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Emory Dental Plan

  
   
 

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Accesss Plan T – 185 Dental Option

  
   
  T-185 Co-pay Overview  
   
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Residents Only Dental Option

  
   
  Traditional Plan Overview  
   
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Access Plan E Dental Option

  
   
  Plan E Overview  
   
  Plan E Summary of Benefits  
   
  Plan E FAQs  
   
  Plan E Search for Providers  
   
  Resources  
   
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Plan E Summary of Benefits

Annual Maximum Limitation: $1,000 Per Person
Preventive & Diagnostic Office Visit Co-pay: $10.00

Orthodontia Option:
Child in-network: 50% of discounted fee
Out-of-network: 50% of billed charges
Lifetime Benefit Maximum: $1,000 Adult (Available in-network only) $3200.00 maximum fee through network of participating orthodontists

  In-Network 
Patient 
Co-Payment		 Out-of-Network
Patient
Reimbursement
PREVENTIVE & DIAGNOSTIC
ORAL EXAMS
150 Comprehensive Oral Examination NO CHARGE $20
120 Periodic Oral Examination NO CHARGE $13
140 Limited Oral Evaluation NO CHARGE $22
 
 
X-RAYS
210 Intraoral Comp. Series Incl. Bitewing NO CHARGE $39
220 Intraoral Single First Film NO CHARGE $8
230 Intraoral Each Additional NO CHARGE $6
240 Intraoral Occlusal Single First Film NO CHARGE $8
270 Bitewing Single First Film NO CHARGE $8
272 Bitewing Two Films NO CHARGE $12
274 Bitewings Four Films NO CHARGE $16
330 Panoramic X-Ray Maxilla & Mandible NO CHARGE $32
 
 
LAB AND OTHER
460 Pulp Vitality Test NO CHARGE $14
470 Diagnostic Cast NO CHARGE $29
471 Diagnostic Photographs NO CHARGE $19
 
 
PROPHYLAXIS
1110 Prophylaxis Adults NO CHARGE $27
1120 Prophylaxis Children NO CHARGE $20
1201 Topical Appl. Fluor. Excl. Prophy-Child NO CHARGE $29
 
 
FLUORIDE
1203 Topical Appl. Fluor. Excl. Prophy-Child NO CHARGE $9
 
 
SEALANTS
1351 Apply Topical Sealants Per Tooth NO CHARGE $15
 
 
SPACE MAINTAINERS
1510 Fixed Unilateral Space Maintainer NO CHARGE $100
1515 Fixed Bilateral Space Maintainer NO CHARGE $168
1550 Recementation of Space Maintainer NO CHARGE $18
 
 
EMERGENCY
9110 Pall.-Emer. Treat. Dent. Pain Minor P NO CHARGE $25
 
BASIC SERVICES
 
FILLING RESTORATIONS
2110 Amalgam-One Surface Primary $11 $26
2120 Amalgam-Two Surfaces Primary $14 $32
2130 Amalgam-Three Surfaces Primary $16 $39
2131 Amalgam-Four Surfaces Primary $19 $46
2140 Amalgam-One Surface Permanent $12 $31
2150 Amalgam-Two Surfaces Permanent $16 $37
2160 Amalgam-Three Surfaces Permanent $18 $45
2161 Amalgam-Four or More Surf. Perman $22 $53
2190 Pin Retention Per Tooth Excl. Restore $7 $16
2330 Resin-One Surface $14 $36
2331 Resin-Two Surfaces $18 $44
2332 Resin-Three Surfaces $21 $53
2335 Res-3+ Surf of Invincisal Angle $25 $61
2380 Resin-One Surface Posterior-Pri $18 $27
2381 Resin-Two Surfaces $22 $38
2382 Resin-Three Surfaces or More Pos-Pri $26 $44
2385 Resin-One Surface Posterior-Perm $24 $41
2386 Resin-Two Surface Posterior-Perm $32 $53
2387 Resin-Three Surfaces + Pos-Perm $40 $65
2930 Stainless Steel Crown + Primary Only $27 $68
 
 
ENDODONTICS
3110 Pulp Cap-Directo Excl Final Rest $6 $17
3120 Pulp Cap-Indirect Excl Final Rest $6 $15
3220 Theraputic Pulpotomy Exc Final Rest $17 $51
3310 Root Canal Therapy-Anterior $76 $225
3320 Root Canal Therapy-Bicuspid $87 $260
3330 Root Canal Therapy-Molar $111 $333
3351 Apexification (1st Treatment Visit) $22 $66
3352 Apexification (2nd Treatment Visit) $22 $66
3353 Apexification (3rd Treatment Visit) $22 $66
3410 Apicoecotomy Per Tooth-First Root $65 $195
3430 Retograde Filling Per Root $18 $54
3450 Root Amputation-Per Root $75 $224
3920 Hemisection (Including Root Removal) $28 $66
 
 
PERIODONTICS
4100 Initial Exam, With Full Mouth Charting $10 $30
4210 Gingivectomy/Gingivoplasty-Per Quad $34 $102
4211 Gingivectomy/Gingivoplasty-Per Tooth $15 $44
4220 Gingival Curettage By Report $14 $42
4240 Gingival Flap Inc Rt Plan-Per Quad $54 $162
4250 Muco-Gingival Surgery-Per Quad $49 $147
4260 Oss Surg & Flap Ent/Clos-Per Quad $122 $366
4261 Oss Gft-Sgl Site & Flap Ent/Clos/Dnr $66 $200
4262 Oss Gft-Multi Site & Flap Ent/Clos/Dnr $61 $184
4270 Pedicle Soft Tissue Graft $96 $288
4271 Free MSO Sft Tissue Gft & Donor Site $90 $269
4272 Apically Repositioned Flap $48 $144
4320 Provisional Splinting-Intracoronal $29 $87
4321 Provisional Splinting-Extracoronal $28 $85
9951 Occlusal Adjustment Limited $8 $24
9952 Occlusal Adjustment Complete $26 $78
4341 Root Planing-Per Quadrant $24 $73
4342 Irrigation-Root Planing-Per Quadrant $7 $18
4355 Full Mouth Debridement $15 $57
4910 Maint: Follow Surgery or Root Planing $14 $41
 
 
SIMPLE EXTRACTIONS
7110 Single Tooth $13 $31
7120 Each Additional Tooth $12 $30
7130 Root Removable-Exposed Root $18 $44
 
 
SURGICAL EXTRACTIONS
7210 Surgical Removal of Erupted Tooth $24 $72
7220 Extraction Surg Soft Tissue Impact $33 $99
7230 Extraction Surg Partially Bony Impact $42 $126
7240 Extraction Surg Complete Bony Impact $48 $144
7250 Surg Rem Residt Roots-Cutting Proc $25 $75
 
 
ORAL SURGERY
7310 Alveolopl In Conj W/Ext Raac-Per Quad $23 $67
7320 Alveolopl No Extract Per Quad $18 $51
7470 Rem Exotosis-Maxilla or Mandible $48 $141
9310 Consultation Per Session $9 $29
9440 Office Visits After Hours $10 $34
9610 Theraputics Drug Inj By Report $6 $18
 
 
ANESTHESIA
9220 Anesthesia-Gen. Office $42 $127
9230 Analgesia $5 $14
9240 Intravenous Sedation $40 $121
 
MAJOR SERVICES
 
CROWNS
2520 Inlay Metallic-Two Surfaces $258 $128
2530 Inlay Metallic-Three Surfaces (Gold) $247 $123
2543 Onlay Metallic-Three Surfaces $171 $84
2710 Crown-Resin Laboratory $152 $76
2740 Crown-Porcelain/Ceramic Substrate $312 $156
2750 Crown-Porc Fused To Hi Noble Metal $290 $145
2751 Crown-Porc Fused to Predm Base Metal $275 $136
2752 Crown-Porc Fused to Noble Metal $284 $142
2790 Crown-Full Cast High Noble Metal $292 $145
2791 Crown-Full Cast Predom Base Metal $274 $137
2792 Crown-Full Cast Noble Metal $281 $140
2931 Stainless Steel Crown-Permanent $63 $30
2970 Temporary Crown for Fractured Tooth $43 $20
2910 Recement Inlay $21 $10
2920 Recement Crown $22 $11
2932 Pre-Fab Resin Crown $72 $36
2940 Sedative Fillings $22 $10
2950 Crown Build-up Including Any Pins $64 $31
2952 Cast Post And Core (+Crown) $93 $46
2954 Pre-Fab Post & Core (+Crown) $79 $39
2960 Labial Veneer (Laminate) Chairside $119 $58
 
 
DENTURES
5110 Complete Upper $351 $174
5120 Complete Lower $346 $173
5130 Immediate Upper $381 $189
5140 Immediate Lower $363 $181
5211 Upper Partial-Acrylic Base $213 $105
5212 Lower Partial-Acrylic Base $230 $114
5213 Upper Partial Cast Base/Acrylic Saddle $371 $184
5214 Lower Partial Cast Base/Acrylic Saddle $374 $187
5281 Rem. Unilateral Partial Denture/Base Cast $250 $124
 
 
PROSTHODONTICS REPAIR
5510 Repair Broken Complete Denture Base $40 $20
5520 Replace Missing/Broken Denture
(Each Tooth)		 $30 $15
5610 Repair Acrylic Saddle or Base $39 $18
5620 Repair Cast Frame Work $39 $19
5630 Replace or Repair Broken Clasp $43 $21
5640 Replace Broken Teeth per Tooth $35 $21
5650 Add Tooth to Existing Part Denture $43 $24
5660 Add Clasp to Existing Part Denture $48 $23
5710-
5721		 Rebase Upper/Lower Denture Part/Comp $88 $43
5730-
5741		 Dent Reline Complete/Partial U/L Lab $73 $35
5750-
5761		 Reline Dentures U/L, Part./Comp $85 $42
5810-
5821		 Temporary Partial Plate $125 $62
5850-
5851		 Tissue Conditioning $40 $19
8930 Recement Fixed Partial Denture $31 $15
 
 
BRIDGES
6210 Pontic-Cast High Noble Metal $285 $142
6211 Pontic-Cast Base Metal $263 $130
6212 Pontic-Cast Noble Metal $282 $141
6240 Pontic-Porc Fused to Hi Noble Metal $289 $144
6241 Pontic-Porc Fused to Predom BS Metal $269 $133
6242 Pontic-Porc Fused to Noble Metal $280 $139
6545 Cast Metal Retainer/Acid Etch Bridge $129 $63
 
 
BRIDGE ABUTMENTS
6750 Crown-Porc Fused to Hi Noble Metal $290 $144
6751 Crown-Porc Fused to Predom Base Metal $272 $135
6752 Crown-Porc Fused to Noble Metal $283 $140
6790 Crown-Full Cast Noble Metal $289 $143
6791 Crown-Full Cast Predom Base Metal $283 $141
6792 Crown-Full Cast Noble Metal $281 $139
6790 Cast Post/Bridge Retainer $100 $50
       


 

 


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