ILA Employers Welfare Fund

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  Contact Info

OFFICE LOCATION
ILA Employers Welfare Fund
10 Mersey Way,
Savannah, Georgia 31405

MAILING ADDRESS
ILA Employers Welfare Fund
P O Box 1280
Savannah, Georgia 31498

Tel: (912) 233-0218
Fax: (912) 233-5195

OFFICE HOURS
9:00 a.m. to 5:00 p.m.
Monday through Friday,
except for Holidays.

Email: info@ilasav.com

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W E L F A R E

Dental Benefits

Introduction
The welfare plan provides valuable dental coverage designed to give you and your family solid financial protection. The dental plan also offers preventive benefits to promote good oral health.

You do not have to make contributions for your dental coverage. Participating employers make contributions to pay the cost of your coverage.

How the Dental Plan Works
The dental plan pays a percentage of the scheduled amount for diagnostic and preventive, basic, major and orthodontic services.

Benefits are paid for eligible services until you reach

  • the calendar year benefit maximum of $3,000 per person for non-orthodontic care
  • $2,500 per period of orthodontic treatment per person.

Summary of Benefits

The Dental Expense Benefit Pays

Diagnostic and preventive services

Up to 100% of scheduled amount*

Basic services

Up to 100% of scheduled amount*

Major services

Up to 100% of scheduled amount*

Orthodontic services

Up to 100% of scheduled amount*

Dental Expense Benefit Maximums

Non-orthodontic services

$3,000 per calendar year

Orthodontic services

$2,500 per period of treatment

* The scheduled amount for each covered service changes from time to time. You'll receive an updated schedule if changes are made.

 

 

Covered Services
This list of services includes the most commonly used dental services covered by the plan. The abbreviated schedule at the end of this section shows how the plan pays for covered services. If you or your dependents need a dental procedure that is not on the schedule, please contact the Welfare Fund Office to determine if it is a covered procedure.

Diagnostic and Preventive Services

  • Oral examinations, including cleaning and scaling, increased to four per calendar year from two per calendar year, effective January 1, 2002
  • Fluoride treatment for covered persons up to age 15
  • Dental x-rays - up to the scheduled maximum each year
    • full mouth
    • bitewings
  • Space maintainers

Basic Services

  • Fillings
  • Extractions
  • Root canals
  • Inlays
  • Anesthesia
  • Gum surgery
  • Inlay, crown and bridge repair

Major Services

  • Crowns
  • Bridges
  • Full and partial dentures

Orthodontic Services

  • Preventive orthodontic appliances
  • Continuous orthodontic treatment, including initial appliances and treatment

What the Dental Plan Does Not Cover
Dental benefits will not be paid for charges for:

  • dental services or supplies necessary as a result of work related injury or in connection with an illness that is covered by Workers' Compensation or a similar law
  • dental services or supplies that are eligible for benefits payable under any medical coverage you have through the comprehensive medical plan; for services that are covered under both the medical and dental plans, however, the benefit that is the larger amount will be payable
  • dental care or supplies necessary to treat an injury, illness or disease resulting from an actual or attempted crime, whether a felony or misdemeanor
  • dental services or supplies provided strictly for cosmetic purposes
  • dental services or supplies for which you are not charged
  • dental services or supplies which are experimental, temporary, or medical procedures.

Coordinating Benefits with Other Coverages
See Coordinating Benefits With Other Coverages in the vision and hearing section for a description of how benefits are coordinated with other dental plans.

How to File a Claim

  • Complete a dental claim form available from the Welfare Fund Office.
  • Attach the original bills to the claim form and make sure the bills include the plan participant's name and social security number, the patient's name, description of
    treatment, diagnosis, date of service, amount charged, facility where service was received, dentist's tax identification number, and dentist's signature.
  • Return your completed claim form to the Welfare Fund Office. All claims must be filed within two years of the date of treatment.
  • If you filed a duplicate claim with another dental plan, please include all statements of payment or denial.
  • Benefits will be paid directly to you unless you request that benefits be paid to the dentist by completing the appropriate section of the claim form. This is called
    "assigning" benefits to the dentists.

See the Important Information section for information on appealing a denied claim.

When Coverage Ends
Your dental coverage ends at the same time as your vision/hearing coverage. See When Coverage Ends in the vision/hearing section for details.

Continuation of Coverage

Extended Benefits
If your coverage ends while you are receiving dental treatment, benefits may be payable for these services:

  • Charges for dentures are eligible for benefits if
    • the impression was made and the denture was ordered before the date coverage ended, and
    • the denture is installed within three months from the date coverage ends.
  • Charges for fixed bridgework, crowns and inlays are eligible for benefits if
    • the tooth or teeth were prepared, the impression was taken, and the bridgework, crown or inlay was ordered before the date coverage ended, and
    • the bridgework, crown or inlay is installed within three
    months from the date coverage ends.
  • Charges for endodontic treatment, including root canals, are eligible for benefits if
    • the tooth was opened before the date coverage ended, and
    • the procedure is completed within three months from the date coverage ends

Family and Medical Leave Act
The plan will provide coverage to comply with the Family and Medical Leave Act (FMLA). Contact your employer for information about FMLA leave and how your benefits work
during leave.

COBRA
See Continuation Of Coverage in the vision/hearing section for an explanation of the continuation coverage available under COBRA.

Schedule of Dental Services and Supplies

Active and Retired Participants and Dependents
This schedule shows the maximum benefit the dental plan pays for these covered services as of January 1, 2008. This schedule may change from time to time and some covered services may not be listed. Contact the Welfare Fund Office before receiving dental treatment to confirm how the plan may pay for the services you are receiving.

Maximum Benefits  effective as of January 1, 2008.

 

Description

Maximum Benefit

DIAGNOSTIC/PREVENTIVE - CLASS A

 

DIAGNOSTIC

 

INITIAL ORAL EVALUATION

$62

PERIODIC ORAL EVALUATION

$36

LIMITED ORAL EVAL - PROBLEM FOCUSED

$60

 

 

DT&LEXT ORAL EVALUATION - PROBLEM FOCUSED

$161

RE-EVALUATION - LIMITED PROBLEM FOCUSED

$38

COMPREHENSIVE PERIDONTAL EVALUATION - NEW PATIENT

$63

INTRAORAL-COMPLETE SERIES INCLUDING BITEWINGS

$107

INTRAORAL-PERIAPICAL-FIRST FILM

$21

INTRAORAL-PERIAPICAL-EACH ADDITIONAL FILM

$16

INTRAORAL-OCCLUSAL FILM

$30

BITEWINGS-SINGLE FILM

$23

BITEWINGS-TWO FILMS

$36

BITEWINGS - THREE FILMS

$44

BITEWINGS-FOUR FILMS

$51

BITEWINGS-VERTICAL(7-8 FILMS)

$78

POSTERIOR, ANTERIOR OR LATERAL SKULL AND FACIAL BONE SURVEY FILM

$73

SIALOGRAPHY

$186

TMJ ARTHROGRAM, INCLUDING INJECTION

$318

TOMOGRAPHIC SURVEY

$255

PANORAMIC FILM

$87

CEPHALOMETRIC FILM

$54

ORAL/FACIAL IMAGES

$24

BACTERIOLOGIC CULTURES

$9

VIRAL CULTURE

$15

CARIES SUSCEPTIBILITY TEST

$8

PULP VITALITY TEST

$15

DIGANOSTIC CASTS

$30

ACCESSION OF TISSUE, GROSS EXAM

$21

ACCESSION OF TISSUE, GROSS AND MICROSCOPIC EXAM

$41

ACCESSION OF TISSUE, COMPLEX

$51

PROCESSING AND INTERPRETATION OF CYTOLOGIC SMEARS

$30

ACCESSION OF BRUSH BIOPSY SAMPLE, MICROSCOPIC EXAM, PREPARATION AND TRANS

$30

PREVENTIVE

 

PROPHYLAXIS-ADULT

$69

PROPHYLAXIS-CHILD

$48

TOPICAL APPLICATION FLUORIDE PROPHYLAXIS NOT INCLUDED-CHILD

$31

TOPICAL APPLICATION OF FLUORIDE EXCLUDED/PROPHYLAXIS ADULT

$30

TOPICAL FLUORIDE VARNISH; THERAPEUTIC APPLICATION FOR MODERATE TO HIGH CARIES RISK

$31

ORAL HYGIENE INSTRUCTION

$0

SEALANT-PER TOOTH

$41

SPACE MAINTAINER-FIXED-UNILATERAL

$263

SPACE MAINTAINER-FIXED-BILATERAL

$348

SPACE MAINTAINER-REMOVABLE UNILATERAL

$316

SPACE MAINTAINER-REMOVABLE BILATERAL

$448

RECEMENTATION SPACE MAINTAINER

$47

REMOVAL OF FIXED SPACE MAINTAINER

$14

BASIC SERVICES - CLASS B
RESTORATIVE (FILLINGS AND INLAYS/ONLAYS)

 

AMALGAM-ONE SURFACE, PRIMARY OR PERMANENT

$77

AMALGAM-TWO SURFACES, PRIMARY OR PERMANENT

$99

AMALGAM-THREE SURFACES, PRIMARY OR PERMANENT

$121

AMALGAM-FOUR OR MORE SURFACES, PRIMARY OR PERMANENT

$146

RESIN-ONE SURFACE, ANTERIOR

$86

RESIN-TWO SURFACES, ANTERIOR

$110

RESIN-THREE SURFACES, ANTERIOR

$135

RESIN-THREE OR MORE SURFACES OR INCISAL ANGLE ANTERIOR

$160

RESIN-BASED COMPOSITE CROWN - ANTERIOR

$177

RESIN-ONE SURFACE, POSTERIOR, PRIMARY OR PERMANENT

$79

RESIN-TWO SURFACES, POSTERIOR, PRIMARY OR PERMANENT

$103

RESIN-THREE SURFACES, POSTERIOR, PRIMARY OR PERMANENT

$128

RESIN COMPOS - FOUR OR MORE SURFACS POSTERIOR PRIMARY OR PERM

$157

INLAY-METALLIC-ONE SURFACE

$85

INLAY-METALLIC-TWO SURFACES

$109

INLAY-METALLIC-THREE OR MORE SURFACES

$132

ONLAY-METALLIC-2 SURFACES

$85

ONLAY-METALLIC-3 SURFACES

$109

ONLAY-METALLIC-4/MORE SURFACES

$132

INLAY-PORCELAIN/CERAMIC-ONE SURFACE

$112

INLAY-PORCELAIN/CERAMIC-TWO SURFACES

$146

INLAY-PORCELAIN/CERAMIC-THREE OR MORE SURFACES

$181

INLAY-RESIN COMPOS COMPOSITE/RESIN - 1 SURFACE

$79

INLAY-RESIN COMPOS COMPOS/RESIN - 2 SURFACES

$103

INLAY-RSN COMPOS COMPOS/RSN - 3/MORE SURFACES

$128

ONLAY-RESIN-BASD COMPOSITE COMPOSITE/RESN-2 SURF

$79

ONLAY-RESIN-BASD COMPOSITE COMPOSITE/RESN-3 SURF

$103

ONLAY-RESIN-BASD COMPOSITE COMP/RES-3/MORE SURF

$128

MAJOR SERVICES - CLASS C CROWNS

 

CROWN-RESIN-LABORATORY

$174

CROWN 3/4 RESINBASED COMOSITE INLAY

$174

CROWN-RESIN WITH HIGH NOBLE METAL

$476

CROWN-RESIN WITH PREDOMINANTLY BASE METAL

$446

CROWN-RESIN WITH NOBLE METAL

$456

CROWN-PORCELAIN/CERAMIC SUBSTRATE

$489

CROWN-PORCELAIN FUSED TO HIGH NOBLE METAL

$482

CROWN-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$449

CROWN-PORCELAIN FUSED TO NOBLE METAL

$460

CROWN-3/4 CAST HI NOBLE METAL

$463

CROWN-3/4 CAST PREDOMINANTLY BASE METAL

$435

CROWN-3/4 CAST NOBLE METAL

$450

CROWN-3/4 PORCELAIN/CERAMIC

$476

CROWN-FULL CAST HIGH NOBLE METAL

$466

CROWN-FULL CAST PREDOMINANTLY BASE METAL

$441

CROWN-FULL CAST NOBLE METAL

$449

CROWN-TITANIUM

$476

PROVISIONAL CROWN

$193

 

 

RECEMENT INLAY

$63

RECEMENT CAST OR PREFABRICATED POST AND CORE

$63

RECEMENT CROWN

$66

PREFABRICATED STAINLESS STEEL CROWN-PRIMARY

$180

PREFABRICATED STAINLESS STEEL CROWN-PERMANENT

$204

PREFABRICATED RESIN CROWN

$223

PREFAB STAINLESS STEEL CROWN W/RESIN WINDOW

$249

SEDATIVE FILLING

$69

CORE BUILDUP INCLUDING PINS

$108

PIN RETENTION-PER TOOTH IN ADD TO RESTORATION

$22

CAST POST AND CORE IN ADDITION TO CROWN

$164

EA ADD CAST POST-SAME TOOTH

$82

PREFABRICATED POST AND CORE IN ADDITION TO CROWN

$136

POST REMOVAL

$102

EACH ADDITIONAL POST REMOVAL

$68

TEMPORARY CROWN (FRACTURED TOOTH)

$97

ENDODONTICS

 

PULP CAP-DIRECT (EXCLUDING FINAL RESTORATION)

$51

PULP CAP-INDIRECT (EXCLUDING FINAL RESTORATION)

$40

THERAPEUTIC PULPOTOMY (EXCLUDING FINAL REST)

$119

GROSS PULPAL DEBRID-PRIM & PERM TEETH

$131

PULPAL THERAPY - ANTERIOR PRIMARY TOOTH

$126

PULPAL THERAPY - POSTERIOR PRIMARY TOOTH

$135

ROOT CANAL-ANTERIOR(EXCLUDING FINAL RESTORATION)

$502

ROOT CANAL-BICUSPID(EXCLUDING FINAL RESTORATION)

$614

ROOT CANAL-MOLAR (EXCLUDING FINAL RESTORATION)

$792

APICOECTOMY/PERIRADICULAR SURGERY- ANTERIOR

$575

APICOECTOMY/PERIRADICULAR SURGERY-BICUSP (FIRST ROOT)

$628

APICOECTOMY/PERIRADICULAR SURGERY-MOLAR(FIRST ROOT)

$710

APICOECTOMY/PERIRADICULAR SURGERY (EACH ADDITIONAL ROOT)

$236

RETROGRADE FILLING-PER ROOT

$174

ROOT AMPUTATION-PER ROOT

$352

HEMISECTION (INCLUDING ROOT REMOVAL)
NOT INCLUDING ENDODONTICS

$275

PERIODONTICS

 

GINGIVECTOMY OR GINGIVOPLASTY-PER
QUADRANT

$427

GINGIVECTOMY OR GINGIVOPLASTY -PER TOOTH

$182

GINGIVAL FLAP PROCEDURE INCLUDING ROOT
PLANING/QUADRANT

$502

GINGL FLP PROC 1-3 CONTIG/BOUND TEETH SPACE-QUAD

$259

APICALLY POSITIONED FLAP

$362

CROWN LENGTHENING-HARD/SOFT TISSUE BY REPORT

$573

OSSEOUS SURGERY INCUDING FLAP ENTRY/CLOSURE/QUADRANT

$507

OSSEOUS SURG 1-3 CONTIG/BOUND TEETH SPACES-QUAD

$264

BONE REPLACEMENT GRAFT-FIRST SITE

$153

BONE REPLACEMENT GRAFT-EACH ADD'L. SITE

$76

GUIDED TISSUE REGENERATION BY REPORT

$237

PEDICLE SOFT TISSUE GRAFT PROCEDURE

$375

FREE SOFT TISSUE GRAFT PROCEDURE
(INCLUDING DONOR SITE SURGERY)

$385

PROVISIONAL SPLINTING-INTRACORONAL

$175

PROVISIONAL SPLINTING-EXTRACORONAL

$153

PERIODONTAL SCALING AND ROOT PLANINGPER QUADRANT

$152

PRDONTAL SCALING & ROOT PLANNING 1-3 TEETH - QUAD

$84

LOC DEL ANTIMICROBL AGTS CREVICULR TISS TOOTH BR - PER TOOTH, NO MORE THAN 3 TEETH

$28

PERIODONTAL MAINTENANCE PROCEDURE FOLLOWING ACTIVE THERAPY

$91

PROSTHODONTICS

 

COMPLETE DENTURE-MAXILLARY

$389

COMPLETE DENTURE-MANDIBULAR

$389

IMMEDIATE DENTURE-UPPER

$424

IMMEDIATE DENTURE-LOWER

$424

MAXILLARY PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$328

MANDIBULAR PARTIAL DENTURE-RESIN BASE (CLASP/RESTS)

$382

MAXILLARY PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$430

MANDIBULAR PARTIAL DENTURE-METAL FRAME WITH RESIN BASE

$430

MAXILLARY PARTIAL DENTURE-FLEXIBLE BASE

$328

MANDIBULAR PARTIAL DENTURE FLESIBLE BASE

$382

REMOVABLE UNILATERAL PARTIAL DENTURE- 1 PIECE METAL(WITH TEETH)

$251

ADJUST COMPLETE DENTURE-MAXILLARY

$34

ADJUST COMPLETE DENTURE-MANDIBULAR

$34

ADJUST PARTIAL DENTURE-MAXILLARY

$34

ADJUST PARTIAL DENTURE-MANDIBULAR

$34

REPAIR BROKEN COMPLETE DENTURE BASE

$68

REPLACE MISSING/BROKEN TEETH-COMPLETE DENTURE/TOOTH

$57

REPAIR RESIN DENTURE BASE

$74

REPAIR CAST FRAMEWORK, PARTIAL DENTURE

$79

REPAIR OR REPLACE BROKEN CLASP, PARTIAL DENTURE

$97

REPLACE BROKEN TEETH-PER TOOTH, PARTIAL DENTURE

$63

ADD TOOTH TO EXISTING PARTIAL DENTURE

$86

ADD CLASP TO EXISTING PARTIAL DENTURE

$102

REPLACE ALL TEETH & ACRYLIC CAST METAL FRMEWRK MAX

$250

REBASE COMPLETE MAXILLARY DENTURE

$253

REBASE COMPLETE MANDIBULAR DENTURE

$241

REBASE PARTIAL UPPER DENTURE

$238

REBASE PARTIAL LOWER DENTURE

$238

RELINE COMPLETE UPPER DENTURE-CHAIRSIDE

$143

RELINE COMPLETE LOWER DENTURE-CHAIRSIDE

$143

RELINE UPPER PARTIAL DENTURE-CHAIRSIDE

$131

RELINE LOWER PARTIAL DENTURE CHAIRSIDE

$131

RELINE COMPLETE MAXILLARY DENTURE (LABORATORY)

$190

RELINE COMPLETE MANDIBULAR DENTURE (LABORATORY)

$190

RELINE MAXILLARY PARTIAL DENTURE (LABORATORY)

$188

RELINE MANDIBULAR PARTIAL DENTURE (LABORATORY)

$188

TEMPORARY PARTIAL - STAYPLATE UPPER DENTURE

$233

TEMPORARY PARTIAL - STAYPLATE LOWER DENTURE

$247

TISSUE CONDITIONING- UPPER DENTURE

$60

TISSUE CONDITIONING - LOWER DENTURE

$60

SURGICAL PLACEMENT IMPLANT BODY: ENDOSTEAL IMPLANT

$650

PONTIC-CAST HIGH NOBLE METAL

$450

PONTIC-CAST PREDOMINANTLY BASE METAL

$421

PONTIC-CAST NOBLE METAL

$438

PONTIC TITANIUM

$453

PONTIC-PORCELAIN FUSED TO HIGH NOBLE METAL

$444

PONTIC-PORCELAIN FUSED TO PREDOMINANTLY BASE METAL

$410

PONTIC-PORCELAIN FUSED TO NOBLE METAL

$432

PONTIC-PORCELAIN/CERAMIC

$458

PONTIC-RESIN WITH HIGH NOBLE METAL

$438

PONTIC-RESIN WITH PREDOMINANTLY BASE METAL

$404

PONTIC-RESIN WITH NOBLE METAL

$417

CAST METAL RETAINER FOR ACID ETCH BRIDGE

$187

RETAINER - PORCELN/CERAMIC RSN BONDED FIX PROSTH

$205

INLAY - PORCELAIN/CERAMIC TWO SURFACES

$370

INLAY - PORCELAIN/CERAMIC THREE OR MORE SURFACES

$389

INLAY - CAST HIGH NOBLE METAL TWO SURFACES

$396

INLAY - CAST HIGH NOBLE METAL 3/MORE SURFACES

$435

INLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES

$388

INLAY - CAST PREDOM BASE METAL 3/MORE SURFACES

$411

INLAY - CAST NOBLE METAL 2 SURFACES

$382

INLAY - CASE NOBLE METAL 3 OR MORE SURFACES

$424

ONLAY - PORCELAIN/CERAMIC 2 SURFACES

$403

ONLAY - PORCELAIN/CERAMIC 3 OR MORE SURFACES

$420

ONLAY - CAST HIGH NOBLE METAL 2 SURFACES

$427

ONLAY - CAST HIGH NOBLE METAL 3 OR  MORE SURFACES

$467

ONLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES

$425

ONLAY - CAST PREDOMIN BASE METAL 3/MORE SURFACES

$444

ONLAY - CAST NOBLE METAL 2 SURFACES

$416

ONLAY - CAST NOBLE METAL 3 OR MORE SURFACES

$432

INLAY TITANIUM

$396

ONLAY TITANIUM

$416

CROWN RESIN WITH HIGH NOBLE METAL

$495

CROWN RESIN WITH PREDOMINANTLY BASE METAL

$469

CROWN RESIN WITH NOBLE METAL

$478

CROWN-RETAINER-PORCELAIN FUSED HIGH NOBLE METAL

$507

CROWN-RETAINER-PORCELAIN FUSED PREDOMINANTLY BASE METAL

$473

CROWN-RETAINER-PORCELAIN FUSED TO NOBLE METAL

$484

CROWN-3/4 CAST HIGH NOBLE METAL

$478

CROWN - 3/4 CAST PREDOMINATELY BASED METAL

$478

CROWN - 3/4 CAST NOBLE METAL - DENTURE

$444

CROWN - 3/4 PORCELAIN/CERAMIC - DENTURE

$492

CROWN-RETAINER-FULL CAST HIGH NOBLE METAL

$489

CROWN-RETAINER-FULL CAST PREDOMINANTLY BASE METAL

$463

CROWN-RETAINER-FULL CAST NOBLE METAL

$481

CROWN TITANIUM

$481

CONNECTOR BAR

$85

RECEMENT FIXED PARTIAL DENTURE

$59

STRESS BREAKER

$135

PRECISION ATTACHMENT

$263

CAST POST AND CORE IN ADDITION TO BRIDGE

$164

PREFAB POST & CORE-ADD TO FIX PART DENT RETAINER

$133

CORE BUILD UP FOR RETAINER INCLUDE ANY PINS

$108

 

 

ORAL SURGERY

 

EXTRACTION-CORONAL REMNANTS DECIDUOUS TOOTH

$62

EXTRACTION-ERUPTED TOOTH OR EXPOSED ROOT

$81

SURGICAL REMOVAL ERUPTED TOOTH REQUIRING
FLAP/BONE REMOVAL/SECTION TOOTH

$161

REMOVAL OF IMPACTED TOOTH-SOFT TISSUE

$202

REMOVAL OF IMPACTED TOOTH-PARTIAL BONY 0

$269

REMOVAL OF IMPACTED TOOTH-COMPLETE BONY

$316

REMOVAL IMPACTED TTH-COMPLT BONY W/UNUSUAL COMPLIC

$248

SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS
(CUTTING PROCEDURE)

$106

ORDANTRAL FISTULA CLOSURE

$1,045

TOOTH REPLANTATION

$217

TTH TRANSPL (INCLUDE REIMPLNT & SPLNT &/OR STABILZ)

$308

SURGICAL EXPOSURE IMPACTED/UNERUPTED TOOTH ORTHODONTICS

$183

SURGICAL EXPOSURE IMPACTED/UNERUPTED TOOTH TO AID ERUPTION

$201

BIOPSY OF ORAL TISSUE-HARD

$420

BIOPSY OF ORAL TISSUE-SOFT

$173

BRUSH BIOPSY TRANSEPITHELIAL SAMPLE COLLECTION

$39

ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS-PER QUAD

$117

ALVEOLOPLASTY CONJNC XTRACT 1-3 TEETH/SPACES QUAD

$91

ALVEOLOPLASTY NOT IN CONJUNCTION WITH EXTRACTIONS-PER QUAD

$170

ALVEOLOPLSTY NO CNJNC XTRCT 1-3 TEETH/SPCE QUAD

$144

VESTIBULOPLASTY-RIDGE EXTENSION (SECTION EPITHELIUM)

$940

RADICAL EXCISION-LESION DIAMETER UP TO 1.25 CENTIMETERS

$374

EXCISION OF BENIGN LESION GREATER THAN 1.25 CM

$639

EXCISION OF BENIGN LESION COMPLICATED

$711

EXCISION OF MALIGNANT LESION UP TO 1.25 CM

$483

EXCISION OF MALIGNANT LESION >1.25 CM

$718

EXCISION OF MALIGNANT LESION COMPLICATED

$770

EXCISION MALIGNANT TUMOR LESION TO 1.25 CENTIMETERS

$661

EXCISION MALIGNANT TUMOR LESION OVER 1.25 CENTIMETERS

$1,028

REMOVAL ODONTOGENIC CYST/TUMOR-LESION TO 1.25 CENTIMETERS

$374

REMOVAL ODONTOGENIC CYST/TUMOR -LESION OVER 1.25 CENTIMETERS

$588

REMOVAL NON-ODONTOGENIC CYST/TUMOR-LESION TO 1.25 CENTIMETERS

$374

REMOVAL NON-ODONTOGENIC CYST/TUMOR-LESION OVER 1.25 CENTIMETERS

$603

DESTRUCTION OF LESIONS BY PHYSICAL METHODS

$213

REMOVAL EXOSTOSIS-MAXILLA OR MANDIBLE

$388

INCISION AND DRAINAGE ABCESS-INTRAORAL SOFT TISSUE

$112

I & D ABSCESS INTRAORAL SOFT TISSUE COMPLICATED

$170

SEQUESTRECTONY FOR OSTEOMYELITIS

$133

OCCLUSAL ORTHOTIC DEVICE BY REPORT

$288

SUTURE OF COMPLEX WOUNDS UP TO 5 CENTIMETERS

$427

FRENECTOMY/FRENOTOMY-SEPARATE PROCEDURE

$105

EXCISION OF HYPERPLASTIC TISSUE-PER ARCH

$255

EXCISION PERICORONAL GINGIVA

$81

ANESTHESIA/ANALGESIA

 

LOCAL ANESTHESIA FOR NONSURGICAL PROCEDURE

$20

LOCAL ANESTHESIA

$20

GENERAL ANESTHESIA-1ST 30-MINUTES

$262

GENERAL ANESTHESIA-EACH ADDITIONAL 15-MINUTES

$109

ANALGESIA

$36

INTRAVENOUS SEDATION-1ST 30 MINUTES

$206

MISCELLANEOUS

 

CONSULTING DIAGNOSTIC SERVICES BY
NONTREATING PRACTITIONER

$138

OFFICE VISIT OBSERVATION-SCHEDULED HOURS-NO OTHER SERVICES

$46

OFFICE VISIT-AFTER REGULARLY SCHEDULED HOURS

$84

APPLICATION OF DESENSITIZING MEDICATION

$29

APPLIC DESENZT RSN CERV &OR ROOT SURF - TOOTH

$46

OCCLUSAL GUARDS BY REPORT

$169

OCCLUSAL ANALYSIS-MOUNTED CASE + RELATED PROCEDURES

$114

OCCLUSION ADJUSTMENT-LIMITED

$83

OCCLUSION ADJUSTMENT-COMPLETE

$292

ORTHODONTIC SERVICES - CLASS B

 

INITIAL APPLIANCE

$600

EACH ADDITIONAL SIX MONTHS OF TREATMENT

RETAINERS

$480

$100

MAXIMUM BENEFITS PER PERIOD OF TREATMENT

$2,500

 

Recently Deleted Codes

OTHER TMJ FILMS B/R

BLEACHING OF DISCOLORED TOOTH

PROVISIONAL SPLINTING-INTRACORONAL

PROVISIONAL SPLINTING-EXTRACORONAL

OVERDENTURE COMPLETE BR

OVERDENTURE PARTIAL BR

PRECISION ATTACHMENT BR

INLAY-METALLIC 2 SURFACES

INLAY-METALLIC 3 OR MORE SURFACES

GRAFT OST PERI CART AUTHONAUTMAN

THERAPEUTIC DRUG INJECTION BR

OTHER DRUGS AND/OR MED BR

TREATMENT OF POST SURGICAL COMP BR

 

Other Non-Covered Services

Implants (surgery and placement)

Implant-borne prosthesis (crown, inlays, onlays, partial and full dentures)

 

 

 

 

Not Covered Under Dental Plans, Though Codes Exist

EXTRAORAL FILM

EXTRAORAL - EACH ADD'L

INCISION AND DRAINAGE ABCESS-EXTRAORAL SOFT TISSUE

MOST 7000 AND MANY 5000 CODES

 
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