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Health

State PPO

HMO

Life Insurance

Dental

Vision

Supplemental

   

Indemnity Dental Plan

With the Indemnity Dental option, you may receive care from any dentist. You have a deductible to meet and then pay part of the cost for the services you receive.

Use the chart below to see costs for basic services for the Indemnity dental plan. The rows show the monthly premium and the amount or percentage you pay for the common dental services listed. "Cost above" means you pay any dollar amount that is higher than the amount shown.

 

 

Humana
(CompBenefits)
Schedule B
4084
   Monthly Premiums
 


      Employee Only
      Employee + Spouse
      Employee + Child(ren)
      Employee + Spouse + Child(ren)


$14.74
$21.96
$23.30
$37.10

 

      Calendar Year Deductible

Employee $50
Family $150

 

      Calendar Year Maximum

$1,000/person

ADA Code Exams You Pay

D0120

      Periodic Checkup

Cost above $11.701

D0140

      Limited

Cost above $15.301

D0150

      Comprehensive Initial

Cost above $15.301

  X-Rays

 

D0230

      Additional Intraoral

Cost above $6.30

D0272

      2 Bite Wings

Cost above $12.60

D0330

      Panoramic

Cost above $23.40

  Preventive Services

 

D1110

      Prophy (adult cleaning)

Cost above $18.901

D1120

      Prophy (child cleaning)

Cost above $18.00

D1203

      Fluoride, child

Cost above $15.302

D1351

      Sealant

Cost above $6.304

  Silver Fillings

 

D2140

      Amalgam, 1 surface

Cost above $11.70

D2150

      Amalgam, 2 surfaces

Cost above $18.00

     White Fillings, Front Teeth

 

D2330

      Anterior Composite, 1 surface

Cost above $15.30

D2331

      Anterior Composite, 2 surfaces

Cost above $22.50

  White Fillings, Back Teeth

 

D2391

      Posterior Composite, 1 surface

Cost above $11.70

D2392

      Posterior Composite, 2 surfaces

Cost above $18.80

     Onlays and Crowns

 

D2740

      Crown, All Porcelain

Cost above $95.40

D2750

      Crown, Porcelain fused to High Noble

Cost above $180.00

D2950

      Core Build Up

Cost above $36.00

  Periodontal Care (for gums)

 

D4341

      Periodontal Therapy, 4+ teeth/quadrant

Cost above $14.401

D4910

      Periodontal Maintenance

Cost above $19.801

  Extractions

 

D7140

      Extraction, Erupted Tooth or Exposed Root

Cost above $14.40

D7210

      Extraction, Surgical

Cost above $26.10

  Orthodontia Treatment6

 

D8080

Comprehensive orthodontic treatment of adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances)

Not Covered

D8090

Comprehensive orthodontic treatment of adult dentition (full treatment case up to 24 months - including fixed/removable appliances)

Not Covered

None

Bracketing (for above procedures D8080 or D8090)

Not Covered

D8660

Pre-orthodontic treatment visit (consult/records/exam)

Not Covered

D8680

Orthodontic retention (removal of applicances, construction and placement of retainer(s))

Not Covered

D8999

Unspecified Orthodontic Procedure - By Report (Orthodontic Treatment Plan and Records)

Not Covered

1Limited to once every six months
2Only for children under age 16
3Only for children under age 14
4Only for children under age 13
5Services require separate payment for laboratory charges
6Copays do not include pre-exam and retention
775% during first year; 50% for 2nd and subsequent years of continuous coverage
8Plan payments for covered preventive procedures are not deducted from your annual maximum benefit.
9Copayment for General Dentist or Specialist is the same