Charges for co-paid services received after your annual maximum has been reached are not covered.
| Service |
You Will Pay
|
|
Restorative
|
|
Amalgam (silver) filling once every 24 months on the same surface of
the same tooth |
|
| one surface |
15.00
|
| two surfaces |
18.00
|
| three surfaces |
21.00
|
| four or more surfaces |
26.00
|
Composite resin (white) filling, front teeth only once every 24 months
on the same surface of the same tooth |
|
|
one surface
|
15.00
|
| two surfaces |
21.00
|
| three surfaces |
26.00
|
| four or more surfaces |
35.00
|
Composite resin (white) one-surface filling, posterior teeth, once
every 24 months on the same surface of the same tooth |
|
| one surface |
18.00
|
| two surfaces |
50.00
|
| three surfaces |
60.00
|
| four or more surfaces |
70.00
|
| Composite resin crown, front baby teeth only |
40.00
|
| Onlays (per tooth, once every 60 months per tooth) |
|
| three surfaces |
210.00
|
| four or more surfaces |
220.00
|
| Crowns: (per tooth, once every 60 months per tooth) |
|
|
crown resin (laboratory)
|
75.00
|
|
crowns (co-pay depends on type of material used)
|
190.00
230.00
or 290.00
|
| Stainless steel crowns, once every 24 months |
35.00
|
Recement cast or prefab post and core, crown, implant/abutment
supported crown/fixed partial dentre, or bridge, once per lifetime
when performed by same provider |
17.00
|
|
Sedative filling, once every 60 months per tooth
|
15.00
|
| Core build-up, including any pins, once every 60 months per tooth |
45.00
|
| Pin retention, per tooth not per pin, in addition to restoration |
10.00
|
Cast post and core, in addition to crown, once every 60 months per
tooth |
60.00
|
Prefabricated post and core, in addition to crown, once every 60
months per tooth |
60.00
|
| Temporary crown (fractured tooth) |
35.00
|
|
Additional procedures to construct new crown under existing partial
denture framework
|
35.00
|
|
Repair of crown or bridge, once every 12 months
|
35.00
|
|
Endodontics
|
|
| Pulp cap - indirect (excluding final restoration) |
10.00
|
|
Therapeutic pulpotomy (excluding final restoration), dependents age
13 and under, once every 60 months
|
20.00
|
Pulpal debridement, dependents age 13 and under, once every 60
months |
25.00
|
|
Root canal therapy, once per tooth, per lifetime:
|
|
| Anterior |
100.00
|
|
Bicuspid
|
140.00
|
| Molars |
160.00
|
|
Incomplete endodontic therapy
|
25.00
|
| Apicoectomy, first root, once every 24 months |
|
| Anterior |
100.00
|
| Bicuspid |
110.00
|
| Molar |
125.00
|
|
Each additional root
|
50.00
|
| Retrograde filling, per root |
40.00
|
|
Root amputation, per root
|
80.00
|
|
Hemisection, once per lifetime, once every 60 months per root amputation
|
60.00
|
|
Periodontics
|
|
| Gingivectomy, once every 36 months, per quadrant: |
|
|
1-3 teeth
|
40.00
|
|
4 or more contiguous teeth
|
100.00
|
| Gingival flap, including root planing, once every 36 months, per quadrant: |
|
| 1-3 teeth |
75.00
|
| 4 or more contiguous teeth |
120.00
|
|
Crown lengthening, once every 60 months
|
130.00
|
| Osseous surgery, once every 36 months, per quadrant: |
|
| 1-3 teeth |
140.00
|
| 4 or more contiguous teeth or bounded teeth spaces |
175.00
|
| Bone replacement graft, once every 36 months, per quadrant: |
|
|
First site in quadrant
|
65.00
|
| Each additional site |
40.00
|
|
Biological materials to aid in soft and osseous tissue regeneration,
once every 36 months
|
75.00
|
|
Pedicle soft tissue graft/free soft tissue graft/soft tissue allograph,
once every 36 months
|
165.00
|
| Subepithelial connective tissue graft, once every 36 months |
185.00
|
|
Scaling and Root Planing, once every 24 months, per quadrant:
|
|
| 1-3 teeth |
20.00
|
|
4 or more teeth
|
35.00
|
| Full mouth debridement, once per lifetime |
15.00
|
Localized delivery of therapeutic agents via a controlled release
vehicle allowed only after root planing or one year after surgery on
isolated teeth that have not had healing, 1,2, or 3 teeth, 5 mm or
greater pocket depth, per tooth |
20.00
|
|
Periodontal prophylaxis, once every 3 months following active
periodontal treatment
|
23.00
|
|
Periodontal appliance (includes occlusal guards)
|
80.00
|
|
Prosthodontics (Including routine post-delivery care)
|
|
| Fixed: (once every 60 months) |
|
|
Bridge abutment or bridge pontic (co-pay depends on type of
material used)
|
190.00
230.00
or 290.00
|
| Implant Services: (once every 60 months per tooth)* |
|
| Endosteal Implant |
620.00
|
| Implant Abutement |
220.00
|
|
Implant Abutement Crown
|
290.00
|
*Benefit is for the replacement of a single missing tooth in lieu of a
three-unit bridge under certain conditions. The teeth on either side
of the implant must be healthy. All implants require X-rays and
prior approval. No additional bridge coverage for this tooth
available for 60 months after implant placement. |
|
| Removable: (once every 60 months) |
|
|
Complete upper or lower denture
|
200.00
|
|
Immediate upper or lower denture
|
225.00
|
| Upper/lower partial, resin-based (includes clasps, rests and teeth) |
150.00
|
|
Upper/lower partial, cast metal framework with resin base
(includes clasps, rests and teeth)
|
225.00
|
|
Upper/lower partial, flexible base (includes clasps, rests and teeth)
|
225.00
|
Removable unilateral partial denture, one piece cast metal
(includes clasps and teeth) |
150.00
|
|
Adjust complete/partial denture, upper/lower
|
12.00
|
| Repairs: (once every 12 months unless stated otherwise) |
|
|
Repair broken complete denture base
|
36.00
|
| Replace missing or broken teeth - complete denture (each tooth) |
20.00
|
| Repair parital resin saddle or base |
25.00
|
| Repair cast framework |
30.00
|
| Repair or replace broken clasp |
30.00
|
|
Replace broken tooth (partial) each tooth
|
25.00
|
|
Add tooth to partial
|
35.00
|
Replace all teeth and acrylic on cast metal framework once every 5
years |
150.00
|
| Add clasp to existing partial denture |
35.00
|
|
Reline upper/lower complete/partial denture, chairside, once every
18 months
|
45.00
|
|
Reline upper/lower complete/partial denture, laboratory, once every
36 months
|
55.00
|
|
Rebase complete/partial denture, upper/lower
|
75.00
|
|
Oral Surgery
|
|
|
Coronal remnants - deciduous tooth
|
15.00
|
| Extraction, erupted tooth or exposed root (elevation and/or forceps removal) |
25.00
|
|
Surgical removal of erupted tooth
|
45.00
|
|
Surgical removal of impacted tooth:
|
|
| soft tissue |
60.00
|
|
partially bony
|
85.00
|
| completely bony |
100.00
|
| completely bony with complications |
110.00
|
|
Surgical removal of residual tooth roots
|
40.00
|
|
Surgical access of an unerupted tooth
|
100.00
|
| Placement of device to facilitate eruption of impacted tooth |
40.00
|
|
Alveoplasty, once per lifetime, per quadrant
|
65.00
|
| With extractions |
45.00
|
|
Alveoplasty, once per lifetime, 1-3 teeth
|
35.00
|
|
With extractions
|
30.00
|
| Vestibuloplasty-ridge extension |
90.00
|
|
Incision and drainage
|
35.00
|
| Frenulectomy |
80.00
|
|
Frenuloplasty, once per site, per lifetime
|
75.00
|
|
Excision of periocoronal gingiva
|
25.00
|
|
Other Services
|
|
|
Consultation, per session
|
15.00
|
| Intravenous sedation: |
|
| first 30 minutes |
45.00
|
|
each additional 15 minutes
|
20.00
|
| Occlusal guards, once every 5 years |
80.00
|
|
Repair and/or relining of occlusal guard
|
15.00
|
|
Palliative
|
|
| Palliative (emergency) treatment of dental pain, minor procedures (excludes prosthetic adjustments or periodontal treatment), three occurrences in 6 months |
15.00
|
|
Orthodontics (Braces)
|
|
| Orthodontic benefits are based on case complexity and are considered once per lifetime per patient regardless of what coverage, if any, you had on the original treatment date. To determine benefit, your MPE Exclusive Provider Network (EPN) dentist must submit a pre-treatment estimate to Delta Dental of Massachusetts |
|
| Orthodontic Diagnostic Workup |
130.00
|
| Orthodontic Treatment(Class I, Class II and Class III Maloclussion)* |
|
| Level 1 |
410.00
|
| Level 2 |
1,000.00
|
| Level 3 |
1,150.00
|
| Level 4 |
1,450.00
|
| Level 5 |
1,500.00
|
* Orthodontic patients agree to complete their treatment with the same orthodontist. Your member co-payment will not be guaranteed if you change to a new orthodontist during the course of your treatment, nor can any payments be made by the Fund to a second orthodontist. You are responsible for replacing lost or broken orthodontic appliances.
|
|