Hansel

Delta Dental of Missouri Mailing Address: PO Box 8690, St. Louis, MO 63126 Customer Service:- Print Date: 06/11/2025 Please be advised member benefits and eligibility, pre-treatment estimates and claims are not available in real time and may be subject to delay. Member subscriber Group details Group name: NORTHWEST R-I SCHOOL DISTRICT DAVID OETJEN Subscriber ID:- Relationship: Self Group number: MO- Eligible Program type: Delta Dental (PPO) DOB: 11/03/XXXX Benefit cycle: Calendar Year 01/01 Pre-existing missing tooth clause: No Max advantage: No Ortho coverage: Yes Alternate benefits may apply COB type: Standard Enrollment effective date: 11/20/2024 Healthy Smiles Healthy Lives program: No Waiting period: No Age limits Special group details Dependent children covered: 26 None Full-time students covered: 26 Qualifying children covered: N Orthodontic age limit: No age limit. Additional orthodontic information: Orthodontic payment cycle: Quarterly Orthodontic treatment in progress rule: Ongoing orthodontic treatment considered for eligible members, when proof of prior coverage is submitted. If prior coverage is not available then 12 month wait applies. Member benefits is being provided for your convenience. Benefits described are not a guarantee of payment. All information provided is subject to change, and the subsequent submission of other claims as well as changes in eligibility, the member’s dental plan or the availability other coverage may impact the benefits available. Eligibility is not a guarantee of coverage, and benefit payment is determined when a claim is received. Plan summary Individual This table displays benefits for the member selected based on the selected member's benefit design Deductible Annual PPO Network Regular Met $50 | Rem $0 Periodontic SHARED Premier Network Total $50 Met $50 | Rem $0 SHARED 1 of 28 Out of Network Total $50 Met $50 | Rem $0 SHARED Total $50 Delta Dental of Missouri Maximum Annual PPO Network Premier Network Met $362.40 | Rem $1,337.60 Regular Periodontic Total $1700 Met $362.40 | Rem $637.60 SHARED Lifetime Total $1000 SHARED PPO Network Orthodontic Out of Network Met $362.40 | Rem $637.60 SHARED Premier Network Met $0 | Rem $1500 Total $1500 Total $1000 Out of Network Met $0 | Rem $1500 Total $1500 Met $0 | Rem $1500 Total $1500 Family Deductible Annual PPO Network Premier Network Regular Met $50 | Rem $100 Periodontic SHARED Total $150 Out of Network Met $50 | Rem $100 Total $150 SHARED Met $50 | Rem $100 Total $150 SHARED Benefit breakdown This table only includes codes that are part of the member's benefit plan design. Some codes are by report only and may be subject to clinical review or subject to Delta Dental Plans Association guidelines. The codes that are not part of the member's benefit plan design are not shown. The list of codes below is provided for your convenience. It is not meant to be an all-inclusive description of the coverage, limitations and exclusions under the member’s benefit plan and is not a guarantee of payment. All claims are processed in accordance with Delta Dental’s standard processing policies and may be subject to review. Alternate benefits may apply. PPO network Premier network Out of network Benefit grouping Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Preventative 100% NA 100% NA 100% NA Basic 90% Yes 70% Yes 70% Yes Major 60% Yes 50% Yes 50% Yes Orthodontics 50% NA 50% NA 50% NA Benefit Breakdown for Preventative PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period Frequency if applicable D0120 Periodic Oral Evaluation Established Patient 100% NA 100% NA 100% NA none 2 per Calendar Year D0140 Limited Oral Evaluation Problem Focused 100% NA 100% NA 100% NA none 2 per Calendar Year D0145 Oral Evaluation, Patient Under Three 100% NA 100% NA 100% NA none 2 per Calendar Year 2 of 28 Age limit, if applicable 3+ 0 to 2 Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period Frequency if applicable Age limit, if applicable D0150 Comprehensive Oral Evaluation - New Or Established Patient 100% NA 100% NA 100% NA none 2 per Calendar Year 3+ D0160 Detailed And Extensive Oral Evaluation - Problem Focused, By Report 100% NA 100% NA 100% NA none 2 per Calendar Year 3+ D0180 Comprehensive Periodontal Evaluation New Or Established Patient 100% NA 100% NA 100% NA none 2 per Calendar Year 3+ none 1 every 12 Months from the last date of service of the same treatment none 1 every 12 Months from the last date of service of the same treatment 1 every 36 Months from the last date of service of the same treatment D0190 Screening Of A Patient 100% 100% NA NA 100% 100% NA NA 100% 100% NA D0191 Assessment Of A Patient NA D0210 Intraoral – Comprehensive series of radiographic images 100% NA 100% NA 100% NA none D0220 Intraoral - Periapical First Radiographic Image 100% NA 100% NA 100% NA none D0230 Intraoral - Periapical Each Additional Image 100% NA 100% NA 100% NA none D0240 Intraoral - Occlusal Radiographic Image 100% NA 100% NA 100% NA none D0250 Extraoral - 2D Projection Radiographic image 100% NA 100% NA 100% NA none D0251 Extra-Oral Posterior Dental Radiographic Image 100% NA 100% NA 100% NA none D0270 Bitewing - Single Radiographic Image 100% NA 100% NA 100% NA none 2 per Calendar Year D0272 Bitewings - Two Radiographic Images 100% NA 100% NA 100% NA none 2 per Calendar Year D0273 Bitewings - Three Radiographic Images 100% NA 100% NA 100% NA none 2 per Calendar Year D0274 Bitewings - Four Radiographic Images 100% NA 100% NA 100% NA none 2 per Calendar Year D0277 Vertical Bitewings - 7 To 8 Radiographic Images 100% NA 100% NA 100% NA none 2 per Calendar Year 1 every 36 Months from the last date of service of the same treatment D0330 Panoramic Radiographic Image 100% NA 100% NA 100% NA none D0419 assessment of salivary flow by measurement 100% NA 100% NA 100% NA none D0460 Pulp Vitality Tests 100% NA 100% NA 100% NA none D0472 Accession Of Tissue, Gross Examination 100% NA 100% NA 100% NA none D0473 Accession Of Tissue, Gross And Microscopic Examination 100% NA 100% NA 100% NA none D0474 Accession Of Tissue, Gross And Microscopic Examination 100% NA 100% NA 100% NA none D0475 Decalcification Procedure 100% NA 100% NA 100% NA none D0476 Special Stains For Microorganisms 100% NA 100% NA 100% NA none D0477 Special Stains, Not For Microorganisms 100% NA 100% NA 100% NA none D0478 Immunohistochemical Stains 100% NA 100% NA 100% NA none 3 of 28 Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D0479 Tissue In-Situ Hybridization, Including Transmission 100% NA 100% NA 100% NA none D0480 Accession Of Exfoliative Cytologic Smears, Microscopic Examination 100% NA 100% NA 100% NA none D0481 Electron Microscopy 100% NA 100% NA 100% NA none D0482 Direct Immunofluorescence 100% NA 100% NA 100% NA none D0483 Indirect Immunofluorescence 100% NA 100% NA 100% NA none D0485 Consultation, Including Preparation Of Slides From Biopsy Material 100% NA 100% NA 100% NA none D0486 Accession Of Transepithelial Cytologic Sample, Microscopic Examination 100% NA 100% NA 100% NA none D0502 Other Pathology Procedures, By Report 100% NA 100% NA 100% NA none D0601 Caries Risk Assessment And Documentation, With A Finding of Low Risk D0602 Caries Risk Assessment And Documentation, With A Finding of Moderate Risk D0603 Caries Risk Assessment And Documentation, With A Finding of High Risk 100% NA 100% NA 100% D0999 Unspecified Diagnostic Procedures, By Report 100% NA 100% NA D1110 Prophylaxis - Adult 100% NA 100% D1120 Prophylaxis - Child 100% NA D1206 Topical Application Of Fluoride Varnish 100% D1208 Topical Application of Fluoride 100% D1351 Sealant - Per Tooth 100% 100% 100% none 3+ none 1 every 12 Months from the last date of service of the same treatment 3+ NA none 1 every 12 Months from the last date of service of the same treatment 3+ 100% NA none NA 100% NA none 2 per Calendar Year 14+ 100% NA 100% NA none 2 per Calendar Year 0 to 13 NA 100% NA 100% NA none 1 per Calendar Year 0 to 15 NA 100% NA 100% NA none 1 per Calendar Year 0 to 15 none 1 every 36 Months from the last date of service of the same treatment 0 to 15 1 every 24 Months from the last date of service of the same treatment 0 to 14 NA NA NA 100% 100% 100% NA NA NA 100% 100% 100% NA NA NA Preventive Resin Restoration 100% NA 100% NA 100% NA none D1353 Sealant Repair - Per Tooth 100% NA 100% NA 100% NA none D1354 Interim Caries Arresting Medicament Application per tooth D1510 D1516 Space Maintainer - Fixed Unilateral Space maintainer - fixed bilateral, maxillary. 100% 100% Age limit, if applicable 1 every 12 Months from the last date of service of the same treatment D1352 100% Frequency if applicable NA NA NA 100% 100% 100% NA NA NA 4 of 28 100% 100% 100% NA NA NA none 2 every 12 Months from the last date of service of the same treatment none 1 every 60 Months from the last date of service of the same treatment 0 to 15 none 1 every 60 Months from the last date of service of the same treatment 0 to 15 Other benefit limitations On first and second permanent caries free molars only. Delta Dental of Missouri PPO network Procedure code D1517 Procedure description Space maintainer - fixed bilateral, mandibular. Benefit level Premier network Deductible applies 100% NA Benefit level Deductible applies 100% Out of network Benefit level NA Deductible applies 100% NA Waiting period none 0 to 15 none 1 every 60 Months from the last date of service of the same treatment 0 to 15 none 1 every 60 Months from the last date of service of the same treatment 0 to 15 1 every 60 Months from the last date of service of the same treatment 0 to 15 0 to 8 Space Maintainer Removable - Unilateral D1526 Space maintainer removable – bilateral, maxillary. D1527 Space maintainer removable – bilateral, mandibular. 100% NA 100% NA 100% NA none D1551 re-cement or re-bond bilateral space maintainer – maxillary 100% NA 100% NA 100% NA none D1552 re-cement or re-bond bilateral space maintainer – mandibular 100% NA 100% NA 100% NA none D1553 re-cement or re-bond unilateral space maintainer – per quadrant 100% NA 100% NA 100% NA none D1556 removal of fixed unilateral space maintainer – per quadrant 100% NA 100% NA 100% NA none D1557 removal of fixed bilateral space maintainer – maxillary 100% NA 100% NA 100% NA none D1558 removal of fixed bilateral space maintainer – mandibular 100% NA 100% NA 100% NA none NA 100% 100% NA NA 100% 100% NA NA 100% NA Age limit, if applicable 1 every 60 Months from the last date of service of the same treatment D1520 100% Frequency if applicable D1575 Distal shoe space maintainer - fixed 100% NA 100% NA 100% NA none 1 every 60 Months from the last date of service of the same treatment D4355 Full Mouth Debridement 100% NA 100% NA 100% NA none 2 per Calendar Year D9110 Palliative treatment of dental pain – per visit 100% NA 100% NA 100% NA none Other benefit limitations Benefit Breakdown for Basic PPO network Procedure code D2140 D2150 Procedure description Amalgam - One Surface, Primary Or Permanent Amalgam - Two Surfaces, Primary Or Permanent Benefit level 90% 90% Deductible applies Yes Yes Premier network Benefit level 70% 70% Deductible applies Yes Yes 5 of 28 Out of network Benefit level 70% 70% Deductible applies Yes Yes Waiting period Frequency if applicable none 1 every 24 Months from the last date of service of the same treatment none 1 every 24 Months from the last date of service of the same treatment Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code D2160 D2161 D2330 D2331 D2332 D2335 D2391 D2392 D2393 D2394 D2921 D2930 Procedure description Amalgam - Three Surfaces, Primary Or Permanent Amalgam - Four Or More Surfaces, Primary Or Permanent Resin-Based Composite - One Surface, Anterior Resin-Based Composite - Two Surfaces, Anterior Resin-Based Composite - Three Surfaces, Anterior Resin-Based Composite - Four Or More Surfaces (Anterior) Resin-Based Composite - One Surface, Posterior Resin-Based Composite - Two Surfaces, Posterior Resin-Based Composite - Three Surfaces, Posterior Resin-Based Composite - Four Or More Surfaces, Posterior Reattachment Of Tooth Fragment, Incisal Edge Or Cusp Prefabricated Stainless Steel Crown - Primary Tooth Benefit level 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Premier network Benefit level 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 6 of 28 Out of network Benefit level 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% 70% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Waiting period Frequency if applicable Age limit, if applicable Other benefit limitations none 1 every 24 Months from the last date of service of the same treatment none 1 every 24 Months from the last date of service of the same treatment none 1 every 24 Months from the last date of service of the same treatment none 1 every 24 Months from the last date of service of the same treatment none 1 every 24 Months from the last date of service of the same treatment none 1 every 24 Months from the last date of service of the same treatment none 1 every 24 Months from the last date of service of the same treatment Covered as amalgam on molars. none 1 every 24 Months from the last date of service of the same treatment Covered as amalgam on molars. none 1 every 24 Months from the last date of service of the same treatment Covered as amalgam on molars. none 1 every 24 Months from the last date of service of the same treatment Covered as amalgam on molars. none 1 every 24 Months from the last date of service of the same treatment none 1 every 60 Months from the last date of service of the same treatment Delta Dental of Missouri PPO network Procedure code D2931 D2932 D2933 Procedure description Prefabricated Stainless Steel Crown - Permanent Tooth Prefabricated Resin Crown Prefabricated Stainless Steel Crown With Resin Window Benefit level 90% 90% 90% Deductible applies Yes Yes Yes Premier network Benefit level 70% 70% 70% Deductible applies Yes Yes Yes Out of network Benefit level 70% 70% 70% Deductible applies Yes Yes Yes Waiting period none 1 every 60 Months from the last date of service of the same treatment none 1 every 60 Months from the last date of service of the same treatment none 1 every 60 Months from the last date of service of the same treatment 1 every 60 Months from the last date of service of the same treatment D2934 Prefabricated Esthetic Coated Stainless Steel Crown - Primary Tooth 90% Yes 70% Yes 70% Yes none D2940 Protective Restoration 90% Yes 70% Yes 70% Yes none D2941 Interim Therapeutic Restoration - Primary Dentition 90% Yes 70% Yes 70% Yes none D2951 Pin Retention - Per Tooth, In Addition To Restoration 90% Yes 70% Yes 70% Yes none D2976 band stabilization – per tooth 90% Yes 70% Yes 70% Yes none D2999 Unspecified Restorative Procedure, By Report 90% Yes 70% Yes 70% Yes none Extraction, Coronal Remnants PrimaryTooth 90% Yes 70% Yes 70% Yes none D7140 Extraction, Erupted Tooth Or Exposed Root 90% Yes 70% Yes 70% Yes none D7210 Extraction, Erupted Tooth 90% Yes 70% Yes 70% Yes none D7220 Removal Of Impacted Tooth Soft Tissue 90% Yes 70% Yes 70% Yes none D7230 Removal Of Impacted Tooth Partially Bony 90% Yes 70% Yes 70% Yes none D7240 Removal Of Impacted Tooth Completely Bony 90% Yes 70% Yes 70% Yes none D7241 Removal Of Impacted Tooth Completely Bony, Unusual Surgical Complications 90% Yes 70% Yes 70% Yes none D7250 Removal Of Residual Tooth (Cutting Procedure) 90% Yes 70% Yes 70% Yes none D7251 Coronectomy - Intentional Partial Tooth Removal 90% Yes 70% Yes 70% Yes none D7252 partial extraction for immediate implant placement 90% Yes 70% Yes 70% Yes none D7260 Oroantral Fistula Closure 90% Yes 70% Yes 70% Yes none D7261 Primary Closure Of Sinus Perforation 90% Yes 70% Yes 70% Yes none D7270 Reimplantation And/Or Stabilization Of Accidentally Evulsed / Displaced Tooth 90% Yes 70% Yes 70% Yes none D7282 Mobilization Of Erupted Or Malpositioned Tooth To Aid Eruption 90% Yes 70% Yes 70% Yes none D7284 excisional biopsy of minor salivary glands 90% Yes 70% Yes 70% Yes none D7285 Incisional Biopsy Of Oral Tissue - Hard (Bone, Tooth) 90% Yes 70% Yes 70% Yes none D7286 Incisional Biopsy Of Oral Tissue - Soft 90% Yes 70% Yes 70% Yes none D7111 7 of 28 Frequency if applicable 1 per Lifetime 1 per Lifetime Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D7287 Exfoliative Cytological Sample Collection 90% Yes 70% Yes 70% Yes none D7288 Brush Biopsy - Transepithelial Sample Collection 90% Yes 70% Yes 70% Yes none D7290 Surgical Repositioning Of Teeth 90% Yes 70% Yes 70% Yes none D7291 Transseptal Fiberotomy/Supra Crestal Fiberotomy, By Report 90% Yes 70% Yes 70% Yes none D7310 Alveoloplasty In Conjunction With Extractions - Four Or More Teeth 90% Yes 70% Yes 70% Yes none D7311 Alveoloplasty In Conjunction With Extractions - One To Three Teeth 90% Yes 70% Yes 70% Yes none D7320 Alveoloplasty Not In Conjunction With Extractions Four Or More Teeth 90% Yes 70% Yes 70% Yes none D7321 Alveoloplasty Not In Conjunction With Extractions One To Three Teeth 90% Yes 70% Yes 70% Yes none D7340 Vestibuloplasty - Ridge Extension (Secondary Epithelialization) 90% Yes 70% Yes 70% Yes none D7350 Vesibuloplasty - Ridge Extension (Including Soft Tissue Grafts) 90% Yes 70% Yes 70% Yes none D7410 Excision Of Benign Lesion Up To 1.25 Cm 90% Yes 70% Yes 70% Yes none D7411 Excision Of Benign Lesion Greater Than 1.25 Cm 90% Yes 70% Yes 70% Yes none D7412 Excision Of Benign Lesion, Complicated 90% Yes 70% Yes 70% Yes none D7413 Excision Of Malignant Lesion Up To 1.25 Cm 90% Yes 70% Yes 70% Yes none D7414 Excision Of Malignant Lesion Greater Than 1.25 Cm 90% Yes 70% Yes 70% Yes none D7415 Excision Of Malignant Lesion, Complicated 90% Yes 70% Yes 70% Yes none D7440 Excision Of Malignant Tumor Lesion Diameter Up To 1.25 Cm 90% Yes 70% Yes 70% Yes none D7441 Excision Of Malignant Tumor Lesion Diameter Greater Than 1.25 Cm 90% Yes 70% Yes 70% Yes none D7450 Removal Of Benign Odontogenic Cyst Or Tumor Dia Up To 1.25 Cm 90% Yes 70% Yes 70% Yes none D7451 Removal Of Benign Odontogenic Cyst Or Tumor Dia Greater Than 1.25 Cm 90% Yes 70% Yes 70% Yes none D7460 Removal Of Benign Nonodontogenic Cyst Or Tumor - Dia Up To 1.25 Cm 90% Yes 70% Yes 70% Yes none D7461 Removal Of Benign Nonodontogenic Cyst Or Tumor - Dia Greater Than 1.25 Cm 90% Yes 70% Yes 70% Yes none D7465 Destruction Of Lesion(S) By Physical Or Chemical Method, By Report 90% Yes 70% Yes 70% Yes none D7471 Removal Of Lateral Exostosis (Maxilla Or Mandible) 90% Yes 70% Yes 70% Yes none D7472 Removal Of Torus Palatinus 90% Yes 70% Yes 70% Yes none D7473 Removal Of Torus Mandibularis 90% Yes 70% Yes 70% Yes none D7485 Reduction Of Osseous Tuberosity 90% Yes 70% Yes 70% Yes none D7510 Incision And Drainage Of Abscess - Intraoral Soft Tissue 90% Yes 70% Yes 70% Yes none 8 of 28 Frequency if applicable Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D7511 Incision And Drainage Of Abscess - Intraoral Soft Tissue Complicated 90% Yes 70% Yes 70% Yes none D7520 Incision And Drainage Of Abscess - Extraoral Soft Tissue 90% Yes 70% Yes 70% Yes none D7521 Incision And Drainage Of Abscess - Extraoral Soft Tissue - Complicated 90% Yes 70% Yes 70% Yes none D7530 Removal Of Foreign Body From Mucosa 90% Yes 70% Yes 70% Yes none D7540 Removal Of Reaction Producing Foreign Bodies 90% Yes 70% Yes 70% Yes none D7550 Partial Ostectomy/Sequestrectomy For Removal Of Non-Vital Bone 90% Yes 70% Yes 70% Yes none D7560 Maxillary Sinusotomy For Removal Of Tooth Fragment Or Foreign Body 90% Yes 70% Yes 70% Yes none D7610 Maxilla - Open Reduction (Teeth Immobilized, If Present) 90% Yes 70% Yes 70% Yes none D7620 Maxilla - Closed Reduction (Teeth Immobilized, If Present) 90% Yes 70% Yes 70% Yes none D7630 Mandible - Open Reduction (Teeth Immobilized, If Present) 90% Yes 70% Yes 70% Yes none D7640 Mandible - Closed Reduction (Teeth Immobilized, If Present) 90% Yes 70% Yes 70% Yes none D7650 Malar And/Or Zygomatic Arch Open Reduction 90% Yes 70% Yes 70% Yes none D7660 Malar And/Or Zygomatic Arch Closed Reduction 90% Yes 70% Yes 70% Yes none D7670 Alveolus - Closed Reduction, May Include Stabilization Of Teeth 90% Yes 70% Yes 70% Yes none D7671 Alveolus - Open Reduction, May Include Stabilization Of Teeth 90% Yes 70% Yes 70% Yes none D7680 Facial Bones - Complicated Reduction With Fixation And Multiple Surgical 90% Yes 70% Yes 70% Yes none D7710 Maxilla - Open Reduction 90% Yes 70% Yes 70% Yes none D7720 Maxilla - Closed Reduction 90% Yes 70% Yes 70% Yes none D7730 Mandible - Open Reduction 90% Yes 70% Yes 70% Yes none D7740 Mandible - Closed Reduction 90% Yes 70% Yes 70% Yes none D7750 Malar And/Or Zygomatic Arch Open Reduction 90% Yes 70% Yes 70% Yes none D7760 Malar And/Or Zygomatic Arch Closed Reduction 90% Yes 70% Yes 70% Yes none D7770 Alveolus - Open Reduction Stabilization Of Teeth 90% Yes 70% Yes 70% Yes none D7771 Alveolus - Closed Reduction Stabilization Of Teeth 90% Yes 70% Yes 70% Yes none D7780 Facial Bones - Complicated Reduction With Fixation And Multiple Approaches 90% Yes 70% Yes 70% Yes none D7910 Suture Of Recent Small Wounds Up To 5 Cm 90% Yes 70% Yes 70% Yes none D7911 Complicated Suture - Up To 5 Cm 90% Yes 70% Yes 70% Yes none D7912 Complicated Suture - Greater Than 5 Cm 90% Yes 70% Yes 70% Yes none D7961 buccal / labial frenectomy (frenulectomy) 90% Yes 70% Yes 70% Yes none D7962 lingual frenectomy (frenulectomy) 90% Yes 70% Yes 70% Yes none D7963 Frenuloplasty 90% Yes 70% Yes 70% Yes none 9 of 28 Frequency if applicable Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D7970 Excision Of Hyperplastic Tissue - Per Arch 90% Yes 70% Yes 70% Yes none D7971 Excision Of Pericoronal Gingiva 90% Yes 70% Yes 70% Yes none D7972 Surgical Reduction Of Fibrous Tuberosity 90% Yes 70% Yes 70% Yes none D7979 Non-Surgical Sialolithotomy 90% Yes 70% Yes 70% Yes none D7980 Surgical Sialolithotomy 90% Yes 70% Yes 70% Yes none D7981 Excision Of Salivary Gland, By Report 90% Yes 70% Yes 70% Yes none D7982 Sialodochoplasty 90% Yes 70% Yes 70% Yes none D7983 Closure Of Salivary Fistula 90% Yes 70% Yes 70% Yes none D7991 Coronoidectomy 90% Yes 70% Yes 70% Yes none D7999 Unspecified Oral Surgery Procedure, By Report 90% Yes 70% Yes 70% Yes none D9610 Therapeutic Parenteral Drug, Single Administration 90% Yes 70% Yes 70% Yes none D9612 Therapeutic Parenteral Drugs, Two Or More Administrations 90% Yes 70% Yes 70% Yes none D9930 Treatment Of Complications (Post Surgical) - Unusual Circumstances, By Report 90% Yes 70% Yes 70% Yes none D9951 Occlusal Adjustment - Limited 90% Yes 70% Yes 70% Yes none D9999 Unspecified Adjunctive Procedure, By Report 90% Yes 70% Yes 70% Yes none Frequency if applicable Age limit, if applicable Other benefit limitations 1 per Calendar Year Benefit Breakdown for Major PPO network Procedure code D2390 D2410 D2420 D2430 D2542 D2543 Procedure description Resin-Based Composite Crown, Anterior Gold Foil - 1 Surface Gold Foil - 2 Surfaces Gold Foil - 3 Surfaces Onlay - Metallic - Two Surfaces Onlay - Metallic - Three Surfaces Benefit level 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes 10 of 28 Out of network Benefit level 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Waiting period Frequency if applicable Age limit, if applicable none 1 every 60 Months from the last date of service of the same treatment none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ Other benefit limitations Delta Dental of Missouri PPO network Procedure code D2544 D2642 D2643 D2644 D2662 Procedure description Onlay - Metallic - Four Or More Surfaces Onlay - Porcelain/Ceramic Two Surfaces Onlay - Porcelain/Ceramic Three Surfaces Onlay - Porcelain/Ceramic Four Or More Surfaces Onlay - Resin-Based Composite - Two Surfaces D2663 Onlay - Resin-Based Composite - Three Surfaces D2664 Onlay - Resin-Based Composite - Four Or More Surfaces D2710 D2712 D2720 D2721 D2722 D2740 D2750 Crown - Resin-Based Composite (Indirect) Crown - 3/4 Resin-Based Composite (Indirect) Crown - Resin With High Noble Metal Crown - Resin With Predominantly Base Metal Crown - Resin With Noble Metal Crown - Porcelain/Ceramic Crown - Porcelain Fused To High Noble Metal Benefit level 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 11 of 28 Out of network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Waiting period Frequency if applicable Age limit, if applicable none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ Other benefit limitations Delta Dental of Missouri PPO network Procedure code D2751 D2752 D2753 D2780 D2781 D2782 D2783 D2790 D2791 D2792 Procedure description Crown - Porcelain Fused To Predominantly Base Metal Crown - Porcelain Fused To Noble Metal crown - porcelain fused to titanium or titanium alloy Crown - 3/4 Cast High Noble Metal Crown - 3/4 Cast Predominantly Base Metal Crown - 3/4 Cast Noble Metal Crown - 3/4 Porcelain/Ceramic Crown - Full Cast High Noble Metal Crown - Full Cast Predominantly Base Metal Crown - Full Cast Noble Metal Benefit level 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Out of network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Waiting period Frequency if applicable none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ 1 every 60 Months from the last date of service of the same treatment 12+ D2794 Crown - Titanium 60% Yes 50% Yes 50% Yes none D2910 Re-Cement Or Re-Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration 60% Yes 50% Yes 50% Yes none D2915 Re-Cement or Re-Bond Cast Indirectly Fabricated Or Pre-Fabricated Post and Core 60% Yes 50% Yes 50% Yes none D2920 Re-Cement or Re-Bond Crown 60% Yes 50% Yes 50% Yes none D2928 prefabricated porcelain/ceramic crown – permanent tooth 60% Yes 50% Yes 50% Yes none 1 every 60 Months from the last date of service of the same treatment D2929 Prefabricated Porcelain / Ceramic Crown - Primary Tooth 60% Yes 50% Yes 50% Yes none 1 per Lifetime 12 of 28 Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D2950 Core Buildup, Including Any Pins When Required 60% Yes 50% Yes 50% Yes none D2952 Post And Core In Addition To Crown, Indirectly Fabricated 60% Yes 50% Yes 50% Yes none D2953 Each Additional Indirectly Fabricated Post - Same Tooth 60% Yes 50% Yes 50% Yes none D2954 Prefabricated Post And Core In Addition To Crown 60% Yes 50% Yes 50% Yes none D2955 Post Removal 60% Yes 50% Yes 50% Yes none D2957 Each Additional Prefabricated Post - Same Tooth 60% Yes 50% Yes 50% Yes none D2960 D2961 Labial Veneer (Resin Laminate) - Chairside Labial Veneer (Resin Laminate) - Laboratory 60% 60% Yes Yes 50% 50% Yes Yes 50% 50% Yes Yes Age limit, if applicable none 1 every 60 Months from the last date of service of the same treatment 12+ none 1 every 60 Months from the last date of service of the same treatment 12+ 1 every 60 Months from the last date of service of the same treatment 12+ D2962 Labial Veneer (Porcelain Laminate) - Laboratory 60% Yes 50% Yes 50% Yes none D2971 Additional Procedures To Construct New Crown Under Existing Partial 60% Yes 50% Yes 50% Yes none D2980 Crown Repair 60% Yes 50% Yes 50% Yes none D2981 Inlay Repair 60% Yes 50% Yes 50% Yes none D2982 Onlay Repair 60% Yes 50% Yes 50% Yes none D2983 Veneer Repair 60% Yes 50% Yes 50% Yes none D3110 Pulp Cap - Direct (Excluding Final Restoration) 60% Yes 50% Yes 50% Yes none D3120 Pulp Cap - Indirect (Excluding Final Restoration) 60% Yes 50% Yes 50% Yes none D3220 Therapeutic Pulpotomy 60% Yes 50% Yes 50% Yes none D3221 Pulpal Debridement Primary And Permanent Teeth 60% Yes 50% Yes 50% Yes none D3222 Partial Pulpotomy For Apexogenesis - Permanent Tooth 60% Yes 50% Yes 50% Yes none D3230 Pulpal Therapy (Resorbable Filling) - Anterior, Primary Tooth 60% Yes 50% Yes 50% Yes none D3240 Pulpal Therapy (Resorbable Filling) - Posterior, Primary Tooth 60% Yes 50% Yes 50% Yes none D3310 Endodontic Therapy, Anterior Tooth (Excluding Final Restoration) 60% Yes 50% Yes 50% Yes none D3320 Endodontic Therapy Premolar Tooth (Excluding Final Restoration) 60% Yes 50% Yes 50% Yes none D3330 Endodontic Therapy, Molar tooth (Excluding Final Restoration) 60% Yes 50% Yes 50% Yes none D3331 Treatment Of Root Canal Obstruction; Non-Surgical Access 60% Yes 50% Yes 50% Yes none D3332 Incomplete Endodontic Therapy 60% Yes 50% Yes 50% Yes none 13 of 28 Frequency if applicable Other benefit limitations Delta Dental of Missouri PPO network Premier network Out of network Procedure code Procedure description Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D3333 Internal Root Repair Of Perforation Defects 60% Yes 50% Yes 50% Yes none D3346 Retreatment Of Previous Root Canal Therapy Anterior 60% Yes 50% Yes 50% Yes none D3347 Retreatment Of Previous Root Canal Therapy Premolar 60% Yes 50% Yes 50% Yes none D3348 Retreatment Of Previous Root Canal Therapy - Molar 60% Yes 50% Yes 50% Yes none D3351 Apexification / Recalcification - Initial Visit 60% Yes 50% Yes 50% Yes none D3352 Apexification / Recalcification - Interim 60% Yes 50% Yes 50% Yes none D3353 Apexification / Recalcification - Final Visit 60% Yes 50% Yes 50% Yes none D3410 Apicoectomy - Anterior 60% Yes 50% Yes 50% Yes none D3421 Apicoectomy - Premolar (First Root) 60% Yes 50% Yes 50% Yes none D3425 Apicoectomy - Molar (First Root) 60% Yes 50% Yes 50% Yes none D3426 Apicoectomy - Each Additional Root) 60% Yes 50% Yes 50% Yes none D3428 Bone Graft In Conjunction With Periradicular Surgery Per Tooth, Single Site 60% Yes 50% Yes 50% Yes none D3429 Bone Graft In Conjunction With Periradicular Surgery Each Additional Tooth 60% Yes 50% Yes 50% Yes none D3430 Retrograde Filling - Per Root 60% Yes 50% Yes 50% Yes none D3450 Root Amputation - Per Root 60% Yes 50% Yes 50% Yes none D3470 Intentional Reimplantation (Including Necessary Splinting) 60% Yes 50% Yes 50% Yes none D3471 surgical repair of root resorption - anterior 60% Yes 50% Yes 50% Yes none D3472 surgical repair of root resorption – premolar 60% Yes 50% Yes 50% Yes none D3473 surgical repair of root resorption – molar 60% Yes 50% Yes 50% Yes none D3501 surgical exposure of root surface without apicoectomy or repair of root resorpti 60% Yes 50% Yes 50% Yes none D3502 surgical exposure of root surface without apico– premolar 60% Yes 50% Yes 50% Yes none D3503 surgical exposure of root surface without apico – molar 60% Yes 50% Yes 50% Yes none D3910 Surgical Procedure For Isolation Of Tooth With Rubber Dam 60% Yes 50% Yes 50% Yes none D3920 Hemisection (Including Any Root Removal), Not Including Root Canal Therapy 60% Yes 50% Yes 50% Yes none D3921 Decoronation or submergence of an erupted tooth 60% Yes 50% Yes 50% Yes none D3950 Canal Preparation And Fitting Of Preformed Dowel Or Post 60% Yes 50% Yes 50% Yes none D3999 Unspecified Endodontic Procedure, By Report 60% Yes 50% Yes 50% Yes none 14 of 28 Frequency if applicable Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D4210 Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth 60% Yes 50% Yes 50% Yes none D4211 Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth 60% Yes 50% Yes 50% Yes none D4240 Gingival Flap Procedure, Including Root Planing Four Or More Contiguous Teeth 60% Yes 50% Yes 50% Yes none D4241 Gingival Flap Procedure, Including Root Planing One To Three Contiguous Teeth 60% Yes 50% Yes 50% Yes none D4245 Apically Positioned Flap 60% Yes 50% Yes 50% Yes none D4249 Clinical Crown Lengthening - Hard Tissue 60% Yes 50% Yes 50% Yes none D4260 Osseous Surgery (Including Flap And Closure) - Four Or More Teeth 60% Yes 50% Yes 50% Yes none D4261 Osseous Surgery (Including Flap And Closure) - One To Three Teeth 60% Yes 50% Yes 50% Yes none D4263 Bone Replacement Graft First Site In Quadrant 60% Yes 50% Yes 50% Yes none D4264 Bone Replacement Graft Each Additional Site In Quadrant 60% Yes 50% Yes 50% Yes none D4265 Biologic Materials To Aid In Soft And Osseous Tissue Regeneration 60% Yes 50% Yes 50% Yes none D4266 Guided tissue regeneration, natural teeth – resorbable barrier, per site 60% Yes 50% Yes 50% Yes none D4267 Guided tissue regeneration, natural teeth – nonresorbable barrier, per site 60% Yes 50% Yes 50% Yes none D4268 Surgical Revision Procedure, Per Tooth 60% Yes 50% Yes 50% Yes none D4270 Pedicle Soft Tissue Graft Procedure 60% Yes 50% Yes 50% Yes none D4273 Autogenous Connective Tissue Graft Proc, First Tooth, Implant Or Tooth Position 60% Yes 50% Yes 50% Yes none D4274 Distal Or Proximal Wedge Procedure 60% Yes 50% Yes 50% Yes none D4275 Non-Autogenous Connective Tissue Graft, First Tooth, Implant Or Tooth Position 60% Yes 50% Yes 50% Yes none D4276 Combined Connective Tissue And Double Pedicle Graft, Per Tooth 60% Yes 50% Yes 50% Yes none D4277 Free Soft Tissue Graft Procedure (Including Donor Site Surgery) First 60% Yes 50% Yes 50% Yes none D4278 Free Soft Tissue Graft Procedure (Including Donor Site Surgery) Each Additional 60% Yes 50% Yes 50% Yes none D4283 Autogenous Connective Tissue Graft Procedures, Each Additional 60% Yes 50% Yes 50% Yes none D4285 Non-Autogenous Connective Tissue Graft, Each Additional 60% Yes 50% Yes 50% Yes none D4286 removal of non-resorbable barrier 60% Yes 50% Yes 50% Yes none 15 of 28 Frequency if applicable Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period Frequency if applicable D4322 Splint intra-coronal; natural teeth or prosthetic crowns 60% Yes 50% Yes 50% Yes none D4323 Splint extra-coronal; natural teeth or prosthetic crowns 60% Yes 50% Yes 50% Yes none D4341 Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant 60% Yes 50% Yes 50% Yes none D4342 Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant 60% Yes 50% Yes 50% Yes none D4346 Scaling in moderate or severe gingival inflammation 60% Yes 50% Yes 50% Yes none 2 per Calendar Year D4910 Periodontal Maintenance 60% Yes 50% Yes 50% Yes none 2 per Calendar Year D4920 Unscheduled Dressing Change (By Someone Other Than Treating Dentist Or Staff) 60% Yes 50% Yes 50% Yes none D4999 Unspecified Periodontal Procedure, By Report 60% Yes 50% Yes 50% Yes none D5110 D5120 D5130 D5140 D5211 Complete Denture Maxillary Complete Denture Mandibular Immediate Denture Maxillary Immediate Denture Mandibular Maxillary Partial Denture Resin Base D5212 Mandibular Partial Denture - Resin Base D5213 Maxillary Partial Denture Cast Metal Framework With Resin Denture Bases D5214 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases D5221 D5222 Maxillary Partial Denture Resin Base Mandibular Partial Denture - Resin Base 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 16 of 28 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Age limit, if applicable none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description D5223 Maxillary Partial Denture Cast Metal Framework With Resin Denture Bases D5224 Mandibular Partial Denture - Cast Metal Framework With Resin Denture Bases D5225 D5226 Maxillary Partial Denture Flexible Base Mandibular Partial Denture - Flexible Base Benefit level 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Out of network Benefit level 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Waiting period none 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ 1 every 60 Months from the last date of service of the same treatment 16+ Immediate maxillary partial denture - flexible base D5228 Immediate mandibular partial denture - flexible base D5282 Removable maxillary unilateral partial denture cast metal. D5283 Removable mandibular unilateral partial denture cast metal. D5284 Removable unilateral partial denture flexible base - per quadrant D5286 Removable unilateral partial denture resin - per quadrant 60% Yes 50% Yes 50% Yes none D5410 Adjust Complete Denture Maxillary 60% Yes 50% Yes 50% Yes none D5411 Adjust Complete Denture Mandibular 60% Yes 50% Yes 50% Yes none D5421 Adjust Partial Denture Maxillary 60% Yes 50% Yes 50% Yes none D5422 Adjust Partial Denture Mandibular 60% Yes 50% Yes 50% Yes none D5511 Repair Broken Complete Denture Base - Mandibular 60% Yes 50% Yes 50% Yes none D5512 Repair Broken Complete Denture Base - Maxillary 60% Yes 50% Yes 50% Yes none D5520 Replace Missing Or Broken Teeth - Complete Denture (Each Tooth) 60% Yes 50% Yes 50% Yes none D5610 Repair resin denture base 60% Yes 50% Yes 50% Yes none D5611 Repair Resin Partial Denture Base - Mandibular 60% Yes 50% Yes 50% Yes none D5612 Repair Resin Partial Denture Base - Maxillary 60% Yes 50% Yes 50% Yes none D5620 Repair cast framework 60% Yes 50% Yes 50% Yes none 60% 60% 60% 60% Yes Yes Yes Yes Yes 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes 17 of 28 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Age limit, if applicable 1 every 60 Months from the last date of service of the same treatment D5227 60% Frequency if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D5621 Repair Cast Partial Framework - Mandibular 60% Yes 50% Yes 50% Yes none D5622 Repair Cast Partial Framework - Maxillary 60% Yes 50% Yes 50% Yes none D5630 Repair Or Replace Broken Clasp - Per Tooth 60% Yes 50% Yes 50% Yes none D5640 Replace Broken Teeth - Per Tooth 60% Yes 50% Yes 50% Yes none D5650 Add Tooth To Existing Partial Denture 60% Yes 50% Yes 50% Yes none D5660 Add Clasp To Existing Partial Denture - Per Tooth 60% Yes 50% Yes 50% Yes none D5670 Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary) 60% Yes 50% Yes 50% Yes none D5671 Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular) 60% Yes 50% Yes 50% Yes none D5710 Rebase Complete Maxillary Denture 60% Yes 50% Yes 50% Yes none D5711 Rebase Complete Mandibular Denture 60% Yes 50% Yes 50% Yes none D5720 Rebase Maxillary Partial Denture 60% Yes 50% Yes 50% Yes none D5721 Rebase Mandibular Partial Denture 60% Yes 50% Yes 50% Yes none D5725 Rebase hybrid prosthesis 60% Yes 50% Yes 50% Yes none D5730 Reline Complete Maxillary Denture (Chairside) 60% Yes 50% Yes 50% Yes none D5731 Reline Complete Mandibular Denture (Chairside) 60% Yes 50% Yes 50% Yes none D5740 Reline Maxillary Partial Denture (Chairside) 60% Yes 50% Yes 50% Yes none D5741 Reline Mandibular Partial Denture (Chairside) 60% Yes 50% Yes 50% Yes none D5750 Reline Complete Maxillary Denture (Laboratory) 60% Yes 50% Yes 50% Yes none D5751 Reline Complete Mandibular Denture (Laboratory) 60% Yes 50% Yes 50% Yes none D5760 Reline Maxillary Partial Denture (Laboratory) 60% Yes 50% Yes 50% Yes none D5761 Reline Mandibular Partial Denture (Laboratory) 60% Yes 50% Yes 50% Yes none D5765 Soft liner for complete or partial remove denture indirect 60% Yes 50% Yes 50% Yes none D5850 Tissue Conditioning, Maxillary 60% Yes 50% Yes 50% Yes none D5851 Tissue Conditioning, Mandibular 60% Yes 50% Yes 50% Yes none D5862 Precision Attachment, By Report 60% Yes 50% Yes 50% Yes none D5867 Replacement Of Replaceable Part Of SemiPrecision Or Precision Attachment 60% Yes 50% Yes 50% Yes none D5899 Unspecified Removable Prosthodontic Procedure, By Report 60% Yes 50% Yes 50% Yes none D5999 Unspecified Maxillofacial Prosthesis, By Report 60% Yes 50% Yes 50% Yes none 18 of 28 Frequency if applicable Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code D6010 D6013 D6040 Procedure description Surgical Placement Of Implant Body: Endosteal Implant Surgical Placement Of Mini Implant Surgical Placement: Eposteal Implant Benefit level 60% 60% 60% Deductible applies Yes Yes Yes Premier network Benefit level 50% 50% 50% Deductible applies Yes Yes Yes Out of network Benefit level 50% 50% 50% Deductible applies Yes Yes Yes Waiting period none 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ Surgical Placement: Transosteal Implant 60% Yes 50% Yes 50% Yes none D6055 Connecting Bar - Implant Supported Or Abutment Supported 60% Yes 50% Yes 50% Yes none D6056 Prefabricated Abutment Includes Modification And Placement D6057 Custom Fabricated Abutment - Includes Placement D6058 Abutment Supported Porcelain/Ceramic Crown D6059 Abutment Supported Porcelain Fused To Metal Crown (High Noble Metal) D6060 Abutment Supported Porcelain Fused To Metal Crown (Predominantly Base Metal) D6061 Abutment Supported Porcelain Fused To Metal Crown (Noble Metal) D6062 Abutment Supported Cast Metal Crown (High Noble Metal) D6063 Abutment Supported Cast Metal Crown (Predominantly Base Metal) D6064 D6065 Abutment Supported Cast Metal Crown (Noble Metal) Implant Supported Porcelain/Ceramic Crown 60% 60% 60% 60% 60% 60% 60% 60% 60% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 19 of 28 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Age limit, if applicable 1 every 60 Months from the last date of service of the same treatment D6050 60% Frequency if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code D6066 Procedure description Implant Supported Porcelain Fused To Metal Crown D6067 Implant Supported Metal Crown D6068 Abutment Supported Retainer For Porcelain/Ceramic Fpd D6069 Abutment Supported Retainer For Porcelain Fused To Metal Fpd (High Noble Metal) D6070 Abutment Supported Retainer For Porcelain Fused To Metal Fpd (Base Metal) D6071 Abutment Supported Retainer For Porcelain Fused To Metal Fpd (Noble Metal) D6072 Abutment Supported Retainer For Cast Metal Fpd (High Noble Metal) D6073 Abutment Supported Retainer For Cast Metal Fpd (Base Metal) D6074 Abutment Supported Retainer For Cast Metal Fpd (Noble Metal) D6075 Implant Supported Retainer For Ceramic Fpd D6076 Implant Supported Retainer For Porcelain Fused To Metal Fpd Benefit level 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Out of network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Waiting period none 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ 1 every 36 Months from the last date of service of the same treatment 16+ 1 every 60 Months from the last date of service of the same treatment 16+ Implant Supported Retainer For Cast Metal Fpd D6080 Implant Maintenance Procedures, Including Removal And Reinsertion Of Prosthesis 60% Yes 50% Yes 50% Yes none D6081 Scaling and debridement 60% Yes 50% Yes 50% Yes none D6082 Implant supported crown porcelain fused to base alloys 60% Yes Yes 50% 50% Yes Yes 20 of 28 50% 50% Yes Yes Age limit, if applicable 1 every 60 Months from the last date of service of the same treatment D6077 60% Frequency if applicable none Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description D6083 implant supported crown porcelain fused to noble alloys D6084 implant supported crown porcelain fused to titanium or titanium alloy D6086 D6087 implant supported crown predominantly base alloys implant supported crown noble alloys D6088 implant supported crown titanium/titanium alloys D6089 accessing and retorquing loose implant screw - per screw Benefit level 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Out of network Benefit level 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Waiting period none 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 24 Months from the last date of service of the same treatment 16+ 1 every 24 Months from the last date of service of the same treatment 16+ 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ 1 every 60 Months from the last date of service of the same treatment 16+ Repair Implant Supported Prosthesis, By Report 60% Yes 50% Yes 50% Yes none D6091 Replacement Of SemiPrecision Or Precision Attachment 60% Yes 50% Yes 50% Yes none D6092 Re-Cement Or Re-Bond Implant/Abutment Supported Crown 60% Yes 50% Yes 50% Yes none D6093 Re-Cement Or Re-Bond Implant/Abutment Supported Fixed Partial Denture 60% Yes 50% Yes 50% Yes none D6094 Abutment Supported Crown (Titanium) 60% Yes 50% Yes 50% Yes none D6095 Repair Implant Abutment, By Report 60% Yes 50% Yes 50% Yes none D6096 Remove Broken Implant Retaining Screw 60% Yes 50% Yes 50% Yes none D6097 abutment supported crown - porcelain fused to titanium or titanium alloys D6098 Implant support retainer metal FPD porcelain fused to base alloy D6099 implant supported retainer for metal FPD - porcelain fused to noble alloys 60% Yes 50% Yes 50% Yes none D6100 Implant Removal, By Report 60% Yes 50% Yes 50% Yes none 60% Yes Yes 50% 50% Yes Yes 21 of 28 50% 50% Yes Yes Age limit, if applicable 1 every 60 Months from the last date of service of the same treatment D6090 60% Frequency if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period Frequency if applicable Age limit, if applicable D6101 Debridement Of A PeriImplant Defect And Surface Cleaning 60% Yes 50% Yes 50% Yes none D6102 Debridement/Osseous Contouring Of Peri-Implant Defect; Includes Surface Cleaning 60% Yes 50% Yes 50% Yes none D6103 Bone Graft For Repair Of Peri-Implant Defect - Not Including Flap Entry/Closure 60% Yes 50% Yes 50% Yes none D6104 Bone Graft At Time Of Implant Placement 60% Yes 50% Yes 50% Yes none D6105 removal of implant body not requiring bone removal or flap elevation 60% Yes 50% Yes 50% Yes none 1 per Lifetime 16+ D6110 Implant/Abutment Supported Removable Denture For Edentulous Maxillary Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6111 Implant/Abutment Supported Removable Denture For Edentulous Mandibular Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6112 Implant/Abutment Supported Removable Denture-Partially Edentulous Maxillary Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6113 Implant/Abutment Supported Removable Denture-Partially Edentulous Mand. Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6114 Implant/Abutment Supported Fixed Denture For Edentulous Maxillary Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6115 Implant/Abutment Supported Fixed Denture For Edentulous Mandibular Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6116 Implant/Abutment Supported Fixed DenturePartially Edentulous Maxillary Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6117 Implant/Abutment Supported Fixed DenturePartially Edentulous Mandibular Arch none 1 every 60 Months from the last date of service of the same treatment 16+ D6120 Implant support retainer porcelain fused titanium/titanium alloy none 1 every 60 Months from the last date of service of the same treatment 16+ D6121 Implant support retainer for metal FPD predominantly base alloys none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ D6122 Implant supported retainer for metal FPD noble alloys 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 22 of 28 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description D6123 Implant supported retainer for metal FPD titanium/titanium alloy D6180 implant maintenance of fixed hybrid prosthesis and abutments without removal Benefit level 60% 60% Deductible applies Yes Yes Premier network Benefit level 50% 50% Deductible applies Yes Yes Out of network Benefit level 50% 50% Deductible applies Yes Yes Waiting period none 16+ none 1 every 36 Months from the last date of service of the same treatment 16+ none 1 every 24 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ 1 every 24 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ replacement of an implant screw D6194 Abutment Supported Retainer Crown For Fpd (Titanium) D6195 Abutment support retainer porcelain fused titanium/titanium alloy D6197 replacement of restorative material used to close an access opening 60% Yes 50% Yes 50% Yes none D6199 Unspecified Implant Procedure, By Report 60% Yes 50% Yes 50% Yes none D6205 D6210 D6211 D6212 D6214 D6240 D6241 D6242 Pontic - Indirect Resin Based Composite Pontic - Cast High Noble Metal Pontic - Cast Predominantly Base Metal Pontic - Cast Noble Metal Pontic - Titanium Pontic - Porcelain Fused To High Noble Metal Pontic - Porcelain Fused To Predominantly Base Metal Pontic - Porcelain Fused To Noble Metal 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 23 of 28 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Age limit, if applicable 1 every 60 Months from the last date of service of the same treatment D6193 60% Frequency if applicable Other benefit limitations Delta Dental of Missouri PPO network Procedure code D6243 D6245 D6250 D6251 Procedure description Pontic - porcelain fused to titanium or titanium alloys Pontic - Porcelain/Ceramic Pontic - Resin With High Noble Metal Pontic - Resin With Predominantly Base Metal D6252 Pontic - Resin With Noble Metal D6545 Retainer - Cast Metal For Resin Bonded Fixed Prosthesis D6548 Retainer Porcelain/Ceramic For Resin Bonded Fixed Prosthesis D6549 Resin Retainer - For Resin Bonded Fixed Prosthesis D6600 Retainer Inlay Porcelain/Ceramic, Two Surfaces D6601 Retainer Inlay Porcelain/Ceramic, Three Or More Surfaces D6602 Retainer Inlay - Cast High Noble Metal, Two Surfaces D6603 Retainer Inlay - Cast High Noble Metal, Three Or More Surfaces D6604 Retainer Inlay - Cast Predominantly Base Metal, Two Surfaces D6605 Retainer Inlay - Cast Predominantly Base Metal, Three Or More Surfaces Benefit level 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 24 of 28 Out of network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Waiting period Frequency if applicable Age limit, if applicable none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ Other benefit limitations Delta Dental of Missouri PPO network Procedure code Procedure description D6606 Retainer Inlay - Cast Noble Metal, Two Surfaces D6607 Retainer Inlay - Cast Noble Metal, Three Or More Surfaces D6608 Retainer Onlay Porcelain/Ceramic, Two Surfaces D6609 Retainer Onlay Porcelain/Ceramic, Three Or More Surfaces D6610 Retainer Onlay - Cast High Noble Metal, Two Surfaces D6611 Retainer Onlay - Cast High Noble Metal, Three Or More Surfaces D6612 Retainer Onlay - Cast Predominantly Base Metal, Two Surfaces D6613 Retainer Onlay - Cast Predominantly Cast Base Metal, Three Or More Surfaces D6614 Retainer Onlay - Cast Noble Metal, Two Surfaces D6615 Retainer Onlay - Cast Noble Metal, Three Or More Surfaces D6624 D6634 D6710 D6720 Retainer Inlay - Titanium Retainer Onlay - Titanium Retainer Crown - Indirect Resin Based Composite Retainer Crown - Resin With High Noble Metal Benefit level 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 25 of 28 Out of network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Waiting period Frequency if applicable Age limit, if applicable none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ Other benefit limitations Delta Dental of Missouri PPO network Procedure code D6721 D6722 D6740 Procedure description Retainer Crown - Resin With Predominantly Base Metal Retainer Crown - Resin With Noble Metal Retainer Crown Porcelain/Ceramic D6750 Retainer Crown - Porcelain Fused To High Noble Metal D6751 Retainer Crown - Porcelain Fused To Predominantly Base Metal D6752 Retainer Crown - Porcelain Fused To Noble Metal D6753 Retainer crown - porcelain fused to titanium or titanium alloys D6780 D6781 D6782 D6783 D6784 D6790 D6791 Retainer Crown - 3/4 Cast High Noble Metal Retainer Crown - 3/4 Cast Predominantly Base Metal Retainer Crown - 3/4 Cast Noble Metal Retainer Crown - 3/4 Porcelain/Ceramic retainer crown ¾ - titanium and titanium alloys Retainer Crown - Full Cast High Noble Metal Retainer Crown - Full Cast Predominantly Base Metal Benefit level 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Premier network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 26 of 28 Out of network Benefit level 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% 50% Deductible applies Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Waiting period Frequency if applicable Age limit, if applicable none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ Other benefit limitations Delta Dental of Missouri PPO network Procedure code D6792 Procedure description Retainer Crown - Full Cast Noble Metal Benefit level 60% Deductible applies Yes Premier network Benefit level 50% Deductible applies Yes Out of network Benefit level 50% Deductible applies Yes Waiting period none 16+ 1 every 60 Months from the last date of service of the same treatment 16+ none 1 every 60 Months from the last date of service of the same treatment 16+ 1 every 60 Months from the last date of service of the same treatment 16+ Retainer Crown - Titanium 60% Yes 50% Yes 50% Yes none D6930 Re-Cement Or Re-Bond Fixed Partial Denture 60% Yes 50% Yes 50% Yes none D6940 Stress Breaker 60% Yes 50% Yes 50% Yes none D6950 Precison Attachment 60% Yes 50% Yes 50% Yes none D6980 Fixed Partial Denture Repair 60% Yes 50% Yes 50% Yes none D6999 Unspecified Fixed Prosthodontic Procedure, By Report 60% Yes 50% Yes 50% Yes none D7950 Osseous, Osteoperiosteal, Or Cartilage Graft Of The Mandible Or Maxilla D7953 Bone Replacement Graft For Ridge Preservation Per Site 60% Yes 50% Yes 50% Yes none D9120 Fixed Partial Denture Sectioning 60% Yes 50% Yes 50% Yes none D9222 Deep Sedation/General Anesthesia - First 15 Minutes D9223 Deep Sedation / General Anesthesia - Each subsequent 15 Minute Increment D9239 Intravenous Moderate (Conscious) Sedation/Analgesia - First 15 Minutes D9243 Intravenous Moderate (Conscious) Sedation/Analgesia - Each Subsequent 15 Minute 60% 60% 60% 60% Yes Yes Yes Yes Yes 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes 50% 50% 50% 50% 50% Yes Yes Yes Yes Yes Age limit, if applicable 1 every 60 Months from the last date of service of the same treatment D6794 60% Frequency if applicable Other benefit limitations none Benefits for extraction and surgical procedures. none Benefits for extraction and surgical procedures. none Benefits for extraction and surgical procedures. none Benefits for extraction and surgical procedures. Benefit Breakdown for Orthodontics PPO network Procedure code Procedure description Premier network Out of network Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D0340 2D Cephalometric Radiographic Image 50% NA 50% NA 50% NA none D0350 Oral/Facial Photographic Images 50% NA 50% NA 50% NA none D0470 Diagnostic Casts 50% NA 50% NA 50% NA none D7280 Exposure of an Unerupted Tooth 50% NA 50% NA 50% NA none D7283 Placement Of Device To Facilitate Eruption Of Impacted Tooth 50% NA 50% NA 50% NA none D8010 Limited Orthodontic Treatment Of The Primary Dentition 50% NA 50% NA 50% NA none 27 of 28 Frequency if applicable Age limit, if applicable Other benefit limitations Delta Dental of Missouri PPO network Premier network Out of network Procedure code Procedure description Benefit level Deductible applies Benefit level Deductible applies Benefit level Deductible applies Waiting period D8020 Limited Orthodontic Treatment Of The Transitional Dentition 50% NA 50% NA 50% NA none D8030 Limited Orthodontic Treatment Of The Adolescent Dentition 50% NA 50% NA 50% NA none D8040 Limited Orthodontic Treatment Of The Adult Dentition 50% NA 50% NA 50% NA none D8070 Comprehensive Orthodontic Treatment Of The Transitional Dentition 50% NA 50% NA 50% NA none D8080 Comprehensive Orthodontic Treatment Of The Adolescent Dentition 50% NA 50% NA 50% NA none D8090 Comprehensive Orthodontic Treatment Of The Adult Dentition 50% NA 50% NA 50% NA none D8091 comprehensive orthodontic treatment with orthognathic surgery 50% NA 50% NA 50% NA none D8210 Removable Appliance Therapy 50% NA 50% NA 50% NA none D8220 Fixed Appliance Therapy 50% NA 50% NA 50% NA none D8660 Pre-Orthodontic Treatment Examination To Monitor Growth And Development 50% NA 50% NA 50% NA none D8670 Periodic Orthodontic Treatment Visit 50% NA 50% NA 50% NA none D8671 periodic orthodontic treatment visit associated with orthognathic surgery 50% NA 50% NA 50% NA none D8680 Orthodontic Retention (Removal Of Appliances, Place Retainers) 50% NA 50% NA 50% NA none D8698 Re-cement or re-bond fixed retainer – maxillary 50% NA 50% NA 50% NA none D8699 Re-cement or re-bond fixed retainer – mandibular 50% NA 50% NA 50% NA none D8999 Unspecified Orthodontic Procedure, By Report 50% NA 50% NA 50% NA none Frequency if applicable Age limit, if applicable Other benefit limitations 2 per Calendar Year Patient history (prior 7 years only) Date of Service Tooth 04/30/2025 00 Surface Procedure D0140 Description Limited Oral Evaluation Problem Focused Periodontal Scaling And 03/26/2025 LL D4342 Root Planing - One To Three Teeth Per Quadrant Periodontal Scaling And 03/26/2025 LR D4342 Root Planing - One To Three Teeth Per Quadrant Comprehensive Oral 03/12/2025 00 D0150 Evaluation - New Or Established Patient Intraoral – Comprehensive 03/12/2025 00 D0210 series of radiographic images 28 of 28