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HealthState PPO HMO
Life InsuranceDentalVisionSupplemental |
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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. Use the cost estimator to compare your likely total costs under each plan.
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CompBenefits Schedule B 4084 |
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| Monthly Premiums | |||
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Calendar Year Deductible |
Employee $50 |
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Calendar Year Maximum |
$1,000/person |
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| ADA Code | Exams | You Pay | |
D0120 |
Periodic Checkup |
Cost above $11.701 |
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D0140 |
Limited |
Cost above $15.301 |
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D0150 |
Comprehensive Initial |
Cost above $15.301 |
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| X-Rays |
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D0230 |
Additional Intraoral |
Cost above $6.30 |
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D0272 |
2 Bite Wings |
Cost above $12.60 |
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D0330 |
Panoramic |
Cost above $23.40 |
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| Preventive Services |
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D1110 |
Prophy (adult cleaning) |
Cost above $18.901 |
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D1120 |
Prophy (child cleaning) |
Cost above $18.00 |
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D1203 |
Fluoride, child |
Cost above $15.302 |
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D1351 |
Sealant |
Cost above $6.304 |
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| Silver Fillings |
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D2140 |
Amalgam, 1 surface |
Cost above $11.70 |
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D2150 |
Amalgam, 2 surfaces |
Cost above $18.00 |
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| White Fillings, Front Teeth |
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D2330 |
Anterior Composite, 1 surface |
Cost above $15.30 |
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D2331 |
Anterior Composite, 2 surfaces |
Cost above $22.50 |
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| White Fillings, Back Teeth |
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D2330 |
Posterior Composite, 1 surface |
Cost above $11.70 |
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D2331 |
Posterior Composite, 2 surfaces |
Cost above $18.80 |
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| Onlays and Crowns |
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D2740 |
Crown, All Porcelain |
Cost above $95.40 |
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D2750 |
Crown, Porcelain fused to High Noble |
Cost above $180.00 |
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D2950 |
Core Build Up |
Cost above $36.00 |
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| Periodontal Care (for gums) |
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D4341 |
Periodontal Therapy, 4+ teeth/quadrant |
Cost above $14.401 |
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D4910 |
Periodontal Maintenance |
Cost above $19.801 |
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| Extractions |
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D7140 |
Extraction, Erupted Tooth or Exposed Root |
Cost above $14.40 |
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D7210 |
Extraction, Surgical |
Cost above $26.10 |
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| Orthodontia Treatment6 |
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D8080 |
Comprehensive orthodontic treatment of adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances) |
Not Covered |
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D8090 |
Comprehensive orthodontic treatment of adult dentition (full treatment case up to 24 months - including fixed/removable appliances) |
Not Covered |
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1Once 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.
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