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| Members | Summary of BenefitsBelow is a brief summary of the dental benefits under the Prestige 15 plan. 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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| PRESTIGE 15 | ||
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APPOINTMENTS |
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| 9430 Office Visit (normal hours) | $5.00 | |
| 9430 Emergency Visit (normal hours) | $20.00 | |
| 9440 Emergency Visit (after hours) | $35.00 | |
| 0999 Broken appointments (without 24 hr notice, per 15 min) | $10.00 | |
| Maximum $40 per broken appointment. No charge will be made due to emergencies. |
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| 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 | |
| 0270 Bitewings - single film | NO CHARGE | |
| 0272 Bitewings - two films | NO CHARGE | |
| 0274 Bitewings - four fims | 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 maintainer | $10.00 | |
| RESTORATIVE (Fillings) | ||
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2999 Sedative base (under fillings) |
NO CHARGE | |
| Amalgam (Silver) | ||
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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 |
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| 2332 Anterior three surfaces | $45.00 | |
| 2510 Inlay - metallic - one surface | $85.00 | |
| 2520 Inlay - metallic - two surfaces | $95.00 | |
| 2530 Inlay - metallic - three 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 | |
| 2750/2751/2752/6750/6751/6752 Porcelain fused to metal crown | $240.00 | |
| 2810 Three quarter cast metal 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 Recement inlay/onlay/crown/bridge (per unit) | $10.00 | |
| 3220 Therapeutic pulpotomy | $30.00 | |
| Root Canals | ||
| 3310 Anterior | $100.00 | |
| 3320 Bicuspid | $190.00 | |
| 3330 Molar |
$240.00 |
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| 3410 Apicoectomy (anterior only) | $95.00 | |
| PERIODONTICS (Gum Treatment) | ||
| 4210 Gingivectomy/gingivoplasty - per quadrant | $120.00 | |
| 4211 Gingivectomy/gingivoplasty - per tooth | $36.00 | |
| 4220 Gingival curettage, surgical - per quadrant | $65.00 | |
| 4260 Osseous surgery - per quadrant | $300.00 | |
| 4271 Free soft tissue graft | $215.00 | |
| 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 | |
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Partial dentures (includes adjustments within 30 days) |
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| 5211/5212 Maxillary/mandibular partial - resin base (with 2 clasps) | $280.00 | |
| 5213/5214 Maxillary/mandibular partial - case 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 | |
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5850/5851 Tissue conditioning |
$25.00 | |
| 5730/5731/5740/5741 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 |
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| 7130 Root removal - exposed roots | $10.00 | |
| 7210 Surgical extraction of erupted tooth | $25.00 | |
| 7220 Soft tissue impaction | $40.00 | |
| 7230 Partially bony impaction | $75.00 | |
| 7240 Completely bony impaction | $75.00 | |
| 7250 Surgical removal of residual tooth roots | $25.00 | |
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7310 Alveoloplasty in conjunction with extractions - per quadrant |
$20.00 | |
| 7320 Alveoloplasty not in conjunction with extractions - per quadrant | $50.00 | |
| 7510 Incision and drainage (intraoral) | $20.00 | |
| ANESTHESIA | ||
| 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 | ||
| 8070/8080/8090 Children up to 19 years of age | ||
| Up to 24 months of routine orthodontic treatment for Class I and Class II cases | ||
| Consultation | NO CHARGE | |
| Evaluation | $35.00 | |
| Records/Treatment Planning | $250.00 | |
| Orthodontic Treatment | $1,650.00 | |
| 8090 Adults 19 years of age and over | ||
| Up to 24 months of routine orthodontic treatment for Class I and Class II cases | ||
| Consultation | NO CHARGE | |
| Evaluation | $35.00 | |
| Records/Treatment Planning | $250.00 | |
| Orthodontic Treatment | $1,850.00 | |
| 8680 Retention | Additional | |
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THE
ABOVE COPAYMENTS DO NOT INCLUDE THE ADDITIONAL COST All
procedures listed may not be performed by the Participating General
Dentist you select. The copayments shown apply to those Company Plan
Participating General Dentists who do perform those services. 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%. 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. Copayment amounts are
applicable when treatment is performed by selected Participating General
Dentist or by Participating Specialists. Benefits for procedures not
listed on the schedule of benefits, that are performed by a Participating
Specialist are available at the Participating Specialist's usual and
customary fee less 25%. 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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COMPBENEFITS
FAMILY OF COMPANIES CompDent
, CompBenefits Insurance Company , American Dental Plan, Inc.
Current Dental Terminology © 2004 American Dental Association. All rights reserved
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