Subject to payment of the Annual Deductible. The following services are subject to a limit of one time every 60 months. Gold foil – one surface. Gold foil – two surfaces. Gold foil – three surfaces. Onlay - metallic - two surfaces. Onlay - metallic - three surfaces. Onlay - metallic - four surfaces. Onlay – porcelain/ceramic – two surfaces. Onlay – porcelain/ceramic – three surfaces. Onlay – porcelain/ceramic – four or more surfaces. Onlay – composite – two surfaces (must utilize indirect technique). Onlay – composite – three surfaces (must utilize indirect technique). Onlay – composite – four or more surfaces (must utilize indirect technique). Crown – resin-based composite (indirect). Crown -- 3/4 resin-based composite (indirect). Crown – resin with high noble metal. Crown – resin with predominantly base metal. Crown – resin with noble metal. Crown - porcelain/ceramic substrate. Crown - porcelain fused to high noble metal. Crown - porcelain fused to predominately base metal. Crown - porcelain fused to noble metal. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Crown - porcelain fused to titanium and titanium alloys. Crown - 3/4 cast high noble metal. Crown - 3/4 cast predominately base metal. Crown - 3/4 porcelain/ceramic. Crown - full cast high noble metal. Crown - full cast predominately base metal. Crown - full cast noble metal. Crown - titanium and titanium alloys. Prefabricated stainless steel crown - primary tooth. Prefabricated stainless steel crown - permanent tooth. The following services are not subject to a frequency limit. Inlay - metallic - one surface. Inlay - metallic - two surfaces. Inlay - metallic - three surfaces. Re-cement inlay. Re-cement crown. The following service is not subject to a frequency limit. Protective restoration. 40% The following service is limited to one time per tooth every 60 months. Prefabricated porcelain crown - primary. Prefabricated resin crown. Prefabricated stainless steel crown with resin window. Prefabricated esthetic coated stainless steel, primary tooth. 40% The following service is not subject to a frequency limit. Core buildup, including any pins. Pin retention - per tooth, in addition to crown. Crown cast post/core. Prefabricated post and core in addition to crown. Post removal, not in conjunction with endodontic. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. The following services are...
Subject to payment of the Annual Deductible. The following services are limited to one time every 60 months. Endosteal implant. Surgical placement of interim implant body. Eposteal implant. Transosteal implant, including hardware. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant supported complete denture. Implant supported partial denture. Connecting bar implant or abutment supported. Prefabricated abutment. Custom abutment. Abutment supported porcelain ceramic crown. Abutment supported porcelain fused to high noble metal. Abutment supported porcelain fused to predominately base metal crown. Abutment supported porcelain fused to noble metal crown. Abutment supported cast high noble metal crown. Abutment supported cast predominately base metal crown. Abutment supported porcelain/ceramic crown. Implant supported porcelain/ceramic crown. Implant supported crown - porcelain fused to high noble alloys. Implant supported crown - high noble alloys. Abutment supported retainer for porcelain/ceramic fixed partial denture. Abutment supported retainer for porcelain fused to high noble metal fixed partial denture. Abutment supported retainer for porcelain fused to predominately base metal fixed partial denture. Abutment supported retainer for porcelain fused to noble metal fixed partial denture. Abutment supported retainer for cast high noble metal fixed partial denture. Abutment supported retainer for predominately base metal fixed partial denture. Abutment supported retainer for cast metal fixed partial denture. Implant supported retainer for ceramic fixed partial denture. Implant supported retainer for FPD - porcelain fused to high noble alloys. Implant supported retainer for metal FPD - high noble alloys. SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Implant/abutment supported fixed partial denture for completely edentulous arch. Implant/abutment supported fixed partial denture for partially edentulous arch. Implant maintenance procedure. Scaling and debridement in the presence of inflammation or mucositis of a single implant, including cleaning of the implant surfaces, without flap entry and closure. Implant supported crown - porcelain fused to predominantly base alloys. Implant supported crown - porcelain fused to noble alloys. Implant supported crown - porcelain fused to titanium and titanium alloys. Implant supported crown - predominantly ...
Subject to payment of the Annual Deductible. The following services are limited to a frequency of one every 36 months. Gingivectomy or gingivoplasty - four or more teeth. Gingivectomy or gingivoplasty - one to three teeth. Gingivectomy or gingivoplasty - with restorative procedures, per tooth. 40% The following services are limited to one every 36 months. Gingival flap procedure , four or more teeth. Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant. 40% The following service is not subject to a frequency limit. Clinical crown lengthening - hard tissue. 40% The following services are limited to one every 36 months. Osseous surgery. Osseous surgery (including flap entry and closure), one to three contiguous teeth or bounded teeth spaces per quadrant. Bone replacement graft - first site in quadrant. 40% The following services are not subject to a frequency limit. Pedicle soft tissue graft procedure. Free soft tissue graft procedure. 40% The following services are not subject to a frequency limit. Subepithelial connective tissue graft procedures, per tooth. Soft tissue allograft. Free soft tissue graft - first tooth. Free soft tissue graft - additional teeth. 40% The following services are limited to one time per quadrant every 24 months. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Periodontal scaling and root planing - four or more teeth per quadrant. Periodontal scaling and root planing - one to three teeth per quadrant. Scaling in presence of generalized moderate or severe gingival inflammation - full mouth, after oral evaluation. The following service is limited to a frequency to one per lifetime. Full mouth debridement to enable comprehensive evaluation and diagnosis. 40% The following service is limited to four times every 12 months in combination with prophylaxis. Periodontal maintenance. 40%
Subject to payment of the Annual Deductible. The following service is not subject to a frequency limit; however, it is covered as a separate Benefit only if no other services (other than the exam and radiographs) were done on the same tooth during the visit. Palliative (Emergency) treatment of dental pain - minor procedure. 40% Covered only when clinically Necessary. Deep sedation/general anesthesia first 30 minutes. Dental sedation/general anesthesia each additional 15 minutes. Deep sedation/general anesthesia - first 15 minutes. Intravenous moderate (conscious) sedation/anesthesia - first 15 minutes. Intravenous conscious sedation/analgesia - first 30 minutes. Intravenous conscious sedation/analgesia - each additional 15 minutes. Therapeutic drug injection, by report. 40% Covered only when clinically Necessary. Consultation (diagnostic service provided by a dentist or Physician other than the practitioner providing treatment). 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts.
Subject to payment of the Annual Deductible. The following services are limited to one time every 60 months. Endosteal implant. Surgical placement of interim implant body. Eposteal implant. Transosteal implant, including hardware. Implant supported complete denture. Implant supported partial denture. None SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts.
Subject to payment of the Annual Deductible. The following service is not subject to a frequency limit. Therapeutic pulpotomy (excluding final restoration). 50% The following service is not subject to a frequency limit. Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development. 50% The following services are not subject to a frequency limit. Pulpal therapy (resorbable filling) - anterior primary tooth (excluding final restoration). Pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration). 50% The following services are not subject to a frequency limit. Anterior root canal (excluding final restoration). Bicuspid root canal (excluding final restoration). Molar root canal (excluding final restoration). Retreatment of previous root canal therapy - anterior. 50% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Retreatment of previous root canal therapy - bicuspid. Retreatment of previous root canal therapy - molar. The following services are not subject to a frequency limit. Apexification/recalcification - initial visit. Apexification/recalcification - interim medication replacement. Apexification/recalcification - final visit. 50% The following service is not subject to a frequency limit. Pulpal regeneration. 50% The following services are not subject to a frequency limit. Apicoectomy/periradicular - anterior. Apicoectomy/periradicular - bicuspid. Apicoectomy/periradicular - molar. Apicoectomy/periradicular - each additional root. Surgical repair of root resorption - anterior. Surgical repair of root resorption - premolar. Surgical repair of root resorption - molar. Surgical exposure of root surface without apicoectomy or repair of root resorption - anterior. Surgical exposure of root surface without apicoectomy or repair of root resorption - premolar. Surgical exposure of root surface without apicoectomy or repair of root resorption - molar. 50% The following service is not subject to a frequency limit. Root amputation - per root. 50% The following service is not subject to a frequency limit. Hemisection (including any root removal), not including root canal therapy. 50% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. The following services are limited to a frequency of one every 36 months. Gingivectomy or gingivoplasty - four or more teeth. Gingivectomy or gingivoplasty - one to three teet...
Subject to payment of the Annual Deductible. The following service is not subject to a frequency limit; however, it is covered as a separate Benefit only if no other services (other than the exam and radiographs) were done on the same tooth during the visit. Palliative (Emergency) treatment of dental pain - minor procedure. 40% Covered only when clinically Necessary. Deep sedation/general anesthesia first 30 minutes. Dental sedation/general anesthesia each additional 15 minutes. Deep sedation/general anesthesia - first 15 minutes. Intravenous moderate (conscious) sedation/anesthesia - first 15 minutes. Intravenous conscious sedation/analgesia - first 30 minutes. Intravenous conscious sedation/analgesia - each additional 15 minutes. Therapeutic drug injection, by report. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts. Covered only when clinically Necessary. Consultation (diagnostic service provided by a dentist or Physician other than the practitioner providing treatment). 40% The following are limited to one guard every 12 months. Occlusal guard - hard appliance, full arch. Occlusal guard - soft appliance, full arch. Occlusal guard - hard appliance, partial arch. 40%
Subject to payment of the Annual Deductible. The following service is not subject to a frequency limit; however, it is covered as a separate Benefit only if no other services (other than the exam and radiographs) were done on the same tooth during the visit. Palliative (Emergency) treatment of dental pain - minor procedure. None Covered only when clinically Necessary. Deep sedation/general anesthesia first 30 minutes. Dental sedation/general anesthesia each additional 15 minutes. Deep sedation/general anesthesia - first 15 minutes. Intravenous moderate (conscious) sedation/anesthesia - first 15 minutes. Intravenous conscious sedation/analgesia - first 30 minutes. Intravenous conscious sedation/analgesia - each additional 15 minutes. Therapeutic drug injection, by report. None Covered only when clinically Necessary. Consultation (diagnostic service provided by a dentist or Physician other than the practitioner providing treatment). None The following are limited to one guard every 12 months. Occlusal guard - hard appliance, full arch. Occlusal guard - soft appliance, full arch. Occlusal guard - hard appliance, partial arch. None
Subject to payment of the Annual Deductible. The following service is not subject to a frequency limit; however, it is covered as a separate Benefit only if no other services (other than the exam and radiographs) were done on the same tooth during the visit. Palliative (Emergency) treatment of dental pain 30% Covered only when clinically Necessary. Deep sedation/general anesthesia first 30 minutes. Dental sedation/general anesthesia each additional 15 minutes. Deep sedation/general anesthesia - first 15 minutes. Inhalation of nitrous oxide/analgesia. Intravenous moderate (conscious) sedation/anesthesia - first 15 minutes. Intravenous conscious sedation/analgesia - first 30 minutes. Intravenous conscious sedation/analgesia - each additional 15 minutes. Non-intravenous moderate (conscious) sedation. Therapeutic drug injection, by report. 30% Covered only when clinically Necessary. 30% Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts.
Subject to payment of the Annual Deductible. The following services are limited to a frequency of one every 36 months. D4210 - Gingivectomy or gingivoplasty - four or more teeth. D4211 - Gingivectomy or gingivoplasty - one to three teeth. D4212 - Gingivectomy or gingivoplasty - with restorative procedures, per tooth. 40% The following services are limited to one every 36 months. D4240 - Gingival flap procedure, four or more teeth. D4241 - Gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quadrant. 40% The following service is not subject to a frequency limit. D4249 - Clinical crown lengthening - hard tissue. 40% The following services are limited to one every 36 months. D4261, D4260 - Osseous surgery. D4261 - Osseous surgery (including flap entry and closure), one to three contiguous teeth or bounded teeth spaces per quadrant. D4263 - Bone replacement graft - first site in quadrant. 40% SAMPLE Amounts which you are required to pay as shown below in the Schedule of Benefits are based on Allowed Dental Amounts.
