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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