(315) (315) $1,500 & PREVENTIVE
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1 SERVICE EMPLOYEES BENEFIT FUND Phone (315) Fax (315) Dental Schedule of Benefits Calendar year maximum $1,500 per person/no deductible Procedure Code Description Reimbursement DIAGNOSITC & PREVENTIVE 0120 Periodic Oral Exam $ Limited Oral Evaluation $ Oral Evaluation for patient under 3 $ Comprehensive Oral Evaluation $ Detailed Extensive Oral Evaluation-Problem $ Re-evaluation, Limited, Problem Focused $ Intra-Oral - Complete Series $ Intra-Oral - Periapical - 1st Film $ Intra-Oral/Periapical Add'l $ Intra-Oral - Occlusal Film $ Extra-Oral X-ray - First Film $ Extra-Oral X-ray -Add'l Film $ Bitewing X-ray-Single Film $ Bitewings - Two Film $ Bitewings - Three Film $ Bitewings - Four Film $ Vertical Bitewing 7-8 Films $ Posterior -Anterior/Lateral Film $ Sialography $ TMJ Arthpgram/Inc. Injection $ TMJ - Single Film $ Panoramic X-ray $ Cephalometric X-ray $ Oral/Facial Images (intra and extra oral) $ ViziLite Oral Cancer Screening N/C 0460 Pulp Vitality Tests N/C 0470 Diagnostic Cast N/C 0999 Unspecified Diag Proc By Report BR 1110 Adult Dental Prophylaxis $ Child Dental Prophylaxis $ Fluoride - Exc - Prophy - Child $ Fluoride - Inc - Prophy - Adult N/C 1206 Topical Fluoride Varnish $ Application of Topical Fluoride $ Oral Hygiene Instruction N/C 1351 Sealant - Per - Tooth $ Space Maint - Fixed Unilateral $ Space Maint - Fixed Bilateral $ Space Maint - Removable Unilat $ Space Maint - Removable Bilat $ Recement Space Maintainer $30 Page 1
2 RESTORATIONS 2110 One Surf Amalgam - Deciduous $ Two Surf Amalgam - Deciduous $ Three Surf Amalgam - Deciduous $ Four or more Surf Amalgam - Deciduous $ One Surf Amalgam - Permanent $ Two Surf Amalgam - Permanent $ Three Surf Amalgam - Permanent $ Four or More Surf Amalgam - Permanent $ Resin - 1 Filling, Anterior $ Resin - 2 Fillings, Anterior $ Resin - 3 Fillings, Anterior $ Resin - 4 Fillings, Inc, Angle $ Resin Crown - Ant, Primary $ Composite One Surface Posterior $ Composite Two Surface Posterior $ Composite Three Surface Posterior $ Composite Four + Surface Posterior $ Inlay Metallic - One Surface $ Inlay Metallic - Two Surfaces $ Inlay Metallic - Three Surfaces $ Onlay Metallic - Two Surfaces $ Onlay Metallic - Three Surfaces $ Onlay Metallic - Four + Surfaces $ Inlay Porc/Ceramic, One Surface $ Inlay Porc/Ceramic, Two Surfaces $ Inlay Porc/Ceramic, Three Surfaces $ Onlay Porc/Ceramic, Two Surfaces $ Onlay Porc/Ceramic, Three Surfaces $ Onlay Porc/Ceramic, Four + Surfaces $ Inlay Comp: Resin One Surface $ Inlay Comp: Resin Two Surfaces $ Inlay Comp: Resin Three Surfaces $ Onlay Comp: Resin One Surface $ Onlay Comp: Resin Two Surfaces $ Onlay Comp: Resin Three Surfaces $325 Page 2
3 CROWN RESTORATION 2710 Crown - Resin - Lab $ Resin - High Noble Metal Crown $ Resin - Base Metal Crown $ Resin - Noble Metal Crown $ Porcelain Crown $ Porcelain/High Noble Crown $ Porcelain/Base Metal Crown $ Porcelain/Noble Metal Crown $ /4 Cast High Noble Metal $ /4 Cast Predominantly Base Metal $ /4 Cast Noble Metal $ Full Cast High Noble Crown $ Full Cast Base Metal Crown $ Full Cast Noble Metal Crown $ Provisional Crown N/C 2910 Recement Inlay $ Recement Cast or Prefab Post & Core $ Recement Crown $ Prefab. Stainless Steel Crown, Primary $ Prefabricated Resin Crown $ Prefabricated Resin Crown $ Prefabricated Stainless Steel Crown Resin $ Sedative Filling $ Core Buildup, Inc. Any Pins $ Pin Retention/Tooth Plus Restoration $ Cast Post and Core With Crown $ Pin Retention - Additional $ Prefabricated Post & Core in Addition to Crown $ Post Removal $ Labial Veneer - Lamin, Chair side $ Labial Veneer/Resin Lamin - Lab $ Labial Veneer/Porcelain Lamin - Lab $ Temporary Crown - Fractured Tooth N/C 2971 Addl Proc for New Crown -Partial Framework $ Crown Repair By Report $ Unspecified Restorative procedure B/R Page 3
4 ENDODONTICS 3110 Pulp Cap - Direct, Excluding Final Restoration N/C 3120 Pulp Cap - Indirect, Excluding Final Restoration N/C 3220 Pulpotomy $ Pulpal Debridement $ Pulpal Therapy- Anterior Primary Tooth $ Pulpal Therapy- Posterior Primary Tooth $ Root Canal Therapy - 1 Canal $ Root Canal Therapy - 2 Canals $ Root Canal Therapy - 3 Canals $ Incomplete Endo Therapy $ Internal Root Repair $ Retreatment - Root Canal Therapy - 1 Canal $ Retreatment - Root Canal Therapy - 2 Canals $ Retreatment - Root Canal Therapy - 3 Canals $ Apexification - Initial Visit $ Apexification - Interim Visit $ Apexification - Final Visit $ Apicoectomy - 1st Root $ Apiocectomy - Bicuspid, 1st Root $ Apiocectomy - Molar, 1st Root $ Apiocectomy - Each Additional Root $ Retrograde Filling $ Root Amputation $ Endodontic Endosseous Implant N/C 3470 Intention Replant Including Splint N/C 3910 Surgical Procedure to Place Rubber Dam N/C 3920 Hemisection $ Canal Preparation for Post or Dowels N/C 3999 Unspecified Endodontic Procedure BR Page 4
5 PERIODONTICS 4210 Gingivectomy Per Quadrant $ Gingivectomy Per Tooth $ Gingival Flap Surgery per Quadrant $ Gingival Flap Surgery 1-3 Teeth $ Apically Positioned Flap $ Crown Lengthening By Report $ Mucogingival Surgery Per Quadrant $ Osseous Surgery Per Tooth $ Osseous Surgery Per Quadrant $ Osseous Graft Single Site $ Osseous Graft Per Quadrant $ Bone Replacement Graft-First Site Quadrant $ Bone Replacement Graft Additional Site $ Biological Materials N/C 4266 Guided Tissue Regeneration, Per Tooth $ Guided Tissue Regeneration, Per Site $ Surgical Revision Procedure $ Pedicle Soft Tissue Graft $ Free Soft Tissue Graft $ Subepithelial Connective Tissue Graft Procedure $ Distal/Proximal Wedge - Single Procedure BR 4320 Provis Splint - Intra Coronal N/C 4321 Provis Splinting - Extra - Coronal N/C 4341 Perio/Scaling/Planning Quad $ Perio/Scaling/Planning 1-3 Teeth Per Quad $ Full Mouth Debridement for Comprehensive Perio Evaluation $ Arestin N/C 4910 Periodontal Prophylaxis $ Unspecified Periodontal Procedure BR Page 5
6 REMOVABLE PROSTHODONTICS 5110 Complete Upper Denture $ Complete Lower Denture $ Immediate Upper Denture $ Immediate Lower Denture $ Upper Part Acrylic Base - Clasps $ Lower Part Acrylic Base - Clasps $ Partial Upper - Base/Resin $ Partial Lower - Base/Resin $ Maxillary Partial Denture-Flex Base $ Mandibular Partial Denture -Flex base $ Adjust Complete Upper Denture $ Adjust Complete Lower Denture $ Adjust Partial Upper Denture $ Adjust Partial Lower Denture $ Repair Broken Full Denture Base $ Repair Broken Teeth - Each $ Repair Resin Saddle or Base $ Repair Cast Framework $ Repair/Replace Broken Clasp $ Replace 1 Broken Tooth $ Additional Tooth - Exist Part/1st TTH $ Add clasp to existing partial denture $ Replace Teeth/Acrylic Cast -Maxillary $ Replace Teeth/Acrylic Cast -Mandibular $ Rebase Complete Upper Denture $ Rebase Complete Lower Denture $ Rebase Partial Upper Denture $ Rebase Partial Lower Denture $ Reline Full Upper Denture - OFC $ Reline Full Lower Denture - OFC $ Reline Partial Upper Denture - OFC $ Reline Partial Lower Denture - OFC $ Reline Full Upper Denture - Lab $ Reline Full Lower Denture - Lab $ Reline Partial Upper Denture - Lab $ Reline Partial Lower Denture - Lab $ Interim Complete Denture Upper N/C 5811 Interim Complete Denture Lower N/C 5820 Interim Partial Denture Upper N/C 5821 Interim Partial Denture Lower N/C 5850 Tissue Condition Upper/Per Unit $ Tissue Condition Lower/Per Unit $ Overdenture - Complete $ Overdenture - Partial $ Precision Attachment BR BR 5867 Replace Semi/Precision Attachment BR 5899 Unspecified Removable Prosthodontic Procedure BR Page 6
7 FIXED PROSTHODONTICS 6010 Surgical Placement of Implant N/C 6056 Prefabricated Abutment N/C 6058 Abutment Supported Porc/Ceramic Crown $ Abutment Supported PFM High Noble Metal $ Abutment Supported PFM Base Metal $ Abutment Supported PFM Noble Metal $ Abutment Supported Cast Crown High Noble $ Abutment Supported Cast Crown Base Metal $ Abutment Supported Cast Crown Noble Metal $ Implant Supported Porcelain/Ceramic Crown $ Implant Supported PFM Crown $ Cast High Noble Pontic $ Predominantly Base Metal Pontic $ Cast Noble Metal Pontic $ Porcelain/High Noble Metal Pontic $ Porcelain/Base Metal Pontic $ Porcelain/Noble Metal Pontic $ Resin/High Noble Metal Pontic $ Resin/Base Metal Pontic $ Resin/Noble Metal Pontic $ Cast Metal Resin - Acid Etch $ Onlay -Cast High Noble Metal-2 Surface $ Resin/High Noble Metal Crown $ Resin - Base Metal Crown $ Porcelain/Noble Metal Crown $ Porcelain High Noble Metal Crown $ Porcelain Base Noble Metal Crown $ Porcelain - Noble Metal Crown $ /4 Cast High Noble Metal Crown $ Full Cast High Noble Metal Crown $ Full Cast Base Noble Crown $ Full Cast Noble Metal Crown $ Re-cement Bridge $ Stress Breaker N/C 6950 Precision Attachment N/C 6970 Cast/Post - Core with Retainer $ Prefabricated Post & Core add to Retainer $ Core Buildup for Retainer w/pins $ Coping - Metal $ Bridge Repair by Report $ Unspecified Fixed Prosthodontic Procedure BR Page 7
8 ORAL SURGERY 7111 Extraction, Coronal Remnants -Deciduous Tth $ Routine Extraction - Erupted Tooth $ Surgical - Extraction $ Soft Tissue Impaction $ Partial Bony Impaction $ Fully Bony Impaction $ Full Bony Impaction - Unusual $ Surgical Removal of Roots $ Coronectomy-Intentional Partial Tth Removal $ Oral Antral Fistula Closure $ Tooth Transplantation N/C 7280 Surgical Exp Impact Tooth - Ortho $ Surgical Exposure Impacted Tooth $ Mobilization of Erupted Tooth $ Placement of Device for Impacted Tth Eruption $ Biopsy - Hard Tissue $ Biopsy - Soft Tissue $ Surgical Repositioning of Tooth $ Transseptal Fibertomy $ Alveoplasty/Quad with Extraction $ Alveoplasty per Tooth with Extraction $ Alveoplasty/Quad w/out Extraction $ Alveoplasty/Quad w/out Extraction $ Excision - Lesion Diam. Up to 1.25 cm $ Excision of Benign Lesion < 1.25cm $ Excision of Benign Lesion, Complicated $ Excision Tumor to 1.25 cm - Malignant $ Excision Tumor Over 1.25 cm - Malignant $ Removal Odont Cyst Tumor to 1.25 cm $ Removal Odont Cyst Tumor cm $ Removal of Nonondot Cyst Tumor 1.25cm $ Removal of Nonondot Cyst Tumor 1.25+cm $ Destruction of Lesion- by Physical or Chemical $ Removal of Exocytosis $ Incision/Drainage - Intra - Oral $ I&D Periodontal Abscess $ Incision/Drainage - Extra -Oral $ Incision/Drainage - Extra -Oral -Complicated $ Removal of Foreign Body BR 7540 Removal of Reaction Producing Foreign Body BR 7910 Suture of Small Wound up to 5 cm $ Complicated Suture; up to 5 cm $ Complicated Suture; Greater than 5 cm BR 7953 Bone Replacement Graft for Ridge Preservation $70 Page 8
9 ORAL SURGERY (Cont'd) 7960 Frenulectomy $ Hyperplastic Tissue Removal $ Excision of Pericoronal Gingiva $ Unspecified Oral Surgical Procedures BR ADJUNCTIVE SERVICES 9110 Palliative Treatment $ Local Anesthesia - No Surgery N/C 9211 Regional Block Anesthesia N/C 9212 Trigeminal Division Block N/C 9220 General Anesthesia - 1st 30 min $ General Anesthesia - Add'l 15 min $ Analgesia N/C 9241 Intravenous Sedation - first 30 minutes $ Intravenous Sedation - each additional 15 min $ Non-Intravenous Conscious Sedation N/C 9310 Consultation $ Office Visit for Observation $ Office Visit After Hours $ Therapeutic Drug Injection BR 9910 Desensitizing Medicament N/C 9930 Post Surgical Complications N/C 9951 Occlusal Adjustment - Limited $ Occlusal Adjustment - Complete $ Infection Control N/C 9999 Unspecified Adjunctive Procedure by Report BR Page 9
10 LIMITATIONS: Exams - Limited to two per calendar year, per person X-rays - Full mouth x-rays or panorex are limited to one per three year period X-rays - Bitewings limited to four per 12 month period Prophylaxis - Limited to two per calendar year, per person Fluorides - Limited to two per calendar year, per child to age 19 Sealants - Application is for posterior teeth only, once in a three-year period, for children to age 14 Periodontal Scaling - Limited to each quad once per calendar year (2 quads per visit) Full Mouth Debridment - Limited to once per calendar year Periodontal Prophylaxis - Limited to twice per calendar year on addition to prophylaxis (with prior Periodontal treatment) EXCLUSIONS: Infection Control fees Temporary prosthetics Pulp Vitality Tests Diagnostic costs Adult Fluorides Sealants for children 14 years and over Orthodontics Bleaching Cosmetic Services Tooth Implants Periodontal surgery in same area limited to once per three-year period Duplicate prosthetics within a five-year period Replacement dentures and partials within a five-year period Replacement of lost or stolen dentures within a five-year period Hygiene Instruction Dietary Instruction or Educational Programs Completion of Form Experimental Services 12/19/2014 Page 10
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