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HealthState PPO
HMO
Life InsuranceDentalVisionSupplemental |
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Dental PPO Plan
With the PPO Dental plan, you may choose to receive care from any dentist; your cost is lower when you use network dentists. You generally have an annual deductible to meet before the plan starts paying benefits, and then you pay a percentage of the cost for the care you receive.
Use the chart below to see costs for basic services for the PPO dental plan. The rows show the monthly premium and the amount or percentage you pay for the common dental services listed. The columns list the costs by plan. Use the cost estimator to compare your likely total costs under each plan.
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Humana (CompBenefits) Preferred Plus 4054 |
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Monthly Premiums |
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Employee Only Employee + Spouse Employee + Child(ren) Employee + Spouse + Child(ren) |
$31.76 $58.76 $65.66 $95.32 |
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Calendar Year Deductible |
Out-of-Network |
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Calendar Year Maximum |
$1,200/person |
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| In Network | Out-of-Network | ||
| ADA Code | Exams | You Pay | You Pay |
D0120 |
Periodic Checkup |
$01 |
20%1 |
D0140 |
Limited |
$01 |
20%1 |
D0150 |
Comprehensive Initial |
$0 |
20% |
| X-Rays |
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D0230 |
Additional Intraoral |
$0 |
20% |
D0272 |
2 Bite Wings |
$0 |
20% |
D0330 |
Panoramic |
$0 |
20% |
| Preventive Services |
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D1110 |
Prophy (adult cleaning) |
$01 |
20%1 |
D1120 |
Prophy (child cleaning) |
$01 |
20%1 |
D1203 |
Fluoride, child |
$02 |
20%2 |
D1351 |
Sealant |
$02 |
20%2 |
| Silver Fillings |
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D2140 |
Amalgam, 1 surface |
20% |
50% |
D2150 |
Amalgam, 2 surfaces |
20% |
50% |
| White Fillings, Front Teeth |
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D2330 |
Anterior Composite, 1 surface |
20% |
50% |
D2331 |
Anterior Composite, 2 surfaces |
20% |
50% |
| White Fillings, Back Teeth |
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D2391 |
Posterior Composite, 1 surface |
20% |
50% |
D2392 |
Posterior Composite, 2 surfaces |
20% |
50% |
| Onlays and Crowns |
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D2740 |
Crown, All Porcelain |
50% |
70% |
D2750 |
Crown, Porcelain fused to High Noble |
50% |
70% |
D2950 |
Core Build Up |
50% |
70% |
| Periodontal Care (for gums) |
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D4341 |
Periodontal Therapy, 4+ teeth/quadrant |
20% |
50% |
D4910 |
Periodontal Maintenance |
20% |
50% |
| Extractions |
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D7140 |
Extraction, Erupted Tooth or Exposed Root |
20% |
50% |
D7210 |
Extraction, Surgical |
20% |
50% |
| Orthodontia Care6 |
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D8080 |
Comprehensive orthodontic treatment of adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances) |
50%; $1,500 lifetime max benefit |
Not Covered |
D8090 |
Comprehensive orthodontic treatment of adult dentition (full treatment case up to 24 months - including fixed/removable appliances) |
50%; $1,500 lifetime max benefit |
Not Covered |
None |
Bracketing (for above procedures D8080 or D8090) |
Included |
Not Covered |
D8660 |
Pre-orthodontic treatment visit (consult/records/exam) |
50%; $1,500 lifetime max benefit |
Not Covered |
D8680 |
Orthodontic retention (removal of applicances, construction and placement of retainer(s)) |
50%; $1,500 lifetime max benefit |
Not Covered |
D8999 |
Unspecified Orthodontic Procedure - By Report (Orthodontic Treatment Plan and Records) |
Included |
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
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