $565 | $650 |
| D6116 | Implant/abutment supported fixed denture for partially edentulous arch (maxillary) | $440 | $565 | $650 |
| D6117 | Implant/abutment supported fixed denture for partially edentulous arch (mandibular) | $440 | $565 | $650 |
| D6118 | Implant/abutment supported interim fixed denture for edentulous arch (mandibular) | $440 | $565 | $650 |
| D6119 | Implant/abutment supported interim fixed denture for edentulous arch (maxillary) | $440 | $565 | $650 |
| D6930 | Recement Fixed Partial Denture | $70 | $75 | $75 |
| D9120 | Fixed Partial Denture Sectioning | $70 | $75 | $75 |
Extractions and Other Oral Surgery Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| D7111 | Coronal Remnants (deciduous tooth) | $70 | $80 | $105 |
| D7140 | Extraction, Erupted Tooth, or Exposed Root (elevation and/or forceps removal) | $75 | $80 | $90 |
| D7210 | Surgical Removal of Erupted Tooth Requiring Elevation of Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth | $125 | $145 | $155 |
| D7220 | Removal of Impacted Tooth (soft tissue) | $150 | $175 | $215 |
| D7230 | Removal of Impacted Tooth (partially bony) | $215 | $225 | $250 |
| D7240 | Removal of Impacted Tooth (completely bony) | $225 | $265 | $275 |
| D7241 | Removal of Impacted Tooth (completely bony, with unusual surgical complications) | $265 | $300 | $300 |
| D7250 | Surgical Removal of Residual Tooth Roots (cutting procedure) | $125 | $145 | $150 |
| D7251 | Coronectomy (intentional partial tooth removal) | $125 | $145 | $150 |
| D7260 | Oroantral Fistula Closure | $315 | $345 | $390 |
| D7270 | Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth and/or Alveolus | $315 | $345 | $390 |
| D7280 | Surgical Access of an Unerupted Tooth | $345 | $390 | $440 |
| D7281 | Sugical Exposure of Impacted or Unerupted Tooth to Aid Eruption | $115 | $140 | $145 |
| D7282 | Mobilization of Erupted or Malpositioned Tooth to Aid Eruption | $115 | $140 | $145 |
| D7283 | Placement of device to facilitate eruption of impacted tooth | $115 | $140 | $145 |
| D7285 | Biopsy of Oral Tissue — Hard (bone, tooth) | $650 | $690 | $740 |
| D7286 | Biopsy of Oral Tissue — Soft (all others) | $265 | $300 | $315 |
| D7310 | Alveoloplasty in Conjunction with Extractions (per quadrant) | $115 | $125 | $140 |
| D7311 | Alveoloplasty in Conjunction with Extractions (one to three teeth or tooth spaces, per quadrant) | $115 | $125 | $140 |
| D7320 | Alveoloplasty Not in Conjunction with Extractions (per quadrant) | $145 | $150 | $175 |
| D7321 | Alveoloplasty Not in Conjunction with Extractions (one to three teeth or tooth spaces, per quadrant) | $145 | $150 | $175 |
| D7340 | Vestibuloplasty — Ridge Extension (secondary epithelialization) | $1,300 | $1,470 | $1,690 |
| D7350 | Vestibuloplasty — Ridge Extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment, and management of hypertrophied and hyperplastic tissue) | $1,205 | $1,380 | $1,600 |
| D7410 | Excision of Benign Lesion (up to 1.25 cm) | $905 | $1,000 | $1,125 |
| D7411 | Excision of Benign Lesion (greater than 1.25 cm) | $905 | $1,000 | $1,125 |
| D7412 | Excision of Benign Lesion (complicated) | $905 | $1,000 | $1,125 |
| D7413 | Excision of Malignant Lesion (up to 1.25 cm) | $1,125 | $1,250 | $1,380 |
| D7414 | Excision of Malignant Lesion (greater than 1.25 cm) | $1,125 | $1,250 | $1,380 |
| D7415 | Excision of Malignant Lesion (complicated) | $1,125 | $1,250 | $1,380 |
| D7440 | Excision of Malignant Tumor (lesion diameter up to 1.25 cm) | $1,125 | $1,250 | $1,380 |
| D7441 | Excision of Malignant Tumor (lesion diameter greater than 1.25 cm) | $1,125 | $1,250 | $1,380 |
| D7450 | Removal of Benign Odontogenic Cyst or Tumor (lesion diameter up to 1.25 cm) | $905 | $1,000 | $1,125 |
| D7451 | Removal of Benign Odontogenic Cyst or Tumor (lesion diameter greater than 1.25 cm) | $905 | $1,000 | $1,125 |
| D7460 | Removal of Benign Nonodontogenic Cyst or Tumor (lesion diameter up to 1.25 cm) | $905 | $1,000 | $1,125 |
| D7461 | Removal of Benign Nonodontogenic Cyst or Tumor (lesion diameter greater than 1.25 cm) | $905 | $1,000 | $1,125 |
| D7471 | Removal of Lateral Exostosis (maxilla or mandible) | $650 | $740 | $780 |
| D7472 | Removal of Torus Palatinus | $650 | $740 | $780 |
| D7473 | Removal of Torus Mandibularis | $650 | $740 | $780 |
| D7485 | Surgical Reduction of Osseous Tuberosity | $740 | $865 | $950 |
| D7510 | Incision and Drainage of Abscess (intraoral soft tissue) | $175 | $195 | $215 |
| D7511 | Incision and Drainage of Abscess (intraoral soft tissue, complicated; includes drainage of multiple fascial spaces) | $780 | $905 | $1,000 |
| D7520 | Incision and Drainage of Abscess (extraoral soft tissue) | $780 | $905 | $1,000 |
| D7521 | Incision and Drainage of Abscess (extraoral soft tissue, complicated; includes drainage of multiple fascial spaces) | $780 | $905 | $1,000 |
| D7530 | Removal of Foreign Body From Mucosa, Skin, or Subcutaneous Alveolar Tissue | $300 | $315 | $345 |
| D7540 | Removal of Reaction-Producing Foreign Bodies (musculoskeletal system) | $315 | $345 | $390 |
| D7550 | Partial Ostectomy/Sequestrectomy for Removal of Nonvital Bone | $215 | $225 | $250 |
| D7560 | Maxillary Sinusotomy for Removal of Tooth Fragment or Foreign Body | $1,205 | $1,380 | $1,600 |
| D7610 | Maxilla (open reduction; teeth immobilized, if present) | $1,205 | $1,380 | $1,600 |
| D7620 | Maxilla (closed reduction; teeth immobilized, if present) | $1,205 | $1,380 | $1,600 |
| D7630 | Mandible (open reduction; teeth immobilized, if present) | $115 | $125 | $140 |
| D7640 | Mandible (closed reduction; teeth immobilized, if present) | $145 | $155 | $175 |
| D7650 | Malar and/or Zygomatic Arch (open reduction) | $1,205 | $1,380 | $1,600 |
| D7660 | Malar and/or Zygomatic Arch (closed reduction) | $950 | $1,040 | $1,125 |
| D7670 | Alveolus (closed reduction, may include stabilization of teeth) | $1,250 | $1,380 | $1,470 |
| D7671 | Alveolus (open reduction, may include stabilization of teeth) | $605 | $690 | $780 |
| D7710 | Maxilla (open reduction) | $1,250 | $1,380 | $1,600 |
| D7720 | Maxilla (closed reduction) | $1,205 | $1,380 | $1,600 |
| D7730 | Mandible (open reduction) | $145 | $150 | $175 |
| D7740 | Mandible (closed reduction) | $145 | $150 | $175 |
| D7750 | Malar and/or Zygomatic Arch (open reduction) | $520 | $605 | $690 |
| D7760 | Malar and/or Zygomatic Arch (closed reduction) | $520 | $605 | $690 |
| D7770 | Alveolus (open reduction stabilization of teeth) | $605 | $690 | $780 |
| D7771 | Alveolus (closed reduction stabilization of teeth) | $1,250 | $1,380 | $1,470 |
| D7960 | Frenulectomy (frenectomy or frenotomy; separate procedure) | $145 | $150 | $175 |
| D7963 | Frenuloplasty | $145 | $150 | $175 |
| D7970 | Excision of Hyperplastic Tissue (per arch) | $145 | $150 | $175 |
| D7971 | Excision of Pericoronal Gingiva | $125 | $140 | $150 |
Pain Relief and Adjunctive Services Benefits
| ADA Code |
Description | Basic | Standard | Premier |
|---|---|---|---|---|
| Benefits D9220 and D9230 are not payable for the same surgery. | ||||
| D9110 | Palliative (emergency) Treatment of Dental Pain (minor procedure) | $50 | $50 | $70 |
| D9219 | Evaluation for Deep Sedation or General Anesthesia | $45 | $50 | $70 |
| D9220 | Deep Sedation/General Anesthesia | $140 | $150 | $155 |
| D9222 | Deep Sedation/General Anesthesia (first 15 minutes) | $140 | $150 | $155 |
| D9223 | Deep Sedation/General Anesthesia (each 15 minute increment) | $140 | $150 | $155 |
| D9230 | Analgesia, Anxiolysis, Inhalation of Nitrous Oxide | $140 | $150 | $155 |
| D9241 | Intravenous Conscious Sedation/Analgesia (first 30 minutes) | $215 | $225 | $250 |
| D9243 | Intravenous Moderate (Conscious) Sedation/Analgesia (each 15 minute increment) | $215 | $225 | $250 |
| D9248 | Non-Intravenous Conscious Sedation | $100 | $105 | $115 |
| D9310 | Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) | $45 | $50 | $70 |
| D9311 | Consultation with a medical health care professional | $45 | $50 | $70 |
| D9410 | House/Extended-Care Facility Call | $45 | $50 | $70 |
| D9420 | Hospital Call | $45 | $50 | $70 |
| D9440 | Office Visit (after regularly scheduled hours) | $45 | $50 | $70 |
| D9450 | Case Presentation, Detailed and Extensive Treatment Planning | $45 | $50 | $70 |
| D9995 | Teledentistry (synchronous; real-time encounter) | $45 | $50 | $70 |
| D9996 | Teledentistry (asynchronous; information stored and forwarded to dentist for subsequent review) | $45 | $50 | $70 |
*Current Dental Terminology © 2002 American Dental Association. All rights reserved.
E810FL
2/19
Coverage is underwritten by
American Family Life Assurance Company of Columbus.
Worldwide Headquarters | 1932 Wynnton Road | Columbus, Georgia 31999
800.99.AFLAC (800.992.3522)