The Dental Plan Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation Now you can have comprehensive DENTAL coverage at a cost you can afford! Since 1981, Denta-Chek has been providing quality dental coverage to thousands of individuals and families and has continued to receive recognition throughout the years on the many benefits The Denta- Chek Dental Plan offers. Even if you are having extensive dental work done now, or you or a family member may need dental care, The Denta-Chek Dental Plan allows you to start receiving benefits immediately upon your effective date. The typical family could save hundreds, even thousands of dollars on the cost of dental care. For example, many services such as office visits, examinations, cleanings and most x-rays are provided at NO CHARGE. Other procedures are at greatly reduced fees, such as fillings, crowns, dentures, orthodontics (braces), periodontics (gum treatments) and endodontics (root canal therapy). There are NO waiting periods, pre-existing condition limitations, or even claim forms to complete! Other special features include no deductibles, no lifetime or annual limits on benefits and no limits on the number of office visits. Applicant Only What is my monthly cost? Applicant + 1 Applicant + 2 or more $15 $20 $25 There is also a one-time $10 application fee. See application inside for payment options and enrollment instructions. If, for any reason, you are not completely satisfied with the Plan, Denta-Chek will refund your initial payment if your written notice, Certificate of Coverage and ID card are returned during the first 30 days of coverage. However, you will have to pay the dentist his or her usual fees for any services rendered. The application fee is not refundable. Once coverage has been in force for more than 30 days, no fees are refundable. For more information, write or call: (410)997-3300 (Baltimore Metro Area) (888)478-8833 (Elsewhere) www.dentachek.com DM2008SAGP
Important Questions & Answers about the Dental Plan WHO IS ELIGIBLE? Denta-Chek Dental Plan subscribers and their legal dependents. Dependent children can be covered as long as they are under 19, or if they are full time students, to age 23. Coverage of a child who attains age 19 will be continued while he or she is incapable of self-sustaining employment by reason of mental incapacity or physical handicap. Children may take out their own individual plan when they are no longer eligible. MUST I USE A PARTICIPATING DOCTOR? No. However, benefits are MUCH better when you use one of the many participating dentists located throughout the area. In addition, there are many specialists, such as oral surgeons, orthodontists, endodontists and periodontists who will provide care for you and your family under this plan. Call our office to find out who participates and how your present dentist can participate. WHAT IF I CANCEL BEFORE I VE COMPLETED A FULL YEAR OF COVERAGE? Enrollment in the dental plan is for at least one year. If you decide to drop the plan before completing a full year of coverage, you will owe the plan the usual, customary and reasonable fees for any services rendered under the plan, reduced by the sum of the Subscription Fees and Subscriber s Charges paid by or on behalf of the Subscriber and Dependents. MONEY BACK GUARANTEE If you are not completely satisfied with the plan, the plan will refund your subscriber fee if your written notice, Certificate of Coverage and ID card are returned during the first 30 days of coverage. However, you will have to pay the dentist his or her usual fees for any services rendered. The application fee is not refundable. Once coverage has been in force for more than 30 days, no fees are refundable. WHAT HAPPENS IN AN EMERGENCY? Should you or a covered dependent be more than 50 miles from a participating dentist and need emergency care, this plan will reimburse up to $50 to see any dentist. See your Certificate of Coverage for details. ARE THERE ANY OTHER LIMITS? As with other plans, there are services which this plan does not provide, such as services which are covered under Workers Compensation or Employers Liability Laws. For a complete list of exclusions, please check your Certificate of Coverage. Of Maryland, Inc. 7125 Thomas Edison Dr., #105 Columbia, MD 21046 For more information, write or call: (410)997-3300 (Baltimore Metro Area) (888)478-8833 (Elsewhere) www.dentachek.com
DENTA-CHEK OF MARYLAND, INC. FEE SCHEDULE EFFECTIVE 5/1/2008 DIAGNOSTIC/PREVENTIVE MISC. CONSULTATION NO CHARGE MISC. ORAL CANCER EXAMINATION NO CHARGE D0120 PERIODIC ORAL EXAMINATION, ONCE EVERY SIX MONTHS NO CHARGE D0140 LIMITED ORAL EVALUATION PROBLEM FOCUSED $56 D0145 ORAL EVALUATION FOR CHILD UNDER THREE YEARS OF AGE $25 D0150 COMPREHENSIVE ORAL EVALUATION NEW OR ESTABLISHED PATIENT NO CHARGE D0160 DETAILED AND EXTENSIVE ORAL EVALUATION PROBLEM FOCUSED, BY REPORT $56 D0170 RE-EVALUATION-LIMITED PROBLEM FOCUSED NO CHARGE D0210 INTRAORAL-COMPLETE SERIES (INCLUDING BITEWINGS) NO CHARGE D0220-D0240 INTRAORAL FILMS NO CHARGE D0250-D0260 EXTRAORAL FILMS NO CHARGE D0270-D0277 BITEWINGS NO CHARGE D0330 PANORAMIC FILM $70 D0340 CEPHALOMETRIC FILM $70 D0460 PULP VITALITY TESTS $35 D0470 DIAGNOSTIC CASTS $40 D1110-D1120 PROPHYLAXIS, ONCE EVERY SIX MONTHS NO CHARGE D1110 ADDITIONAL ADULT PROPHYLAXIS, (OVER 19 YEARS OF AGE) $80 D1120 ADDITIONAL CHILD PROPHYLAXIS, (19 AND UNDER) $65 D1203-D1204 TOPICAL APPLICATION OF FLUORIDE (ANNUALLY) $30 D1351 SEALANT-PER TOOTH $25 D1360 O.S.H.A. INFECTION CONTROL PROCEDURES, PER VISIT $10 SPACE MAINTAINERS D1510 SPACE MAINTAINER-FIXED-UNILATERAL $200 D1515 SPACE MAINTAINER-FIXED-BILATERAL $245 D1520 SPACE MAINTAINER-REMOVABLE-UNILATERAL $220 D1525 SPACE MAINTAINER-REMOVABLE-BILATERAL $270 RESTORATIVE (FILLINGS INCLUDING CEMENT BASE) D2140 AMALGAM-ONE SURFACE $63 D2150 AMALGAM-TWO SURFACES $77 D2160 AMALGAM-THREE SURFACES $91 D2161 AMALGAM-FOUR OR MORE SURFACES $105 D2330 RESIN-BASED COMPOSITE-ONE SURFACE, ANTERIOR $91 D2331 RESIN-BASED COMPOSITE TWO SURFACES, ANTERIOR $105 D2332 RESIN-BASED COMPOSITE-THREE SURFACES, ANTERIOR $120 D2335 RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES OR INVOLVING INCISAL ANGLE (ANTERIOR) $145 D2391 RESIN-BASED COMPOSITE-ONE SURFACE, POSTERIOR $98 D2392 RESIN-BASED COMPOSITE-TWO SURFACES, POSTERIOR $115 D2393 RESIN-BASED COMPOSITE-THREE SURFACES, POSTERIOR $135 D2394 RESIN-BASED COMPOSITE- FOUR OR MORE SURFACES, POSTERIOR $160 D2510 INLAY-METALLIC-ONE SURFACE $420 D2520 INLAY-METALLIC-TWO SURFACES $465 D2530 INLAY-METALLIC-THREE OR MORE SURFACES $480 D2542 ONLAY-METALLIC-TWO SURFACES $495 D2543 ONLAY-METALLIC-THREE SURFACES $504 D2544 ONLAY-METALLIC-FOUR OR MORE SURFACES $581 D2610 INLAY-PORCELAIN/CERAMIC-ONE SURFACE $435 D2620 INLAY-PORCELAIN/CERAMIC-TWO SURFACES $490 D2630 INLAY-PORCELAIN/CERAMIC-THREE OR MORE SURFACES $515 D2642 ONLAY-PORCELAIN/CERAMIC-TWO SURFACES $530 D2643 ONLAY-PORCELAIN/CERAMIC-THREE SURFACES $590 D2644 ONLAY-PORCELAIN/CERAMIC-FOUR OR MORE SURFACES $609 D2650 INLAY-RESIN-BASED COMPOSITE-ONE SURFACE $380 D2651 INLAY-RESIN-BASED COMPOSITE-TWO SURFACES $450 D2652 INLAY-RESIN-BASED COMPOSITE-THREE OR MORE SURFACES $480 D2662 ONLAY-RESIN-BASED COMPOSITE-TWO SURFACES $500 D2663 ONLAY-RESIN-BASED COMPOSITE-THREE SURFACES $525 D2664 ONLAY-RESIN-BASED COMPOSITE-FOUR OR MORE SURFACES $555
CROWNS (CAPS) (AS SINGLE RESTORATIONS ONLY)* D2710 CROWN-RESIN (LABORATORY) $315 D2720 CROWN-RESIN WITH HIGH NOBLE METAL $520 D2721 CROWN-RESIN WITH PREDOMINATELY BASE METAL $505 D2722 CROWN-RESIN WITH NOBLE METAL $505 D2740 CROWN-PORCELAIN/CERAMIC SUBSTRATE $620 D2750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $610 D2751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $545 D2752 CROWN-PORCELAIN FUSED TO NOBLE METAL $565 D2780 CROWN-3/4 CAST HIGH NOBLE METAL $485 D2781 CROWN-3/4 CAST PREDOMINANTLY BASE METAL $430 D2782 CROWN-3/4 CAST NOBLE METAL $460 D2783 CROWN-3/4 PORCELAIN/CERAMIC $515 D2790 CROWN-FULL CAST HIGH NOBLE METAL $580 D2791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $520 D2792 CROWN-FULL CAST NOBLE METAL $570 D2794 CROWN-TITANIUM $605 D2799 PROVISIONAL CROWN $195 D2910-D2920 RECEMENT INLAY OR CROWN $63 D2930-D2931 PREFABRICATED STAINLESS STEEL CROWN $70 D2940 SEDATIVE FILLING $49 D2950 CORE BUILDUP, INCLUDING ANY PINS $155 D2951 PIN RETENTION, IN ADDITION TO RESTORATION $45 D2952 CAST POST AND CORE IN ADDITION TO CROWN, INDIRECTLY FABRICATED $195 D2953 EACH ADDITIONAL INDIRECTLY FABRICATED POST SAME TOOTH $93 D2954 PREFABRICATED POST AND CORE IN ADDITION TO CROWN $180 D2961 LABIAL VENEER (RESIN LAMINATE)-LABORATORY $540 D2962 LABIAL VENEER (PORCELAIN LAMINATE)-LABORATORY $650 D2970 TEMPORARY CROWN (FRACTURED TOOTH) $120 * A HIGH NOBLE METAL (GOLD) SURCHARGE MAY BE ADDED FOR ACTUAL LAB FEES, NOT TO EXCEED $50 ENDODONTICS (ROOT CANAL) (EXCLUDING FINAL RESTORATION) WHEN PERFORMED BY PLAN GENERAL PRACTITIONER: D3110-D3120 PULP CAP $49 D3220 THERAPEUTIC PULPOTOMY $126 D3310 ANTERIOR $365 D3320 BICUSPID $450 D3330 MOLAR $550 D3410 APICOECTOMY/PERIRADICULAR SURGERY (ANTERIOR) $350 D3421 APICOECTOMY/PERIRADICULAR SURGERY (BICUSPID-FIRST ROOT) $371 D3425 APICOECTOMY/PERIRADICULAR SURGERY (MOLAR-FIRST ROOT) $406 D3426 APICOECTOMY/PERIRADICULAR SURGERY (EACH ADDITIONAL ROOT) $170 D3430 RETROGRADE FILLING-PER ROOT $170 D3450 ROOT AMPUTATION-PER ROOT $270 WHEN PERFORMED BY PLAN ENDONTIST: PERIODONTICS (GUM TREATMENT) WHEN PERFORMED BY PLAN GENERAL PRACTITIONER: D4210 GINGIVECTOMY OR GINGIVOPLASTY-FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT $315 D4211 GINGIVECTOMY OR GINGIVOPLASTY-ONE TO THREE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES, PER QUADRANT $150 D4240 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT $430 D4241 GINGIVAL FLAP PROCEDURE, INCLUDING ROOT PLANING-ONE TO THREE TEETH, PER QUADRANT $340 D4260 OSSEOUS SURGERY (INCLUDING FLAP ENTRY & CLOSURE)-FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT $550 D4261 OSSEOUS SURGERY (INCLUDING FLAP ENTRY & CLOSURE)-ONE TO THREE CONTIGOUS TEETH OR BOUNDED TEETH SPACES, PER QUADRANT $350 D4263 BONE REPLACEMENT GRAFT-FIRST SITE IN QUADRANT $430 D4264 BONE REPLACEMENT GRAFT-EACH ADDITIONAL SITE IN QUADRANT $315 D4341 PERIODONTAL SCALING & ROOT PLANING-FOUR OR MORE CONTIGUOUS TEETH OR BOUNDED TEETH SPACES PER QUADRANT $161 D4342 PERIODONTAL SCALING & ROOT PLANING-ONE TO THREE TEETH, PER QUADRANT $85 D4355 FULL MOUTH DEBRIDEMENT TO ENABLE COMPREHENSIVE EVALUATION AND DIAGNOSIS $130 D4910 PERIODONTAL MAINTENANCE $98 WHEN PERFORMED BY PLAN PERIODONTIST:
PROSTHETICS D5110-D5120 COMPLETE DENTURE-UPPER OR LOWER $785 D5130-D5140 IMMEDIATE DENTURE-UPPER OR LOWER $820 D5211-D5212 UPPER OR LOWER PARTIAL DENTURE-RESIN BASE (INCLUDING CLASPS, RESTS AND TEETH) $640 D5213-D5214 UPPER OR LOWER PARTIAL DENTURE-CAST METAL (INCLUDING CLASPS AND TEETH) $798 D5225 MAXILLARY PARTIAL DENTURE FLEXIBLE BASE (INCLUDING ANY CLASPS, RESTS AND TEETH) $620 D5226 MANDIBULAR PARTIAL DENTURE FLEXIBLE BASE D5281 (INCLUDING ANY CLASPS, RESTS AND TEETH) $620 REMOVABLE UNILATERAL PARTIAL DENTURE-ONE PIECE CAST METAL (INCLUDING CLASPS AND TEETH) $798 D5410-D5411 ADJUST COMPLETE DENTURE-UPPER OR LOWER $50 D5421-D5422 ADJUST PARTIAL DENTURE-UPPER OR LOWER $50 D5510 REPAIR BROKEN COMPLETE DENTURE BASE $105 D5520 REPLACE MISSING OR BROKEN TEETH-COMPLETE DENTURE (EACH TOOTH) $98 D5610 REPAIR RESIN DENTURE BASE $105 D5620 REPAIR CAST FRAMEWORK $133 D5630 REPAIR OR REPLACE BROKEN CLASP $120 D5640 REPLACE BROKEN TEETH-PER TOOTH $98 D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE $120 D5660 ADD CLASP TO EXISTING PARTIAL DENTURE $140 D5710 REBASE COMPLETE MAXILLARY DENTURE $315 D5711 REBASE COMPLETE MANDIBULAR DENTURE $330 D5720 REBASE MAXILLARY PARTIAL DENTURE $295 D5721 REBASE MANDIBULAR PARTIAL DENTURE $290 D5730-D5731 RELINE COMPLETE DENTURE-UPPER OR LOWER (CHAIRSIDE) $210 D5740-D5741 RELINE PARTIAL DENTURE-UPPER OR LOWER (CHAIRSIDE) $190 D5750-D5751 RELINE COMPLETE DENTURE-UPPER OR LOWER (LABORATORY) $275 D5760-D5761 RELINE PARTIAL DENTURE-UPPER OR LOWER (LABORATORY) $255 D6205 PONTIC-INDIRECT RESIN BASED COMPOSITE $560 D6210 PONTIC-CAST HIGH NOBLE METAL $609 D6211 PONTIC-CAST PREDOMINANTLY BASE METAL $580 D6212 PONTIC-CAST NOBLE METAL $595 D6240 PONTIC PORCELAIN FUSED TO HIGH NOBLE METAL $610 D6241 PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $620 D6242 PONTIC-PORCELAIN FUSED TO NOBLE METAL $600 D6245 PONTIC-PORCELAIN/CERAMIC $640 D6250 PONTIC-RESIN WITH HIGH NOBLE METAL $590 D6251 PONTIC- RESIN WITH PREDOMINANTLY BASE METAL $575 D6252 PONTIC-RESIN WITH NOBLE METAL $580 D6253 PROVISIONAL PONTIC $295 D6545 RETAINER-CAST METAL FOR RESIN BONDED FIXED PROSTHESIS $329 D6750 CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL $620 D6751 CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL $580 D6752 CROWN-PORCELAIN FUSED TO NOBLE METAL $600 D6780 CROWN-3/4 CAST HIGH NOBLE METAL $520 D6781 CROWN-3/4 CAST PREDOMINANTLY BASE METAL $485 D6782 CROWN-3/4 CAST NOBLE METAL $495 D6783 CROWN-3/4 CAST PORCELAIN/CERAMIC $580 D6790 CROWN-FULL CAST HIGH NOBLE METAL $575 D6791 CROWN-FULL CAST PREDOMINANTLY BASE METAL $505 D6792 CROWN-FULL CAST NOBLE METAL $525 D6793 PROVISIONAL RETAINER CROWN $340 D6794 CROWN-TITANIUM $550 D6930 RECEMENT FIXED PARTIAL DENTURE $85 D6950 PRECISION ATTACHMENT $290
ORAL SURGERY WHEN PERFORMED BY PLAN GENERAL PRACTITIONER: D7140 EXTRACTION, ERUPTED TOOTH OR EXPOSED ROOT (ELEVATION AND/OR FORCEPS REMOVAL) $90 D7210 SURGICAL REMOVAL OF ERUPTED TOOTH $150 D7220 REMOVAL OF IMPACTED TOOTH-SOFT TISSUE $160 D7230 REMOVAL OF IMPACTED TOOTH-PARTIALLY BONY $225 D7240 REMOVAL OF IMPACTED TOOTH-COMPLETELY BONY $255 D7241 REMOVAL OF IMPACTED TOOTH-COMPLETE BONY, WITH UNUSUAL SURGICAL COMPLICATIONS $320 D7250 SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE) $155 D7285 BIOPSY OF ORAL TISSUE-HARD (BONE, TOOTH) $190 D7286 BIOPSY OF ORAL TISSUE-SOFT (ALL OTHERS) $175 D7310 D7311 D7320 D7321 ALVEOLOPLASTY IN CONJUCTION WITH EXTRACTIONS FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT $150 ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT $170 ALVEOLOPLASTY NOT IN CONJUCTION WITH EXTRACTIONS FOUR OR MORE TEETH OR TOOTH SPACES, PER QUADRANT $215 ALVEOLOPLASTY NOT IN CONJUCTION WITH EXTRACTIONS ONE TO THREE TEETH OR TOOTH SPACES, PER QUADRANT $205 D7510 INCISION AND DRAINAGE OF ABSCESS-INTRAORAL SOFT TISSUE $120 D7960 FRENECTOMY OR FRENOTOMY-SEPARATE PROCEDURE $189 D7970 EXCISION OF HYPERPLASTIC TISSUE-PER ARCH $210 WHEN PERFORMED BY PLAN ORAL SURGEON: OTHER SERVICES D9110 PALLIATIVE (EMERGENCY) TREATMENT OF DENTAL PAIN-MINOR PROCEDURE $50 D9120 FIXED PARTIAL DENTURE SECTIONING $145 D9210 LOCAL ANESTHESIA $30 D9220 DEEP SEDATION/GENERAL ANESTHESIA-FIRST 30 MINUTES $160 D9221 DEEP SEDATION/GENERAL ANESTHESIA-EACH ADDITIONAL 15 MINUTES $95 D9230 ANALGESIA, ANZIOOLYSIS, INHALATION OF NITROUS OXIDE $35 D9241 INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA-FIRST 30 MINUTES $170 D9242 INTRAVENOUS CONSCIOUS SEDATION/ANALGESIA-EACH ADDITIONAL D9310 15 MINUTES $85 CONSULTATION (DIAGNOSTIC SERVICE PROVIDED BY DENTIST OR PHYSICIAN OTHER THAN REQUESTING DENTIST OR PHYSICIAN) $80 D9440 OFFICE VISIT AFTER REGULARLY SCHEDULED HOURS $80 D9940 OCCLUSAL GUARD, BY REPORT $320 D9941 FABRICATION OF ATHLETIC MOUTHGUARD $260 D9951 OCCLUSAL ADJUSTMENT-LIMITED $95 D9952 OCCLUSAL ADJUSTMENT-COMPLETE $250 WHEN PERFORMED BY PLAN SPECIALIST: ORTHODONTICS (BRACES) WHEN DONE BY PLAN ORTHODONTIST: INITIAL CONSULTATION NO CHARGE DIAGNOSTIC RECORDS AND CONSULTATION FEES (INCLUDING X-RAYS BY ORTHORDONTIST) $320 FOR STANDARD 2 YEAR CASE: CHILD (UP TO AGE 19): $3700 ADULT: $4100 RETENTION BEYOND 2 YEARS IS AT A 25% REDUCTION OF USUAL, CUSTOMARY AND REASONABLE FEES FOR ALL PROCEDURES ALL OTHER PROCEDURES NOT LISTED ARE AT DENTIST S USUAL, CUSTOMARY AND REASONABLE (U.C.R.) FEES LESS 25% THIS SCHEDULE APPLIES ONLY TO PARTICIPATING DENTISTS. SEE PARTS III, IX AND XVII OF YOUR CERTIFICATE OF COVERAGE FOR BENEFITS APPLICABLE TO NON-PARTICIPATING DENTISTS.