DENTAL COVERAGE INFORMATION
Members have a choice of more than 18,000 dental providers nationwide - all carefully credentialed to offer the kind of care we demand and our patients expect. Our dentists must meet the Plan's standard of quality and service. All have agreed to provide dental care at the low co-payments available only to members.
NETWORK DENTAL SCHEDULE OF BENEFITS
Preferred Plan 300
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Member Pays |
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DIAGNOSTIC |
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0999 0150 0120 0140 0210 0220 0230 0270 0330 9440 9999 |
Broken Appointment W/O 24 Hour Notice Comprehensive Oral Evaluation Periodic Oral Evaluation Limited Oral Evaluation - Problem Focused (Emergency) X-Rays Intraoral - Complete Series (Incl. Bitewings) X-Rays Intraoral - Periapical - First Film X-Rays Intraoral - Periapical - Each Additional Film X-Rays - Bitewing - Single Film X-Ray Panoramic Film Office Visit - After Regularly Scheduled Hours OSHA Charges (ASEPSIS) |
$ 10.00 10.00 8.00 10.00 25.00 5.00 2.00 5.00 25.00 35.00 6.00 |
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PREVENTIVE |
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1110 1201 1351 1510 1515 1520 1525 |
Prophylaxis Tropical Application of Flouride (Incl. PX) - Child Sealant - Per Tooth Space Maintainer - Fixed - Unilateral Plus Lab Space Maintainer - Fixed - Bilateral Plus Lab Space Maintainer - Removable - Unilateral Plus Lab Space Maintainer - Removable - Bilateral Plus Lab |
$ 22.00 8.00 10.00 95.00 95.00 65.00 65.00 |
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RESTORATIVE |
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2140 2150 2160 2161 2330 2331 2332 2999 2385 2386 2387 2940 |
Amalgam - 1 Surface, Permanent Amalgam - 2 Surfaces, Permanent Amalgam - 3 Surfaces, Permanent Amalgam - 4 or more Surfaces, Permanent Resin - 1 Surface, Anterior Resin - 2 Surfaces, Anterior Resin - 3 Surfaces, Anterior Acid Etch For Restoration Resin - 1 Surface - Posterior - Permanent Resin - 2 Surfaces - Posterior - Permanent Resin - 3 (+)Surfaces - Posterior - Permanent Sedative Filling |
$ 22.00 30.00 45.00 45.00 30.00 39.00 50.00 10.00 50.00 80.00 100.00 10.00 |
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CROWNS |
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2750 2751 2791 2931 2950 2951 2952 |
Crown - Porcelain Fused to High Noble Metal Crown - Porcelain Fused to Predominantly Base Metal Crown - Full Cast Predominantly Base Metal Prefabricated Satinless Steel Crown - Primary Tooth Core Buildup, Including Any Pins Pin Retention Per Tooth in Addition to Restoration Cast Post and Core in Addition to Crown |
$ 380.00 325.00 300.00 50.00 62.00 10.00 90.00 |
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ENDODONTICS |
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3120 3220 3310 3320 3330 3999 3410 |
Pulp Cap - Indirect Excluding Final Restoration Therapeutic Pulpotomy Excluding Final Restoration Root Canal Anterior Excluding Final Restoration Root Canal Bicuspid Excluding Final Restoration Root Canal Molar Excluding Final Restoration Root Canal 4+ Canals Excluding Final Restoration Apicoectomy/Periradicular Surgery - Anterior |
$ 10.00 30.00 185.00 235.00 300.00 325.00 140.00 |
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PERIDONTICS |
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4210 4341 4910 4999 |
Gingivectomy or Gingivoplasty - Per Quad Peridontal Scaling & Root Planning - Per Quadrant Peridontal Maintenance Proc. (Following Active Therapy) Peridontal Probing |
$ 210.00 40.00 45.00 25.00 |
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PROSTHDONTICS - REMOVABLE |
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5110 5120 5130 5140 5211 5212 5213 5214 5410 5411 5510 5520 5630 5650 5660 5730 5741 5750 5761 5850 5851 |
Complete Denture - Maxillary Complete Denture - Mandibular Immediate Denture - Maxillary Immediate Denture - Mandibular Maxillary Partial Denture - Resin Base (Incl. Any Convetional Clasps, Rests, or Teeth) Mandibular Partial Denture - Resin Base (Incl. Any Convetional Clasps, Rests, or Teeth) Maxillary Partial Denture - Cast Metal Framework w/ Resin Denture Bases (Incl. Any Conv. Clasps, Rests or Teeth) Mandibular Partial Denture - Cast Metal Framework w/ Resin Denture Bases (Incl. Any Conv. Clasps, Rests or Teeth) Adjust Complete Denture - Maxillary (After 6 Mos.) Adjust Complete Denture - Mandibular (After 6 Mos.) Repair Broken Complete Denture Base + Lab Replace Missing/Broken Teeth - Complete Denture (Each Tooth) + Lab Repair or Replace Broken Clasp Add Tooth to Existing Partial Denture + Lab Add Clasp to Existing Partial Denture + Lab Reline Complete Maxillary Denture (Chairside) Reline Complete Mandibular Denture (Chairside) Reline Maxillary Complete Denture (Laboratory) Reline Mandibular Complete Denture (Laboratory) Tissue Conditioning, Per Arch Tissue Conditioning, Per Arch |
$ 398.00 398.00 425.00 425.00 399.00 399.00 460.00 460.00 10.00 10.00 25.00 25.00 25.00 15.00 40.00 85.00 85.00 109.00 109.00 35.00 35.00 |
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FIXED PROSTHETICS |
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6241 6242 6751 6752 |
Pontic - Porcelain Fused to Predominantly Bast Metal Pontic - Porcelain Fused to Noble Metal Crown - Procelain Fused to Predominantly Base Metal Crown - Porcelain Fused to Noble Metal |
$ 300.00 300.00 325.00 380.00 |
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ORAL SURGERY |
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7110 7120 7220 7230 7240 7250 7310 7510 |
Extraction - Single Tooth Extraction - Each Additional Tooth Surgical Extraction - Removal of Impacted Tooth - Soft Tissue Surgical Extraction - Removal of Impacted Tooth - Partially Bony Surgical Extraction - Removal of Impacted Tooth - Completely Bony Surgical Extraction - Surgical Removal of Residual Roots (Cutting Procedure) Alveoplasty in Conjunction w/Extractions - Per Quad. Incision & Drainage of Abscess - Intraoral Soft Tissue |
$ 35.00 29.00 70.00 99.00 150.00 40.00 45.00 30.00 |
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ORTHODONTICS |
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8600 8080 8090 8680 8999 |
Pre-Orthodontic Treatment Visit Comprehensive Orthodontic Treatment of the Adolescent Dentition Comprehensive Orthodontic Treatment of the Adult Dentition Orthodontic Retentition (Removal of Appliances, Construction and Placement of Retainers) Maxillary Expansion (Describe Procedures) |
$ 115.00 1990.00 2190.00 90.00 375.00 |
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MISCELLANEOUS SERVICES |
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9230 9950 9951 |
Analgesia - Per Visit Occlusion Analysis - Mounted Case Occlusal Adjustment - Limited |
$ 10.00 30.00 50.00 |
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All of the above charges are reduced fees for services performed by a participating general dentist. Fees subject to change without notice. Any procedure not listed is available on a fee for service basis at a 20% discount from the participating provider's fee schedule. Consult with your participating dentist prior to beginning any treatment. Fees do not include lab costs which are the members responsibility. Some services, at the discretion of the general dentist, may need to be referred to a specialist (advanced degree). Please see "Additional Specialty Services." Additional Specialty Services Any treatment provided by a participating specialist, if available, in Oral Surgery, Orthodontics, Periodontics, Pedodontics or Endodontics will be charged at a 20% reduction of participating specialist's fees for that particular case. Some specialists may require a consultation visit before treatment is initiated. Discuss each case with specialist prior to beginning any treatment. Plan Exclusions (1) Work in progress is not covered. (2) Work in progress after enrollment on the dental plan must be completed before selecting another participating dentist. (3) Any dental procedures performed by a non-participating dentist are not covered. (4) We cannot guarantee the continued participation of any dentist. If he/she leaves the plan, you will need to select another dentist. (5) Not all types of dentists may be available in your area; you may have to travel to receive care from a participating general dentist or specialist. (6) Some providers may charge for missed or broken appointments with no prior notice. (7) Please verify that the dentist is a participating provider when scheduling your appointment. | ||