|
Type
I: Diagnostic And Preventive |
In- Network |
Out-of- Network |
| Procedure |
| Deductible
does not apply |
| X-ray-
complete series including bitewings (1 per 36
months) |
100% |
100% |
| X-ray
periapical-first film |
100% |
100% |
| X-ray
panoramic |
100% |
100% |
| Diagnostic
Casts |
100% |
100% |
| Initial
oral examination (1 per 6 months) |
100% |
100% |
| Prophylaxis-adult
(1 per 6 months) |
100% |
100% |
| Prophylaxis-child
(1 per 6 months) |
100% |
100% |
| Topical
application of fluoride (child) |
100% |
100% |
| Sealants
per tooth |
100% |
100% |
| Emergency
oral examination |
100% |
80% |
| |
|
|
|
Type
II: Basic Services |
In- Network |
Out-of- Network |
| Procedure |
|
|
| Amalgam-
1 surface primary |
90% |
80% |
| Amalgam-
1 surface permanent |
90% |
80% |
| Amalgam-
3 surfaces permanent |
90% |
80% |
| Resin-
1 surface anterior |
90% |
80% |
| Single
tooth extraction |
90% |
80% |
| Surgical
removal of erupted tooth |
90% |
80% |
| Surgical
extraction- fully bony impaction |
90% |
80% |
| Root
recovery (surgical removal of residual root) |
90% |
80% |
| Replace
broken teeth on denture-per tooth |
90% |
80% |
| Adding
tooth to partial denture for extracted tooth |
90% |
80% |
| Periodontal
prophylaxis ( 1 per 6 months) |
90% |
80% |
| Root
planing- per quadrant |
90% |
80% |
| Root
canal- one canal |
90% |
80% |
| Root
canal-three canals |
90% |
80% |
| Apicoectomy |
90% |
80% |
| |
|
|
|
Type III: Major Services |
In- Network |
Out-of- Network |
| Procedure |
|
|
| Space
maintainer-fixed unilateral type |
50% |
50% |
| Crown-porcelain
fused to noble metal |
50% |
50% |
| Pontic-
porcelain fused to noble metal |
50% |
50% |
| Recement
bridge |
50% |
50% |
| Gingivectomy
or gingivoplasty per quadrant |
50% |
50% |
| Gingival
flap procedures- per quadrant |
50% |
50% |
| Complete
upper or lower denture |
50% |
50% |
| Complete
upper or lower partial dentures - Acrylic base with
clasp/rests |
50% |
50% |
| Partial
upper or lower denture adjustment |
50% |
50% |
| |
|
|
|
Type
IV: Orthodontic Care |
Orthodontic
care procedures are limited to eligible adult and dependent
children under the age of 19. In-network and out of
network benefits are payable at 50% of usual,
customary, and reasonable fees. The lifetime maximum
benefit is $1,500 per insured.
|
