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)
|
180.00
220.00
or 280.00
|
| 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) |
30.00
|
|
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
|
18.00
|
Pulpal debridement, dependents age 13 and under, once every 60
months |
20.00
|
|
Root canal therapy, once per tooth, per lifetime:
|
|
| Anterior |
95.00
|
|
Bicuspid
|
125.00
|
| Molars |
135.00
|
|
Incomplete endodontic therapy
|
20.00
|
| Apicoectomy, first root, once every 24 months |
|
| Anterior |
85.00
|
| Bicuspid |
95.00
|
| Molar |
115.00
|
|
Each additional root
|
45.00
|
| Retrograde filling, per root |
35.00
|
|
Root amputation, per root
|
62.00
|
|
Hemisection, once per lifetime, once every 60 months per root amputation
|
50.00
|
|
Periodontics
|
|
| Gingivectomy, once every 36 months, per quadrant: |
|
|
1-3 teeth
|
25.00
|
|
4 or more contiguous teeth
|
90.00
|
| 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 |
130.00
|
| 4 or more contiguous teeth or bounded teeth spaces |
168.00
|
| Bone replacement graft, once every 36 months, per quadrant: |
|
|
First site in quadrant
|
62.00
|
| Each additional site |
36.00
|
|
Biological materials to aid in soft and osseous tissue regeneration,
once every 36 months
|
62.00
|
|
Pedicle soft tissue graft/free soft tissue graft/soft tissue allograph,
once every 36 months
|
155.00
|
| Subepithelial connective tissue graft, once every 36 months |
175.00
|
|
Scaling and Root Planing, once every 24 months, per quadrant:
|
|
| 1-3 teeth |
20.00
|
|
4 or more teeth
|
32.00
|
| Full mouth debridement, once per lifetime |
13.00
|
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 |
22.00
|
|
Periodontal prophylaxis, once every 3 months following active
periodontal treatment
|
23.00
|
|
Periodontal appliance (includes occlusal guards)
|
77.00
|
|
Prosthodontics (Including routine post-delivery care)
|
|
| Fixed: (once every 60 months) |
|
|
Bridge abutment or bridge pontic (co-pay depends on type of
material used)
|
180.00
220.00
or 280.00
|
| Implant Services: (once every 60 months per tooth)* |
|
| Endosteal Implant |
620.00
|
| Implant Abutement |
200.00
|
|
Implant Abutement Crown
|
280.00
|
*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
|
175.00
|
|
Immediate upper or lower denture
|
205.00
|
| Upper/lower partial, resin-based (includes clasps, rests and teeth) |
142.00
|
|
Upper/lower partial, cast metal framework with resin base
(includes clasps, rests and teeth)
|
215.00
|
|
Upper/lower partial, flexible base (includes clasps, rests and teeth)
|
215.00
|
Removable unilateral partial denture, one piece cast metal
(includes clasps and teeth) |
125.00
|
|
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 |
29.00
|
|
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 |
125.00
|
| Add clasp to existing partial denture |
35.00
|
|
Reline upper/lower complete/partial denture, chairside, once every
18 months
|
42.00
|
|
Reline upper/lower complete/partial denture, laboratory, once every
36 months
|
53.00
|
|
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
|
40.00
|
|
Surgical removal of impacted tooth:
|
|
| soft tissue |
50.00
|
|
partially bony
|
75.00
|
| completely bony |
90.00
|
| completely bony with complications |
100.00
|
|
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 |
82.00
|
|
Incision and drainage
|
35.00
|
| Frenulectomy |
75.00
|
|
Frenuloplasty, once per site, per lifetime
|
65.00
|
|
Excision of periocoronal gingiva
|
25.00
|
|
Other Services
|
|
|
Consultation, per session
|
12.00
|
| Intravenous sedation: |
|
| first 30 minutes |
45.00
|
|
each additional 15 minutes
|
15.00
|
| Occlusal guards, once every 5 years |
77.00
|
|
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. To determine benefit, your MPE Preferred Provider 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 |
400.00
|
| Levels 2 and 3 |
1,050.00
|
| Levels 4 and 5 |
1,300.00 |
* Orthodontic patients must 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. You are responsible for replacing lost or broken orthodontic appliances.
|
|