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Your eligible dependents are covered only if you elected Family Coverage and are working enough hours to qualify for full-time coverage.
Maximum Allowance for Most Common Procedures — Effective July 1, 2011
(ADA Procedure Code is listed in third column for each procedure)
Diagnostic and Palliative Treatment — No Deductible Required
| Prophylaxis—Adult (maximum two treatments in any calendar year) |
$65.00 |
1110 |
| Prophylaxis—Child (maximum two treatments in any calendar year) |
65.00 |
1120 |
| Oral Examination |
43.00 |
0120 |
| Topical application of fluoride |
30.00 |
1203 |
| Topical sealant, per tooth |
50.00 |
1351 |
| Radiographs |
Complete series, including bitewings
(once each calendar year) |
113.00 |
0210 |
| Periapical—single, first film |
25.00 |
0220 |
| Periapical—each additional film |
20.00 |
0230 |
| Bitewings—two films |
38.00 |
0272 |
| Bitewings—four or more films |
55.00 |
0274 |
Panoramic x-ray
(once each calendar year) |
105.00 |
0330 |
| Palliative treatment (emergency) |
83.00 |
9110 |
| Diagnostic casts |
80.00 |
0470 |
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Basic Dental Benefits
| Surgical Extractions (including routine post-operative visits) |
| Each single uncomplicated extraction |
73.00 |
7140 |
| Surgical extraction, erupted |
128.00 |
7210 |
| Removal of impacted tooth (soft tissue) |
162.00 |
7220 |
| Removal of impacted tooth (partially bony) |
195.00 |
7230 |
| Removal of impacted tooth (completely bony) |
225.00 |
7240 |
| Surgical placement of implant |
677.00 |
6010 |
| Alveoplasty with extractions (per quadrant) |
107.00 |
7310 |
| General anesthesia (in or out of hospital) |
248.00 |
9220 |
| General analgesia |
24.00 |
9230 |
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Restorative Dentistry
| Amalgam Restorations |
| One surface |
57.00 |
2140 |
| Two surfaces |
63.00 |
2150 |
| Three surfaces |
83.00 |
2160 |
| Four or more surfaces |
88.00 |
2161 |
| Composite Resin Restorations |
| One surface |
69.00 |
2330 |
| Two surfaces |
83.00 |
2331 |
| Three surfaces |
93.00 |
2332 |
| Four surfaces or incisal angle |
130.00 |
2335 |
| Inlay Restorations—Non-Abutment |
| One surface, gold |
316.00 |
2510 |
| One surface, porcelain |
362.00 |
2610 |
| One surface, composite |
339.00 |
2650 |
| Two surfaces, gold |
384.00 |
2520 |
| Two surfaces, porcelain |
407.00 |
2620 |
| Two surfaces, composite |
362.00 |
2651 |
| Three surfaces, metallic |
388.00 |
2530 |
| Three surfaces onlay, metallic |
407.00 |
2543 |
| Four or more surfaces onlay, metallic |
429.00 |
2544 |
| Four or more surfaces onlay, porcelain |
474.00 |
2644 |
| Four or more surfaces onlay, composite |
429.00 |
2664 |
| Crowns—Non-Abutment |
| Plastic prefabricated |
125.00 |
2932 |
| Porcelain |
483.00 |
2740 |
| Porcelain with gold |
483.00 |
2750 |
| Porcelain with nonprecious metal |
425.00 |
2751 |
| Porcelain with semiprecious metal |
468.00 |
2752 |
| Gold full cast |
468.00 |
2790 |
| Metal full cast |
488.00 |
2792 |
| Stainless steel crown |
170.00 |
2930 |
| Steel post and amalgam core |
138.00 |
2954 |
| Cast post and gold core |
170.00 |
2952 |
| Recement inlays |
30.00 |
2910 |
| Recementation of crown |
44.00 |
2920 |
| Sedative filling |
48.00 |
2940 |
| Crown buildup-pin retention |
123.00 |
2950 |
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Endodontics
| Pulp capping, direct |
33.00 |
3110 |
| Pulp capping, indirect |
23.00 |
3120 |
| Vital pulpotomy |
88.00 |
3220 |
| Root Canal Therapy |
| Anterior (excludes final restoration) |
327.00 |
3310 |
| Bi-cuspid (excludes final restoration |
388.00 |
3320 |
| Molar (excludes final restoration) |
459.00 |
3330 |
| Apicoectomy (separate procedure) |
338.00 |
3410 |
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Periodontics
| Osseous surgery (per quadrant; minimum 4 teeth) |
407.00 |
4260 |
| Periodontal scaling (full-mouth debridement prior to periodontal therapy) |
74.00 |
4355 |
| Periodontal scaling and root planing (per quadrant; minimum of 4 teeth) |
100.00 |
4341 |
| Maintenance periodontal prophylaxis (following periodontal therapy) |
60.00 |
4910 |
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Prosthetic Replacements
| Fixed Bridgework |
| Crowns—Abutment Teeth |
| Porcelain, gold |
308.00 |
6750 |
| Porcelain, nonprecious |
282.00 |
6751 |
| Porcelain, semiprecious |
287.00 |
6752 |
| Gold (full cast) |
269.00 |
6790 |
| Nonprecious cast |
241.00 |
6791 |
| Semiprecious cast |
254.00 |
6792 |
| Pontics |
| Cast gold (sanitary) |
269.00 |
6210 |
| Cast nonprecious metal |
241.00 |
6211 |
| Cast semiprecious metal |
254.00 |
6212 |
| Porcelain, gold |
308.00 |
6240 |
| Porcelain, nonprecious |
282.00 |
6241 |
| Porcelain, semiprecious |
287.00 |
6242 |
| Recement bridge |
47.00 |
6930 |
| Complete Denture |
| Upper (Maxillary) |
367.00 |
5110 |
| Lower (Mandibular) |
367.00 |
5120 |
| Removable Partial Denture |
| Upper, resin base |
367.00 |
5211 |
| Lower, resin base |
367.00 |
5212 |
| Upper, cast framework, resin base |
424.00 |
5213 |
| Lower, cast framework, resin base |
424.00 |
5214 |
Removable unilateral partial,
1 piece cast metal |
282.00 |
5281 |
| Reline—Rebase |
| Office reline (chairside), full denture |
62.00 |
5730 |
| Office reline (chairside), partial denture |
43.00 |
5741 |
| Laboratory reline, full denture |
107.00 |
5750 |
| Laboratory reline, partial denture |
85.00 |
5760 |
| Full denture rebase |
107.00 |
5710 |
| Partial denture rebase |
127.00 |
5720 |
| Space Maintainers |
| Removable, unilateral |
181.00 |
1520 |
| Removable, bilateral |
275.00 |
1525 |
| Recementation |
40.00 |
1550 |
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(Updated 06/12/12)
