The Fund will reimburse the amount listed under “The Fund will Pay” for the following covered dental services, subject to all other plan limitations. Patients are responsible for the difference between the “Fund Will Pay” amounts listed and the dentist’s charges.
| Code | Procedure | The Fund will Pay |
| Preventive and Diagnostic | ||
| D0120 | Periodic oral examination – established patient (once every 6 consecutive months) |
36.00
|
| D0140 | Limited oral evaluation – problem focused (no separate benefit will be paid if definitive treatment was performed within prior 30 days). Only two occurrences allowed in 12 months with same dental office |
62.00
|
| D0145 | Oral evaluation for a patient under 3 years of age and counseling with primary caregiver, once every 6 consecutive months until age 3 |
48.00
|
| D0150 | Comprehensive oral evaluation-new or established patient once every 60 consecutive months per dental office |
55.00
|
| D0160 | Detailed and extensive oral evaluation-problem focused, by report | 75.00 |
| D0170 | Re-evaluation – limited problem focused, by report | 55.00 |
| D0171 | Re-evaluation – post-operative office visit | 55.00 |
| D0180 | Comprehensive periodontal evaluation – new or established patient – once every 60 consecutive months per dental office | 80.00 |
| D0210 | Intraoral x-rays, complete series once every 60 months | 105.00 |
| D0220 | Intraoral periapical x-rays first film |
21.00
|
| D0230 | Intraoral periapical x-ray each additional film |
15.00
|
| D0240 | Intraoral – occlusal film |
33.00
|
| Bitewing x-rays, once every 6 consecutive months for dependents age 18 and under; once every 12 months for adults (not allowed less than 6 months after full mouth series) | ||
| D0270 | Bitewing single film |
22.00
|
| D0272 | Bitewings two films |
32.00
|
| D0273 | Bitewings three films |
40.00
|
| D0274 | Bitewings four films |
50.00
|
| D0277 | Vertical bitewings – 7 to 8 films |
81.00
|
| D0330 | Panoramic film, once every 60 months | 98.00 |
| D0364 | Cone beam CT – less than one whole jaw, once every 12 months | 150.00 |
| D0365 | Cone beam CT – mandible, once every 12 months | 150.00 |
| D0366 | Cone beam CT – maxilla, with/without cranium, once every 12 months | 150.00 |
| D0367 | Cone beam CT – both jaws, with/without cranium, once every 12 months | 150.00 |
| Cone beam CT covered only from licensed dentist, not from mobile imaging service | ||
| D0460 | Pulp vitality tests | 55.00 |
| D1110 | Adult prophylaxis (cleaning), once every 6 consecutive months |
86.00
|
| D1120 | Child prophylaxis (cleaning), under age 14, once every 6 consecutive months |
69.00
|
| D1206 | Topical fluoride varnish, therapeutic application for moderate to high caries risk patients, payable up to 4 times per year |
33.00
|
| D1208 | Topical application of fluoride, payable up to 4 times per year |
29.00
|
| D1351 | Sealant per tooth, only on unrestored permanent molars, once every 48 months for patients age 18 and under |
48.00
|
| D1352 | Preventive resin restoration in a moderate to high risk patient – permanent tooth, once every 48 months |
48.00
|
| D1354 | Interim caries arresting medicament application – per tooth |
15.00
|
| Space maintainers, once per quadrant, per lifetime, age 14 and under: | ||
| D1510 | Space maintainer – fixed unilateral |
300.00
|
| D1516/1517 | Space maintainer – fixed bilateral, maxillary/mandibular |
411.00
|
| D1520 | Space maintainer – removable unilateral |
291.00
|
| D1526/1527 | Space maintainer – removable bilateral, maxillary/mandibular | 444.00 |
| D1551/D1552 | Re-cement or re-bond bilateral space maintainer, maxillary/mandibular, once per appliance per lifetime |
58.00
|
| D1553 | Re-cement or re-bond unilateral space maintainer, per quadrant, once per appliance per lifetime |
58.00
|
| D1556 | Removal of fixed space maintainer, per quadrant, once per appliance per lifetime |
58.00
|
| D1557/D1558 | Removal of fixed bilateral space maintainer, per quadrant, once per appliance per lifetime |
58.00
|
| D1575 | Distal shoe space maintainer – fixed – unilateral | 304.00 |
| D1999 | Prescription fluoride toothpaste | 17.00 |
| D1999 | Chlorhexidine | 17.00 |
| D2991 | Application of hydroxyapatite regeneration medicament, per tooth | 35.00 |
| D4346 | Scaling in presence of generalized moderate or severe gingival inflammation – full mouth, after oral evaluation | 84.00 |
| D4910 | Periodontal maintenance, once every 3 months following active periodontal treatment |
75.00
|
| Restorative Services | ||
| Amalgam (silver) filling and composite resin (white) filling, once every 24 months on the same surface of the same tooth | ||
| D2140 | Amalgam – one surface, primary or permanent | 43.00 |
| D2150 | Amalgam – two surfaces, primary or permanent | 51.00 |
| D2160 | Amalgam – three surfaces, primary or permanent | 62.00 |
| D2161 | Amalgam – four or more surfaces, primary or permanent | 80.00 |
| D2330 | Resin based composite – one surface, front teeth | 54.00 |
| D2331 | Resin-based composite – two surfaces, front teeth | 64.00 |
| D2332 | Resin-based composite – three surfaces, front teeth | 85.00 |
| D2335 | Resin-based composite – four or more surfaces, front teeth | 102.00 |
| D2390 | Resin-based composite crown, front baby teeth only | 102.00 |
| D2391 | Resin-based composite – one surface, posterior | 54.00 |
| D2392 | Resin-based composite – two surfaces, posterior | 64.00 |
| D2393 | Resin-based composite – three surfaces, posterior | 85.00 |
| D2394 | Resin-based composite – four or more surfaces, posterior | 102.00 |
| Onlays, per tooth, once every 84 months: | ||
| D2543 | Onlay – metallic – three surfaces | 281.00 |
| D2544 | Onlay – metallic – four or more surfaces | 306.00 |
| D2643 | Onlay – porcelain/ceramic – three surfaces | 281.00 |
| D2644 | Onlay – porcelain/ceramic – four or more surfaces | 306.00 |
| Crowns, once per tooth every 84 months due to fracture or decay | ||
| D2710 | Crown – resin based composite (indirect) | 204.00 |
| D2740 | Crown – porcelain/ceramic substrate | 342.00 |
| D2750 | Crown – porcelain fused to high noble metal | 342.00 |
| D2751 | Crown – porcelain fused to predominantly base metal | 342.00 |
| D2752 | Crown – porcelain fused to noble metal | 342.00 |
| D2753 | Crown – porcelain fused to titanium and titanium alloys | 342.00 |
| D2780 | Crown – 3/4 cast high noble metal | 306.00 |
| D2781 | Crown – 3/4 predominantly base metal | 306.00 |
| D2782 | Crown – 3/4 cast noble metal | 306.00 |
| D2783 | Crown – 3/4 porcelain/ceramic | 306.00 |
| D2790 | Crown – full cast high noble metal | 342.00 |
| D2791 | Crown – full cast predomininantly base metal | 342.00 |
| D2792 | Crown – full cast noble metal | 342.00 |
| D2794 | Crown – titanium | 342.00 |
| Recement – once per item per lifetime when performed by same dental office: | ||
| D2910 | Recement inlay, onlay, or partial coverage restoration | 29.00 |
| D2915 | Recement cast or prefabricated post and core | 43.00 |
| D2920 | Recement crown | 43.00 |
| D2929 | Prefabricated porcelain/ceramic crown – primary tooth | 92.00 |
| D2930 | Prefabricated stainless steel crown – primary tooth | 92.00 |
| D2931 | Prefabricated stainless steel crown – permanent tooth | 92.00 |
| D2934 | Prefabricated esthetic coated stainless steel crown, primary tooth | 92.00 |
| D2940 | Protective restoration – direct placement of a restorative material to protect teh tooth adn/or tissue form, once per tooth per 60 months | 33.00 |
| D2941 | Interim therapeutic restoration – primary dentition | 33.00 |
| D2950 | Core build-up, including any pins, once per tooth every 84 months due to fracture or decay | 91.00 |
| D2951 | Pin retention, per tooth not per pin, only with fillings | 23.00 |
| Post and core, in addition to crown, once per tooth every 84 months: | ||
| D2952 | Post and core in addition to crown, indirectly fabricated | 136.00 |
| D2954 | Prefabricated post and core in addition to crown | 100.00 |
| D2971 | Additional procedures to construct new crown under existing partial denture framework, once every 84 months in addition to crown | 51.00 |
| D2976 | Band stabilization, per tooth | 50.00 |
| D2980 | Crown repair necessitated by restorative material failure once every 12 months, only after 24 months of initial insertion | 97.00 |
| D2982 | Onlay repair necessitated by restorative material failure once every 12 months, only after 24 months of initial insertion | 97.00 |
| Endodontics | ||
| Endodontic treatments are once per tooth per lifetime | ||
| D3220 | Therapeutic pulpotomy (excluding final restoration), baby teeth only | 51.00 |
| D3221 | Gross pulpal debridement, dependents age 13 and under | 33.00 |
| D3310 | Root canal therapy, anterior tooth (excluding final restoration) | 219.00 |
| D3320 | Root canal therapy, bicuspid tooth (excluding final restoration) | 270.00 |
| D3330 | Root canal therapy, molar tooth (excluding final restoration) | 357.00 |
| D3332 | Incomplete endodontic treatment, inoperable, unrestorable or fractured tooth, subject to review | 46.00 |
| D3346 | Retreatment of previous root canal therapy, anterior tooth, by report | 255.00 |
| D3347 | Retreatment of previous root canal therapy, bicuspid tooth, by report | 306.00 |
| D3348 | Retreatment of previous root canal therapy, molar tooth, by report | 383.00 |
| Apicoectomy, once per root per lifetime: | ||
| D3410 | Apicoectomy/periradicular surgery – anterior | 235.00 |
| D3421 | Apicoectomy/periradicular surgery – bicuspid (first root) | 242.00 |
| D3425 | Apicoectomy/periradicular surgery – molar (first root) | 278.00 |
| D3426 | Apicoectomy/periradicular surgery – (each additional root) | 102.00 |
| D3430 | Retrograde filling – once per root per lifetime | 71.00 |
| D3450 | Root amputation – once per root per lifetime | 153.00 |
| D3920 | Hemisection (including any root removal), not including root canal therapy | 112.00 |
| Periodontics | ||
| Periodontic treatments are covered once every 36 months unless otherwise noted: | ||
| D4210 | Gingivectomy or gingivoplasty – four or more contiguous teeth or tooth bounded spaces per quadrant | 255.00 |
| D4211 | Gingivectomy or gingivoplasty – one to three teeth or tooth bounded spaces per quadrant | 84.00 |
| D4240 | Gingival flap procedure, including root planing four or more contiguous teeth or tooth bounded spaces per quadrant | 301.00 |
| D4241 | Gingival flap procedure, including root planing one to three contiguous teeth or tooth bounded spaces per quadrant | 112.00 |
| D4249 | Clinical crown lenghening – hard tissue, once every 84 months | 316.00 |
| D4260 | Osseous surgery (including flap entry & closure) – four or more contiguous teeth or tooth bounded spaces per quadrant | 408.00 |
| D4261 | Osseous surgery (including flap entry & closure) – on to three contiguous teeth or tooth bounded spaces per quadrant | 316.00 |
| D4263 | Bone replacement graft – first site in quadrant | 78.00 |
| D4264 | Bone replacement graft – each additional site in quadrant | 54.00 |
| D4265 | Biologic materials to add in soft tissue and osseous tissue regeneration | 77.00 |
| D4270 | Pedicle soft tissue graft procedure | 326.00 |
| D4273 | Subepitelial connective tissue grafts procedure, per tooth (including donor site surgery) | 357.00 |
| D4275 | Soft tissue allograft | 326.00 |
| D4277 | Free soft tissue graft procedure (inlcuding donor site surgery), first tooth or edentulous tooth position in graft | 326.00 |
| D4278 | Free soft tissue graft procedure (including donor site surgery), each additional contiguous tooth or edentulous tooth position in same graft site | 163.00 |
| D4283 | Autogenous connective tissue graft procedure (including donor and recipient surgical sites) first tooth, implant or edentulous tooth position in same graft site | 357.00 |
| D4285 | Non-autogenous connective tissue graft procedure (including donor and recipient surgical sites) each additional contiguous tooth, implant or edentulous tooth position in same graft site | 180.00 |
| D4341 | Periodontal scaling and root planing – four or more disease teeth per quadrant, once every 24 months | 73.00 |
| D4342 | Periodontal scaling and root planing – one to three disease teeth per quadrant, once every 24 months | 43.00 |
| D4355 | Full mouth debridement to enable comprehensive evaluation and diagnosis, once per lifetime | 94.00 |
| Prosthodontics – removable | ||
| Prosthodontics include routine post-delivery care and are once every 84 months unless otherwise noted: | ||
| D5110 | Complete denture – maxillary, once every 60 months | 406.00 |
| D5120 | Complete denture – mandibular, once every 60 months | 406.00 |
| D5130 | Immediate complete denture – maxillary, once every 60 months | 406.00 |
| D5140 | Immediate complete denture – mandibular. once every 60 months | 406.00 |
| D5211 | Maxillary partial denture – resin base | 347.00 |
| D5212 | Mandibular partial denture – resin base | 347.00 |
| D5213 | Maxillary partial denture -cast metal framework with resin denture base | 500.00 |
| D5214 | Mandibular partial denture -cast metal framework with resin denture base | 500.00 |
| D5221 | Immediate maxillary partial denture – resin base (including any conventional clasps, rests and teeth) | 347.00 |
| D5222 | Immediate mandibular partial denture – resin base (including any conventional clasps, rests and teeth) | 347.00 |
| D5223 | Immediate maxillary partial denture – cast metal framework with resin denture base (including any conventional clasps, rests and teeth) | 500.00 |
| D5224 | Immediate mandibular partial denture – cast metal framework with resin denture base (including any conventional clasps, rests and teeth) | 500.00 |
| D5225 | Maxillary partial denture – flexible base | 342.00 |
| D5226 | Mandibular partial denture – flexible base | 342.00 |
| D5227/D5228 | Immediate partial denture – flexible base, maxillary/mandibular | 347.00 |
| D5282/5283 | Removable unilateral partial denture – one piece cast metal (including clasps and teeth), maxillary/mandibular | 237.00 |
| D5284 | Removable unilateral partial denture – one piece flexible base (including clasps and teeth) – per quadrant | 237.00 |
| D5286 | Removable unilateral partial denture – one piece resin (including clasps and teeth) – per quadrant | 237.00 |
| D5410 | Adjust complete denture – maxillary | 28.00 |
| D5411 | Adjust complete denture – mandibular | 28.00 |
| D5421 | Adjust partial denture – maxillary | 28.00 |
| D5422 | Adjust partial denture – mandibular | 28.00 |
| Repairs are once every 12 months unless otherwise noted: | ||
| D5511 | Repair broken complete denture base, mandibular | 56.00 |
| D5512 | Repair broken complete denture base, maxillary | 56.00 |
| D5520 | Replace missing or broken teeth complete denture (each tooth) | 43.00 |
| D5611 | Repair resin denture base, mandibular | 54.00 |
| D5612 | Repair resin denture base, maxillary | 54.00 |
| D5621 | Repair cast framework, mandibular | 54.00 |
| D5622 | Repair cast framework, maxillary | 54.00 |
| D5630 | Repair or replace broken clasp | 61.00 |
| D5640 | Replace broken teeth – per tooth | 45.00 |
| D5650 | Add tooth to existing partial denture | 54.00 |
| D5660 | Add clasp to existing partial denture | 64.00 |
| D5670 | Replace all teeth and acrylic on cast metal framework (maxillary), once every 84 months | 255.00 |
| D5671 | Replace all teeth and acrylic on cast metal framework (mandibular), once every 84 months | 255.00 |
| Rebase procedures are once every 36 months, Reline are once every 12 mths: | ||
| D5710 | Rebase complete maxillary denture | 148.00 |
| D5711 | Rebase complete mandibular denture | 148.00 |
| D5720 | Rebase maxillary partial denture | 148.00 |
| D5721 | Rebase mandibular partial denture | 148.00 |
| D5725 | Rebase hybrid prosthesis | 148.00 |
| D5730 | Reline complete maxillary denture (chairside) | 150.00 |
| D5731 | Reline complete mandibular denture (chairside) | 150.00 |
| D5740 | Reline maxillary partial denture (chairside) | 150.00 |
| D5741 | Reline mandibular partial denture (chairside) | 150.00 |
| D5750 | Reline complete maxillary denture (lab) | 150.00 |
| D5751 | Reline complete mandibular denture (lab) | 150.00 |
| D5760 | Reline maxilllary partial denture (lab) | 150.00 |
| D5761 | Reline mandibular partial denture (lab) | 150.00 |
| D5765 | Soft liner for complete or partial removable denture – indirect | 148.00 |
| Prosthodontics – fixed | ||
| Procedure codes D6010 and D6013 are eligible for a separate “implant annual plan maximum” of $1,500. | ||
| D6010 | Surgical placement of implant body, endosteal implant (this code includes second stage surgery and placement of healing cap where indicated) | 454.00 |
| D6013 | Surgical placement of mini implant | 227.00 |
| D6056 | Prefabricated abutment (iincludes modification & placement) | 179.00 |
| D6057 | Custom abutment (includes placement) | 179.00 |
| D6058 | Abutment supported porcelain/ceramic crown) | 357.00 |
| D6059 | Abutment supported porcelain fused to metal crown (high noble metal) | 357.00 |
| D6060 | Abutment supported porcelain fused to metal crown (base metal) | 357.00 |
| D6061 | Abutment supported porcelain fused to metal crown (noble metal) | 357.00 |
| D6062 | Abutment supported cast metal crown (high noble metal) | 357.00 |
| D6063 | Abutment supported cast metal crown (base metal) | 357.00 |
| D6064 | Abutment supported cast metal crown (noble metal) | 357.00 |
| D6065 | Implant supported porcelain/ceramic crown | 357.00 |
| D6066 | Implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) | 357.00 |
| D6067 | Implant supported metal crown (titanium, titanium alloy, high noble metal) | 357.00 |
| D6069 | Abutment supported retainer for porcelain fused to metal FPD (high noble metal) | 357.00 |
| D6070 | Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) | 357.00 |
| D6071 | Abutment supported retainer for porcelain fused to metal FPD (noble metal) | 357.00 |
| D6082 | Implant supported crown – porcelain fused to predominantly base alloys | 357.00 |
| D6083 | Implant supported crown – porcelain fused to noble alloys | 357.00 |
| D6084 | Implant supported crown – porcelain fused to titanium and titanium alloys | 357.00 |
| D6086 | Implant supported crown – predominantly base alloys | 357.00 |
| D6087 | Implant supported crown – noble alloys | 357.00 |
| D6088 | Implant supported crown – titanium and titanium alloys | 357.00 |
| D6089 | Accessing and retorquing loose implant screw, per screw | 50.00 |
| D6092 | Recement implant/abutment supported crown | 43.00 |
| D6093 | Recement implant/abutment supported fixed partial denture | 43.00 |
| D6094 | Abutment supported crown – titanium | 342.00 |
| D6097 | Abutment supported crown – porcelain fused to titanium and titanium alloys | 357.00 |
| D6098 | Abutment supported crown – porcelain fused to predominantly base alloys | 342.00 |
| D6099 | Implant supported retainer for FPD porcelain fused to noble alloys | 243.00 |
| D6100 | Surgical removal of implant body | 82.00 |
| D6104 | Bone graft at time of implant placement | 78.00 |
| D6105 | Removal of implant body not requiring bone removal or flap elevation | 41.00 |
| D6120 | Implant supported retainer – porcelain fused to titanium and titanium alloys | 243.00 |
| D6121 | Implant supported retainer for metal FPD – noble alloys | 243.00 |
| D6122 | Implant supported retainer for metal FPD – noble alloys | 243.00 |
| D6123 | Implant supported retainer for metal FPD – titanium and titanium alloys | 243.00 |
| D6194 | Abutment supported retainer crown for FPD (titanium) | 342.00 |
| D6195 | Abutment supported retainer – porcelain fused to titanium and titanium alloys | 357.00 |
| D6197 | Replacement of restorative material used to close access opening of screw retained implant | 54.00 |
| D6210 | Pontic – cast high noble metal | 342.00 |
| D6211 | Pontic – cast predominantly base metal | 342.00 |
| D6212 | Pontic – cast noble metal | 342.00 |
| D6214 | Pontic – titanium | 342.00 |
| D6240 | Pontic – porcelain fused to high noble metal | 342.00 |
| D6241 | Pontic – porcelain fused to predominantly base metal | 342.00 |
| D6242 | Pontic – porcelain fused to noble metal | 342.00 |
| D6243 | Pontic – porcelain fused to titanium and titanium alloys | 342.00 |
| D6245 | Pontic – porcelain/ceramic | 342.00 |
| D6545 | Retainer – cast metal for resin bonded fixed prosthesis (Maryland bridge) | 190.00 |
| D6549 | Resin retainer – for resin bonded fixed prosthesis | 190.00 |
| D6740 | Crown – porcelain/ceramic | 342.00 |
| D6750 | Crown – porcelain fused to high noble metal | 342.00 |
| D6751 | Crown – porcelain fused to predominantly base metal | 342.00 |
| D6752 | Crown – porcelain fused to noble metal | 342.00 |
| D6753 | Retainer crown – porcelain fused to titanium and titanium alloys | 400.00 |
| D6783 | Retainer crown 3/4 – porcelain/ceramic | 342.00 |
| D6784 | Retainer crown 3/4 – titanium and titanium alloys | 342.00 |
| D6790 | Crown – full cast high noble metal | 342.00 |
| D6791 | Crown – full cast predominantly base metal | 342.00 |
| D6792 | Crown – full cast noble metal | 342.00 |
| D6794 | Crown – titanium | 342.00 |
| D6930 | Recement fixed bridge | 43.00 |
| D6980 | Fixed partial denture repair, by report | 97.00 |
| Oral Surgery | ||
| D7111 | Extraction, coronal remnants – deciduous tooth | 32.00 |
| D7140 | Extraction, erupted tooth or exposed root (elevation and/or forceps removal) | 41.00 |
| D7210 | Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated | 82.00 |
| D7220 | Removal of impacted tooth – soft tissue | 114.00 |
| D7230 | Removal of impacted tooth – partially bony | 148.00 |
| D7240 | Removal of impacted tooth – completely bony | 173.00 |
| D7241 | Removal of impacted tooth – completely bony, with unusual surgical complications | 184.00 |
| D7250 | Surgical removal of residual tooth roots (cutting procedure) | 102.00 |
| D7280 | Surgical access of an unerupted tooth | 191.00 |
| D7283 | Placement of device to facilitate eruption of impacted tooth, once per tooth per lifetime, allowed with orthodontics only | 51.00 |
| D7284 | Excisional biopsy of minor salivary glands | 250.00 |
| D7310 | Alveoplasty in conjunction with extractions – four or more teeth or tooth spaces, per quadrant, once per lifetime | 101.00 |
| D7311 | Alveoplasty in conjunction with extractions – one to three teeth or tooth spaces, per quadrant, once per lifetime | 52.00 |
| D7320 | Alveoplasty not in conjunction with extractions – four or more teeth or tooth spaces, per quadrant, once per lifetime | 123.00 |
| D7321 | Alveoplasty not in conjunction with extractions – one to three teeth or tooth spaces, per quadrant, once per lifetime | 104.00 |
| D7340 | Vestibuloplasty – ridge extension, once per arch per lifetime (secondary epithelialization) | 153.00 |
| D7510 | Incision and drainage of abscess – intraoral soft tissue (involves incision through mucosa) | 70.00 |
| D7511 | Incision and drainage of abscess – intraoral soft tissue – complicated (includes drainage of multiple fascial spaces) | 108.00 |
| D7961 | Buccal/labial frenectomy (Frenulectomy) | 169.00 |
| D7962 | Lingual frenectomy (Frenulectomy) | 204.00 |
| D7963 | Frenuloplasty, once per site, per lifetime | 204.00 |
| D7971 | Excision of periocoronal gingival, subject to review | 50.00 |
| Other | ||
| D9110 | Palliative (emergency) treatment dental plan, minor procedures, three occurrences in 6 months, not allowed on same day as sedative filling | 33.00 |
| D9120 | Fixed partial denture sectioning | 66.00 |
| Intravenous sedation or general anesthesia, subject to review, up to a total of 1 hour: | ||
| D9222 | Deep sedation/general anesthesia – first 15 minutes | 75.00 |
| D9223 | Deep sedation/general anesthesia – each 15 minute increment | 75.00 |
| D9239 | Intravenous conscious sedation/analgesia – first 15 minutes | 75.00 |
| D9243 | Intravenous conscious sedation/analgesia – each 15 minute increment | 75.00 |
| D9310 | Consultation, per session | 28.00 |
| D9941 | Athletic mouthguard – once per patient, (age 18 and under, every 24 months) | 75.00 |
| D9942 | Repair and/or reline of occlusal guard, only after 6 months after insertion | 26.00 |
| D9943 | Occlusal guard adjustment | 28.00 |
| D9944 | Occlusal guards, by report – hard appliance, full arch | 190.00 |
| D9945 | Occlusal guards, by report – soft appliance, full arch | 50.00 |
| D9946 | Occlusal guards, by report – hard appliance, partial arch | 75.00 |
| Orthodontic Services – Other |
||
| D8698 | Recement or re-bond fixed retainer – maxillary | 100.00 |
| D8699 | Recement or re-bond fixed retainer – mandibular | 100.00 |
| D8701 | Repair of fixed retainers, includes reattachment – maxillary | 75.00 |
| D8702 | Repair of fixed retainers, includes reattachment – mandibular | 75.00 |
| D8703 | Replacement of lost or broken retainer – maxillary | 300.00 |
| D8704 | Replacement of lost or broker retainer – mandibular | 300.00 |
| Orthodontic Services (Braces) | ||
The maximum reimbursement per individual, per lifetime is $1,200.00. Your orthodontic benefit is 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 $1,200 lifetime maximum per patient, regardless of what coverage, if any, you had on the original treatment date. Orthodontic benefits are also subject to verification of continuing treatment and eligibility.
- Orthodontic treatment that began prior to the date on which you became eligible for benefits is not a covered service.
- If you change your dental plan enrollment or terminate coverage before the orthodontic treatment is completed and before all periodic payments have been made, no further payments will be made by the Fund.
- If you are enrolled in the Indemnity Plan, and receive orthodontic services from an MPE Exclusive Provider Network dentist, you are subject to the above guidelines under the Indemnity Plan.
- All mail-order or self administered orthodontic treatment kits are not a covered benefit under the MPE Fund Plans.