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Dental Plan Coverage
The Benefits of a Scheduled Dental Plan
The following are potential advantages of a schedule plan versus a traditional indemnity plan:
- The schedule plan offers the insured the same flexibility as an indemnity plan. You are free to utilize any provider, anywhere, at any time. Unlike an indemnity plan, a schedule plan offers potential cost savings by allowing the insured the opportunity to select a participating provider. The insured will benefit from the savings of our negotiated discounts.
- The schedule plan offers the employer and the insured more premium stability than an indemnity plan. With the utilization of the payment schedule, we are better able to forecast and control costs. This cost control is passed through to you in the form of more stable premiums and renewals.
- The schedule plan empowers the insured. The insured is given a copy of the entire schedule. Armed with the amount of the payment from us, the insured is able to compare providers to see which provider will perform the necessary services most reasonably. For example, if we will pay $209.00 for a crown, the insured is free to contact any provider and compare the charges of each provider. This offers the insured the potential for even greater savings.
Select Dental Plan 1500 - Service Payment Schedule
The following is a sample list of dental procedures payable under this plan. Click here to download a complete list of the procedures and service payment schedules.
CODE
|
DESCRIPTION OF SERVICE
|
COVERED EXPENSE
|
|
0150
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Comprehensive oral evaluation - new or established patient
|
$33.00
|
|
0274
|
X-Ray - bitewings - four films
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$26.00
|
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1110
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Routine Prophylaxis - adult (once every six months)
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$38.00
|
|
2331
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Resin filling - two surfaces, anterior
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$50.00
|
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2750
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Crown -porcelain fused to high noble metal*
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$187.00
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3330
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Root Canal - Molar*
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$196.00
|
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4341
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Periodontal scaling and root planning - per quadrant*
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$48.00
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7110
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Single tooth (extraction)
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$40.00
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Select Dental Plan 1000 - Service Payment Schedule
The following is a sample list of dental procedures payable under this plan. Click here to download a complete list of the procedures and service payment schedules.
CODE
|
DESCRIPTION OF SERVICE
|
COVERED EXPENSE
|
Preventive
|
0120
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Periodic Oral Evaluation (Twice in a Benefit Period).
|
$19.00
|
1110
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Prophylaxis - adult (Twice in a Benefit Period).
|
$40.00
|
1203
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Topical Fluoride (separate code) in conjunction with prophylaxis.
|
$15.00
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0210
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Intraoral - complete series (including bitewings).
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$60.00
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0272
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Bitewings - two films (Twice in a Benefit Period).
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$17.00
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1510
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Fixed space maintainer, unilateral.
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$141.00
|
Basic
|
1351
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Sealant - per tooth
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$16.00
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2140
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Amalgam restoration - one surface, primary or permanent.
|
$38.00
|
7140
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Extraction, erupted tooth or exposed root (elevation and/or forceps removal).
|
$42.00
|
7240
|
Surgical removal of tooth (completely bony).
|
$158.00
|
5510
|
Denture repair - Repair broken base.
|
$48.00
|
9220
|
Deep sedation/general anesthesia.
|
$122.00
|
Major
|
5211
|
Maxillary partial denture - resin base.
|
$185.00
|
3310
|
Endodontics - root canal, anterior.
|
$145.00
|
4341
|
Periodontal scaling and root planing, four or more teeth. Each quadrant is eligible for consideration once in a 2 year period.
|
$48.00
|
2792
|
Crown - full cast noble metal.
|
$209.00
|
2980
|
Crown repair.
|
$40.00
|
6242
|
Pontics - porcelain fused to noble metal.
|
$215.00
|
Value Dental Plan 1000 - Service Payment Schedule
The following is a sample list of dental procedures payable under this plan. Click here to download a complete list of the procedures and service payment schedules.
CODE
|
DESCRIPTION OF SERVICE
|
COVERED EXPENSE
|
Preventive
|
0120
|
Periodic Oral Evaluation (Twice in a Benefit Period).
|
$9.00
|
1110
|
Prophylaxis - adult (Twice in a Benefit Period).
|
$19.00
|
1203
|
Topical Fluoride (separate code) in conjunction with prophylaxis.
|
$7.00
|
1510
|
Fixed space maintainer, unilateral.
|
$67.00
|
Basic
|
0210
|
Intraoral - complete series (including bitewings).
|
$24.00
|
0272
|
Bitewings - two films (Twice in a Benefit Period).
|
$7.00
|
1351
|
Sealant - per tooth
|
$9.00
|
2140
|
Amalgam restoration - one surface, primary or permanent.
|
$20.00
|
7140
|
Extraction, erupted tooth or exposed root (elevation and/or forceps removal).
|
$22.00
|
7240
|
Surgical removal of tooth (completely bony).
|
$83.00
|
5510
|
Denture repair - Repair broken base.
|
$25.00
|
9220
|
Deep sedation/general anesthesia.
|
$64.00
|
Major
|
5211
|
Maxillary partial denture - resin base.
|
$114.00
|
3310
|
Endodontics - root canal, anterior.
|
$89.00
|
4341
|
Periodontal scaling and root planing, four or more teeth. Each quadrant is eligible for consideration once in a 2 year period.
|
$30.00
|
2792
|
Crown - full cast noble metal.
|
$129.00
|
2980
|
Crown repair.
|
$25.00
|
6242
|
Pontics - porcelain fused to noble metal.
|
$133.00
|
|
|
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