Download Real people, real benefits

Real people, real benefits
Thank you for considering a HumanaDental plan.
Enroll exclusively at
www.ers.state.tx.us
Learn more at
HumanaDental.com/ers
We’re committed to providing you with the benefits to
promote good dental health – which has an impact on
your overall health – and save on your out-of-pocket costs.
HumanaDental offers two plans. You can choose the
plan that’s right for you – either the State of Texas Dental
Choice Plan or the HumanaDental DHMO plan. You also
can expect great service. We have more than 30 years of
dental benefits experience, plus 1,000 associates who are
experts in servicing dental benefits.
Again, thank you for considering a HumanaDental dental.
We look forward to serving you.
Protect your health and your pocketbook
Oral health impacts your overall health
Dental care is an important part of maintaining good overall health. In fact, research
shows that periodontal (gum) disease can cause or aggravate other health problems
such as heart disease, stroke, diabetes, and premature births. Our dental plans encourage
preventive treatment, enabling you to achieve oral health while minimizing your costs.
Choose the plan that’s right for you
State of Texas
Dental Choice Plan
HumanaDental
DHMO
Must I visit a participating
dentist?
No
Yes
Do I save money if I visit
a participating dentist?
Yes
Yes. Benefits will not be
paid if you do not use a
participating dentist.
Do I pay coinsurance?
Yes
None – only a copayment
is required
Are major services covered?
(crowns, bridgework,
dentures, etc.)
Yes
Yes
Do I have to wait to get
full coverage?
No. Now there is no three-year
phase-in for coverage.
No
Oral health impacts overall health. You can
complete My Dental IQ and take steps
now to invest in your health. Following
a few simple steps could help lower your
total health care costs over time.
www.MyDentalIQ.com
1
Our people provide prompt,
friendly service. In fact, 9 out of 10
of our members would recommend
our products to a friend.
~ 2007 HumanaDental Member
Customer Measurement Survey
Visit dentists you know and trust
It’s easy to find a provider near your home or office who will deliver
the quality service you expect.
Finding a dentist is easy:
❯❯ Look on HumanaDental.com/ers and find your plan
❯❯ Call (877) 377-0987, 7 a.m. to 7 p.m. CT, Monday - Friday
Get the answers you need
Our convenient web tools at HumanaDental.com/ers help you to
manage your plan and find the information you need.You can:
❯❯ Compare plans
❯❯ View your benefits schedule
❯❯ View a certificate
You can talk with a knowledgeable Customer Care specialist
7 a.m. to 7 p.m. CT, Monday - Friday at (877) 377-0987.
Dental Plans comparison
HumanaDental DHMO
State of Texas Dental Choice Plan
Dentists
Must use a participating dentist
Can choose any dentist but will receive a better benefit by
selecting a participating dentist
Deductibles
None
Participating Dentist
$0 for Preventive services
$50 for Basic and Major services
Non-participating Dentist
$50 for Preventive services
$100 for Basic and Major services
Coinsurance
Vary according to service.
Participating Dentist
You pay 0% for Preventive services
You pay 10% for Basic services
You pay 50% for Major services
Non-participating Dentist
You pay 10% for Preventive services
You pay 30% for Basic services
You pay 60% for Major services
Annual Maximum
Unlimited
$1,500 (excludes orthodontia services)
Lifetime Maximum
Unlimited
$1,500 for orthodontia services
2
State of Texas Dental Choice Plan Benefit Schedule
(Three-year phase in service does not apply to this plan.)
See a participating dentist
Preventive services
See a non-participating dentist
100% no deductible
90% after deductible
90% after deductible
70% after deductible
50% after deductible
40% after deductible
(excludes orthodontia services)
Preventive deductible
Basic/Major/Prosthodonic deductible
Individual
Family
Individual
Family
$0
$50
$0
$150
$50
$100
$150
$300
Annual maximum
$1,500
❯❯ Oral examinations
❯❯ X-rays
❯❯ Cleanings
❯❯ Topical fluoride treatment (to age 19*)
❯❯ Sealants (covered only when applied by Innetwork provider) (to age 14*)
❯❯ Space maintainers (to age 19*)
❯❯ Emergency care for pain relief
Basic services
❯❯ Fillings
Major services
❯❯ Routine extractions
❯❯ Crowns
❯❯ Inlays and onlays
❯❯ Bridgework
❯❯ Dentures
❯❯ Denture relines and rebases
❯❯ Denture repair and adjustments
❯❯ Periodontics
❯❯ Endodontics (root canals)
❯❯ Oral Surgery
Calendar-year deductible
(excludes orthodontia services)
Orthodontia
Child orthodontia—covers children through age 19. Plan pays 50 percent (no deductible) of the
covered orthodontia services, up to: $1,500 lifetime orthodontia maximum
* Dependent children only
Non-participating dentists can bill you for charges above the amount covered by your HumanaDental plan.
To ensure you do not receive additional charges, visit a participating PPO Network dentist. See plan booklet for actual coverages and limitations.
3
HumanaDental DHMO Benefits Schedule
The HumanaDental DHMO plans focus on maintaining oral health, prevention and cost-containment. A member may see a
primary care dentist as often as necessary. There are no yearly maximums, no deductibles to meet, and no waiting periods.
The HumanaDental DHMO plan copayments for listed procedures are applicable only at a participating general dentist and
orthodontists.
Any services not specifically listed are the responsibility of the member and are payable at the participating dentist’s standard fees. If in doubt, ask your dentist.
Diagnostic Dentistry
D9430
D9440
D0120
D0140
D0145
D0150
D0160
D0170
D0180
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
D0330
D0350
D0415
D0425
D0460
D0470
D0472-D0480
D0486
D0502
D0999
D4999
D9999
Office visit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Office visit after regularly scheduled hours. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Periodic oral evaluation (2 per calendar year*). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Limited oral evaluation—problem focused. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral evaluation for a patient under three years of age and counseling with primary caregiver. . . . . . . . . .
Clinical oral exam/evaluation (initial). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Detailed and extensive oral evaluation—problem focused, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Re-evaluation—limited, problem focused. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Comprehensive periodontal evaluation—new or established patient . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray intraoral—complete series (including bitewings) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray intraoral—periapical, first film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray intraoral—periapical, each additional film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray intraoral—occlusal film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray extraoral—first film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray extraoral—each additional film. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray bitewing—single film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray bitewings—two films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray bitewings—three films . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray bitewings—four films. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray vertical bitewings—7 to 8 films. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-ray panoramic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral/facial images. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Collection of microorganisms for culture and sensitivity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Caries susceptibility tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diagnostic casts (excluding ortho) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral pathology procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Accession of brush biopsy sample, microscopic examination, preparation and transmission
of written report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other oral pathology procedures, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unspecified diagnostic procedures, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Periodontal probing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sterilization fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preventive
D1110
D1120
D1203
D1204
D1206
D1310
D1330
D1351
D1510
D1515
D1520
D1525
Member pays
No Charge
$ 30.00
No Charge
$ 22.00
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$ 42.00
No Charge
No Charge
$ 13.00
$
7.00
Member pays
Dental cleaning/prophylaxis—adult (2 per calendar year*) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dental cleaning/prophylaxis—child, 12 years and under (2 per calendar year*). . . . . . . . . . . . . . . . . . . . .
Topical application of fluoride—child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Topical application of fluoride—adult. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Topical fluoride varnish; therapeutic application for moderate to high caries risk patients. . . . . . . . . . . . .
Nutritional counseling for control of dental disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral hygiene instructions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sealant—per tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Space maintainer—fixed, unilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Space maintainer—fixed, bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Space maintainer—removable, unilateral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Space maintainer—removable, bilateral. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* This limit will not apply if needed more frequently due to medical necessity as determined by your primary care dentist.
$ 12.00
$ 12.00
No Charge
No Charge
No Charge
No Charge
No Charge
$ 10.00
$ 90.00
$ 90.00
$ 90.00
$ 90.00
4
HumanaDental DHMO Benefits Schedule
D1550
D1555
D1555
Recementation of space maintainer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10.00
Removal of fixed space maintainer (by original dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Removal of fixed space maintainer (by different dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 12.00
Restorative
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2410
D2420
D2430
Member pays
Amalgam—1 surface, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amalgam—2 surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amalgam—3 surfaces, primary or permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amalgam—4 or more surfaces, primary or permanent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—1 surface, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—2 surfaces, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—3 surfaces, anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—4 or more surfaces or involving incisal angle (anterior). . . . . . . . . . . . . . . . . . . .
Resin-based composite crown, anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—1 surface, posterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—2 surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—3 surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin-based composite—4 or more surfaces, posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gold foil restoration—1 surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gold foil restoration—2 surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gold foil restoration—3 surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Major Restorative
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751
D2752
D2780
D2781
D2782
D2783
D2790
D2791
D2792
D2794
D2910
D2910
5
$ 22.00
$ 27.00
$ 32.00
$ 37.00
$ 27.00
$ 32.00
$ 37.00
$ 52.00
$ 40.00
$ 47.00
$ 57.00
$ 67.00
$ 74.00
$ 60.00
$ 140.00
$ 180.00
Member pays
Inlay—metallic, 1 surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—metallic, 2 surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—metallic, 3 or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—metallic, 2 surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—metallic, 3 surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—metallic, 4 or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—porcelain/ceramic, 1 surface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—porcelain/ceramic, 2 surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—porcelain/ceramic, 3 or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—porcelain/ceramic, 2 surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—porcelain/ceramic, 3 surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—porcelain/ceramic, 4 or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—resin-based composite, 1 surface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—resin-based composite, 2 surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—resin-based composite, 3 or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—resin-based composite, 2 surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—resin-based composite, 3 surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—resin-based composite, 4 or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—resin based composite (indirect). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 resin based composite (indirect). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—resin with noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain/ceramic substrate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain fused to high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain fused to predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain fused to noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 cast high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 cast noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 cast porcelain/ceramic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—full cast high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—full cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—full cast noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—titanium .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recement inlay, onlay or partial coverage restoration (by original dentist). . . . . . . . . . . . . . . . . . . . . . . . .
Recement inlay, onlay or partial coverage restoration (by new dentist) . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 140.00
$ 170.00
$ 200.00
$ 250.00
$ 260.00
$ 270.00
$ 247.00
$ 297.00
$ 297.00
$ 317.00
$ 317.00
$ 327.00
$ 172.00
$ 182.00
$ 212.00
$ 212.00
$ 222.00
$ 237.00
$ 318.00
$ 318.00
$ 368.00
$ 260.00
$ 299.00
$ 410.00
$ 410.00
$ 360.00
$ 399.00
$ 399.00
$ 350.00
$ 389.00
$ 350.00
$ 410.00
$ 360.00
$ 399.00
$ 410.00
No Charge
$
5.00
HumanaDental DHMO Benefits Schedule
D2915
D2920
D2920
D2930
D2931
D2932
D2933
D2934
D2940
D2950
D2951
D2952
D2953
D2954
D2957
D2961
D2962
D2970
D2971
D2975
D2980
D2999
D2999
Endodontics
D3999
D3110
D3120
D3220
D3310
D3320
D3330
D3351-D3353
D3410
D3421
D3425
D3426
D3430
D3450
D3470
D3910
D3920
D3999
D3999
Periodontics
D4999
D4210
D4211
D4240
D4241
D4260
D4261
D4263
D4264
D4265
D4320
Recement cast or prefabricated post and core . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
5.00
Recement crown (by original dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Recement crown (by new dentist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
5.00
Prefabricated stainless steel crown—primary tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 50.00
Prefabricated stainless steel crown—permanent tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55.00
Prefabricated resin crown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Prefabricated stainless steel crown with resin window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 65.00
Prefabricated esthetic coated stainless steel crown primary tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 65.00
Sedative filling. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
5.00
Core buildup, including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 65.00
Pin retention—per tooth, in addition to restoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Post and core, in addition to crown, indirectly fabricated. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 62.00
Each additional indirectly fabricated post—same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 18.00
Prefabricated post and core, in addition to crown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 58.00
Each additional prefabricated post—same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 15.00
Labial veneer (resin laminate)—laboratory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 297.00
Labial veneer (porcelain laminate)—laboratory. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 380.00
Temporary crown (fractured tooth). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 25.00
Additional procedures to construct new crown under existing partial denture framework. . . . . . . . . . . . . $ 15.00
Coping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 148.00
Crown repair, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 30.00
Unspecified restorative procedure, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Temporary metal crown (with permanent) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Member pays
Endodontic consultation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Pulp cap direct (excluding final restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Pulp cap indirect (excluding final restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Therapeutic pulpotomy (excluding final restoration). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35.00
Root canal therapy—anterior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 170.00
Root canal therapy—bicuspid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 190.00
Root canal therapy—molar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 250.00
Apexification/recalcification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Apicoectomy/periradicular surgery—anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 140.00
Apicoectomy/periradicular surgery—bicuspid (first root). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 140.00
Apicoectomy/periradicular surgery molar (first root). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 170.00
Apicoectomy/periradicular surgery (each add’l root). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 90.00
Retrograde filling—per root. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 35.00
Root amputation—per root. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55.00
Intentional replantation (including necessary splinting). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 55.00
Surgical procedure for isolation of tooth with rubber dam. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
3.00
Hemisection (including any root removal), not including root therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 66.00
Unspecified endodontic procedure, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Culturing canal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Member pays
Periodontal consultation, evaluation and treatment plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gingivectomy or gingivoplasty—4 or more contiguous teeth or bounded teeth spaces per quadrant . . . .
Gingivectomy or gingivoplasty—1 to 3 contiguous teeth or bounded teeth spaces, per quadrant. . . . . . .
Gingival flap procedure, including root planing—4 or more contiguous teeth or bounded teeth
spaces, per quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gingival flap procedure, including root planning—1 to 3 contiguous teeth or bounded teeth spaces,
per quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osseous surgery (including flap entry and closure)—4 or more contiguous teeth or bounded spaces,
by quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osseous surgery (including flap entry and closure)—1 to 3 contiguous teeth or bounded teeth spaces,
per quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bone replacement graft—first site in quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bone replacement graft—each add’l site in quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biologic materials to aid in soft and osseous tissue regeneration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Provisional splinting—intracoronal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
No Charge
$ 156.00
$ 94.00
$ 220.00
$ 132.00
$ 220.00
$
$
$
$
$
132.00
150.00
150.00
150.00
60.00
6
HumanaDental DHMO Benefits Schedule
D4321
D4341
D4342
D4355
D4910
D4920
D4999
D4999
D4999
D4999
Provisional splinting—extracoronal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Periodontal scaling and root planing—4 or more teeth per quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Periodontal scaling and root planing—1 to 3 teeth, per quadrant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Full mouth debridement to enable comprehensive evaluation and diagnosis. . . . . . . . . . . . . . . . . . . . . . .
Periodontal maintenance procedures (following active therapy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unscheduled dressing change (other than treating dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Unspecified periodontal procedure (by report) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Home care instructions for periodontal management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Post-therapeutic evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Non-surgical service periodontal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prosthodontics—removable
7
D5110
D5120
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5225
D5226
D5410
D5410
D5411
D5411
D5421
D5421
D5422
D5422
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
D5760
D5761
D5810
D5811
D5820
D5821
D5850
$ 60.00
$ 50.00
$ 32.00
$ 42.00
$ 37.00
No Charge
No Charge
No Charge
No Charge
No Charge
Member pays
Complete denture—maxillary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complete denture—mandibular. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complete denture—maxillary (duplicate). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Complete denture—mandibular (duplicate). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Immediate denture—maxillary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Immediate denture—mandibular. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Maxillary partial denture—resin base (including any conventional clasps, rests and teeth). . . . . . . . . . . . .
Mandibular partial denture—resin base (including any conventional clasps, rests and teeth). . . . . . . . . . .
Maxillary partial denture—cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mandibular partial denture—cast metal framework with resin denture bases
(including any conventional clasps, rests and teeth) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Maxillary partial denture flexible base (including any clasps, rests and teeth). . . . . . . . . . . . . . . . . . . . . . .
Mandibular partial denture—flexible base (including any clasps, rests and teeth) . . . . . . . . . . . . . . . . . . .
Adjust complete denture—maxillary (by original dentist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adjust complete denture—maxillary (by new dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adjust complete denture—mandibular (by original dentist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adjust complete denture—mandibular (by new dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adjust partial denture—maxillary (by original dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adjust partial denture—maxillary (by new dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adjust partial denture—mandibular (by original dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Adjust partial denture—mandibular (by new dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Repair broken complete denture base . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Repair missing or broken teeth—complete denture (each tooth). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Repair resin denture base. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Repair cast framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Repair or replace broken clasp. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Replace broken teeth—per tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add tooth to existing partial denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Add clasp to existing partial denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Replace all teeth and acrylic on cast metal framework (maxillary). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Replace all teeth and acrylic on cast metal framework (mandibular). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rebase complete maxillary denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rebase complete mandibular denture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rebase maxillary partial denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Rebase mandibular partial denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline complete maxillary denture (chairside). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline complete mandibular denture (chairside). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline maxillary partial denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline mandibular partial denture (chairside) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline complete maxillary denture (laboratory). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline complete mandibular denture (laboratory). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline maxillary partial denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reline mandibular partial denture (laboratory) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interim complete denture (maxillary) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interim complete denture (mandibular) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interim partial denture (maxillary). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Interim partial denture (mandibular). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Tissue conditioning (maxillary) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
$
$
490.00
490.00
260.00
260.00
518.00
518.00
503.00
503.00
$ 578.00
$ 578.00
$ 538.00
$ 538.00
No Charge
$ 10.00
No Charge
$ 10.00
No Charge
$ 10.00
No Charge
$ 10.00
$ 35.00
$ 20.00
$ 78.00
$ 78.00
$ 78.00
$ 78.00
$ 78.00
$ 78.00
$ 164.00
$ 164.00
$ 164.00
$ 164.00
$ 164.00
$ 164.00
$ 60.00
$ 60.00
$ 60.00
$ 60.00
$ 75.00
$ 75.00
$ 75.00
$ 75.00
$ 60.00
$ 60.00
$ 90.00
$ 90.00
$ 20.00
HumanaDental DHMO Benefits Schedule
D5851
D5862
D5899
Tissue conditioning (mandibular) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 20.00
Precision attachment, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 150.00
Unspecified removable prosthodontic procedure, by report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . No Charge
Implant services
D6010
Surgical placement of implant body: endosteal implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 900.00
Implant supported prosthetics
D6053
D6054
D6058
D6059
D6060
D6061
D6062
D6063
D6064
D6065
D6066
D6067
D6068
D6069
D6070
D6071
D6072
D6073
D6074
D6075
D6076
D6077
D6091
D6092
D6093
D6094
D6194
Member pays
Member pays
Implant/abutment supported removable denture for completely edentulous arch. . . . . . . . . . . . . . . . . . . $
Implant/abutment supported removable denture for partially edentulous arch. . . . . . . . . . . . . . . . . . . . . $
Abutment supported porcelain/ceramic crown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported porcelain fused to metal crown (high noble metal) . . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported porcelain fused to metal crown (predominantly base metal) . . . . . . . . . . . . . . . . . . $
Abutment supported porcelain fused to metal crown (noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported cast metal crown (high noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported cast metal crown (predominantly base metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported cast metal crown (noble metal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Implant supported porcelain/ceramic crown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Implant supported porcelain fused to metal crown (titanium, titanium alloy, or high noble metal). . . . . . $
Implant supported metal crown (titanium, titanium alloy, or high noble metal). . . . . . . . . . . . . . . . . . . . . $
Abutment supported retainer for porcelain/ceramic fixed partial denture. . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported retainer for porcelain fused to metal fixed partial denture (high noble metal) . . . . . $
Abutment supported retainer for porcelain fused to metal fixed partial denture (predominantly base metal).$
Abutment supported retainer for porcelain fused to metal fixed partial denture (noble metal) . . . . . . . . . $
Abutment supported retainer for cast metal fixed partial denture (high noble metal) . . . . . . . . . . . . . . . . $
Abutment supported retainer for cast metal fixed partial denture (predominantly base metal) . . . . . . . . . $
Abutment supported retainer for cast metal fixed partial denture (noble metal). . . . . . . . . . . . . . . . . . . . $
Implant supported retainer for ceramic fixed partial denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Implant supported retainer for porcelain fused to metal fixed partial denture
(titanium, titanium alloy, or high noble metal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Implant supported retainer for cast metal fixed partial denture
(titanium, titanium alloy, or high noble metal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Replacement of semi-precision or precision attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Recement implant / abutment supported crown. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Recement implant / abutment supported fixed partial denture. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported crown—titanium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Abutment supported retainer crown for FPD—titanium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
Prosthodontics—fixed
590.00
687.00
461.00
461.00
412.00
451.00
461.00
412.00
451.00
461.00
461.00
461.00
461.00
461.00
412.00
451.00
461.00
412.00
451.00
461.00
461.00
461.00
155.00
20.00
20.00
461.00
461.00
Member pays
The following bridge prices are listed on a per unit basis. A unit equals each tooth restored or replaced.
D6205
D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6253
D6545
D6548
D6600
D6601
D6602
D6603
D6604
Pontic—indirect resin based composite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—cast high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—cast predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—cast noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—porcelain fused to high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—porcelain fused to predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—porcelain fused to noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—porcelain/ceramic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—resin with high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—resin with predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pontic—resin with noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Provisional pontic (interim of at least 6 months). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retainer—cast metal for resin bonded fixed prosthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Retainer—porcelain/ceramic for resin bonded fixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—porcelain / ceramic, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—porcelain / ceramic, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—cast high noble metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—cast high noble metal, three and more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—cast predominantly base metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
350.00
410.00
360.00
399.00
410.00
410.00
360.00
399.00
360.00
399.00
350.00
389.00
200.00
236.00
236.00
297.00
297.00
200.00
230.00
170.00
8
HumanaDental DHMO Benefits Schedule
D6605
D6606
D6607
D6608
D6609
D6610
D6611
D6612
D6613
D6614
D6615
D6624
D6634
D6710
D6720
D6721
D6722
D6740
D6750
D6751
D6752
D6780
D6781
D6782
D6783
D6790
D6791
D6792
D6793
D6794
D6930
D6930
D6940
D6950
D6970
D6972
D6973
D6975
D6976
D6977
D6980
Oral surgery
D7111
D7140
D7210
D7220
D7230
D7240
D7241
D7250
D7280
D7282
D7283
D7285
D7286
D7287
D7288
D7310
D7311
9
Inlay—cast predominantly base metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—cast noble metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—cast noble metal, three or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—porcelain / ceramic, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—porcelain / ceramic, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—cast high noble metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—cast high noble metal, three or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—cast predominantly base metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—cast predominantly base metal, three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—cast noble metal, two surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—cast noble metal, three or more surfaces. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Inlay—titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Onlay—titanium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—indirect resin based composite. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—resin with high noble metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—resin with predominantly base metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—resin with noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain/ceramic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain fused to high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain fused to predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—porcelain fused to noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 cast high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 cast noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—3/4 porcelain/ceramic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—full cast high noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—full cast predominantly base metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—full cast noble metal. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Provisional retainer crown (interim of at least 6 months). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Crown—titanium. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recement fixed partial denture (by original dentist) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recement fixed partial denture (by new dentist). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stress breaker. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Precision attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Post and core in addition to fixed partial denture retainer, indirectly fabricated. . . . . . . . . . . . . . . . . . . . .
Prefabricated post and core in addition to fixed partial denture retainer. . . . . . . . . . . . . . . . . . . . . . . . . .
Core build up for retainer, including any pins. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Coping—metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Each additional indirectly fabricated post—same tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Each additional prefabricated post—same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fixed partial denture repair, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 200.00
$ 190.00
$ 220.00
$ 317.00
$ 317.00
$ 280.00
$ 290.00
$ 250.00
$ 260.00
$ 270.00
$ 280.00
$ 200.00
$ 280.00
$ 260.00
$ 368.00
$ 260.00
$ 299.00
$ 410.00
$ 410.00
$ 360.00
$ 399.00
$ 399.00
$ 350.00
$ 389.00
$ 350.00
$ 410.00
$ 360.00
$ 399.00
$ 200.00
$ 410.00
No Charge
$ 15.00
$ 148.00
$ 145.00
$ 62.00
$ 58.00
$ 65.00
$ 148.00
$ 18.00
$ 15.00
$ 123.00
Member pays
Extraction, coronal remnants – deciduous tooth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Extraction, erupted tooth or exposed root (elevation and/or forceps removal). . . . . . . . . . . . . . . . . . . . . .
Surgical removal of erupted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Removal of impacted tooth, soft tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Removal of impacted tooth, partially bony. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Removal of impacted tooth, completely bony. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Removal of impacted tooth, completely bony, with unusual surgical complications. . . . . . . . . . . . . . . . . .
Surgical removal of residual tooth roots (cutting procedure). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Surgical access of an unerupted tooth to aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mobilization of erupted or malpositioned tooth to aid eruption. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Placement of device to facilitate eruption of impacted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biopsy of oral tissue—hard (bone, tooth). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Biopsy of oral tissue—soft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exfoliative cytologicaly sample collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Brush biopsy—transepithelial sample collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Alveoloplasty in conjunction with extractions—four or more teeth or tooth spaces, per quadrant. . . . . . .
Alveoloplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant. . . . . . .
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
15.00
28.00
42.00
64.00
78.00
115.00
126.00
50.00
90.00
75.00
18.00
150.00
150.00
40.00
40.00
50.00
25.00
HumanaDental DHMO Benefits Schedule
D7320
D7321
D7471
D7472
D7473
D7485
D7510
D7511
D7520
D7521
D7950
D7953
D7960
D7963
D7970
D7972
Alveoloplasty not in conjunction with extraction—four or more teeth or tooth spaces, per quadrant . . . .
Alveoloplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant. . . .
Removal of lateral exostosis (maxilla or mandible). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Removal of torus palatinus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Removal of torus mandibularis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Surgical reduction of osseous tuberosity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incision and drainage per abscess—intraoral soft tissue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incision and drainage of abscess—intraoral soft tissue, complicated
(includes drainage of multiple fascial spaces) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incision and drainage per abscess—extraoral soft tissue. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Incision and drainage of abscess—extraoral soft tissue, complicated
(includes drainage of multiple fascial spaces) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Osseous, osteoperiosteal, periosteal, or cartilage graft of the mandible or facial bones—autogenous
or nonautogeneous, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Bone replacement graft for ridge preservation—per site. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frenulectomy (frenectomy or frenotomy) separate procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Frenuloplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Excision of hyperplastic tissue, per arch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Surgical reduction of fibrous tuberosity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Orthodontics
D8999
D8010
D8020
D8070
D8080
D8090
D8220
D8680
D8999
D8999
D8999
D8999
D8999
75.00
38.00
150.00
150.00
150.00
150.00
35.00
$
$
38.00
40.00
$
44.00
$ 150.00
$ 18.00
$ 84.00
$ 86.00
$ 100.00
$ 50.00
Member pays
Orthodontic exam (including consultation). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Limited orthodontic treatment of the primary dentition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Limited orthodontic treatment of the transitional dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Comprehensive orthodontic treatment of the transitional dentition . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Comprehensive orthodontic treatment of the adolescent dentition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Comprehensive orthodontic treatment of the adult dentition. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fixed appliance therapy (habit appliance). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Orthodontic retention (removal of appliances, construction and placement of retainer(s). . . . . . . . . . . . .
Adjusting retainers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Elastics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Final orthodontic records. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Reattach brackets and bands (limit 3). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Replace broken ligature wires (limit 3) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other services
D9110
D9120
D9211
D9212
D9215
D9230
D9310
D9450
D9940
D9942
D9951
D9952
D9999
$
$
$
$
$
$
$
$ 126.00
$ 500.00
$ 500.00
$1,800.00
$2,100.00
$2,100.00
$ 250.00
$ 100.00
No Charge
No Charge
No Charge
No Charge
No Charge
Member pays
Palliative (emergency) treatment of dental pain—minor procedure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fixed partial denture sectioning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Regional block anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Trigeminal division block anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Local anesthesia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analgesia, anxiolysis, inhalation of nitrous oxide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Consultation (diagnostic service provided by dentist or physician other than practitioner
providing treatment) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Case presentation, detailed and extensive treatment planning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusal guard, by report. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Repair and/or relining of an occlusal guard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusal adjustment—limited. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusal adjustment—complete. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Preparatory fee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ 15.00
$ 125.00
No Charge
No Charge
No Charge
$ 10.00
No Charge
No Charge
$ 150.00
$ 39.00
$ 10.00
$ 40.00
No Charge
Current Dental Terminology © 2007 American Dental Association - All rights reserved
10
HumanaDental DHMO Benefits Schedule
Exclusions and Limitations (Charges not covered)
2.
3.
4.
5.
6.
7.
1.
A charge for a service not reasonably necessary, or not customarily performed, for the dental care of the covered person.
A charge in connection with a service not listed in the Schedule of Benefits.
A charge for treatment by other than a Dentist; except for services performed by a licensed dental hygienist. In this case,
the treatment must be given under the supervision and guidance of a Dentist.
A charge for a service to the extent that it is more than the usual charge made by the dentist for the service when there is
no coverage.
A charge for a service to the extent that it is above the prevailing charge in the area for dental care of a comparable nature.
A charge is above the prevailing charge to the extent that it is above the range of charges generally made in the area for dental
care of a comparable nature. The area and that range are as determined by HumanaDental.
A charge for prescription drugs.
A charge for treatment for malignancies or neoplasms.
8.
A charge for hospitalization, outpatient surgical center, general anesthesia, or intravenous sedation.
9.
A charge for any procedure not performed in a General Dentist’s or Specialty Dentist’s office, except for Emergency Care and
certain charges for Non-Member Dental Providers.
Offered by DentiCare, Inc. (d/b/a Compbenefits),
a member of the HumanaDental family of companies
GN-52094-HD 5/09