|
The Fund Will Pay
|
|
Diagnostic and Preventive
|
|
| Comprehensive oral evaluation, for new or established patient, once every 5 years per provider |
37.00
|
| Periodic oral examination, once every 6 consecutive months(1) |
18.00
|
Oral evaluation for a patient under 3 years of age and counseling with
primary caregiver |
18.00
|
Limited oral evaluation, (no separate benefit paid for some definitive
treatment if performed on the same day), three occurrences in 6
months |
39.00
|
| Panorex, once every 60 months |
65.00
|
| Intraoral X-ray |
|
| periapical first film |
13.00
|
| periapical each additional film |
10.00
|
| occlusal film |
22.00
|
| complete series (once every 60 months) |
71.00
|
| Bitewing X-Rays (2) |
|
| single or two films |
19.00
|
| three films |
24.00
|
| four films |
32.00
|
| vertical |
71.00
|
| Pulp vitality test |
37.00
|
|
Adult Prophylaxis (cleaning), once every 6 consecutive months (1)
|
45.00
|
| Child Prophylaxis (cleaning), once every 6 consecutive months (1) |
36.00
|
|
Fluoride treatment, once every 6 consecutive months for
dependents age 18 and under (1)
|
18.00
|
Topical fluoride varnish, therapeutic application for moderate to high
caries risk patients, once every 6 consecutive months (1) |
18.00
|
|
Prescription strength fluoride toothpaste dispensed in the dental
office available for patients following certain periodontal surgeries
|
13.00
|
| Sealant per tooth, only on unrestored permanent molars, once every 48 months for dependents up to age 18 and under |
24.00
|
Chlorhexidine anti-bacterial mouthrinse dispensed in the dental
office available twice per year for patients receiving periodontal
scaling and root planing |
13.00
|
| Space Maintainers, once per lifetime for dependents age 14 and under |
|
| fixed/removable unilateral |
175.00
|
| fixed/removable bilateral |
300.00
|
| Re-cementation of space maintainer |
15.00
|
| Removal of fixed space maintainer |
19.00
|
| (1) For example, if you have an examination and cleaning on July 15, 2008 you may not have another covered examination or cleaning until January 15, 2009. |
|
| (2) Once every 12 consecutive months for adults and once every 6 consecutive months for dependents age 18 and under. |
|
|
Restorative
|
|
| Amalgam (silver) filling, once every 24 months,per surface, per tooth: |
|
| one surface |
42.00
|
| two surfaces |
50.00
|
| three surfaces |
61.00
|
| four surfaces |
78.00
|
Composite resin (white) filling, front teeth only, once every 24 months
per surface, per tooth*: |
|
| one surface |
53.00
|
|
two surfaces
|
63.00
|
|
three surfaces
|
83.00
|
| four surfaces |
100.00
|
|
Composite resin (white) crown, front baby teeth only
|
100.00
|
|
Onlays, once every 60 months, per tooth
|
|
|
three surfaces
|
275.00 |
|
four or more surfaces
|
300.00
|
Crown, composite resin (laboratory), per tooth, once every 60
months per tooth |
200.00
|
All porcelain and /or metal crowns, per tooth, once every 60 months
per tooth |
335.00
|
All porcelain and /or metal 3/4 crowns, per tooth, once every 60
months per tooth |
300.00
|
| Prefabricated stainless steel crown, once every 24 months |
90.00
|
| Temporary crown (fractured tooth) |
80.00
|
|
Recement cast or prefab post & core, crown, implant/abutment
supported crown/fixed partial denture or bridge, once per lifetime
per provider
|
28.00
|
| Sedative filling, per tooth, once every 60 months per tooth |
32.00
|
|
Core build-up, including any pins, once every 60 months per tooth
|
89.00
|
| Pin retention, per tooth not per pin, in addition to restoration |
22.00
|
|
Cast post and core, in addition to crown, once every 60 months per
tooth
|
133.00
|
Prefabricated post and core, in addition to crown, once every 60
months per tooth |
98.00
|
Additional procedures to construct new crown under existing partial
denture framework |
50.00
|
| Repair of crown or bridge, once every 12 months |
95.00
|
|
Endodontics
|
|
|
Pulp cap-indirect (excluding final restoration)
|
25.00
|
|
Therapeutic pulpotomy, dependents age 13 and under, once every
60 months
|
50.00
|
|
Pulpal debridement, (excluding final restoration), dependents age 13
and under, once every 60 months
|
32.00
|
| Root canal therapy: (once per tooth, per lifetime) |
|
|
Anterior
|
215.00
|
|
Bicuspid
|
265.00
|
| Molar |
350.00
|
| Incomplete endodontic therapy |
45.00
|
| Apicoectomy, first root only, once every 24 months |
|
| Anterior |
230.00
|
| Bicuspid |
237.00
|
| Molar |
273.00
|
| Each additional root |
100.00
|
| Retrograde filling, per root |
70.00
|
| Root amputation, per root |
150.00
|
|
Hemisection, once per lifetime, once every 60 months per root
amputation
|
110.00
|
|
Periodontics
|
|
|
Gingivectomy, once every 36 months, per quadrant
|
|
|
1-3 teeth
|
82.00
|
| 4 or more contiguous teeth |
250.00
|
| Gingival flap, including root planing, once every 36 months: |
|
|
1-3 teeth per quadrant
|
110.00
|
|
4 or more contiguous teeth per quardrant
|
295.00
|
|
Crown Lengthening, once every 60 months
|
310.00
|
|
Osseous surgery, once every 36 months, per quadrant
|
|
|
1-3 teeth
|
310.00
|
|
4 or more contiguous teeth or bounded teeth spaces
|
400.00
|
|
Bone replacement graft, once every 36 months per quadrant:
|
|
|
first site in quadrant
|
76.00
|
| each additional site |
53.00
|
|
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 allograft,
once every 36 months |
320.00
|
| Subepithelial connective tissue graft, once every 36 months |
350.00
|
| Scaling and root planing, once every 24 months |
|
|
1-3 teeth per quadrant
|
42.00
|
|
4 or more teeth per quadrant
|
71.00
|
| Full mouth debridement, once per lifetime |
43.00
|
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 teeh, 5mm or
greater pocket depth, per tooth |
45.00
|
Periodontal prophylaxis, once every 3 months following active
periodontal therapy |
40.00
|
| Periodontal appliance (includees occlusal guards) |
186.00
|
|
Prosthodontics
|
|
| Fixed: (once every 60 months) |
|
|
Bridge Abutment or bridge pontic
|
335.00
|
| Implant Services: (once every 60 months per tooth)* |
|
|
Endosteal implant
|
445.00
|
| Implant abutement |
175.00
|
| Implant abutement crown |
350.00
|
|
*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 is
available for 60 months after implant replacement.
|
|
| Retainer - cast metal for resin bonded fixed prosthesis |
186.00
|
| Removable: (once every 60 months) |
|
|
Complete upper and lower denture
|
366.00
|
| Immediate upper and lower denture |
398.00
|
|
Upper/lower paritial, resin based (includes clasps, rests and teeth)
|
340.00
|
Upper/lower paritial, cast metal framework with resin base
(includes clasps, rests and teeth) |
490.00
|
| Upper/lower partial denture, flexible base (includes clasps and teeth) |
335.00
|
Removable unilateral partial denture, one piece cast metal
(includes clasps and teeth) |
232.00
|
| Adjust complete/partial denture, upper/lower |
27.00
|
| Repairs: |
|
| Repair broken complete denture base |
55.00
|
| Replace missing or broken teeth - complete denture (each tooth) |
42.00
|
| Repair partial resin saddle or base |
53.00
|
| Repair cast framework |
62.00
|
| Repair or replace broken clasp |
60.00
|
| Replace broken tooth (partial), each tooth |
44.00
|
| Add tooth to partial |
53.00
|
| Add clasp to existing partial denture |
63.00
|
Replace all teeth & acrylic on cast metal framework once every 5
years |
250.00
|
| Reline denture/partial, chairside, once every 18 months |
120.00
|
| Reline denture/partial, laboratory, once every 36 months |
145.00
|
| Rebase complete/partial upper/lower |
145.00
|
|
Recement fixed partial denture
|
42.00
|
| Fixed partial denture repair, by report |
95.00
|
|
Oral Surgery
|
|
| Coronal remnants - deciduous tooth |
31.00
|
Extraction, erupted tooth or exposed root
(elevation and/or forceps removal) |
40.00
|
| Surgical removal of erupted tooth |
80.00
|
| Surgical removal of impacted tooth: |
|
|
Soft tissue
|
112.00
|
| Partially bony |
145.00
|
|
Completely bony
|
170.00
|
| Completely bony with complications |
180.00
|
| Surgical removal of residual tooth roots |
100.00
|
| Surgical access of an unerupted tooth |
187.00
|
| Placement of device to facilitate eruption of impacted tooth |
50.00
|
| Alveoloplasty, once per lifetime, per quadrant |
121.00
|
| With extractions |
99.00
|
| Alveoloplasty, once per lifetime, 1-3 teeth |
102.00
|
| With extractions |
51.00
|
| Vestibuloplasty - ridge extension |
150.00
|
| Incision and drainage |
69.00
|
| Incision and drainage - complications |
106.00
|
| Frenulectomy |
166.00
|
| Excision of periocoronal gingiva |
49.00
|
| Frenuloplasty, once per site, per lifetime |
200.00
|
|
Other Services
|
|
| Consultation, per session |
27.00
|
| Intravenous sedation: |
|
| first 30 minutes |
111.00
|
| each additional 15 minutes |
62.00
|
| Occlusal guards, once every 5 years |
186.00
|
| Repair and/or reline of occlusal guard |
25.00
|
| Fixed parital denture sectioning |
65.00
|
|
Palliative
|
|
Palliative (emergency) treatment of dental pain, minor procedures,
three occurrences in 6 months. |
32.00
|
|
Orthodontics
|
|
| The maximum reimbursement per individual, per lifetime is $1,000.00 |
|
Delta Dental calculates your orthodontic benefit based on the total case fee and the estimated length of treatment submitted by your dental provider. Benefits are subject to a 50% co-payment and a $1,000 lifetime maximum and are also subject to verification of continuing treatment and eligibility. Reimbursement is made monthly. Orthodontic treatment which began prior to the date on which you became eligible for benefits is not a covered service.
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