GUARANTY ASSURANCE COMPANY - DINA Dental Plan SCHEDULED BENEFITS RIDER
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1 OSHA Charge for disposables for patients protection, per person, per visit* $ Periodic oral exam $ Limited oral exam $ Comprehensive oral evaluation $ Comprehensive Perio evaluation $ X-ray - complete series $ X-ray - intraoral - periapical No Charge 230 X-ray - intraoral - periapical No Charge 240 X-ray - intraoral - occlusal film No Charge 250 X-ray - extraoral - first film No Charge 260 X-ray extraoral - each extra No Charge 270 X-ray - bitewing - single film $ X-ray - bitewings - two films $ X-ray - bitewings - four films $ X-ray - panoramic film $ Diagnostic casts No Charge 1110 Prophylaxis- adult $ Prophylaxis- child $ Topical fluoride - child $ Sealant - per tooth $ Space maintainer - fixed unilateral $ Space maintainer - fixed bilateral $ Space maintainer - removable unilat. $ Space maintainer - removable bilat. $ Space maintainer recementation $ Palliative treatment $ Local anesthesia not in conjunction with operative or surgical procedures No Charge 9310 Consultation (diagnostic service performed by a Specialist** upon referral) No Charge *NOTE YOU MUST BE PREPARED TO PAY AT LEAST $5.00 TO YOUR SELECTED DENTIST, PER PERSON, PER VISIT, PLUS ALL CO-PAYMENTS WHICH ARE LISTED IN THIS SCHEDULE OF BENEFITS RIDER THAT ARE DUE WHEN SUCH SERVICES ARE PERFORMED FOR YOU OR YOUR DEPENDENT(S). ** No Charge only if performed by a Participating Specialist. FEES DO NOT INCLUDE LAB COSTS, WHICH ARE THE MEMBERS RESPONSIBILITY. updated 4/26/04
2 2140 Amalgam - one surface $ Amalgam - two surface $ Amalgam - three surfaces $ Amalgam - four or more surfaces $ Resin - one surface, anterior $ Resin - two surfaces, anterior $ Resin - three surfaces, anterior $ Resin - four or more surfaces, anterior $ Resin-based composite crown, anterior $ Resin-based one surface, posterior $ Resin-based two surface, posterior $ Resin-based three surface, posterior $ Resin-based four or more surfaces, posterior $ Inlay - metallic - one surface $ Inlay - metallic - two surfaces $ Inlay - metallic - three surfaces $ Onlay - metallic - three surfaces $ Onlay - metallic - four surfaces $ Inlay - porcelain/ceramic - 1 surface $ Inlay - porcelain/ceramic - 2 surfaces $ Inlay - porcelain/ceramic - 3 surfaces $ Onlay - porcelain/ceramic - 2 surf. $ Onlay - porcelain/ceramic - 3 surf. $ Onlay - porcelain/ceramic - 4 surf. $ Crown - resin (lab) $ Crown - resin with high noble metal $ Crown - resin with base metal $ Crown - resin with noble metal $ Crown - porcelain/ceramic substrate $ Crown - porcelain fused high noble $ Crown - porcelain fused base metal $ Crown - porcelain fused noble metal $ Crown - full cast high noble metal $ Crown - full cast base metal $ Crown - full cast noble metal $ Recement inlay $ Recement crown $ Prefabricated stainless crown - prim $ Prefabricated stainless crown - perm $ Prefabricated resin crown $ Sedative filling $ Core buildup, including any pins $ Pin retention - per tooth, plus restor. $ Cast post and core plus crown $ Prefabricated post core plus crown $ Temporary crown (fractured tooth) $60.00
3 3110 Pulp cap - direct (excl. restoration) $ Pulp cap - indirect (excl. restoration) $ Therapeutic pulpotomy (excl. rest.) $ Endodontic therapy - Anterior $ Endodontic therapy - Bicuspid $ Endodontic therapy - Molar $ Apexification/recalcification - initial $ Apexification/recalcification - interim $ Apexification/recalcification - final $ Apicoectomy/Perir surgery-anterior $ Apicoectomy/Perir surgery-bicuspid $ Apicoectomy/Perir surgery-molar $ Apicoectomy/Perir surgery per extra root $ Retrograde filling - per root $ Root amputation - per root $ Surgical procedure to isolate tooth $ Gingivectomy - per quadrant $ Gingivectomy - per tooth $ Gingival flap procedure - per quad. $ Gingival flap procedure $ Osseous surgery - per quad. $ Osseous surgery-one to three contiguous $ Pedicle soft tissue graph procedure $ Free soft tissue graph procedure $ Provisional splinting - intracoronal $ Provisional splinting - extracoronal $ Perio scaling, root planning - per quad. $ Perio scaling, root planning-1 to 3 teeth quad $ Full mouth debridement $ Periodontal prophylaxis $ Complete denture - maxillary $ Complete denture - mandibular $ Immediate denture - maxillary $ Immediate denture - mandibular $ Maxillary partial - resin base $ Mandibular partial - resin base $ Maxillary partial - cast metal frame $ Mandibular partial - cast metal frame $ Removable unilateral partial - cast $ BR
4 5410 Adjust complete denture - maxillary $ Adjust complete denture - mandibular $ Adjust partial denture - maxillary $ Adjust partial denture - mandibular $ Repair broken compl. Denture base $ Replace missing/broken teeth - each $ Repair resin denture base $ Repair cast framework $ Repair or replace broken clasp $ Replace broken teeth - per tooth $ Add tooth to existing partial denture $ Add clasp to existing partial denture $ Rebase complete maxillary denture $ Rebase complete mandibular denture $ Rebase maxillary partial denture $ Rebase mandibular partial denture $ Reline maxillary denture (chairside) $ Reline mandibular denture (chairside) $ Reline maxillary partial (chairside) $ Reline mandibular partial (chairside) $ Reline maxillary denture (lab) $ Reline mandibular denture (lab) $ Reline maxillary partial (lab) $ Reline mandibular partial (lab) $ Interim complete denture (maxillary) $ Interim complete denture (mandibular) $ Interim partial denture (maxillary) $ Interim partial denture (mandibular) $ Pontic - cast high noble metal $ Pontic - cast base metal $ Pontic - cast noble metal $ Pontic - porcelain/high noble metal $ Pontic - porcelain fused to base metal $ Pontic - porcelain fused to noble metal $ Pontic - resin with high noble metal $ Pontic - resin with base metal $ Pontic - resin with noble metal $290.00
5 6720 Crown - resin with high noble metal $ Crown - resin with base metal $ Crown - resin with noble metal $ Crown - porcelain/high noble metal $ Crown - porcelain fused to base metal $ Crown - porcelain fused to noble metal $ Crown - 3/4 cast high noble metal $ Crown - full cast high noble metal $ Crown - full cast base metal $ Crown - full cast noble metal $ Recement fixed partial denture $ Extraction, coronal remnants- deciduous tooth $ Extraction, erupted tooth or exposed root $ Surgical removal of erupted tooth $ Removal - impacted - soft tissue $ Removal - impacted - partially bony $ Removal - impacted - completely bony $ Surgical removal of residual roots $ Oroantral fistula closure $ Tooth reimplantation $ Surgical exposure for orthodontics $ Surgical exposure to aid eruption $ Alveoloplasty w/extracts - per quad. $ Alveoloplasty w/o extracts - per quad. $ Vestibuloplasty - ridge extension $ Removal of exostosis - maxilla or mandible $ Incision and drainage of abscess - intraoral $ Incision and drainage of abscess - extraoral $ Excision hyperplastic tissue - per arch $ SPECIALIST SERVICE DISCOUNTS 9310 Consultation (diagnostic 2nd dentist) No Charge 2999 All pediatric procedures performed by Participating Specialist 80% of Usual Fee 3999 All endodontic procedures performed by Participating Specialist 80% of Usual Fee 4999 All periodontic procedures performed by Participating Specialist 80% of Usual Fee 6999 All prosthodontic procedures performed by Participating Specialist 80% of Usual Fee 7999 All oral & maxillofacial surgery procedures performed by Participating Specialist 80% of Usual Fee 8660 Pre-treatment visit with Participating Specialist No Charge 8999 All orthodontic procedures performed by Participating Specialist 80% of Usual Fee
ASSISTANT SECRETARY PRESIDENT
Charge Code TYPE I* Benefit Co-Insurance $21.00 0120* Periodic oral exam $21.00 Balance Billing $30.00 0140* Limited oral exam $30.00 Balance Billing $35.00 0150* Comprehensive oral evaluation $35.00 Balance
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