Summary of BenefitsBelow is a brief summary of the dental benefits. This is provided as an overview document. Details about your coverage are outlined in your Schedule of Dental Benefits. Should there be any difference between this summary and the Benefits Schedule, the terms and conditions of the Benefits Schedule will prevail.
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| ADA CODE | PROCEDURE | PATIENT PAYS |
| APPOINTMENTS | ||
| 9430 | Office Visit (normal hours) | $5.00 |
| 9430 | Emergency Visit (regular hours) | $20.00 |
| 9440 | Emergency Visit (after hours) | $35.00 |
| 0999 | Broken appointments (without 24 hr notice,
per 15 min) Maximum $40 per broken appointment. No charge will be made due to emergencies. |
$10.00 |
| DIAGNOSTIC | ||
| 0140/0150/0160 | Oral Evaluation | NO CHARGE |
| 0120 | Periodic Oral Evaluation | NO CHARGE |
| 0470 | Diagnostic Casts (study models) | NO CHARGE |
| 0999 | Diagnosis and treatment plan presentation | NO CHARGE |
| 9310 | Consultation (second opinion) as provided by participating dentist | $10.00 |
| 0460 | Pulp vitality tests | NO CHARGE |
| RADIOGRAPHS (X-rays) | ||
| 0210 | Intraoral - complete series | NO CHARGE |
| 0220 | Intraoral - periapical - first film | NO CHARGE |
| 0230 | Intraoral - periapical - each additional film | NO CHARGE |
| 0270 | Bitewings - single film | NO CHARGE |
| 0272 | Bitewings - two films | NO CHARGE |
| 0274 | Bitewings - four films | NO CHARGE |
| 0330 | Panoramic | NO CHARGE |
| PREVENTIVE | ||
| 1110/1120 | Prophylaxis (routine, once every 6 months) | NO CHARGE |
| 1110/1120 | Additional prophylaxis | $15.00 |
| 1201/1203 | Topical application of fluoride (up to 16 years of age) | NO CHARGE |
| 1351 | Sealant - per tooth | $7.00 |
| 1330 |
Oral hygiene instruction |
NO CHARGE |
| SPACE MAINTAINERS | ||
| 1510 | Fixed, unilateral | $45.00* |
| 1515 | Fixed, bilateral | $45.00* |
| 1520 | Removable, unilateral | $85.00* |
| 1525 | Removable, bilateral | $85.00* |
| 1550 |
Recementation of space maintainers |
$10.00 |
| RESTORATIVE (Fillings) | ||
| 2999 | Sedative base (under fillings) | NO CHARGE |
| AMALGAM (Silver) | ||
| 2110/2140 | One surface | NO CHARGE |
| 2120/2150 | Two surfaces | NO CHARGE |
| 2130/2160 | Three surfaces | NO CHARGE |
| 2131/2161 | Four or more surfaces | NO CHARGE |
| RESIN RESTORATION (Including acid etch, glass ionomer liner) | ||
| 2330 | Anterior one surface | $30.00 |
| 2331 | Anterior two surfaces | $37.00 |
| 2332 | Anterior three surfaces | $45.00 |
| 2510 | Inlay - metallic - one surface | $85.00 |
| 2520 | Inlay - metallic - two surfaces | $95.00 |
| 2530 | Inlay - metallic - three or more surfaces | $120.00 |
| 2940 | Sedative filling | $15.00 |
| CROWN & BRIDGE | ||
| 2930 | Prefabricated stainless steel - primary tooth | $45.00 |
| 2790/2791/2792/ 6790/6791/6792 |
Full cast crown | $220.00 |
| 27502751/2752/ 6750/6751/6752 |
Porcelain fused to metal crown | $240.00 |
| 2810 | Three quarter cast crown | $220.00 |
| PONTICS | ||
| 6210/6211/6212 | Full cast pontic | $220.00 |
| 6240/6241/6242 |
Porcelain fused to metal pontic |
$240.00 |
| 2950 | Core build up | $40.00 |
| 2951 | Pin retention - per tooth | $12.00 |
| 2952 | Cast post and core | $90.00 |
| 2954 | Prefabricated post and core | $75.00 |
| 2910/2920/6930 | Recment inlay/onlay/crown/bridge (per unit) | $10.00 |
| ENDODONTICS | ||
| 3220 | Theraputic pulpotomy | $30.00 |
| ROOT CANALS | ||
| 3310 |
Anterior |
$100.00 |
| 3320 | Bicuspid | $190.00 |
| 3330 | Molar | $240.00 |
| 3410 | Apicoectomy (anterior only) | $95.00 |
| PERIODONTICS (Gum Treatment) | ||
| 4210 | Gingivectomy/gingivioplasty - per quadrant | $120.00 |
| 4211 | Gingivectomy/gingivioplasty - per tooth | $36.00 |
| 4220 | Gingival curettage, surgical - per quadrant | $65.00 |
| 4341 | Periodontal scaling and root planing - per quadrant | $45.00 |
| 4355 | Full mouth debridement | $35.00 |
| 4381 | Localized delivery of chemotheraputic agents (2 teeth) | $45.00 |
| 4910 | Periodontal maintenance procedures | $45.00 |
| PROSTHODONTICS | ||
| Standard complete dentures (includes adjustments within 30 days) | ||
| 5110 | Complete maxillary (upper) | $260.00 |
| 5120 | Complete mandibular (lower) | $260.00 |
| 5130 | Immediate maxillary (upper) | $280.00 |
| 5140 | Immediate mandibular (lower) | $280.00 |
| Partial dentures (includes adjustments within 30 days) | ||
| 5211/5212 | Maxillary/mandibular partial - resin base (with 2 clasps) | $280.00 |
| 5213/5214 | Maxillary/mandibular partial - cast metal with resin base (with 2 clasps) | $350.00 |
| 5410/5411 | Adjust complete maxillary/mandibular | $15.00 |
| 5421/5422 |
Adjust partial denture - maxillary/mandibular |
$15.00 |
| 5999 | Additional clasps | $30.00 |
| REPAIRS TO PROSTHETICS | ||
| 5510/5610 | Repair broken resin denture base | $15.00* |
| 5520/5640 | Replace missing or broken teeth (each tooth) | $10.00* |
| 5520/5640 | Each additional tooth | $10.00* |
| 5630 | Repair or replace broken clasp | $15.00* |
| 5650 | Add tooth to existing partial denture | $30.00* |
| 5850/5851 | Tissue conditioning | $25.00 |
| 5730/5731/ 5741/5741 |
Relining (chairside) | $45.00 |
| 5750/5751/ 5760/5761 |
Relining (laboratory) | $35.00* |
| EXTRACTIONS/ORAL SURGERY | ||
| 7110 | Single tooth | NO CHARGE |
| 7120 |
Each additional tooth (per visit) |
$10.00 |
| 7130 | Root removal - exposed roots | $10.00 |
| 7210 | Surgical removal of erupted tooth | $25.00 |
| 7220 |
Soft tissue impaction |
$40.00 |
| 7230 | Partially bony impaction | $60.00 |
| 7240 | Completely bony impaction | $75.00 |
| 7250 | Surgical removal of residual tooth roots | $25.00 |
| 7310 | Alveoloplasty in conjunction with extractions - per quadrant | $20.00 |
| 7320 | Alveoloplasty not in conjunction with extractions - per quadrant | $50.00 |
| ANASTHESIA | ||
| 9215 | Local anesthesia | NO CHARGE |
| 9230 | Analgesia (nitrous oxide - per 15 minutes) | $15.00 |
| ADJUNCTIVE SERVICES | ||
| 9951 | Occlusal adjustment - limited | $25.00 |
| 9952 | Occlusal adjustment - complete | $150.00 |
| ORTHODONTICS | ||
| Benefits for orthodontics for adults and children are available from Participating Orthodontists at their usual fee less 25%. | ||
| THE ABOVE COPAYMENTS DO NOT INCLUDE THE ADDITIONAL COST OF PRECIOUS AND SEMI-PRECIOUS METAL. | ||
All procedures listed may not be performed by the Participating General Dentist you select. The copayments shown apply to those Company Participating General Dentists who do perform those services and are not applicable for services performed by a specialist. Therefore, you are encouraged to discuss availability of the scheduled services with your Participating General Dentist. Procedures not listed on the schedule of benefits, that are performed by the selected Participating General Dentist will be charged at that Participating General Dentist's usual and customary fee less 25%. |
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| SPECIALISTS | ||
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Should you need a specialist (i.e., Endodontist, Orthodontist, Oral Surgeon, Periodontist, Prosthodontist, Pediatric Dentist), you may be referred by your Participating General Dentist, or you may refer yourself to any Participating Specialist from our directory. Upon identification of yourself as a Company member, you will receive a 25% reduction from usual and customary fees for services performed. Specialist services are available only in areas where the dental plan has a Participating Specialist. NOTE: When crown and/or bridgework exceeds six consecutive units, the patient may be charged an additional $25.00 per unit. * Plus laboratory fees when applicable.
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Current Dental Terminology © 2004 American Dental Association. All rights reserved
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