Scheduled Dental Benefit Plan Schedule of Dental Allowances
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1 Diagnostic Scheduled Dental Benefit Plan Schedule of Dental Allowances 0120 Periodic Oral Evaluation (once in 5 months after comprehensive) Limited Oral Evaluation Comprehensive Oral Evaluation Intraoral completes series incl. Bitewings (once every 3 years) Intraoral, Periapical, first film Intraoral, Periapical, each additional film Bitewings, single film Bitewings, two films Bitewings, four films Posterior-Anterior/lateral skull and facial bone survey film Other temporomandibular joint films, by report Panoramic film (once every three years) Cephalornetric film Preventive (once every six months 1110, 1120, 1203, 1204) 1110 Prophylaxis Adult Prophylaxis Child (to age 12) Topical application of fluoride (prophylaxis not included) Child Topical application of fluoride (prophylaxis not included) Adult Sealant per tooth (once per lifetime) Space Maintainer Fixed Unilateral Space Maintainer Removable Unilateral Restorative 2140 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 60.00
2 2391 Resin based composite 1 surface, posterior permanent Resin based composite 2 surfaces, posterior permanent Resin based composite 3 surfaces, posterior permanent Resin based composite 4 or more surfaces, posterior permanent Inlay - Metallic - 1 Surface* Inlay - Metallic - 2 Surfaces* Inlay - Metallic - 3 Surfaces* Inlay Porcelain/Ceramic 1 Surface* Crown Resin base composite (indirect)* Crown Resin with high noble metal* Crown Resin with predominantly base metal* Crown Resin with noble metal* Crown - Porcelain/Ceramic Substrate* Crown Porcelain fused to high noble metal* Crown Porcelain fused to predominantly base metal* Crown Porcelain fused to noble metal* Crown Full Cast high noble metal* Crown Full Cast predominantly base metal* Crown Full Cast noble metal* Recement inlay, only or partial coverage restoration Recement crown Prefabricated stainless steel crown - primary tooth Sedative filling Core build-up Cast post and core in addition to crown Prefabricated post and core in addition to crown Temporary crown Crown repair, by report *Prosthetics can only be replaced once every five years.
3 Endodontics (including x-rays but exclusive of restoration) 3110 Pulp cap direct (excluding final restoration) Pulp cap indirect (excluding final restoration) Therapeutic pulpotomy (excluding final restoration) Anterior Root Canal (excluding final restoration) Bicuspid Root Canal (excluding final restoration) Molar Root Canal (excluding final restoration) Retreatment of previous RCT anterior Retreatment of previous RCT bicuspid Retreatment of previous RCT molar Apicoectomy - periradicular surgery anterior Apicoectomy bicuspid periradicular surgery bicuspid (first root) Apicoectomy molar periradicular surgery molar (first root) Apicoectomy/Periradicular surgery (each additional root) Retrograde filling Periodontics 4210 Gingivectomy or Gingivoplasty 4 plus teeth per quadrant Gingivectomy or Gingivoplasty 1-3 teeth per quadrant Gingival flap procedure 4 plus teeth per quadrant Gingival flap procedure 1-3 teeth per quad Clinical crown lengthening Osseous Surgery - 4 plus teeth per quadrant Osseous Surgery (1-3 teeth per quadrant) Bone replacement graft 1st site in quadrant Bone replacement graft each add l site in quadrant Pedicle soft tissue graft procedure Free soft tissue graft procedure (including donor site surgery) Provisional splinting intracoronal Provisional splinting extracoronal Perio scaling & root planing 4 plus teeth per quadrant Perio scaling & root planing (1-3 teeth per quad) Localized delivery of antimicrobial agents* Perio maintenance procedures (following active therapy) 35.00
4 * Maximum of four applications per calendar year. Prosthodontics (removable) 5110 Complete upper dentures* Complete lower dentures* Immediate upper dentures* Immediate lower dentures* Maxillary partial denture resin base* Mandibular partial denture resin base* Maxillary partial denture cast metal frame/resin base* Mandibular partial denture cast metal frame/resin base* Removable unilateral partial denture one piece cast metal (including clasps & pontics)* Adjust complete denture maxillary Adjust complete denture mandibular Adjust partial denture maxillary Adjust partial denture mandibular 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 complete upper denture (chairside) Reline complete lower denture (chairside) Reline upper partial denture (chairside) Reline lower partial denture (chairside) Reline complete upper denture (laboratory) Reline complete lower denture (laboratory)
5 5760 Reline upper partial denture (laboratory) Reline lower partial denture (laboratory) Precision attachment, by report Implant Benefit 6010 Surgical placement of implant body: endosteal implant ** 6040 Surgical placement: eposteal implant ** 6050 Surgical placement: transosteal implant ** ** 100% up to $1500 paid per procedure/$2000 Lifetime Benefit Maximum Implant Supported Prosthetics 6053*, 6054*, 6056*, 6057* *, 6059*, 6060*, 6061*, 6062*, 6063*, 6064*, 6065*, 6066*, 6067*, 6068*, 6069*, 6070*, 6071*, 6072*, 6073*, 6074*, 6075*, 6076*, 6077* Prosthodontics (fixed 6020 Abutment placement or substitution Pontic cast high noble metal* Pontic cast predominantly base metal* Pontic cast noble metal* Pontic porcelain fused to high noble metal* Pontic porcelain fused to predominantly base metal* Pontic porcelain fused to noble metal* Pontic resin with high noble metal* Pontic resin with predominantly base metal* Pontic resin with noble metal* Retainer cast metal* Crown resin with high noble metal* *Prosthetics can only be replaced once every five years Crown resin with predominantly base metal* Crown resin with noble metal* Crown porcelain fused to high noble metal Crown porcelain fused to predominantly base metal*
6 6752 Crown porcelain fused to noble metal* Crown ¾ cast high noble metal* Crown full cast high noble metal* Crown full cast predominantly base metal* Crown full cast noble metal* Recement fixed partial denture Precision attachment Fixed partial denture repair, by report *Prosthetics can only be replaced once every five years. ** 100% up to $1500 paid per procedure/$2000 Lifetime Benefit Maximum Oral Surgery (including local anesthesia and post operative care) 7111 Extraction, coronal remnants deciduous tooth Extraction - erupted tooth or exposed root Surgical removal of erupted tooth requiring elevation mucoperiosteal flap and removal of bone and/or section of tooth Removal of impacted tooth soft tissue Removal of impacted tooth partially bony Removal of impacted tooth completely bony Removal of impacted tooth completely bony w/complications Surgical removal of residual roots (cutting procedure) Alveoplasty with extraction per quadrant Alveoplasty no extractions per quadrant Excision of malignant tumor lesion diameter up to 1.25 cm Excision of malignant tumor lesion diameter over 1.25 cm Incision & drainage of abscess intraoral soft tissue Incision & drainage of abscess extraoral soft tissue Frenulectomy Orthodontics 8080 Comprehensive orthodontic treatment of the adolescent dentition (once per lifetime) Comprehensive orthodontic treatment of the adult dentition (once per lifetime) Pre-orthodontic treatment visit (once per lifetime)
7 8670 Periodic orthodontic treatment visit as part of contract (up to 24 consecutive months) Orthodontic retention-limit $200 (100 ea. top & bottom) Adjunctive General Services 9110 Palliative (emergency) treatment of dental pain General anesthesia first 30 minutes General anesthesia each additional 15 minutes Consultation Occlusal adjustment limited Occlusal adjustment complete 50.00
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