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Summary of Benefits
Below 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 | ||
| 9310 | Consultation (diagnostic service provided by dentist other than practitioner providing treatment) | $15.00 |
| 9430 | Office Visit (normal hours) | $5.00 |
| 9440 | Office Visit (after regularly scheduled hours) | $35.00 |
| 9999 | Emergency Visit (during regularly scheduled hours, by report | $20.00 |
| 9999 | 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 | ||
| 120 | Periodic oral evaluation | NO CHARGE |
| 140/150/160 | Limited/Comprehensive oral evaluation | NO CHARGE |
| 210 | X-Ray Intraoral - complete series including bitewings | NO CHARGE |
| 220 | X-Ray Intraoral - periapical - first film | NO CHARGE |
| 230 | X-Ray Intraoral - periapical - each additional film | NO CHARGE |
| 270 | X-Ray Bitewing - single film | NO CHARGE |
| 272 | X-Ray Bitewings - two films | NO CHARGE |
| 274 | Bitewings - four films | NO CHARGE |
| 330 | Panoramic film | NO CHARGE |
| 460 | Pulp vitality tests | NO CHARGE |
| 470 | Diagnostic casts | NO CHARGE |
| PREVENTIVE CARE | ||
| 1110/1120 | Prophylaxis-adult/child-routine (once every 6 months) | NO CHARGE |
| 1110/1120 | Prophylaxis-adult/child- (additional) | $20.00 |
| 1201 | Topical application of fluoride (including prophylaxis) child (up to 16 years of age) | NO CHARGE |
| 1203 | Topical application of fluoride (not including prophylaxis) child (up to 16 years of age) | NO CHARGE |
| 1330 | Oral hygiene instruction | NO CHARGE |
| 1351 | Sealant - per tooth | $10.00 |
| 1510 | Space maintainer - fixed - unilateral | $45.00 + LAB |
| 1515 | Space maintainer - fixed - bilateral | $45.00 + LAB |
| 1520 |
Space maintainer - removable - unilateral |
$85.00 + LAB |
| 1525 | Space maintainer - removable - bilateral | $85.00 + LAB |
| 1550 | Recementation of space maintainer | $10.00 |
| RESTORATIVE | ||
| 2110 | Amalgam - one surface, primary | NO CHARGE |
| 2120 | Amalgam - two surfaces, primary | NO CHARGE |
| 2130 | Amalgam - three surfaces, primary | NO CHARGE |
| 2131 | Amalgam - four or more surfaces, primary | NO CHARGE |
| 2140 | Amalgam - one surface, permanent | NO CHARGE |
| 2150 | Amalgam - two surfaces, permanent | NO CHARGE |
| 2160 | Amalgam - three surfaces, permanent | NO CHARGE |
| 2161 | Amalgam - four or more surface | NO CHARGE |
| 2940 |
Sedative filling |
$15.00 |
| 2999 | Sedative base (under fillings), by report | NO CHARGE |
| RESIN RESTORATION | ||
| 2330 | Resin - one surface, anterior | $35.00 |
| 2331 | Resin - two surfaces, anterior | $40.00 |
| 2332 | Resin - three surfaces, anterior | $50.00 |
| 2380 | Resin - one surface, posterior - primary | $60.00 |
| 2381 | Resin - two surfaces, posterior - primary | $80.00 |
| 2382 | Resin - three or more surfaces, posterior - primary | $100.00 |
| 2385 | Resin - one surface, posterior - permanent | $60.00 |
| 2386 | Resin - two surfaces, posterior - permanent | $80.00 |
| 2387 | Resin - three surfaces, posterior - permanent | $100.00 |
| 2388 |
Resin - four or more surfaces, posterior - permanent |
$120.00 |
| 2510 | Inlay - metallic - one surface | $95.00 |
| 2520 | Inlay - metallic - two surfaces | $105.00 |
| 2530 | Inlay - metallic - three or more surfaces | $130.00 |
| CROWN & BRIDGE | ||
| 2740 | Crown - porcelain/ceramic substrate | $280.00 + LAB |
| 2750* | Crown - porcelain fused to high noble metal | $280.00 |
| 2751 | Crown - porcelain fused to predominantly base metal | $280.00 |
| 2752* | Crown - porcelain fused to noble metal | $280.00 |
| 2790* | Crown - full cast high noble metal | $280.00 |
| 2791 | Crown - full cast predominantly base metal | $280.00 |
| 2792* | Crown - full cast noble metal | $280.00 |
| 2910 |
Recement inlay |
$15.00 |
| 2920 | Recement crown | $15.00 |
| 2930 | Prefabrication stainless steel crown - primary tooth | $75.00 |
| 2950 | Core buildup, including any pins | $45.00 |
| 2951 | Pin retention - per tooth | $15.00 |
| 2952 | Cast post and core in addition to crown | $90.00 + LAB |
| 2953 | East additional cast post - same tooth | $90.00 + LAB |
| 2954 | Prefabricated post and core in addition to crown | $90.00 |
| 2962 | Labial veneer (porcelain laminate) - laboratory | $280.00 + LAB |
| ENDODONTICS | ||
| 3220 | Therapeutic pulpotomy | $35.00 |
| 3221 | Gross pulpal debridement, primary and permanent teeth | $100.00 |
| 3310 |
Root canal therapy - anterior (excluding final restoration) |
$100.00 |
| 3320 | Root canal therapy - bicuspid (excluding final restoration) | $200.00 |
| 3330 | Root canal therapy - molar (excluding final restoration) | $250.00 |
| 3410 | Apicoectomy/periradicular surgery - anterior | $125.00 |
| PERIODONTICS (Gum Treatment) | ||
| 4210 | Gingivectomy/gingivioplasty - per quadrant | $125.00 |
| 4211 | Gingivectomy/gingivioplasty - per tooth | $40.00 |
| 4220 | Gingival curettage - per quadrant | $70.00 |
| 4341 | Periodontal scaling and root planing - per quadrant | $50.00 |
| 4355 | Full mouth debridement | $45.00 |
| 4381 | Localized delivery of chemotherapeutic agents (per tooth) | $45.00 |
| 4910 | Periodontal maintenance procedures (following active therapy) | $50.00 |
| 4999 |
Complete periodontal probing and treatment plan |
$10.00 |
| PROSTHODONTICS | ||
| 5110 | Complete denture - maxillary | $300.00 + LAB |
| 5120 | Complete denture - mandibular | $300.00 + LAB |
| 5130 | Immediate denture - maxillary | $300.00 + LAB |
| 5140 | Immediate denture - mandibular | $300.00 + LAB |
| 5211 | Maxillary partial denture - resin base | $300.00 + LAB |
| 5212 | Mandibular partial denture - resin base | $300.00 + LAB |
| 5213 | Maxillary partial denture - cast metal framework; resin denture bases | $300.00 + LAB |
| 5214 | Mandibular partial denture - cast metal framework; resin denture bases | $300.00 + LAB |
| 5410 | Adjust complete denture - maxillary | $15.00 |
| 5411 | Adjust complete denture - mandibular | $15.00 |
| 5421 |
Adjust partial denture - maxillary |
$15.00 |
| 5422 | Adjust partial denture - mandibular | $15.00 |
| REPAIRS TO PROSTHETICS | ||
| 5510 | Repair broken complete denture base | $15.00 + LAB |
| 5520 | Repair missing or broken teeth - complete denture (each tooth) | $15.00 + LAB |
| 5610 | Repair resin denture base | $15.00 + LAB |
| 5630 | Repair or replace broken clasp | $15.00 + LAB |
| 5640 | Replace broke teeth - per tooth | $15.00 + LAB |
| 5650 | Add tooth to existing partial denture | $30.00 + LAB |
| 5730 | Reline complete maxillary denture (chairside) | $50.00 |
| 5731 | Reline complete mandibular denture (chairside) | $50.00 |
| 5740 | Reline maxillary partial denture (chairside) | $50.00 |
| 5741 | Reline mandibular partial denture (chairside) | $50.00 |
| 5750 | Reline complete maxillary denture (laboratory) | $35.00 + LAB |
| 5751 | Reline complete mandibular denture (laboratory) | $35.00 + LAB |
| 5760 |
Reline maxillary partial denture (laboratory) |
$35.00 + LAB |
| 5761 | Reline mandibular partial denture (laboratory) | $35.00 + LAB |
| 5850 | Tissue conditioning - maxillary | $30.00 |
| 5751 | Tissue conditioning - mandibular | $30.00 |
| PROSTHODONTICS (Fixed) | ||
| 6210* | Pontic - cast high noble metal | $280.00 |
| 6211 | Pontic - cast predominantly base metal | $280.00 |
| 6212* | Pontic - cast noble metal | $280.00 |
| 6240* | Pontic - porcelain fused to high noble metal | $280.00 |
| 6241 | Pontic - porcelain fused to predominantly base metal | $280.00 |
| 6242* | Pontic - porcelain fused to noble metal | $280.00 |
| 6250* |
Crown - porcelain fused to high noble metal |
$280.00 |
| 6251 | Crown - porcelain fused to predominantly base metal | $280.00 |
| 6252* | Crown - porcelain fused to noble metal | $280.00 |
| 6290* | Crown - full cast high noble metal | $280.00 |
| 6291 | Crown - full cast predominantly base metal | $280.00 |
| 6292* | Crown - full cast noble metal | $280.00 |
| 6930 | Recement fixed partial denture (per unit) | $10.00 |
| EXTRACTIONS/ORAL AND MAXILLOFACIAL SURGERY | ||
| 7110 | Extraction, single tooth | NO CHARGE |
| 7120 | Extraction, each additional tooth (per visit) | $15.00 |
| 7130 | Extraction, root removal - exposed roots | $15.00 |
| 7210 | Surgical removal of erupted tooth | $40.00 |
| 7220 |
Removal of impacted tooth - soft tissue |
$50.00 |
| 7230 | Removal of impacted tooth - partially bony | $70.00 |
| 7240 | Removal of impacted tooth - completely bony | $85.00 |
| 7250 | Surgical removal of residual tooth roots | $35.00 |
| 7310 | Alveoloplasty in conjunction with extractions - per quadrant | $35.00 |
| 7320 | Alveoloplasty not in conjunction with extractions - per quadrant | $70.00 |
| 7510 | Incision and drainage of abscess - intraoral | $25.00 |
| ADJUNCTIVE GENERAL SERVICES | ||
| 9215 | Local anesthesia | NO CHARGE |
| 9230 | Analgesia (nitrous oxide - per 15 minutes) | $15.00 |
| 9951 | Occlusal adjustment - limited | $25.00 |
| 9952 | Occlusal adjustment - complete | $150.00 |
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* THE ABOVE COPAYMENTS DO NOT INCLUDE THE ADDITIONAL COST OF PRECIOUS (HIGH NOBLE) AND SEMI-PRECIOUS (NOBLE) METAL. |
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| THE ADDITIONAL COST OF PRECIOUS METAL SHALL NOT EXCEED $125 PER UNIT AND $75 PER UNIT FOR SEMI-PRECIOUS METAL. | ||
| NOTE: WHEN CROWN AND/OR BRIDGEWORK EXCEEDS SIX UNITS IN THE SAME TREATMENT PLAN, THE PATIENT MAY BE CHARGED AN ADDITIONAL $50.00 PER UNIT | ||
| UNLISTED PROCEDURES ARE AT THE DENTIST'S USUAL FEE LESS 25%. | ||
| SPECIALISTS
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. Upon identification of yourself as a CompBenefits 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. |
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