CODE
PATIENT
PAYS
CODE
PATIENT
PAYS
$0
Test text
D0120-D0180 No Charge D0277 No Charge
D0210 No Charge D0330 No Charge
D0220-D0230 No Charge D0391 No Charge
D0240 No Charge D0470 No Charge
D0250-D0251 No Charge D0472-D0474 No Charge
D0270-D0274 No Charge
D1110 $12 D1510 $100
D1120 $10 D1516-17 $100
D4346 $30 D1520 $100
D1208 No Charge D1526-27 $100
D1206
No Charge D1551-52 $15
D1330 No Charge
D1553
$8
D1351, D1354 $10
D1556
$8
D1352 $10
D1557-58
$15
D1353 $5
D1575
$110
D2990
$10
D2140 $22 D2391 $22
D2150 $32 D2392 $32
D2160 $43 D2393 $43
D2161 $53 D2394 $53
D2330 $40 D2921 $7
D2331 $55 D2940 $15
D2332 $60
D2941
$7
D2335 $70 D2951 $15
D2390 $80
D2510 $275 D6094 $325
D2520 $275 D6097 $325
D2530 $275 D6098 $325
D2542 $275 D6099 $325
D2543 $275 D6110 $350
Resin Infiltration of Lesion
DMO
®
Dental Benefits Summary
Office Visit Copay
PROCEDURE PROCEDURE
Accession of Tissue
Periapicals
Intraoral, Occlusal Image
Extraoral Images
Interpretation of Diagnostic Image
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
DIAGNOSTIC
Diagnostic Casts
Application of Topical Fluoride Varnish
Bitewings
Oral Evaluations
Fluoride - Child
Prophy - Adult
Prophy - Child
PREVENTIVE
Vertical Bitewings - 7 to 8 Films
Space Maintainer - Removable Bilateral
Panoramic Image
Full mouth series Images
Inlay - Metallic 2 Surf
Space Maintainer - Fixed Unilateral
Space Maintainer - Fixed Bilateral
Resin-Based Composite 1 Surf, Anterior
Oral Hygiene Instruction
Amalgam - 4+ Surf Primary or Permanent
Diagnostic and Preventive services may be subject to age and frequency limitations. See your booklet for details.
Resin-Based Composite 3 Surf, Posterior, bi-
cuspid*
Sealant
Preventive Resin Restoration
Amalgam - 1 Surf Primary or Permanent
Amalgam - 2 Surf Primary or Permanent
Recement or re-bond unilateral space
maintainer - per quad
RESTORATIVE
PRIMARY OR PERMANENT TEETH
Resin-Based Composite 1 Surf, Posterior, bi-
cuspid*
Resin-Based Composite 2 Surf, Posterior, bi-
cuspid*
Removal of Space Maintainer
Sealant Repair - Per Tooth
Resin-Based Composite 4+ Surf, Posterior, bi-
cuspid*
Reattachment of tooth fragment, incisal edge or
dusp
Inlay - Metallic 3 Surf
Inlay - Metallic 1 Surf
Implant Sup retainer for FPD - porcelain /
noble alloys
Implant Abut Sup Removable Dent-MaxCom
Implant Sup retainer - porcelain/predominantly
base alloys
Onlay - Metallic 3 Surf
Resin-Based Composite 2 Surf, Anterior
Resin-Based Composite 3 Surf, Anterior
Resin-Based Composite 4+ Surf; Anterior (or
involving Incisal angle)
*If the patient elects to have a resin restoration on a molar or on the stress-bearing surfaces of a premolar, the patient is responsible for the copayment, if any,
for an amalgam restoration plus the difference between the dentist's Aetna approved fees for the resin restoration and the amalgam restoration.
Abutment Supported Crown - (Titanium)
Abutment Sup Crown - porcelain/titanium and
titanium alloys
Resin-Based Composite Crown, Anterior
Interim therapeutic restoration - primary
Pin Retention - In Addition to Restoration
Protective Restoration
Recement Space Maintainer
Amalgam - 3 Surf Primary or Permanent
CROWNS/BRIDGES
Space Maintainer - Removable Unilateral
Scaling in presence of generalized
moderate/severe gingival inflammation - full
mouth, after oral evaluation
Removal of fixed unilateral space maintainer -
per quad
Distal shoe space maintainer - fixed - unilateral
Onlay - Metallic 2 Surf
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
D2544 $275 D6111 $350
D2610 $275 D6112 $375
D2620 $275 D6113 $375
D2630 $275 D6114 $350
D2642 $275 D6115 $350
D2643 $275 D6116 $475
D2644 $275 D6117 $475
D2650 $275 D6120 $325
D2651 $275 D6121 $325
D2652 $275 D6122 $325
D2662 $275 D6123 $325
D2663 $275 D6195 $325
D2664 $275 D6205 $325
D2710 $325 D6210 $325
D2712 $240 D6211 $325
D2720 $325 D6212 $325
D2721 $325 D6214 $325
D2722 $325 D6240 $325
D2740 $325 D6241 $325
D2750 $325 D6242 $325
D2751 $325 D6243 $325
D2752 $325 D6245 $325
D2753 $325 D6250 $325
D2780 $300 D6251 $325
D2781 $300 D6252 $325
D2782 $300 D6545 $275
D2783 $300 D6548 $275
D2790 $325 D6549 $163
D2791 $325 D6600 $275
D2792 $325 D6601 $275
D2794 $325 D6602 $295
D2910 $18 D6603 $295
D2915 $9 D6604 $275
D2920 $18 D6605 $275
D2929 $91 D6606 $295
D2930 $65 D6607 $295
D2931 $80 D6608 $275
D2934 $65 D6609 $275
D2950 $55 D6610 $295
D2952 $95 D6611 $295
D6058 $325 D6612 $275
D6059 $325 D6613 $275
Pontic - Titanium
Pontic - Porcelain/Ceramic
Onlay - Cast Predominantly Base Metal, 2 Surf
Onlay - Cast Predominantly Base Metal, 3+
Surf
Inlay - Cast Noble Metal, 2 Surf
Inlay - Cast Noble Metal, 3+ Surf
Pontic - porcelain fused to titanium and
titanium alloys
Inlay - Cast Predominantly Base Metal, 2 Surf
Onlay - Porcelain/Ceramic, 2 Surf
Inlay - Cast High Noble Metal, 3+ Surf
Onlay - Porcelain/Ceramic, 3+ Surf
Onlay - Cast High Noble Metal, 2 Surf
Onlay - Cast High Noble Metal, 3+ Surf
Crown - Resin With Predominantly Base Metal
Crown - Resin With Noble Metal
Prefab, Stainless Steel Crown - Permanent Tooth
Recement Crown
Prefab Porcelain/Ceramic Crown - Primary Tooth
Recement Inlay, Onlay or Partial Coverage
Recement Cast or Prefab Post and Core
Crown - Porcelain Fused to Predominantly Base
Metal
Crown - Porcelain Fused to Noble Metal
Implant Sup Retainer for metal FPD- noble
alloys
Implant Sup Retainer for metal FPD-
predominantly base alloys
Abutment Sup Retainer - porcelain/titanium
d tit i ll
Implant Abut Sup Fixed Dent-Max Com
Implant Abut Sup Fixed Dent-Max Par
Implant Abut Sup Fixed Dent-Mand Par
Crown - 3/4 Resin-Based Composite, Indirect
Crown - Resin With High Noble Metal
Onlay, Composite/Resin - 4 or More Surf
Crown - Resin-Based Composite, Indirect
Pontic - Cast High Noble Metal
Pontic - Cast Predominantly Base Metal
Pontic - Cast Noble Metal
Onlay, Composite/Resin - 3 Surf
Abutment Sup Retainer - porcelain /titanium
Pontic - Indirect Resin Based Composite
Onlay, Porcelain/Ceramic - 2 Surf
Implant Abut Sup Removable Dent-Mand Com
Implant Abut Sup Fixed Dent-Mand Com
Inlay, Porcelain/Ceramic - 2 Surf
Crown - Porcelain Fused to High Noble Metal
Inlay - Cast Predominantly Base Metal, 3+ Surf
Implant Abut Sup Removable Dent-Max Par
Implant Abut Sup Removable Dent-Mand Par
Pontic - Porcelain Fused to Predominantly Base
Metal
Pontic - Porcelain Fused to Noble Metal
Crown - 3/4 Cast Predominantly Based Metal
Pontic - Resin With Noble Metal
Crown - 3/4 Cast Noble Metal
Retainer - Cast Metal for Resin-Bonded Fixed
Crown - 3/4 Porcelain/Ceramic
Retainer - Porcelain/Ceramic for Resin-Bonded
Crown - Porcelain fused to titanium and titanium
alloys
Pontic - Resin With High Noble Metal
Crown - 3/4 Cast High Noble Metal
Pontic - Resin With Predominantly Base Metal
Abutment Sup Retainer for metal FPD-
Pontic - Porcelain Fused to High Noble Metal
Onlay, Metallic - 4 or More Surf
Inlay, Porcelain/Ceramic - 1 Surf
Crown - Porcelain/Ceramic Substrate
Onlay, Composite/Resin - 2 Surf
Inlay, Composite/Resin - 3 Surf
Inlay, Porcelain/Ceramic - 3 or More Surf
Inlay, Composite/Resin - 1 Surf
Onlay, Porcelain/Ceramic - 3 Surf
Inlay, Composite/Resin - 2 Surf
Onlay, Porcelain/Ceramic - 4 or More Surf
Crown - Titanium
Inlay - Cast High Noble Metal, 2 Surf
Crown - Full Cast High Noble Metal
Resin Retainer - Resin Bonded Prosthesis
Crown - Full Cast Predominantly Base Metal
Inlay - Porcelain/Ceramic, 2 Surf
Crown - Full Cast Noble Metal
Inlay - Porcelain/Ceramic, 3+ Surf
Prefab, Stainless Steel Crown - Primary Tooth
Abutment Supported Porcelain/Ceramic Crown
Abutment Supported Porcelain Fused to Metal
Crown (High Noble Metal)
Post & Core in Addition to Crown
Prefabricated Esthetic Coated Stainless Steel
Core Buildup, Including Any Pins
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
D6060
$325 D6614 $295
D6061 $325 D6615 $295
D6062 $325 D6624 $295
D6063 $325 D6634 $295
D6064 $325 D6710 $325
D6065 $325 D6720 $325
D6066 $325 D6721 $325
D6067 $325 D6722 $325
D6068 $325 D6740 $325
D6069 $325 D6750 $325
D6070 $325 D6751 $325
D6071 $325 D6752 $325
D6072 $325 D6753 $325
D6073 $325 D6780 $325
D6074 $325 D6781 $325
D6075 $325 D6782 $325
D6076 $325 D6783 $325
D6077 $325 D6784 $325
D6082 $325 D6790 $325
D6083 $325 D6791 $325
D6084 $325 D6792 $325
D6086 $325 D6794 $325
D6087 $325 D6930 $20
D6088 $325 $125
D3110 $8 D3333 $130
D3120 $8 D3346 $250
D3220 $50 D3347 $295
D3221 $10 D3348 $395
D3222
$45 D3410 (1) $156
Full mouth rehabilitation is defined as 6 or more units of covered crowns and/or pontics under one treatment plan.
Apicoectomy/Periradicular Surgery - Anterior
Partial Pulpotomy
Retreatment of Previous Root Canal Therapy -
Molar
Recement Fixed Partial Denture
Pulpal Debridement, Primary and Permanent Teeth
Crown - Porcelain Fused to Predominantly
Base Metal
Crown 3/4 - titanium and titanium alloys
Crown - 3/4 Cast Predominantly Base Metal
Crown - 3/4 Porcelain/Ceramic
Crown - Porcelain Fused to Noble Metal
Crown - porcelain fused to titanium and
titanium alloys
Crown - 3/4 Cast High Noble Metal
Crown - Titanium
Abutment Supported Retainer for Cast Metal FPD
(Noble Metal)
Crown - Resin With Predominantly Base Metal
Onlay - Cast Noble Metal, 3+ Surf
Onlay - Cast Noble Metal, 2 Surf
Crown - Resin With Noble Metal
Crown - Porcelain/Ceramic
Inlay - Titanium
Crown - Porcelain Fused to High Noble Metal
Onlay - Titanium
Crown - Indirect Resin Based Composite
Crown - Resin With High Noble Metal
Implant Supported Porcelain/Ceramic Crown
Abutment Supported Cast Metal Crown (Noble
Abutment Supported Cast Metal Crown
(Predominantly Base Metal)
Abutment Supported Retainer for Porcelain Fused
to Metal FPD (Noble Metal)
Therapeutic Pulpotomy (excluding final
restoration)
Pulp Cap - Direct (excluding final restoration)
Implant Sup Crown - noble alloys
Implant Sup Crown - porcelain/titanium and
titanium alloys
Implant Sup Crown - porcelain/predominantly
base alloys
ENDODONTICS
Retreatment of Previous Root Canal Therapy -
Anterior
Internal Root Repair of Perforation Defects
Pulp Cap - Indirect (excluding final restoration)
Implant Supported Retainer for Ceramic FPD
Implant Supported Retainer for FPD - porcelain
fused to high noble alloys
Implant Supported Retainer for FPD - high noble
alloys
Charges for crowns and bridgework are per unit. There will be additional charges for the actual cost for gold/high noble metal.
Additional Charge per Unit for Full Mouth Rehabilitation.
Implant Sup Crown - porcelain fused to noble
alloys
Crown - Full Cast Noble Metal
Implant Sup Crown - titanium and titanium alloys
Crown - Full Cast High Noble Metal
Crown - 3/4 Cast Noble Metal
Crown - Full Cast Predominantly Base Metal
Implant Supported Crown - High Noble alloys
Abutment Supported Retainer for Cast Metal FPD
(High Noble Metal)
Abutment Supported Retainer for Cast Metal FPD
Abutment Supported Retainer for Porcelain Fused
to Metal FPD (Predominantly Base Metal)
Implant Sup Crown - predominantly base alloys
Implant Supported Porcelain Fused to High Noble
alloys
Abutment Supported Retainer for
Porcelain/Ceramic FPD
Abutment Supported Retainer for Porcelain Fused
to Metal FPD (High Noble Metal)
Retreatment of Previous Root Canal Therapy -
Bicuspid
Abutment Supported Porcelain Fused to Metal
Crown (Noble Metal)
Abutment Supported Porcelain Fused to Metal
Crown (Predominantly Base Metal)
Abutment Supported Cast Metal Crown (High
Noble Metal)
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
D3230 $50 D3421 (1) $156
D3240 $50 D3425 (1) $190
D3310 $150 D3426 (1) $130
D3320 $195 D3427 (1) $117
D3330 $295 D3430 (1) $75
D3331 $150 D3450 (1) $100
D3332 $98
D4210 (1) $160 D4275 (1) $310
D4211 (1) $43 D4276 (1) $256
D4212 (1) $17 D4277 (1) $110
D4240 (1) $200 D4278 (1) $55
D4241 (1) $120 D4283 (1) $85
D4245 (1) $200 D4285 (1) $171
D4249 $204 D4341 $65
D4260 (1) $340 D4342 $39
D4261 (1) $204 D4355 $60
D4268 (1) $136 D4910 $60
D4270 (1) $260 D4920 $10
D4273 (1) $155
D5110 $350 D5223-D5224 $546
D5120 $350 D5225 $450
D5130 $400 D5226 $450
D5140 $400 D5282-83 $375
D5211 $375 D5284 $225
D5212 $375 D5286 $188
Complete Denture - Mandibular
PROSTHODONTICS-REMOVABLE (2)
Root Canal Therapy - Bicuspid (excluding final
restoration)
Immediate Denture - Mandibular
Soft Tissue Allograft
(1) Certain services may be covered under the Medical Plan. Contact Member Services for more details.
Pulpal Therapy (Resorbable Filling) - Anterior,
Primary Tooth
Connective Tissue/Pedicle Graft, Per Tooth
Periodontal Maintenance
Pedicle Soft Tissue Graft Procedure
Mandibular Partial Denture - Resin Base
(including any conventional clasps, rests and teeth)
Removable Unilateral Partial Denture - one
piece flex base (including clasps and teeth) -
per quad
Clinical Crown Lengthening, Hard Tissue
Periodontal Scaling and Root Planing - 1-3
Teeth - Per Quadrant
Autogenous connective tissue graft
Free soft tissue graft - each additional tooth
Gingival Flap Procedure, Including Root Planing -
4 or More Teeth - Per Quadrant
Gingivectomy to allow access, per tooth
Periodontal Scaling and Root Planing - 4 or
More Teeth - Per Quadrant
Free soft tissue graft - first tooth
Removable Unilateral Partial Denture - one
piece resin (including clasps and teeth) - per
quad
Removable Unilateral Partial Denture - One
Piece Cast Metal (including clasps and teeth)
Maxillary Partial Denture - Resin Base (including
any conventional clasps, rests and teeth)
Osseous Surgery (Including Flap Entry and
Closure) - 1-3 Teeth - Per Quadrant
Unscheduled Dressing Change (By Someone
Other Than Treating Dentist)
Mandibular Partial Denture - Flexible Base
(including any clasps, rests and teeth)
Immediate max/mand partial denture - cast
base framework w/resin denture base
(including any conventional clasps, rests and
Surgical Revision Procedure, Per Tooth
Immediate Denture - Maxillary
(1) Certain services may be covered under the Medical Plan. Contact Member Services for more details.
Maxillary Partial Denture - Flexible Base
(including any clasps, rests and teeth)
Non-autogenous connective tissue graft
PERIODONTICS
Gingivectomy or Gingivoplasty - 4 or More Teeth -
Per Quadrant
Periradicular surgery without apicoectomy
Apicoectomy/Periradicular Surgery - Molar
(First Root)
Root Amputation - Per Root
Subepithelial Connective Tissue Graft, Per Tooth
Apicoectomy/Periradicular Surgery- Each
Additional Root
Debridement
Complete Denture - Maxillary
Osseous Surgery (Including Flap Entry and
Closure) - 4 or More Teeth - Per Quadrant
Incomplete Endodontic Therapy; Inoperable,
Unrestorable or Fractured Tooth
Root Canal Therapy - Anterior (excluding final
restoration)
Gingival Flap Procedure, Including Root Planing -
1-3 Teeth - Per Quadrant
Apically Positioned Flap
Apicoectomy/Periradicular Surgery - Bicuspid
(First Root)
Treatment of Root Canal Obstruction,
Nonsurgical Access
Retrograde Filling - Per Root
Root Canal Therapy - Molar (excluding final
restoration)
Pulpal Therapy (Resorbable Filling) - Posterior,
Primary Tooth
Gingivectomy or Gingivoplasty - 1-3 Teeth - Per
Quadrant
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
D5213 $475 D5410 $15
D5214 $475 D5411 $15
D5221-D5222 $431 D5421 $15
D5422 $15
D5511-D5512 $35 D5730 $65
D5520 $25 D5731 $65
D5611-D5612 $45 D5740 $65
D5621-D5622 $45 D5741 $65
D5630 $45 D5750 $110
D5640 $45 D5751 $110
D5650 $45 D5760 $110
D5660 $50 D5761 $110
D5670 $95 D5820 $110
D5671 $95 D5821 $110
D5710 $95 D5850 $35
D5711 $95 D5851 $35
D5720 $95 D5876 $35
D5721 $95
D7111 $12 D7285 (1) $100
D7140 $30 D7286 (1) $100
D7210 (1) $60 D7287 (1) $50
D7220 (1) $80 D7310 (1) $55
D7230 (1) $100 D7311 (1) $28
D7240 (1) $150 D7320 (1) $75
D7241 (1) $150 D7321 (1) $38
D7250 (1) $55 D7510 (1) $50
D7251
$75 D7511 (1) $55
D7280 (1) $77 D7960 (1) $128
Immediate max/mand partial dental - resin base
(including any conventional clasps, rests and teeth)
Adjust Partial Denture - Maxillary
Extraction, Coronal Remnants - Deciduous Tooth
Biopsy of Oral Tissue - Hard (Bone, Tooth)
Coronectomy - intentional partial tooth removal
Removal of Impacted Tooth - Completely Bony
Alveoloplasty in Conjunction With Extractions
- 1 to 3 Teeth or Tooth Spaces - Per Quadrant
Extraction, Erupted Tooth or Exposed Root
(Elevation and/or Forceps Removal)
Surgical Removal of Erupted Tooth
Cytological Sample Collection
Tissue Conditioning, Mandibular
Reline Mandibular Partial Denture (Lab)
Rebase Complete Mandibular Denture
Reline Complete Mandibular Denture (Lab)
Reline Complete Maxillary Denture (Chairside)
Replace Missing or Broken Teeth - Complete
Denture (each tooth)
Reline Complete Mandibular Denture
(Chairside)
Repair Resin Partial Denture Base
Reline Complete Maxillary Denture (Lab)
Rebase Complete Maxillary Denture
Maxillary Partial Denture - Cast Metal Framework
with Resin Denture Bases (including any
conventional clasps, rests and teeth)
Replace All Teeth and Acrylic on Cast Metal
Framework (Maxillary)
Repair or Replace Broken Clasp
Repair Broken Complete Denture Base
Repair Cast Partial Framework
Reline Maxillary Partial Denture (Chairside)
Replace All Teeth and Acrylic on Cast Metal
Framework (Mandibular)
Reline Mandibular Partial Denture (Chairside)
REPAIRS TO PROSTHETICS
Tissue Conditioning, Maxillary
Reline Maxillary Partial Denture (Lab)
Replace Broken Teeth - Per Tooth
Adjust Complete Denture - Maxillary
Mandibular Partial Denture - Cast Metal
Framework with Resin Denture Bases (including
any conventional clasps, rests and teeth)
Frenulectomy (Frenectomy, Frenotomy)
Separate Procedure
Surgical Removal of Residual Tooth Roots
Incision and Drainage of Abcess - Intraoral
Soft Tissue
ORAL SURGERY
Alveoloplasty Not in Conjunction With
Extractions - 4 or More Teeth or Tooth Spaces -
Per Quadrant
Removal of Impacted Tooth - Partially Bony
Add metal substructure to acrylic full denture
(per arch)
Removal of Impacted Tooth - Soft Tissue
Alveoloplasty in Conjunction With Extractions
- 4 or More Teeth or Tooth Spaces - Per
Removal of Impacted Tooth - Completely Bony,
With Unusual Surgical Complications
Alveoloplasty Not in Conjunction With
Extractions - 1-3 Teeth or Tooth Spaces - Per
Quadrant
Interim Partial Denture (Maxillary) (3)
Add Clasp to Existing Partial Denture
Rebase Mandibular Partial Denture
(3) Eligible on Anterior Teeth only.
Biopsy of Oral Tissue - Soft
Interim Partial Denture (Mandibular) (3)
Add Tooth to Existing Partial Denture
Rebase Maxillary Partial Denture
Adjust Complete Denture - Mandibular
Surgical Access of Unerupted Tooth
(2) Includes relines, adjustments, rebases within the 1st six months. Adjustments to dentures that are done within six months of placement of the denture, are
limited to no more than four adjustments.
Incision and Drainage of Abcess - Intraoral
Soft Tissue - Complicated
Adjust Partial Denture - Mandibular
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
D7282 (1) $90
D7963 (1)
$134
D7283 $18
D9110 $10 D9942 $23
D9222 $104 D9943 $11
D9223 $83
D9944
$104
D9239 $104
D9945
$90
D9243 $83
D9946
$54
D9310 No Charge D9951 $25
D9311 No Charge D9952 $90
D9932-D9935 $25
$2,000
$2,000
Includes exam, records, retention and appliance
Deep sedation/general anesthesia - 1st 15 min
Occlusal guard adjustment
This Benefit summary of the Aetna Dental Maintenance Organization (DMO®) provides information on benefits provided when services are
rendered by a participating dentist. In order for a covered person to be eligible for benefits, dental services must be provided by a primary care
dentist selected from the network of participating DMO dentists. Out of network benefits may apply. Please refer to your Schedule of Benefits.
PLAN EXCLUSIONS AND LIMITATIONS*
Mobilization of Erupted or Malpositioned Tooth
to Aid Eruption
(b) a non-occupational injury.
(a) under any other part of this Dental Care Plan; or
Comprehensive Orthodontic Treatment
2. Services and supplies to diagnose or treat a disease or injury that is not:
Adult - excludes transitional dentition
Adolescent - excludes transitional dentition
3. Services not listed in the Dental Care Schedule that applies, unless otherwise specified in the Booklet-Certificate.
Intravenous conscious sedation/analgesia - 1st 15
min
Intravenous conscious sedation/analgesia - each
15 minute increment
Palliative (Emergency) Treatment of Dental Pain -
minor procedure
Placement of Device to Facilitate Eruption of
Impacted Tooth
Occlusal guard - hard appliance, full arch
Occlusal guard - hard appliance, partial arch
Frenuloplasty
Occlusal guard - soft appliance, full arch
Repair and/or Reline of Occlusal Guard
(1) Certain services may be covered under the Medical Plan. Contact Member Services for more details.
1. Services or supplies that are covered in whole or in part:
Some Services Not Covered Under the Plan Are:
Deep sedation/general anesthesia - each 15 minute
increment
Consultation with a medical health care
professional
Occlusal Adjustment - complete
Due to state law, limited (varying by state) DMO® benefits for non-emergency services rendered by non-participating providers are available for
plan contracts written in: CT, IL, KY, MA and OH and for members residing in OK (regardless of contract situs state).
Attention Massachusetts residents: Before enrolling, you should be aware that our network of preferred providers in Massachusetts has
providers mainly in the following counties: Barnstable, Berkshire, Bristol, Essex, Hampden, Hampshire, Middlesex, Norfolk, Plymouth, Suffolk
and Worcester. Your out of pocket expenses will be higher if you do not see an in-network provider and, in some plans, benefits may not be
available at all for out-of-network providers.
Other Important Information
Employees in AZ, CA, GA, MA, MD, MO, NC, NJ and TX must either live or work within the approved DMO
®
service area to be eligible to
enroll in the DMO
®
(a) a non-occupational disease; or
(b) under any other plan of group benefits provided by or through your employer.
4. Those for replacement of a lost, missing or stolen appliance, and those for replacement of appliances that have been damaged due to abuse,
misuse or neglect.
Occlusal Adjustment - limited
Consultation - Diagnostic Service Provided by
Dentist or Physician Other Than Requesting
Dentist or Physician
ORTHODONTICS
Denture cleaning and inspection
OTHER (ADJUNCTIVE) SERVICES
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
7. Those for dentures, crowns, inlays, onlays, bridgework, or other appliances or services used for the purpose of splinting, to alter vertical
dimension, to restore occlusion, or to correct attrition, abrasion or erosion. Does not apply to CA contracts.
Your Dental Care Plan Coverage Is Subject to the Following Rules:
2. DMO members may visit an orthodontist without first obtaining a referral from their primary care dentist. In an effort to ease
the administrative burden on both participating Aetna dentists and members, Dental has opened direct access for
DMO members to orthodontic services.
(ii) as a result of accidental injuries sustained while the dependent was a covered dependent; or
(iii) for a primary care service in the Dental Care Schedule that applies as shown under the headings Visits and Exams, and X-rays and Pathology.
16. Services given by a nonparticipating dental provider to the extent that the charges exceed the amount payable for the services shown in the
Dental Care Schedule that applies.
If you need emergency dental care for the palliative treatment (pain relieving, stabilizing) of a dental emergency, you are covered 24 hours a day,
7 days a week. You should contact your Primary Care Dentist to receive treatment. If you are unable to contact your PCD, contact Member
Services for assistance in locating a dentist. Refer to your plan documents for details. Subject to state requirements. Out-of-area emergency dental
care may be reviewed by our dental consultants to verify appropriateness of treatment.
Emergency Dental Care
1. Under the DMO dental plan, services performed by specialists are eligible for coverage only when prescribed by the primary care dentist and
authorized by Aetna Dental. If Aetna's payment to the specialty dentist is based on a negotiated fee, then the member's copayment for the service
will be based on the same negotiated fee.
(a) during the first 31 days the dependent is eligible for this coverage, or
Any exclusion above will not apply to the extent that coverage of the charge is required under any law that applies to the coverage.
Specialty Referrals
21. Services done where there is no evidence of pathology, dysfunction or disease other than covered preventive services. Does not apply to CA
contracts.
20. Services needed solely in connection with non-covered services.
19. Those for surgical removal of impacted wisdom teeth only for orthodontic reasons, unless otherwise specified in the Booklet-Certificate.
5. Those for plastic, reconstructive or cosmetic surgery, or other dental services or supplies, that are primarily intended to improve, alter or
enhance appearance. This applies whether or not the services and supplies are for psychological or emotional reasons. Facings on molar crowns
and pontics will always be considered cosmetic.
15. Those in connection with a service given to a dependent age 5 or older if that dependent becomes a covered dependent other than:
14. Those for treatment by other than a dentist, except that scaling or cleaning of teeth and topical application of fluoride may be done by a
licensed dental hygienist. In this case, the treatment must be given under the supervision and guidance of a dentist.
13. Those for general anesthesia and intravenous sedation, unless specifically covered. For plans that cover these services, they will not be
eligible for benefits unless done in conjunction with another necessary covered service.
17. Those for a crown, cast or processed restoration unless:
(a) It is treatment for decay or traumatic injury and teeth cannot be restored with a filling material; or
(b) The tooth is an abutment to a covered partial denture or fixed bridge.
18. Those for pontics, crowns, cast or processed restorations made with high-noble metals, unless otherwise specified in the Booklet-Certificate.
*This is a partial list of exclusions and limitations, others may apply. Please check your plan booklet for details.
6. Those for or in connection with services, procedures, drugs or other supplies that are determined by Aetna to be experimental or still under
clinical investigation by health professionals.
11. Those for space maintainers, except when needed to preserve space resulting from the premature loss of deciduous teeth.
10. Those for services intended for treatment of any jaw joint disorder, unless otherwise specified in the Booklet-Certificate.
8. Those for any of the following services (Does not apply to TX contracts):
(a) An appliance or modification of one if an impression for it was made before the person became a covered person;
(b) A crown, bridge, or cast or processed restoration if a tooth was prepared for it before the person became a covered person;
(c) Root canal therapy if the pulp chamber for it was opened before the person became a covered person.
9. Services that Aetna defines as not necessary for the diagnosis, care or treatment of the condition involved. This applies even if they are
prescribed, recommended or approved by the attending physician or dentist.
(i) after the end of the 12-month period starting on the date the dependent became a covered dependent; or
12. Those for orthodontic treatment, unless otherwise specified in the Booklet-Certificate.
(b) as prescribed for any period of open enrollment agreed to by the employer and Aetna. This does not apply to charges incurred:
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
Telehealth Services: The plan will reimburse the treating or consulting provider for the diagnosis, consultation, or treatment of an enrollee via
telehealth on the same basis and to the same extent that the plan would reimburse the same covered in-person service.
Tooth Missing But Not Replaced Rule (Does not apply to TX and CA contracts.)
Coverage for the first installation of removable dentures; fixed bridgework and other prosthetic services is subject to the requirements that such
removable dentures; fixed bridgework and other prosthetic services are (i) needed to replace one or more natural teeth that were removed while
this policy was in force for the covered person; and (ii) are not abutments to a partial denture; removable bridge; or fixed bridge installed during
the prior 5 years.
Alternate Treatment Rule: If more than one service can be used to treat a covered person's dental condition, Aetna may decide to authorize
coverage only for a less costly covered service provided that all of the following terms are met:
(a) the service must be listed on the Dental Care Schedule;
(b) the service selected must be deemed by the dental profession to be an appropriate method of treatment; and
(c) the service selected must meet broadly accepted national standards of dental practice.
If treatment is being given by a participating dental provider and the covered person asks for a more costly covered service than that for which
coverage is approved, the specific copayment for such service will consist of:
(a) the copayment for the approved less costly service; plus
(b) the difference in cost between the approved less costly service and the more costly covered service.
Finding Participating Providers
Consult Aetna Dental’s online provider search for the most current provider listings. Participating providers are independent contractors in private
practice and are neither employees nor agents of Aetna Dental or its affiliates. The availability of any particular provider cannot be guaranteed,
and provider network composition is subject to change without notice. Not every provider listed in the directory will be accepting new patients.
Although Aetna Dental has identified providers who were not accepting patients in our DMO plan as known to Aetna Dental at the time the
provider directory was created, the status of a provider’s practice may have changed. For the most current information, please contact the selected
provider or Aetna Member Services at the toll-free number on your online ID card, or use our Internet-based provider search available at
www.aetna.com.
Specific products may not be available on both a self-funded and insured basis. The information in this document is subject to change without
notice. In case of a conflict between your plan documents and this information, the plan documents will govern. In the event of a problem with
coverage, members should contact Member Services at the toll-free number on their online ID cards for information on how to utilize the
grievance procedure when appropriate. All member care and related decisions are the sole responsibility of participating providers. Aetna Dental
does not provide health care services and, therefore, cannot guarantee any results or outcomes.
Replacement Rule
The replacement of; addition to; or modification of:
existing dentures;
crowns;
casts or processed restorations;
removable denture;
fixed bridgework; or
other prosthetic services
is covered only if one of the following terms is met:
The replacement or addition of teeth is required to replace one or more teeth extracted after the existing denture or bridgework was installed. This
coverage must have been in force for the covered person when the extraction took place.
The existing denture, crown; cast or processed restoration, removable denture, bridgework, or other prosthetic service cannot be made serviceable,
and was installed at least 5 years before its replacement.
The existing denture is an immediate temporary one to replace one or more natural teeth extracted while the person is covered, and cannot be
made permanent, and replacement by a permanent denture is required. The replacement must take place within 12 months from the date of initial
installation of the immediate temporary denture.
The extraction of a third molar does not qualify. Any such appliance or fixed bridge must include the replacement of an extracted tooth or teeth.
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
TTY:711
English
Albanian
Amharic
Arabic
Armenian
Bantu-Kirundi
Bengali
Burmese
Catalan
Cebuano
Chamorro
Cherokee
Chinese
Traditional
Choctaw
Chuukese
This material is for informational purposes only and is neither an offer of coverage nor dental advice. It contains only a partial, general
description of plan or program benefits and does not constitute a contract. Aetna does not provide dental services and, therefore, cannot guarantee
any results or outcomes. The availability of a plan or program may vary by geographic service area. Certain dental plans are available only for
groups of a certain size in accordance with underwriting guidelines. Some benefits are subject to limitations or exclusions. Consult the plan
documents (Schedule of Benefits, Certificate/Evidence of Coverage, Booklet, Booklet-Certificate, Group Agreement, Group Policy) to determine
governing contractual provisions, including procedures, exclusions and limitations relating to your plan.
Dental plans are provided or administered by Aetna Life Insurance Company, Aetna Dental Inc., Aetna Dental of California Inc. and/or Aetna
Health Inc.
In Arizona, DMO Dental Plans are provided or administered by Aetna Health Inc.
Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat people differently based on their race, color,
Aetna provides free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call 877-238-6200.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights Complaint Portal,
available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health and Human Services, 200 Independence Avenue SW.,
Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna
Life Insurance Company, Coventry Health Care plans and their affiliates (Aetna).
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a
grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711,
Fax: 859-425-3379 (CA HMO customers: 860-262-7705),
CRCoordinator@aetna.com.
Ձեր նախընտրած լեզվով ավվճար խորհրդատվություն ստանալու համար զանգահարեք ձեր բժշկական
ապահովագրության քարտի վրա նշված հէրախոսահամարով
Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu kawe
।
Per accedir a serveis lingüístics sense cap cost per a vostè, telefoni al número indicat a la seva targeta d’identificació.
Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang numero nga anaa sa imong kard sa ID.
To access language services at no cost to you, call the number on your ID card.
Për shërbime përkthimi falas për ju, telefononi në numrin që gjendet në kartën tuaj të identitetit.
የቋንቋ አገልግሎቶችን ያለክፍያ ለማግኘት፣ በመታወቂያዎት ላይ ያለውን ቁጥር ይደውሉ
.ﻚﻛاﺮﺘﺷا ﺔﻗﺎﻄﺑ ﻰﻠﻋ دﻮﺟﻮﻤﻟا ﻢﻗﺮﻟا ﻰﻠﻋ لﺎﺼﺗﻻا ءﺎﺟﺮﻟا ،ﺔﻔﻠﻜﺗ يأ نود ﺔﯾﻮﻐﻠﻟا تﺎﻣﺪﺨﻟا ﻰﻠﻋ لﻮﺼﺤﻠﻟ
Para un hago' i setbision lengguåhi ni dibåtde para hågu, ågang i numiru gi iyo-mu kard aidentifikasion.
ᏩᎩᏍᏗ
ᎦᏬᏂᎯᏍᏗ
ᎢᏅᎾᏓᏛᏁᏗ
Ꮭ
ᎪᎱᏍᏗ
ᏗᏣᎬᏩᎳᏁᏗ
ᏱᎩ
,
ᏫᎨᎯᏏᎳᏛᏏ
ᎾᏍᎩ
ᏗᏎᏍᏗ
ᏥᏕᎪᏪᎵ
ᎤᎾᎢ
ID
ᏆᏂᏲᏍᏗ
ᏣᏤᎵᎢ
.
如欲使用免費語言服務，請撥打您健康保險卡上所列的電話號碼
Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini holhtena takanli ma i payah
Ren omw kopwe angei aninisin eman chon awewei (ese kamé), kopwe kééri ewe nampa mei mak won noum ena katen ID
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
Cushitic-
Oromo
Dutch
French
French Creole
(Haitian)
German
Greek
Gujarati
Hawaiian
Hindi
Hmong
Igbo
Ilocano
Indonesian
Italian
Japanese
Karen
Korean
Kru-Bassa
Kurdish
Lao
Marathi
Marshallese
Micronesian-
Ponapean
Mon-Khmer,
Cambodian
Navajo
Nepali
Nilotic-Dinka
Norwegian
Pennsylvanian
-Dutch
Persian Farsi
Polish
Portuguese
Punjabi
Romanian
Russian
Samoan
Serbo-
Croatian
Spanish
Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart.
Pour accéder gratuitement aux services linguistiques, veuillez composer le numéro indiqué sur votre carte d'assurance santé.
Pou ou jwenn sèvis gratis nan lang ou, rele nimewo telefòn ki sou kat idantifikasyon asirans sante ou.
Um auf den für Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an.
ત મા રે કો ઇ પણ જા ત ના ખ ર્ ચ વિ ના ભા ષા સે વા ઓ મે ળ વ વા મા ટે , ત મા રા આઇડી ક ા ર્ ડ પર ર હે લ નં બ ર પર કૉ લ કરવો .
Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa eenyummaa (ID) kee irraa jiruun bilbili.
Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera identificativa.
無料の言語サービスは、
ID
カードにある番号にお電話ください。
vXw>urRM>usdmw>rRpXRtw>zH;w>rRwz. vXwtd.'D;tyShRvXeub.[h.tDRt*D><ud;b.vDwJpdeD.*H>vXttd.vXecd.*DR A (ID)
무료 다국어 서비스를 이용하려면 보험 ID 카드에 수록된 번호로 전화해 주십시오.
I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i kat yong matibla
.تﯚﺧ ﯽﺗرﺎﮐ (ID)
,
Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID.
Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga adda ayan ti ID kardmo.
Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon di kartu asuransi Anda.
For tilgang til kostnadsfri språktjenester, ring nummeret på ID-kortet ditt.
Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.
.
ເພື່ອ
ເ ຂົ ້ າ
ເ ຖິ ງ
ບໍ
ລິ
ການ
ພາ
ສາ
ທີ ່
ບໍ ່
ເສຍ
ຄ່ າ
,
ໃ ຫ້
ໂທ
ຫາ
ເ ບີ
ໂທ
ຢູ ່
ໃນ
ບັ ດ
ປະ
ຈຳ
ຕົ ວ
ຂອງ
ທ່ າ ນ
.
, ID .
an kwe, .
Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID.
ដ ើ ម្ បី ទ ទ ួ ល ប ា ន ស េ វ ា ក ម្ មភា សា ដែ លឥតគិ តថ្ លៃសម្ រាប់ លោកអ្ នក សូ ម ហ ៅទ ូ រ ស ព្ ទទ ៅក ា ន់ លេ ខ ដែ ល មា ន ន ៅលើប ណ្ ណស ម ្ គ ា ល ់ ខ្ លួ ន
របស់ លោកអ្ នក។
Para acceder a los servicios lingüísticos sin costo alguno, llame al número que figura en su tarjeta de identificación.
Para aceder aos serviços linguísticos gratuitamente, ligue para o número indicado no seu cartão de identificação.
ਤੁ ਹਾ ਡੇ
ਲਈ
ਬਿ ਨਾ ਂ
ਕਿ ਸੇ
ਕੀ ਮ ਤ
ਵ ਾ ਲ ੀ ਆਂ
ਪੰ ਜਾ ਬੀ
ਸੇ ਵ ਾ ਵਾ ਂ
ਦੀ
ਵ ਰ ਤੋ ਂ
ਕਰਨ
ਲਈ
,
ਆ ਪ ਣੇ
ਆ ਈ ਡੀ
ਕਾ ਰ ਡ
‘
ਤੇ
ਦਿ ੱ ਤੇ
ਨੰ ਬ ਰ
'
ਤੇ
ਫ਼ੋ ਨ
ਕ ਰੋ
।
. në ID kard n de
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
DMO
®
Dental Benefits Summary
Prince George's County, Maryland
809536
Effective Date: 01-01-2023
Sudanic
Fulfulde
Swahili
Syriac-
Assyrian
Swahili
Tagalog
Telugu
Thai
Tongan
Turkish
Ukrainian
Urdu
Vietnamese
Yiddish
Yoruba
.לטראק ID ,
, pe .
భాష సేవలను మీ క ు ఖ ర్ చు లే క ు ం డ ా అం దు క ు నేందు క ు , మీ ఐ డి క ార్ డు పై ఉ న్ న నం బరు కు క ాల్ చే యం డి .
หากท่านต้องการเข้าถึงการบริการทางด้านภาษาโดยไม่มีค่าใช้จ่าย โปรดโทรหมายเลขที�แสดงอยู่บนบัตรประจําตัวของท่าน
ID
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.
. ، ̈ ̄
Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako ya kitambulisho.
Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa iyong ID card.
ed.2020
Proprietary
"Patient Pays" applies to procedures provided by the member's Primary Care Dentist or approved specialty dentist.
Current Dental Terminology © 2020 American Dental Association. All rights reserved.
