Class C Major
Important things you should keep in mind about these benefits:
•
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are necessary for the prevention, diagnosis,
care, or treatment of a covered condition and meet generally accepted dental protocols.
•
There is no calendar year deductible.
•
There is no waiting period for major services.
•
There is no annual benefit maximum.
•
See Section 7 of this brochure for plan limitations.
You Pay:
•
In-Network: The co-pay amount shown in the Schedule of Benefits along with the a $10 office visit
copay (please note that the office visit copay is charged per office visit, not per procedure).
•
Out-of-Network: In full for all charges. There are no out-of-network benefits available except for
emergency services when the services of an in-network provider are not available.
Major Restorative Services
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D2510 Inlay – metallic – one surface
$385
$247
D2520 Inlay – metallic – two surfaces
$444
$282
D2530 Inlay – metallic – three or more surfaces
$487
$290
D2542 Onlay – metallic – two surfaces
$497
$338
D2543 Onlay – metallic – three surfaces
$544
$363
D2544 Onlay – metallic – four or more surfaces
$559
$380
D2740 Crown – porcelain/ceramic substrate
$609
$417
D2750 Crown – porcelain fused to high noble metal
$555
$380
D2751 Crown – porcelain fused to predominately base metal
$555
$380
D2752 Crown – porcelain fused to noble metal
$555
$380
D2780 Crown – ¾ cast high noble metal
$519
$260
D2781 Crown – ¾ cast
predominately base metal
$519
$260
D2782 Crown – ¾ cast noble metal
$519
$260
D2783 Crown – ¾ porcelain/ceramic
$549
$290
D2790 Crown – full cast high noble metal
$543
$366
D2791 Crown – full cast predominately base metal
$543
$366
D2792 Crown – full cast noble metal
$543
$366
D2794 Crown – titanium
$543
$366
D2950 Core buildup, including any pins
$133
$90
D2954 Prefabricated post and core, in addition to crown
$164
$112
D2980 Crown repair, by report
$107
$72
D2981 Inlay repair
$107
$72
Major Restorative Services - continued on next page
18
2018
Enroll at www.BENEFEDS.com
Major Restorative Services (cont.)
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D2982 Onlay repair
$107
$72
D2983 Veneer repair
$107
$72
D2990 Resin infiltration/smooth surface
$28
$12
Endodontic Services
Standard
Option
Copay
Amount
High
Option
Copay
Amount
D3310 Anterior root canal (excluding final restoration)
$391
$260
D3320 Bicuspid root canal (excluding final restoration)
$467
$332
D3330 Molar root canal (excluding final restoration)
$587
$416
D3346 Retreatment of previous root canal therapy-anterior
$493
$290
D3347 Retreatment of previous root canal therapy-bicuspid
$569
$371
D3348 Retreatment of previous root canal therapy-molar
$686
$438
D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations,
root resorption, etc.)
$170
$109
D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific
repair of perforations, root resorption, etc.)
$496
$319
D3353 Apexification/recalcification – final visit (includes completed root canal therapy, apical
closure/calcific repair of perforations, root resorption, etc.)
$378
$243
D3355 Pulpal regeneration - initial visit
$170
$109
D3356 Pulpal regeneration - interim medication replacement
$496
$319
D3357 Pulpal regeneration - completion of treatment
$200
$150
D3410 Apicoectomy, anterior
$416
$238
D3421 Apicoectomy, bicuspid (first root)
$454
$268
D3425 Apicoectomy, molar (first root)
$511
$283
D3426 Apicoectomy (each additional root)
$167
$112
D3427 Periradicular surgery w/o apicoectomy
$344
$171
D3428 Bone graft in conj. w/ periradicular surg., per tooth, single site
$574
$369
D3429 Bone graft in conj. w/ periradicular surg., add.
contiguous tooth, same site
$449
$288
D3430 Retrograde filling – per root
$123
$81
D3431 Biologic materials to aid soft/osseous tissue regen. in conj. w/ periradicular surg.
$294
$189
D3432 Guided tissue regen., resorbable barrier, per site, in conj. w/ periradicular surg.
$590
$379
D3450 Root amputation – per root
$264
$156
D3920 Hemisection (including any root removal) - not including root canal therapy
$226
$145
19
2018
Enroll at www.BENEFEDS.com