|
Exams
|
100%/70%
|
1 per calendar year
|
|
Prophylaxis
|
100%/70%
|
1 per calendar year
|
|
Fluoride
|
Not a benefit
|
|
|
Pulp Test
|
100%/70%
|
1 test per calendar year
|
|
Bitewings, Full Mouth, Occlusal film (D0240)
|
70%/50%
|
Not to exceed the following: (a) one set of bitewings per calendar year, and (b) one full mouth series every FIVE years. Occlusal films as needed
|
|
Panoramic Film
|
70%/50%
|
Panoramic 1 every FIVE years. Additional panoramic available for Oral Surgeons 12 months after full mouth or pano.
|
|
Periapical X–Rays
|
70%/50%
|
As needed
|
|
Sealants
|
Not a benefit
|
|
|
Space Maintainers
|
70%/50%
|
Available to covered members through age 13.
|
|
Palliative Services
|
70%/50%
|
|
|
Endodontic / Periodontic (including D4910)
|
70%/50%
|
|
|
Other dental services (Extractions, fillings, oral surgery and general anesthesia)
|
70%/50%
|
|
|
Crowns, Bridges and Dentures including stainless steel crowns, post & core, build ups and pins.
|
Not a benefit
|
|
|
Occlusual Splint Therapy
|
50% of eligible charge up to $125.
|
|
|
Orthodontia
|
Not a benefit
|
|
