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.

PLAN DESIGN SUMMARY
- $50 DEDUCTIBLE (3 PER FAMILY)
- DEDUCTIBLE WAIVED FOR TYPE I SERVICES
- $1000 ANNUAL MAXIMUM
- NO WAITING PERIODS ON TYPE I, II, & III

 

TYPE I - PREVENTIVE DENTAL SERVICES
00110 Initial oral examination (Covered twice per 12 consecutive months)	$20
00120 Periodic oral examination (Covered twice per 12 consecutive months)	$14
00130 Emergency oral examination (Covered twice per 12 consecutive months)	$25
00210 Intraoral - complete series, inc. bitewings (Covered once per 3 years)	$48
00220 Intraoral - periapical - first film	$9
00230 Intraoral - periapical - each additional film	$7
00240 Intraoral - occlusal film (Covered twice per 12 consecutive months)	$10
00250 Extraoral - first film	$8
00260 Extraoral - each additional	$12
00270 Bitewings - single film (Covered twice per 12 consecutive months)	$11
00272 Bitewings - two films (Covered twice per 12 consecutive months)	$15
00274 Bitewings - four films (Covered twice per 12 consecutive months)	$20
00290 Posterior - anterior or lateral skull and facial bone survey film	$40
00330 Panoramic film (Covered once per 3 year period)	$42
00415 Bacteriologic studies for determination of pathologic agents	$12
01110 Prophylaxis - adult (Covered twice per 12 consecutive months)	$30
01120 Prophylaxis - child (Covered twice per 12 consecutive months)	$25
01201 Topical application of fluoride (prophylaxis included ) - child  (Covered twice per 12 consecutive months for a dependent child under 16)	$36
01203 Topical application of fluoride (prophylaxis not included) - child  (Covered twice per 12 consecutive months for a dependent child under 16)	$12
01351 Sealant - per tooth (Covered once per 12 consecutive months for a dependent child under age 13)	$15
01510 Space maintainer - fixed - unilateral	$125
01515 Space maintainer - fixed - bilateral	$220
01520 Space maintainer - removable - unilateral	$162
01525 Space maintainer - removable - bilateral	$190
01550 Recementation of space maintainer	$30
07285 Biopsy of oral tissue - hard	$100
07286 Biopsy of oral tissue - soft	$100
09110 Palliative treatment (Covered as seperate procedure if no other service, except x-rays, is rendered during the visit)	$30
TYPE II - BASIC DENTAL SERVICE
02110 Amalgam - one surface, primary*	$32
02120 Amalgam - two surfaces, primary*	$41
02130 Amalgam - three surfaces, primary*	$51
02131 Amalgam - four or more surfaces, primary*	$68
02140 Amalgam - one surface, permanent*	$30
02150 Amalgam - two surfaces, permanent*	$40
02160 Amalgam - three surfaces, permanent*	$50
02161 Amalgam - four or more surfaces, permanent*	$60
*(Multiple restorations on one surface will be covered as a single filling)
02210 Silicate cement - per restoration	$20
02330 Resin - one surface, anterior**	$35
02331 Resin - two surfaces, anterior**	$45
02332 Resin - three surfaces, anterior**	$55
02335 Resin - four or more surfaces or involving incisal angle**	$60
02380 Resin - one surface, posterior - primary**	$40
02381 Resin - two surfaces, posterior - primary**	$54
02382 Resin - three or more surfaces, posterior - primary**	$62
02385 Resin - one surface, posterior - permanent**	$40
02386 Resin - two surfaces, posterior - permanent**	$60
02387 Resin - three or more surfaces, posterior - permanent**	$72
**(Mesial-lingual, distal-lingual, mesial-buccal, and distal-buccal restoration on anterior teeth will be deemed single surface restorations)
02910 Recement inlay	$24
02920 Recement crown	$28
02940 Sedative filling	$32
(Covered as seperate procedure if no other service, except x-rays, rendered during the visit)
02950 Core buildup, including any pins	$80
02951 Pin retention - per tooth - in addition to restoration	$18
03220 Therapeutic pulpotomy, excluding final restoration	$52
03310 Root canal therapy - anterior	$200
03320 Root canal therapy - bicuspid	$230
03330 Root canal therapy - molar	$260
03351 Apexification/recalcification - initial visit	$80
03352 Apexification/recalcification - interim medication	$80
03353 Apexification/recalcification - final visit	$80
03410 Apicoectomy/periradicular surgery - anterior	$236
03421 Apicoectomy/periradicular surgery - bicuspid	$200
03425 Apicoectomy/periradicular surgery - molar	$200
03430 Retrograde filling - per tooth	$64
03450 Root amputation - per root	$160
03920 Hemisection (including root removal)	$148
04210 Gingivectomy or gingivoplasty - per quadrant***	$100
04211 Gingivectomy or gingivoplasty - per tooth***	$60
04220 Gingival curettage, surgical - per quadrant***	$40
04240 Gingival flap procedure - per quadrant***	$150
04250 Mucogingival surgery - per quadrant***	$128
***(Only one of these procedures is covered per area of the mouth per 12 consecutive months)
04260 Osseous surgery - per quadrant	$300
04261 Bone replacement graft - single site	$120
04262 Bone replacement graft - multiple sites	$140
04270 Pedicle soft tissue graft procedure	$296
04271 Free soft tissue graft procedure (including donor site surgery)	$288
04320 Provisional splinting - intracoronal	$112
04321 Provisional splinting - extracoronal	$80
04341 Periodontal scaling and root planing, per quadrant (Covered twice per area of the mouth per 12 consecutive months)	$70
04345 Periodontal scaling - gingival inflammation (Covered twice per area of the mouth per 12 consecutive months)	$70
04910 Periodontal maintenance proceedures (Covered twice per area of the mouth per 12 consecutive months)	$40
05510 Repair broken complete denture base****	$44
05520 Replace missing or broken teeth - complete denture****	$40
05610 Repair resin denture base****	$52
05620 Repair cast framework****	$44
05630 Repair or replace broken clasp****	$68
05640 Replace broken teeth - per tooth****	$44
05650 Add tooth to existing partial denture****	$64
05660 Add clasp to existing partial denture****	$71
05710 Rebase complete maxillary denture****	$80
05711 Rebase complete mandibular denture****	$80
05720 Rebase maxillary partial denture****	$80
05721 Rebase mandibular partial denture****	$80
****(Covered only if repairs/adjustments more than 1 year after the initial insertion)
06930 Recement bridge	$40
07110 Extraction, single tooth	$36
07120 Extraction, each additional tooth	$34
07210 Surgical removal of erupted tooth	$72
07220 Removal of impacted tooth - soft tissue	$104
07230 Removal of impacted tooth - partially bony	$146
07240 Removal of impacted tooth - completely bony	$156
07250 Surgical removal of residual tooth roots	$60
07270 Tooth reimplantation	$82
07272 Tooth transplantation	$80
07310 Alveoloplasty in conjunction with extractions - per quadrant	$72
07320 Alveoloplasty not in conjunction with extractions - per quadrant	$91
07340 Vestibuloplasty - ridge extension (second epithelialization)	$144
07350 Vestibuloplasty - ridge extension (incl tissue procedures)	$160
07510 Incision and drainage of abscess - intraoral soft tissue	$48
07520 Incision and drainage of abscess - extraoral soft tissue	$72
07960 Frenulectomy - separate procedure	$140
07970 Excision of hyperplastic tissue - per arch	$88
09220 General anesthesia - first 30 minutes^	$110
09221 General anesthesia - each additional 15 minutes^	$75
^(Covered as a seperate procedure only when required for covered complex oral surgical procedures as determined by the company)
09610 Therapeutic drug injection	$16
09951 Occlusal adjustment - limited^^	$28
09952 Occlusal adjustment - Complete^^	$120
^^(Covered only when performed with periodontal surgery or nonsurgical TMJ dysfunction treatment)
Current Dental Terminology © 2004 American Dental Association. All rights reserved