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Home Benefit Schedule Dental Center Network Enroll/Update About Us Contact Us |
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Benefits & Co-payments |
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Code |
Diagnostic
and Preventive |
Member
Pays |
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0120/50 |
Oral examination and diagnosis |
No Charge |
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1110/20 |
Teeth Cleaning (routine
prophylaxis) |
No Charge |
|
1330 |
Preventive care
instruction/training |
No Charge |
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9215 |
Local anesthetics |
No Charge |
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0460 |
Pulp vitality test |
No Charge |
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1203/4 |
Fluoride treatment (up to age 19) |
No Charge |
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9999 |
Office visits (regular hours) |
$5.00 |
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Code |
X-Ray
Coverage |
Member
Pays |
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0210 |
Complete mouth |
No Charge |
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0330 |
Panoramic |
No Charge |
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0220 |
Single film |
No Charge |
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0230 |
Each additional film |
No Charge |
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027X |
Bitewing(s) |
No Charge |
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Code |
Adjunctive
Services |
Member
Pays |
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9110 |
Palliative treatment |
$ 5.00 |
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9999 |
Unscheduled appointment |
$10.00 |
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2920/6930 |
Re-cementing crown or bridge |
$ 5.00 |
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2940 |
Sedative filing |
$ 5.00 |
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2950/6973 |
Core build-up (including pins) |
$35.00 |
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2952/6970 |
Cast post-core |
$40.00 |
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2954/6972 |
Prefab post-core |
$40.00 |
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1351 |
Sealants (per tooth) |
$ 5.00 |
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Code |
Restorative (fillings) Amalgam restorations |
Member
Pays |
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2110/40 |
Fillings involving one surface |
$ 6.00 |
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2120/50 |
Fillings involving two surfaces |
$10.00 |
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2130/60 |
Fillings involving three surfaces |
$15.00 |
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2131/61 |
Fillings involving four or more
surfaces |
$25.00 |
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Composite
(white) restorations-anterior |
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2330 |
Fillings involving one surface |
$10.00 |
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2331 |
Fillings involving two surfaces |
$15.00 |
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2332 |
Fillings involving three surfaces |
$20.00 |
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2335 |
Fillings involving four or more
surfaces or incisal angle |
$35.00 |
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Code |
Space
Maintainers |
Member
Pays |
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1510 |
Unilateral-fixed |
$35.00 |
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1515 |
Bilateral-fixed |
$45.00 |
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1525 |
Bilateral-removable |
$55.00 |
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1550 |
Re-cementing appliance |
$10.00 |
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Code |
Crown
and Bridges |
Member
Pays |
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2751** |
Crown (per unit) |
$ 85.00 |
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2930/31 |
Stainless steel crown |
$ 40.00 |
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2337 |
Crown (composite resin) |
$ 70.00 |
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2970 |
Temporary crown (fractured tooth) |
$ 30.00 |
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6751** |
Fixed bridge (per unit) |
$130.00 |
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*0270,0272,0274
** Plus lab cost |
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Code |
Endodontics
(interior of tooth) |
Member
Pays |
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3310 |
Anterior root canal therapy (1
canal) |
$ 80.00 |
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3320 |
Premolar root canal therapy (2
canals) |
$ 95.00 |
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3330 |
Molar root canal therapy (3
canals) |
$135.00 |
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3426 |
Additional canals (each
canal) |
$ 40.00 |
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3410/21 |
Apicoectomy-separate procedure (per root) |
$ 95.00 |
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3430 |
Retrograde filling (per
root) |
$ 30.00 |
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3220 |
Therapeutic pulpotomy |
$ 30.00 |
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3110/20 |
Pulp capping (direct
or indirect) |
$ 20.00 |
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Code |
Periodontics
(gums and supporting tissues |
Member
Pays |
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0160 |
Periodontic exam/charting (full
mouth) |
$ 25.00 |
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1130 |
Difficult prophy (heavy
calculus) |
$ 30.00 |
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4345/55 |
Therapeutic scaling/debridement (each visit) |
$ 30.00 |
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4910 |
Periodontic maintenance (each
visit) |
$ 40.00 |
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4341 |
Scaling and root planing (per
quadrant) |
$ 43.00 |
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4381 |
Site
specific therapy (per tooth) |
$ 45.00 |
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4210 |
Gingivectomy (per
quadrant) |
$ 90.00 |
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4250 |
Mucogingival surgery (per
quadrant) |
$ 90.00 |
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4260 |
Osseous surgery (per
quadrant) |
$130.00 |
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9951 |
Occlusal adjustment (limited) |
$ 30.00 |
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Code |
Prosthodontics
(removables) |
Member
Pays |
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5110 |
Complete upper denture |
$200.00 |
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5120 |
Complete lower denture |
$200.00 |
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5130 |
Complete upper immediate denture |
$240.00 |
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5140 |
Complete lower immediate denture |
$240.00 |
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5421 |
Partial upper/lower with chrome
cobalt frame, two clasps and rests and acrylic base |
$280.00 |
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5211/12 |
Partial denture (acrylic
resin base) |
$180.00 |
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5850/51 |
Tissue conditioning (per
arch) |
$ 30.00 |
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54XX** |
Denture/partial adjustment (existing) |
$ 5.00 |
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Code |
Repair
of prosthesis |
Member
Pays |
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5610 |
Repair denture or partial (acrylic
resin base) |
$30.00 |
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5620* |
Repair broken tooth on partial or
denture |
$20.00 |
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5650* |
Add tooth to existing partial
denture |
$35.00 |
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5660* |
Add clasp to existing partial
denture |
$45.00 |
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5630* |
Repair or replace broken clasp |
$40.00 |
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57XX*** |
Relining complete or partial
denture (office) |
$70.00 |
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57XX**** |
Relining complete or partial
denture (lab) |
$70.00 |
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*
Plus lab costs **
5410, 5411, 5421, 5422 *** 5730,
5731, 5740, 5741 **** 5750, 5751,
5760, 5761 (plus lab costs) |
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Code |
Oral Surgery |
Member
Pays |
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Extractions
(by Primary
Care Dentist) |
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7110/20 |
Single tooth |
$12.00 |
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7210 |
Surgical removal of an erupted
tooth |
$30.00 |
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Impactions |
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7220 |
Removal impacted tooth – soft
tissue |
$35.00 |
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7230 |
Removal impacted tooth –
partially bony |
$50.00 |
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7240 |
Removal impacted tooth –
completely bony |
$65.00 |
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7241 |
Removal impacted tooth –
completely bony (diff.) |
$75.00 |
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7310 |
Alveoloplasty with extraction (per
quadrant) |
$30.00 |
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7320 |
Alveoloplasty without extraction (per quadrant) |
$50.00 |
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7471 |
Removal of exostosis (per
site) |
$95.00 |
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7510 |
Incision and drainage of abscess (intraoral) |
$20.00 |
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9241 |
IV anesthesia (for
surgical or multiple extractions) |
50% |
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9430 |
Office Visit/Observation (no other
tx) |
$10.00 |
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9930 |
Treatment of Post
Surgery/Complications |
$10.00 |
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Annual
Maximum Primary Care Dentistry |
$3,000.00 |
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Orthodontics (Approved
referral from DENCAP required for all Orthodontic
Care) |
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Members, under age 19, are
eligible to receive comprehensive orthodontic treatment (24
months), subject to the terms and conditions set forth by a DENCAP
authorized Orthodontic Center. |
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Diagnostic Records |
$ 250.00 |
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Comprehensive Orthodontics |
$2,695.00 |
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SPECIALTY
CARE (Approved referral from DENCAP required for all Specialty
Care) |
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Members referred to another DENCAP
dentist for Specialty Care are responsible for 50% of the fee for covered
treatment, including exams and x-rays (see NOTE). |
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ANNUAL
MAXIMUM for Specialty Care |
$800.00 |
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NOTE:
Having x-rays sent from the Primary Care Dentist to the Specialist may be
cost effective. |
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Benefits and co-payments subject
to change. |
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