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Aflac Dental Insurance – Standard Coverage Policy Series A81200 Aflac will pay the following benefits when a charge is incurred for covered dental treatment that occurs while coverage is in force. If a covered ADA code is revised or replaced by the American Dental Association, Aflac will pay an amount comparable to the amount shown in the Schedule of Dental Procedures for the procedure or code shown below. Dental Wellness Benefit Aflac will pay $50 per visit to you or any covered person for any
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   Aflac Dental Insurance – Standard Coverage Policy Series A81200 D0110Initial Oral EvaluationD0120Periodic Oral EvaluationD0150Comprehensive Oral Evaluation (new or established patient)D0160Detailed and Extensive Oral Evaluation (problem-focused, by report)D0170Re-evaluation – Limited, Problem (established patient; not postoperative visit)D0180Comprehensive Periodontal Evaluation (new or established patient)D0425Caries Susceptibility TestsD1110Prophylaxis (adult)D1120Prophylaxis (child)D1201Topical Application of Fluoride (child, including prophylaxis)D1203Topical Application of Fluoride (child, prophylaxis not included)D1204Topical Application of Fluoride (adult, prophylaxis not included)D1205Topical Application of Fluoride (adult, including prophylaxis)D1310Nutritional Counseling for Control of Dental DiseaseD1320Tobacco Counseling for the Control and Prevention of Oral DiseaseD1330Oral Hygiene InstructionsD4910Periodontal MaintenanceD9430Office Visit for Observation (during regularly scheduled hours, no other services performed)D9910Application of Desensitizing Medicament Form A81275B1 IC(9/06) Refer to the policy for complete details, limitations, and exclusions. American Family Life Assurance Company of Columbus (Aflac) · Worldwide Headquarters · 1932 Wynnton Road · Columbus, Georgia 31999 · aflac.com Dental Wellness Benefit  Aflac will pay $50  per visit to you or any covered person for any one treatment listed below. This benefit is payable once per visit, regardless of the number of treatments received. For benefits to be payable, dental wellness visits must be separated by150 days or more. This benefit is payable twice per policy year, per covered person. The treatment must be performed by adentist or dental hygienist. There is no waiting period for this benefit. X-Ray Benefit  Aflac will pay $25  per visit to you or any covered person for any one of the X-ray procedures listed below. This benefit is payableonce per visit, regardless of the number of X-rays received. This benefit is payable only once per policy year, per covered  person. The treatment must be performed by a dentist or dental hygienist. There is no waiting period for this benefit.D0210Intraoral (complete series, including bitewings)D0220Intraoral (periapical, first film)D0230Intraoral (periapical, each additional film)D0240Intraoral (occlusal film)D0250Extraoral (first film)D0260Extraoral (each additional film)D0270Bitewing (single film)D0272Bitewings (two films)D0274Bitewings (four films)D0277Vertical Bitewings (seven to eight films)D0330Panoramic FilmD0340Cephalometric FilmAflac will pay the following benefits when a charge is incurred for covered dental treatment that occurs while coverage is in force.If a covered ADA code is revised or replaced by the American Dental Association, Aflac will pay an amount comparable to theamount shown in the Schedule of Dental Procedures for the procedure or code shown below.  Other Preventive Benefits Benefits in this category are subject to a 6-month waiting period.D1351Sealant (per tooth). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20D1510Space Maintainer (fixed, unilateral). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85D1515Space Maintainer (fixed, bilateral). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110D1520Space Maintainer (removable, unilateral). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85D1525Space Maintainer (removable, bilateral). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110D1550Recementation of Space Maintainer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Other Diagnostic Benefits Benefits in this category are subject to a 3-month waiting period. Benefits D0130 and D0140 are payableonly for visits where no other covered services are performed.D0130Emergency Oral Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25D0140Limited Oral Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25D0290Posterior-Anterior or Lateral Skull and Facial Bone Survey Film. . . . . . . . . . . . . . . . . . 65D0310Sialography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170D0415Bacteriologic Studies for Determination of Pathologic Agents. . . . . . . . . . . . . . . . . . . . . 15D0460Pulp Vitality Tests. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15D0470Diagnostic Casts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30D0471Diagnostic Photographs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15D0501Histopathologic Exam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Fillings and Other Basic Restorative Benefits Benefits in this category are subject to a 3-month waiting period.D2140Amalgam (one surface)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 45Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60D2150Amalgam (two surfaces)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65D2160Amalgam (three surfaces)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70D2161Amalgam (four or more surfaces)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75D2330Resin-Based Composite (one surface, anterior). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55D2331Resin-Based Composite (two surfaces, anterior). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65D2332Resin-Based Composite (three surfaces, anterior). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75D2335Resin-Based Composite (four or more surfaces or involving incisal angle, anterior). . . 85D2390Resin-Based Composite Crown (anterior). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85D2391Resin-Based Composite (one surface, posterior)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55D2392Resin-Based Composite (two surfaces, posterior)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65D2393Resin-Based Composite (three surfaces, posterior)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Scheduled Benefits The benefits listed below are subject to waiting periods as shown and a policy year maximum of $1,400 per covered person.Benefits will be paid only for specific ADA codes as listed in the policy when a charge is incurred for the covered dentaltreatment while coverage is in force. All treatments must be performed by a dentist.  D2394Resin-Based Composite (four or more surfaces, posterior)Primary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70Permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75D2410Gold Foil (one surface). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225D2420Gold Foil (two surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250 Crowns and Other Major Restorative Benefits Benefits in this category are subject to a 12-month waiting period.D2510Inlay (metallic, one surface). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $200D2520Inlay (metallic, two surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250D2530Inlay (metallic, three or more surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375D2542Onlay (metallic, two surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250D2543Onlay (metallic, three surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275D2544Onlay (metallic, four or more surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2610Inlay (porcelain/ceramic, one surface). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225D2620Inlay (porcelain/ceramic, two surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250D2630Inlay (porcelain/ceramic, three or more surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375D2642Onlay (porcelain/ceramic, two surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275D2643Onlay (porcelain/ceramic, three surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2644Onlay (porcelain/ceramic, four or more surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350D2650Inlay (resin-based composite, one surface). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200D2651Inlay (resin-based composite, two surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225D2652Inlay (resin-based composite, three or more surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . 275D2662Onlay (resin-based composite, two surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250D2663Onlay (resin-based composite, three surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275D2664Onlay (resin-based composite, four or more surfaces). . . . . . . . . . . . . . . . . . . . . . . . . . . 275D2710Crown (resin, indirect). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170D2720Crown (resin with high noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2721Crown (resin with predominantly base metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2722Crown (resin with noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2740Crown (porcelain/ceramic substrate). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2750Crown (porcelain fused to high noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2751Crown (porcelain fused to predominantly base metal). . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2752Crown (porcelain fused to noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2780Crown (3/4-cast high noble metal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2781Crown (3/4-cast predominantly base metal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2782Crown (3/4-cast noble metal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2783Crown (3/4-porcelain/ceramic) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2790Crown (full-cast high noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2791Crown (full-cast predominantly base metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2792Crown (full-cast noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D2910Recement Inlay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35D2920Recement Crown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35D2930Prefabricated Stainless Steel Crown (primary tooth). . . . . . . . . . . . . . . . . . . . . . . . . . . . 75D2931Prefabricated Stainless Steel Crown (permanent tooth). . . . . . . . . . . . . . . . . . . . . . . . . . 80D2932Prefabricated Resin Crown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110D2933Prefabricated Stainless Steel Crown With Resin Window. . . . . . . . . . . . . . . . . . . . . . . . . 130D2940Sedative Filling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30D2950Core Buildup (including any pins). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75D2951Pin Retention (per tooth, in addition to restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15D2952Cast Post and Core (in addition to crown). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110D2954Prefabricated Post and Core (in addition to crown). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110D2955Post Removal (not in conjunction with endodontic therapy). . . . . . . . . . . . . . . . . . . . . . . 85D2970Temporary Crown (fractured tooth). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80D2980Crown Repairs, by Report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160  Root Canals and Other Endodontic Benefits Benefits in this category are subject to a 12-month waiting period.D3110Pulp Cap (direct, excluding final restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20D3120Pulp Cap (indirect, excluding final restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20D3220Therapeutic Pulpotomy (excluding final restoration) Removal of Pulp Coronal to theDentinocemental Junction and Application of Medicament. . . . . . . . . . . . . . . . . . . . . . . 45D3230Pulpal Therapy (resorbable filling; anterior, primary tooth, excluding final restoration). 50D3240Pulpal Therapy (resorbable filling; posterior, primary tooth, excluding final restoration)50D3310Anterior (excluding final restoration, root canal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200D3320Bicuspid (excluding final restoration, root canal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250D3330Molar (excluding final restoration, root canal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D3340Root Canal (four or more) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D3346Retreatment of Previous Root Canal Therapy (anterior). . . . . . . . . . . . . . . . . . . . . . . . . . 180D3347Retreatment of Previous Root Canal Therapy (bicuspid). . . . . . . . . . . . . . . . . . . . . . . . . 225D3348Retreatment of Previous Root Canal Therapy (molar). . . . . . . . . . . . . . . . . . . . . . . . . . . 300D3351Apexification/Recalcification (initial visit; apical closure/calcific repair of perforations,root resorption, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140D3352Apexification/Recalcification (interim medication replacement; apical closure/calcificrepair of perforations, root resorption, etc.). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35D3353Apexification/Recalcification (final visit; includes completed root canal therapy; apicalclosure/calcific repair of perforations, root resorption, etc.). . . . . . . . . . . . . . . . . . . . . . . 75D3410Apicoectomy/Periradicular Surgery (anterior). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160D3421Apicoectomy/Periradicular Surgery (bicuspid; first root). . . . . . . . . . . . . . . . . . . . . . . . . 300D3425Apicoectomy/Periradicular Surgery (molar; first root). . . . . . . . . . . . . . . . . . . . . . . . . . . 325D3426Apicoectomy/Periradicular Surgery (each additional root). . . . . . . . . . . . . . . . . . . . . . . . 120D3430Retrograde Filling (per root). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85D3450Root Amputation (per root). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170D3920Hemisection (including any root removal; not including root canal therapy). . . . . . . . . . 130D3950Canal Preparation and Fitting of Preformed Dowel or Post. . . . . . . . . . . . . . . . . . . . . . . 60 Gum Treatments/Periodontic Benefits Benefits in this category are subject to a 6-month waiting period.D4210Gingivectomy or Gingivoplasty (four or more contiguous teeth or bounded teeth spaces per quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $150D4211Gingivectomy or Gingivoplasty (one to three teeth per quadrant). . . . . . . . . . . . . . . . . . 50D4240Gingival Flap Procedure, Including Root Planing (four or more contiguous teeth or  bounded teeth spaces per quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250D4241Gingival Flap Procedure, Including Root Planing (one to three teeth per quadrant) . . . . 250D4249Clinical Crown Lengthening (hard tissue). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275D4250Mucogingival Surgery (per quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275D4260Osseous Surgery (including flap entry and closure; four or more contiguous teeth or  bounded teeth spaces per quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275D4261Osseous Surgery (including flap entry and closure; one to three teeth per quadrant). . . 275D4263Bone Replacement Graft (first site in quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300D4264Bone Replacement Graft (each additional site in quadrant). . . . . . . . . . . . . . . . . . . . . . . 225D4270Pedicle Soft Tissue Graft Procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300D4271Free Soft Tissue Graft Procedure (including donor site surgery). . . . . . . . . . . . . . . . . . . 300D4273Subepithelial Connective Tissue Graft Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 325D4275Soft Tissue Allograft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300D4320Provisional Splinting (intracoronal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160D4321Provisional Splinting (extracoronal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130D4341Periodontal Scaling and Root Planing (four or more contiguous teeth or bounded teethspaces per quadrant). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65D4342Periodontal Scaling and Root Planing (one to three teeth per quadrant) . . . . . . . . . . . . . 65D4355Full Mouth Debridement to Enable Comprehensive Evaluation and Diagnosis. . . . . . . . 60
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