Download D1014 Dental HMO and Managed Care Contrib CA 400

UnitedHealthcare Dental®
Dental Plan
Select Managed Care Direct Compensation
CA240/covered dental services
ADA
DESCRIPTION
MEMBER’S
COPAYMENT
DIAGNOSTIC SERVICES
D0120
D0140
D0145
D0150
D0160
D0170
D0180
D0190
D0191
D0210
D0220
D0230
D0240
D0250
D0260
D0270
D0272
D0273
D0274
D0277
D0290
D0330
D0340
D0391
D0415
D0416
D0417
D0418
D0421
D0425
D0431
D0460
D0470
D0472
D0473
D0474
D0601
D0602
D0603
PERIODIC ORAL EVAL ESTABLISHED PATIENT
LIMITED ORAL EVAL - PROBLEM FOCUSED
ORAL EVAL PATIENT <3 AND COUNSEL WITH PRIMARY
CARE GIVER
COMPREHENSIVE ORAL EVAL - NEW/ESTABLISHED PATIENT
DETAILED & EXTENSIVE ORAL EVAL - PROBLEM FOCUSED
REPRT
RE-EVAL - LIMITED PROBLEM FOCUSED
COMPREHENSIVE PERIODONTAL EVAL - NEW/ESTABLISHED
PATIENT
SCREENING OF A PATIENT
ASSESSMENT OF A PATIENT
$0
$0
$0
INTRAORAL-COMPLETE SERIES OF RADIOGRAPHIC IMAGES
INTRAORAL - PERIAPICAL FIRST RADIOGRAPHIC IMAGE
INTRAORAL - PERIAPICAL EACH ADDL RADIOGRAPHIC
IMAGE
INTRAORAL - OCCLUSAL RADIOGRAPHIC IMAGE
EXTRAORAL - FIRST RADIOGRAPHIC IMAGE
EXTRAORAL - EACH ADDITIONAL RADIOGRAPHIC IMAGE
BITEWING - SINGLE RADIOGRAPHIC IMAGE
BITEWINGS - TWO RADIOGRAPHIC IMAGES
BITEWINGS - THREE RADIOGRAPHIC IMAGES
BITEWINGS - FOUR RADIOGRAPHIC IMAGES
VERTICAL BITEWINGS - 7 TO 8 RADIOGRAPHIC IMAGES
POST-ANTERIOR LATERAL SKULL & FACIAL RADIOGRAPHIC
IMAGE
PANORAMIC RADIOGRAPHIC IMAGE
CEPHALOMETRIC RADIOGRAPH IMAGE
INTERPRETATION OF DIAGNOSTIC IMAGE
COLLECT MICROORGANISMS CULTURE & SENSITIVITY
VIRAL CULTURE
COLLECTION & PREPARATION OF SALIVA SAMPLE
ANALYSIS OF SALIVA SAMPLE
GENETIC TEST FOR SUSCEPTIBILITY TO ORAL DISEASES
CARIES SUSCEPTIBILITY TESTS
ADJUNCTIVE PREDIAGNOSTIC TEST
PULP VITALITY TESTS
DIAGNOSTIC CASTS
ACCESSION OF TISSUE-GROSS EXAM, PREP & REPRT
ACCESSION OF TISSUE-GROSS/MICRO EXAM PREP & REPRT
ACCESSION OF TISSUE-MICRO GROSS/MICRO EXAM, INCLD
ASSESS MARGIN FOR DISEASE, PREP & REPRT
CARIES RISK ASSESS & DOCUMENT W/FIND LOW RISK
CARIES RISK ASSESS & DOCUMENT W/FIND MODERATE
RISK
CARIES RISK ASSESS & DOCUMENT W/FIND HIGH RISK
$0
$0
$0
$0
$0
$0
$0
D1014
MEMBER’S
COPAYMENT
ADA
DESCRIPTION
D1330
D1351
D1352
D1510
D1515
D1520
D1525
D1550
D1555
ORAL HYGIENE INSTRUCTIONS
SEALANT - PER TOOTH
PREV RESIN RESTORATION MOD HIGH CARIES RISK PATIENT
SPACE MAINTAINER - FIXED-UNILATERAL
SPACE MAINTAINER - FIXED-BILATERAL
SPACE MAINTAINER - REMOVABLE-UNILATERAL
SPACE MAINTAINER - REMOVABLE-BILATERAL
RECEMENTATION OF SPACE MAINTAINER
REMOVAL OF FIXED SPACE MAINTAINER
$0
$0
$0
$0
$0
$0
$0
$0
$0
RESTORATIVE SERVICES
$5
$5
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$10
$5
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
$0
PREVENTIVE SERVICES
D1110
D1120
D1206
D1208
D1310
PROPHYLAXIS - ADULT
PROPHYLAXIS - CHILD
TOPICAL APPLICATION OF FLUORIDE VARNISH
TOPICAL APPLICATION OF FLUORIDE
NUTRITIONAL COUNSELING CONTROL DENTAL DISEASE
$0
$0
$0
$0
$0
D1320
TOBACCO COUNSELING CONTROL & PREV ORAL DISEASE
$0
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
D2390
D2391
D2392
D2393
D2394
D2510
D2520
D2530
D2542
D2543
D2544
D2610
D2620
D2630
D2642
D2643
D2644
D2650
D2651
D2652
D2662
AMALGAM - 1 SURFACE PRIMARY/PERMANENT
AMALGAM- 2 SURFACES PRIMARY/PERMANENT
AMALGAM - 3 SURFACES PRIMARY/PERMANENT
AMALGAM - 4/> SURFACES PRIMARY/PERMANENT
RESIN-BASED COMPOSITE - 1 SURFACE, ANTERIOR
RESIN COMPOSITE - 2 SURFACES, ANTERIOR
RESIN COMPOSITE - 3 SURFACES, ANTERIOR
RESIN COMPOSITE - 4/> SURFACES/W/INCISAL ANG
RESIN COMPOSITE CROWN ANTERIOR
RESIN COMPOSITE - 1 SURFACE POSTERIOR
RESIN COMPOSITE - 2 SURFACES POSTERIOR
RESIN COMPOSITE - 3 SURFACES POSTERIOR
RESIN COMPOSITE- 4/MORE SURFACES POST
INLAY - METALLIC - 1 SURFACE
INLAY - METALLIC - 2 SURFACES
INLAY - METALLIC - 3/> SURFACES
ONLAY - METALLIC - 2 SURFACES
ONLAY - METALLIC - 3 SURFACES
ONLAY - METALLIC 4/> SURFACES
INLAY - PORCELAIN/CERAMIC - 1 SURFACE
INLAY - PORCELAIN/CERAMIC - 2 SURFACES
INLAY - PORCELAIN/CERAMIC - 3/> SURFACES
ONLAY - PORCELAIN/CERAMIC - 2 SURFACES
ONLAY - PORCELAIN/CERAMIC - 3 SURFACES
ONLAY - PORCELAIN/CERAMIC - 4/> SURFACES
INLAY - RESIN BASED COMPOSITE -1 SURFACE
INLAY - RESIN BASED COMPOSITE - 2 SURFACES
INLAY - RESIN BASED COMPOSITE - 3/> SURFACES
ONLAY - RESIN BASED COMPOSITE -2 SURFACES
D2663
D2664
D2710
D2712
D2720
D2721
D2722
D2740
D2750
D2751
ONLAY - RESIN BASED COMPOSITE -3 SURFACES
ONLAY - RESIN BASED COMPOSITE - 4/> 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 HIGH NOBLE METAL*
CROWN - PORCELAIN FUSED PREDOMINANTLY BASE
METAL
CROWN - PORCELAIN FUSED NOBLE METAL*
CROWN - 3/4 CAST HIGH NOBLE METAL*
CROWN - 3/4 CAST PREDOMINANTLY BASE METAL
CROWN - 3/4 CAST NOBLE METAL*
D2752
D2780
D2781
D2782
$5
$5
$10
$10
$5
$5
$10
$10
$20
$5
$10
$10
$10
$95
$95
$95
$95
$95
$95
$35
$40
$45
$95
$95
$95
$30
$35
$40
$30
$40
$45
$20
$20
$40
$30
$30
$100
$100
$90
$100
$95
$90
$95
1
400-5793 - Contrib
4/2014
©2013-2014 United HealthCare Services, Inc.
This plan is underwritten by Dental Benefit Providers of California, Inc.
MEMBER’S
COPAYMENT
ADA
DESCRIPTION
D2783
D2790
D2791
D2792
D2794
D2910
D2915
D2920
D2921
D2929
CROWN - 3/4 PORCELAIN/CERAMIC
CROWN - FULL CAST HIGH NOBLE METAL*
CROWN - FULL CAST PREDOMINANTLY BASE METAL
CROWN - FULL CAST NOBLE METAL*
CROWN TITANIUM*
RECEMENT INLAY, ONLAY/PARTIAL COVERAGE RESTOR
RECEMENT CAST/PREFABRICATED POST & CORE
RECEMENT CROWN
REATTACH TOOTH FRAGMENT, INCISAL EDGE OR CUSP
PREFABRIC PORCELAIN/CERAMIC CROWN-PRIMARYTOOTH
PREFARBICATED STAINLESS STEEL CROWN - PRIMARY
PREFABRICATED STAINLESS STEEL CROWN - PERMANENT
PREFABRICATED RESIN CROWN
D2930
D2931
D2932
D2933
D2934
D2940
D2941
D2950
D2951
D2952
D2953
D2954
D2955
D2957
D2960
D2961
D2962
D2970
D2971
D2975
D2980
D2990
PREFABRICATED STAINLESS STEEL CROWN RESIN WINDOW
PREFABRIC ESTHTC COAT STNLS STL CRWN-PRIMARY
TOOTH
PROTECTIVE RESTORATION
INTERIM THERAPEUTIC RESTORATION – PRIMARY DENTITION
CORE BUILD-UP, INCLUDING ANY PINS
PIN RETENTION - PER TOOTH ADDITION RESTORATION
POST & CORE ADDITION CROWN INDIRECT FABRICATED
EACH ADDL INDIRECTLY FABRICATED POST - SAME TOOTH
PREFABRICATED POST & CORE ADDITION CROWN
POST REMOVAL
EACH ADDITIONAL PREFABRICATED POST - SAME TOOTH
LABIAL VENEER (RESIN BASED) - CHAIRSIDE
LABIAL VENEER (RESIN BASED) - LABORATORY
LABIAL VENEER (PORCELAIN LAMINATE)
TEMPORARY CROWN
ADDL PROCEDURE NEW CROWN EXIST PARTIAL DENTURE
COPING
CROWN REPAIR
RESIN INFILTRATION INCIPIENT SMTH SURFACE LESIONS
$95
$100
$90
$100
$100
$5
$5
$5
$5
$10
$10
$10
$10
$10
$10
$5
$5
$5
$5
$25
$5
$10
$20
$5
$20
$40
$40
$10
$10
$70
$15
$5
ENDODONTIC SERVICES
D3110
D3120
PULP CAP - DIRECT
PULP CAP - INDIRECT
$0
$0
D3220
D3221
D3222
THERAPEUTIC PULPOTOMY
PULPAL DEBRIDEMENT PRIMARY & PERMANENT TEETH
PARTIAL PULPTOMY FOR APEXOGENESIS PERMANENT
TOOTH
PULPAL THERAPY - ANTERIOR PRIMARY TOOTH
PULPAL THERAPY - POSTERIOR PRIMARY TOOTH
ENDODONTIC THERAPY, ANTERIOR TOOTH
ENDODONTIC THERAPY, BICUSPID TOOTH
ENDODONTIC THERAPY, MOLAR
TREATMENT ROOT CANAL OBSTRUCTION; NON-SURG
ACCESS
INCOMPLETED ENDODONTIC THERAPY
INTERNAL ROOT REPAIR PERFORATION DEFECTS
RETREATMENT PREV ROOT CANAL THERAPY - ANTERIOR
RETREATMENT PREV ROOT CANAL THERAPY - BICUSPID
RETREATMENT PREV ROOT CANAL THERAPY - MOLAR
APEXIFICATION/RECALCIFICATION INITIAL VISIT
APEXIFICATION/RECALCIFICATION INTERIM MEDICATION
REPLACEMENT
APEXIFICATION/RECALCIFICATION - FINAL VISIT
PULPAL REGENERATION - INITIAL VISIT
$0
$5
$0
D3230
D3240
D3310
D3320
D3330
D3331
D3332
D3333
D3346
D3347
D3348
D3351
D3352
D3353
D3355
400-5793 - Contrib
4/2014
$0
$0
$15
$20
$60
$5
$0
$5
$15
$20
$35
$5
$5
$10
$5
2
©2013-2014 United HealthCare Services, Inc.
ADA
DESCRIPTION
D3356
D3357
D3410
D3421
D3425
D3426
D3427
D3430
D3450
D3460
D3910
D3920
D3950
MEMBER’S
COPAYMENT
PULPAL REGENERATION -INTERIM MEDICAMENT REPLACEMNT
PULPAL REGENERATION - COMPLETION OF TREATMENT
APICOECTOMY - ANTERIOR
APICOECTOMY - BICUSPID
APICOECTOMY - MOLAR
APICOECTOMY - EACH ADDITIONAL ROOT
PERIRADICULAR SURGERY WITHOUT APICOECTOMY
RETROGRADE FILLING - PER ROOT
ROOT AMPUTATION - PER ROOT
ENDODONTIC ENDOSSEOUS IMPLANT
SURGICAL PROCED ISOLATION TOOTH W/RUBBER DAM
HEMISECTION NOT INCLUDIING ROOT CANAL THERAPY
CANAL PREPARATION & FIT PREFORMED DOWEL/POST
$5
$10
$15
$20
$30
$10
$10
$10
$10
$1950
$5
$5
$5
PERIODONTIC SERVICES
D4210
D4211
D4212
D4240
D4241
D4245
D4249
D4260
D4261
D4263
D4270
D4274
D4277
D4278
D4320
D4321
D4341
D4342
D4355
D4381
D4910
D4920
D4921
GINGIVECTOMY/GINGIVOPLASTY 4/> CNTIG TEETH QUAD
GINGIVECTOMY/GINGIVOPLASTY 1-3 CNTIG TEETH QUAD
GINGIVECTOMY/GINGIVOPLASTY ALLOW ACCESS RESTOR
PROC, PER TOOTH
GINGIVAL FLAP - 4/>CNTIG/BOUND TEETH QUAD
GINGIVAL FLAP - 1-3 CNTIG/BOUND TEETH QUAD
APICALLY POSITIONED FLAP
CLINICAL CROWN LENGTHENING - HARD TISSUE
OSSEOUS SURGERY - 4/> CONTIGUOUS TEETH QUAD
OSSEOUS SURGERY - 1-3 CONTIGUOUS TEETH QUAD
BONE REPLACEMENT GRAFT - 1 SITE QUAD
PEDICLE SOFT TISSUE GRAFT PROCEDURE
DISTAL OR PROXIMAL WEDGE PROCEDURE - SEPARATE
PROCEDURE
FREE SOFT TISSUE GRAFT PROCEDURE (INCLD DONOR
SITE SURGERY), FIRST TOOTH
FREE SOFT TISSUE GRAFT PROCEDURE (INCLD DONOR
SITE SURGERY), EACH ADDL; CONTIGUOUS TOOTH
PROVISONAL SPLINTING - INTRACORONAL
PROVISONAL SPLINTING - EXTRACORONAL
PERIODONTAL SCAL & ROOT PLAN 4/>TEETH-QUAD
PERIODONTAL SCAL & ROOT PLAN 1-3 TEETH
FULL MOUTH DEBRIDEMENT COMP EVAL & DIAGNOSIS
LOCAL DELIVERY ANTIMICROBIAL AGENT PER TOOTH
PERIODONTAL MAINTENANCE
UNSCHEDULED DRESSING CHANGE
GINGIVAL IRRIGATION ‐ PER QUADRANT
$10
$5
$0
$10
$5
$10
$10
$30
$20
$15
$10
$10
$15
$5
$10
$10
$5
$5
$5
$5
$5
$0
$0
REMOVABLE PROSTHODONTICS SERVICES
D5110
D5120
D5130
D5140
D5211
D5212
D5213
D5214
D5225
D5226
D5281
D5410
D5411
D5421
D5422
COMPLETE DENTURE - MAXILLARY
COMPLETE DENTURE - MANDIBULAR
IMMEDIATE DENTURE - MAXILLARY
IMMEDIATE DENTURE - MANDIBULAR
MAXILLARY PARTIAL DENTURE - RESIN BASE
MANDIBULAR PARTIAL DENTURE - RESIN BASE
MAXILLARY PARTIAL DENTURE -CAST METAL W/RESIN
MANDIBULAR PARTIAL DENTURE - CAST METAL W/RESIN
MAXILLARY PARTIAL DENTURE FLEX BASE
MANDIBULAR PARTIAL DENTURE FLEX BASE
REMOVAL UNILATERAL PARTIAL DENTURE -1 PC CAST
METAL
ADJUST COMPLETE DENTURE - MAXILLARY
ADJUST COMPLETE DENTURE - MANDIBULAR
ADJUST PARTIAL DENTURE - MAXILLARY
ADJUST PARTIAL DENTURE - MANDIBULAR
$140
$140
$140
$140
$40
$40
$140
$140
$40
$40
$20
$5
$5
$5
$5
This plan is underwritten by Dental Benefit Providers of California, Inc.
MEMBER’S
COPAYMENT
ADA
DESCRIPTION
D5510
D5520
D5610
D5620
D5630
D5640
D5650
D5660
D5670
D5671
D5710
D5711
D5720
D5721
D5730
D5731
D5740
D5741
D5750
D5751
REPAIR BROKEN COMPLETE DENTURE BASE
REPLACE MISSING/BROKEN TEETH-COMPLETE DENTURE
REPAIR RESIN DENTURE BASE
REPAIR CAST FRAMEWORK
REPAIR OR REPLACE BROKEN CLASP
REPLACE BROKEN TEETH - PER TOOTH
ADD TOOTH EXISTING PARTIAL DENTURE
ADD CLASP EXISTING PARTIAL DENTURE
REPLACE ALL TEETH & ACRYLIC FRAMEWORK MAXILLARY
REPLACE ALL TEETH & ACRYLIC 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
$10
$5
$10
$25
$25
$10
$10
$20
$45
$45
$40
$40
$30
$30
$25
$25
$20
$20
$30
$30
D5760
D5761
D5810
D5811
D5820
D5821
D5850
D5851
D5863
D5864
D5865
D5866
D5992
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
TISSUE CONDITIONING MANDIBULAR
OVERDENTURE - COMPLETE MAXILLARY
OVERDENTURE - PARTIAL MAXILLARY
OVERDENTURE - COMPLETE MANDIBULAR
OVERDENTURE - PARTIAL MANDIBULAR
ADJUST MAXILLOFACIAL PROSTH APPLIANCE, BY REPORT
$30
$30
$40
$40
$30
$30
$5
$5
$140
$140
$140
$140
$5
D6600
D6601
D6602
D6603
D6604
D6605
PONTIC - INDIRECT RESIN BASED COMPOSITE
PONTIC - CAST HIGH NOBLE METAL*
PONTIC - CAST PREDOMINANTLY BASE METAL
PONTIC - CAST NOBLE METAL*
PONTIC - TITANIUM*
PONTIC - PORCELAIN FUSED HIGH NOBLE METAL*
PONTIC - PORCELAIN FUSED PREDOMINANTLY BASE METAL
PONTIC - PORCELAIN FUSED NOBLE METAL*
PONTIC - PORCELAIN/CERAMIC
PONTIC - RESIN W/HIGH NOBLE METAL*
PONTIC - RESIN W/PREDOMINANTLY BASE METAL
PONTIC - RESIN W/NOBLE METAL*
PROVISIONAL PONTIC
RETAINER-CAST METAL, RESIN, BOND FIXED PROSTHETIC
RETAINER-PORCELAIN/CERAMIC, RESN BOND FIXED PROSTHETIC
INLAY - PORCELAIN/CERAMIC 2 SURFACES
INLAY - PORCELAIN/CERAMIC 3/> SURFACES
INLAY - CAST HIGH NOBLE METAL 2 SURFACES*
INLAY - CAST HIGH NOBLE METAL 3/> SURFACES*
INLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES
INLAY - CAST PREDOMINANTLY BASE METAL 3/>SURFACES
DESCRIPTION
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
D6794
D6920
D6930
D6940
D6980
$20
$80
$75
$80
$80
$80
$75
$80
$95
$25
$15
$15
$25
$10
$10
4/2014
INLAY - CAST NOBLE METAL 2 SURFACES*
INLAY - CAST NOBLE METAL 3/> SURFACES*
ONLAY - PORCELAIN/CERAMIC 2 SURFACES
ONLAY - PORCELAIN/CERAMIC 3/> SURFACES
ONLAY - CAST HIGH NOBLE METAL 2 SURFACES*
ONLAY-CAST HIGH NOBLE METAL 3/> SURFACES*
ONLAY - CAST PREDOMINANTLY BASE METAL 2 SURFACES
ONLAY - CAST PREDOMINANTLY BASE METAL 3/>SURFACES
ONLAY - CAST NOBLE METAL 2 SURFACES*
ONLAY - CAST NOBLE METAL 3/> SURFACES*
INLAY TITANIUM*
ONLAY TITANIUM*
CROWN/INDIRECT RESIN BASED COMPOSITION
CROWN - RESIN WITH HIGH NOBLE METAL*
CROWN - RESIN PREDOMINANTLY BASE METAL
CROWN - RESIN WITH NOBLE METAL*
CROWN - PORCELAIN/CERAMIC
CROWN - PORCELAIN FUSED TO HIGH NOBLE METAL*
CROWN - PORCELAIN FUSED PREDOMINANTLY BASE
METAL
CROWN - PORCELAIN FUSED 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 BASE METAL
CROWN - FULL CAST NOBLE METAL*
CROWN TITANIUM*
CONNECTOR BAR
RECEMENT FIXED PARTIAL DENTURE
STRESS BREAKER
FIXED PARTIAL DENTURE REPAIR
$40
$45
$45
$50
$55
$60
$50
$55
$50
$50
$45
$75
$20
$40
$30
$30
$100
$100
$90
$100
$95
$90
$95
$95
$100
$90
$100
$100
$70
$5
$5
$20
D6010
SURGICAL PLACEMENT IMPL BODY: ENDOSTEAL
$1,950
D6013
SURGICAL PLACEMENT OF A MINI-IMPLANT
$1,950
D6052
SEMI-PRECISION ATTACHMENT ABUTMENT
D6053
D6057
IMPLANT/ABUTMENT SUPPORTED REMOVABLE DENTURE $1,840
FOR COMPLETELY EDENTULOUS ARCH
IMPLANT/ABUTMENT SUPPORTED BY REMOVABLE DEN- $1,840
TURE FOR PARTIALLY EDENTULOUS ARCH
CONNECTING BAR-IMPLANT SUPPORTED/ABUTMENT
$540
SUPPORTED
PREFABRICATED/ABUTMENT INCLUDING MODIFICA$368
TION/PLACEMENT
CUSTOM FABRICATED ABUTMENT - INCLUDES IMPLANT
$610
D6058
ABUTMENT SUPPORTED PORCELAIN/CERAMIC CROWN
D6059
ABUTMENT SUPPORTED PORCELAIN FUSED METAL
$915
CROWN (HIGH NOBLE METAL)*
ABUTMENT SUPPORTED PORCELAIN METAL CROWN
$1,050
(PREDOMINANTLY BASE METAL)
ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE
$946
METAL)*
ABUTMENT SUPPORTED CAST METAL CROWN (HIGH
$981
NOBLE METAL)*
ABUTMENT SUPPORTED CAST METAL CROWN (PREDOMI- $854
NANTLY BASE METAL)
ABUTMENT SUPPORTED CAST METAL CROWN (NOBLE
$1,168
METAL)*
D6054
D6055
D6056
D6060
$40
$45
$40
$45
$40
$45
D6061
D6062
D6063
D6064
400-5793 - Conbtrib
MEMBER’S
COPAYMENT
IMPLANT SERVICES
FIXED PROSTHODONTICS SERVICES
D6205
D6210
D6211
D6212
D6214
D6240
D6241
D6242
D6245
D6250
D6251
D6252
D6253
D6545
D6548
ADA
3
©2013-2014 United HealthCare Services, Inc.
$368
$1,050
This plan is underwritten by Dental Benefit Providers of California, Inc.
MEMBER’S
COPAYMENT
ADA
DESCRIPTION
D6065
IMPLANT SUPPORTED PORCELAIN/CERAMIC CROWN
D6066
IMPLANT SUPPORTED PORCELAIN FUSED TO METAL
$1,083
CROWN (TITANIUM, TITANIUM ALLOY, HIGH NOBLE
METAL)*
IMPLANT SUPPORTED METAL CROWN (TITANIUM, TITA$962
NIUM ALLOY, HIGH NOBLE METAL)*
ABUTMENT SUPPORTED RETAINER PORCELAIN/CERAMIC $1,026
FPD
ABUTMENT SUPPORTED RETAINER PORCELAIN FUSED TO $1,050
METAL FPD (PREDOMINANTLY BASE METAL)
$965
ABUTMENT SUPPORTED RETAINER PORCELAIN FUSED TO
D6067
D6068
D6069
D6070
$1,144
METAL FPD (PREDOMINANTLY BASE METAL)
D6071
D6072
D6073
D6074
D6075
ABUTMENT SUPPORTED RETAINER PORCELAIN FUSED TO
$984
METAL FPD (NOBLE METAL)*
ABUTMENT SUPPORTED RETAINER CAST METAL FPD (HIGH
$997
NOBLE METAL)*
ABUTMENT SUPPORTED RETAINER CAST METAL FPD (PRE$910
DOMINANTLY BASE METAL)
ABUTMENT SUPPORTED RETAINER CAST METAL FPD
$967
(NOBLE METAL)*
IMPLANT SUPPORTED RETAINER FOR CERAMIC FPD
$1,018
ADA
DESCRIPTION
D7241
D7250
D7251
D7261
D7270
D7280
D7282
D7285
D7286
D7287
D7288
D7290
D7310
D7311
D7320
IMPLANT SUPPORTED RETAINER FOR PORCELAIN FUSED TO
METAL FPD (TITANIUM, TITANIUM ALLOY, OR HIGH NOBLE
METAL)*
IMPLANT SUPPORTED RETAINER CAST METAL FPD (TITANIUM, TITANIUM ALLOY OR HIGH NOBLE METAL)*
IMPLANT MAINTENANCE PROCEDURE WHEN PROSTHESIS
ARE REMOVED & INSERTED, INCLUD CLEANSING OF PROSTHESES AND ABUTMENTS
REPAIR IMPLANT SUPPORTED BY PROSTHESIS, BY REPORT
$992
D7321
D7340
$962
D7350
D7450
REPLACEMENT SEMI-PRECISION OR PRECISION ATTACHMENT IMPLANT/ABUTMENT PROSTHESIS BY REPORT
RECEMENT IMPLANT/ABUTMENT SUPPORTED CROWN
$410
$124
D6094
RECEMENT IMPLANT/ABUTMENT SUPPORTED FIXED PARTIAL DENTURE
ABUTMENT SUPPORTED CROWN (TITANIUM)*
D6095
REPAIR IMPLANT ABUTMENT, BY REPORT
D6100
IMPLANT REMOVAL, BY REPORT
D6101
DEBRIDEMENT OF A PERIIMPLANT DEFECT & SURFACE
CLEAN EXPSED IMPLANT SURFACE, INCLUD FLAP ENTRY
& CLOSURE
DEBRIDEMENT & OSSEOUS CONTOURING OF A PERIIMPLANT DEFECT; INCLDE SURFACE CLEAN OF EXPOSED
IMPLANT SURFACES AND FLAP ENTRY AND CLOSURE
BONE GRAFT FOR REPAIR OF PERIIMPLANT DEFECT–NOT
INCLUD FLAP ENTRY & CLOSURE OR, WHEN INDICATED,
PLACEMENT OF BARRER MEMBRANE OR BIOLOG MATERIAL TO AID OSSEOUS REGENERATION
RADIOGRAPHIC/SURGICAL IMPLANT INDEX, BY REPORT
D6076
D6077
D6080
D6090
D6091
D6092
D6093
D6102
D6103
D6190
D6194
ABUTMENT SUPPORTER RETAINER CAST METAL FPD
(NOBLE METAL)*
$55
$135
D7220
D7230
D7240
EXTRACT CORONAL REMNANTS DECIDUOUS TOOTH
EXTRACT ERUPTED TOOTH/EXPOSED ROOT
SURGICAL REMOVAL OF ERUPTED TOOTH REQUIRING BONE
AND/OR SECTIONING TOOTH
REMOVAL OF IMPACTED TOOTH - SOFT TISSUE
REMOVAL OF IMPACTED TOOTH - PARTIALLY BONY
REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY
400-5793 - Contrib.
4/2014
D7461
D7471
$79
$810
$55
$600
D7472
D7473
D7485
D7510
D7511
$15
D7520
$50
$350
D7521
D7530
D7910
$265
$835
ORAL SURGERY SERVICES
D7111
D7140
D7210
D7451
D7460
$5
$5
$5
$10
$20
$15
4
©2013-2014 United HealthCare Services, Inc.
D7960
D7963
D7970
D7971
D7972
MEMBER’S
COPAYMENT
REMOVAL OF IMPACTED TOOTH - COMPLETELY BONY,
WITH UNUSUAL SURGICAL COMPLICATIONS
SURGICAL REMOVAL OF RESIDUAL TOOTH ROOTS (CUTTING PROCEDURE)
CORONECTOMY - INTENTIONAL PARTIAL TOOTH REMOVAL
PRIMARY CLOSURE OF SINUS PERFORATION
TOOTH REIMPLANT AND/OR STABILIZATION ACCIDENT
EVULSED OR DISPLACED TOOTH
SURGICAL ACCESS OF UNERUPTED TOOTH
MOBILIZATION OF ERUPTED/MALPOSITIONED TEETH
BIOPSY OF ORAL TISUE - HARD (BONE, TOOTH)
BIOPSY OF ORAL TISSUE - SOFT
EXFOLIATIVE CYTOLOGICAL SAMPLE COLLECTION
BRUSH BIOPSY, TRANSEPITHELIAL SAMPLE COLLECTION
SURGICAL REPOSITIONING OF TEETH
ALVEOLOPLASTY W/EXT 4/> TEETH/SPACE
ALVEOLOPLASTY CONJNCT XTRCT 1-3 TEETH
ALVEOLOPLASTY NOT IN CONJUNCT W/EXTRACTIONS - 4/>
TEETH/SPACE, PER QUADRANT
ALVEOLOPLASTY NOT IN CONJUNCT W/XTRCT 1-3 TEETH
VESTIBULOPLASTY - RIDGE EXTENSION (SECONDARY
EPITHELIALIZATION)
VESTIBULOPLASTY - RIDGE EXTENSION
REMOVAL BENIGN ODONTOGENIC CYST/TUMOR UP TO
1.25 CM
REMOVAL BENIGN ODONTOGENIC CYST/TUMOR >1.25 CM
REMOVAL BENIGN NONODONTOGENIC CYST/TUMOR UP
TO 1.25 CM
REMOVAL BENIGN NONODONTOGENIC CYST/TUMOR
>1.25 CM
REMOVAL OF LATERAL EXOSTOSIS (MAXILLA OR MANDIBLE)
REMOVAL OF TORUS PALATINUS
REMOVAL OF TORUS MANDIBULARIS
SURGICAL REDUCTION OF OSSEOUS TUBEROSITY
INCISION & DRAINAGE ABSCESS-INTRAORAL SOFT TISSUE
INCISION & DRAINAGE ABSCESS INTRAORAL SOFT TISSUE
COMPLICATED
INCISION & DRAINAGE OF ABSCESS - EXTRAORAL SOFT
TISSUE
INCISION & DRAINAGE OF ABSCESS - EXTRAORAL SOFT
TISSUE COMPLICATED
REMOVAL FOREIGN BODY FROM MUCOSA, SKIN, OR SUBCUTANEOUS ALVEOLAR TISSUE
REMOVAL OF REACTION PRODUCING FOREIGN BODIES,
MUSCULOSKELETAL SYSTEM
FRENULECTOMY-ALSO KNOWN AS FRENECTOMY OR FRENOTOMY-SEPAR PROCED NOT INCIDENTAL TO ANOTHER
FRENULOPLASTY
EXCISION HYPERPLASTIC TISSUE - PER ARCH
EXCISION OF PERICORONAL GINGIVA
SURGICAL REDUCTION FIBROUS TUBEROSITY
$25
$5
$5
$10
$10
$10
$5
$5
$5
$5
$5
$10
$5
$5
$10
$5
$20
$30
$20
$30
$20
$30
$15
$30
$15
$25
$5
$5
$10
$10
$5
$0
$5
$5
$10
$10
$20
ADJUNCTIVE GENERAL SERVICES
D9110
D9120
D9210
D9211
PALLIATVE TREATMENT DENTAL PAIN - MINOR PROCEDURE
FIXED PARTIAL DENTURE SECTIONING
LOCAL ANESTHESIA NOT IN CONJUNCT W/OPERATIVE.
SURGICAL PROCEDURE
REGIONAL BLOCK ANESTHESIA
$5
$15
$0
$0
This plan is underwritten by Dental Benefit Providers of California, Inc.
MEMBER’S
COPAYMENT
ADA
DESCRIPTION
D9212
D9215
TRIGEMINAL DIVISION BLOCK ANESTHESIA
LOCAL ANESTHESIA IN CONJUNCTION W TH OPERATIVE OR
SURGICAL PROCEDURE
$0
$0
D9220
D9221
D9230
D9241
D9242
D9248
D9310
$10
$5
$5
$5
$5
$5
$0
D9430
D9440
D9930
D9940
DEEP SEDATION/GENERAL ANESTHESIA - 1ST 30 MIN
DEEP SEDATION/GENERAL ANESTHESIA-EACH ADDL15 MIN
INHALATION OF NITROUS OXIDE/ANALGESIA, ANXIOLYSIS
IV CONSCIOUS SEDATION/ANALGESIA -1ST 30 MIN
IV CONSCIOUS SEDATION/ANALGESIA EACH ADDL 15 MIN
NON-INTRAVENOUS CONSCIOUS SEDATION
CONSULTATION - DIAGNOSTIC SERVICE PROVIDED BY DENTIST/ PHYSICIAN OTHER THAN REQUST DENTIST/PHYSICIAN
OFFICE VISIT - OBSERV - NO OTHER SERVICES PERFORMED
OFFICE VISIT - AFTER REGULARLY SCHEDULED HOURS
TREATMENT OF COMPLICATIONS - POST SURGICAL
OCCLUSAL GUARD BY REPORT
D9951
D9952
D9971
D9972
OCCLUSAL ADJUSTMENT - LIMITED
OCCLUSAL ADJUSMENT - COMPLETE
ODONTOPLASTY - ONE TO THREE TEETH
EXTERNAL BLEACHING - PER ARCH
$0
$5
$0
$15
$5
$5
$0
$125
ORTHODONTIC SERVICES
D8070
D8080
D8090
D8680
D8999
COMPREHENSIVE ORTHODONTIC TREATMENT TRANSITIOINAL DENTITION
COMPREHENSIVE ORTHODONTIC TREATMENT ADOLESCENT
DENTITION
COMPREHENSIVE ORTHODONTIC TREATMENT ADULT
DENTITION
ORTHODONTIC RETENTION (REMOVAL OF APPLICANCES,
CONSTRUCTION AND PLACEMENT OF RETAINER(S)
START-UP FEE (INCLUDING EXAM, BEGINNING RECORDS,
X-RAYS, TRACING, PHOTOS, AND MODELS
$1,500
$1,500
$1,500
$150
$350
5
*An additional charge for the cost of precious metal will be applied for any procedure using noble, high noble, or titanium metal not to exceed $150 per unit.
400-5793 - Contrib
4/2014
©2013-2014 United HealthCare Services, Inc.
This plan is underwritten by Dental Benefit Providers of California, Inc.
UnitedHealthcare Dental®
Dental Exclusions and Limitations
18.
Limitations of Benefits
The following are the limitation of benefits, unless otherwise specifically
listed as a covered benefit on this Plan’s Schedule of Benefits:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
19.
DENTAL PROPHYLAXIS - limited to 1 time per 6 months.
INTRAORAL - Complete Series (including bitewings) - Limited to 1 time
in any 2-year period.
INTRAORAL BITEWING RADIOGRAPHS - Limited to 1 series of 4 films
in any 6 month period.
FLUORIDE TREATMENTS - Limited to 1 time per 6 months.
SCALING AND ROOT PLANING - Limited to 4 quadrants per calendar
year.
PERIODONTAL MAINTENANCE PROCEDURES - Limited to once every
6 months, following active therapy, exclusive of gross debridement.
REMOVABLE PROSTHETICS/FIXED PROSTHETICS/CROWNS,
INLAYS AND ONLAYS (Major Restorative Services) - Replacement of
complete dentures, fixed or removable partial dentures, crowns, inlays
or onlays previously submitted for payment under the plan is limited to 1
time per 5 years from initial or supplemental placement.
REMOVABLE PROSTHETICS/FIXED PROSTHETICS/CROWNS,
INLAYS AND ONLAYS (Major Restorative Services) - Replacement of
complete dentures, and fixed and removable partial dentures or crowns
if damage or breakage was directly related to provider error. This type
of replacement is the responsibility of the Dentist. If replacement is
Necessary because of patient non-compliance, the patient is liable for the
cost of replacement.
CROWNS - Retainers/Abutments - Limited to 1 time per tooth per 5
years.
CROWNS - Restorations - Limited to 1 time per tooth per 5 years.
Covered only when a filling cannot restore the tooth.
TEMPORARY CROWNS - Restorations - Limited to 1 time per tooth per
5 years. Covered only when a filling cannot restore the tooth.
INLAYS/ONLAYS - Retainers/Abutments - Limited to 1 time per tooth per
5 years.
INLAYS/ONLAYS - Restorations - Limited to 1 time per tooth per 5 years.
Covered only when a filling cannot restore the tooth.
STAINLESS STEEL CROWNS - Limited to 1 time per tooth per 5 years.
Covered only when a filling cannot restore the tooth. Prefabricated
esthetic coated stainless steel crown - primary tooth, are limited to
primary anterior teeth.
CROWNS, FIXED BRIDGES, AND IMPLANTS - The maximum benefit
within a 12 month period is any combination of 7 crowns or pontics
(artificial teeth that are part of a fixed bridge). If more than 7 crowns and/
or pontics are done for a Member within a 12 month period, the dentist’s
fee for any additional crowns within that period would not be limited to
the listed Copayment, but instead can reflect the Dentist’s Billed Charges.
POST AND CORES - Covered only for teeth that have had root canal
therapy.
ADJUSTMENTS TO FULL DENTURES, PARTIAL DENTURES,
20.
21.
BRIDGES OR CROWNS - Limited to repairs or adjustments performed
more than 6 months after the initial insertion.
INTRAVENOUS SEDATION OR GENERAL ANESTHESIA Administration of I.V. sedation or general anesthesia is limited to covered
oral surgical procedures involving 1 or more impacted teeth (soft tissue,
partial bony or complete bony impactions).
ADJUNCTIVE - Pre-Diagnostic Test that aids in detection of mucosal
abnormalities including premalignant and malignant lesion, not to include
cytology or biopsy procedures - Limited to 1 time per year, to Covered
Persons over the age of 30.
REPLACEMENT OF COMPLETE DENTURES, FIXED OR
REMOVABLE PARTIAL DENTURES, CROWNS, INLAYS, ONLAYS,
AND IMPLANTS, IMPLANT CROWNS, IMPLANT PROSTHESIS Replacement of complete dentures, fixed or removable partial dentures,
crowns, inlays, onlays, and implant crowns, implant prostheses
previously submitted for payment under the plan is limited to 1 time per
tooth per 5 years from initial or supplemental placement. This includes
retainers, habit appliances, and any fixed or removable orthodontic
appliances.
All Specialty Referral Services Must Be: (A) Pre-Authorized by us;
and (B) Coordinated by a Covered Person’s Participating Dentist. Any
Covered Person who elects specialist care without prior referral by his or
her Participating Dentist and approval by us is responsible for all charges
incurred.
• In order for specialty services to be Covered by this plan, the following
referral process must be followed:
• A Covered Person’s Participating Dentist must coordinate all Dental
Services.
• When the care of a Network Specialist Dentist is required, the Covered
Person’s Participating Dentist must contact us and request authorization.
• If the Participating Dentist request for specialist referral is denied,
the Participating Dentist and the Covered Person will be notified of the
reason for the denial. If the service in question is a Covered service, and
no limitations or exclusions apply, the Participating Dentist may be asked
to perform the service.
• Covered Person who receives authorized specialty services must pay
all applicable Copayments associated with the services provided. When
we authorize specialty dental care, a Covered Person will be referred to a
Network Specialist Dentist for treatment. The Network includes Network
Specialist Dentists in: (a) endodontics; (b) oral surgery; (c) pediatric
dentistry; and (d) orthodontics; and (e) periodontics, located in the
Covered Person’s Service Area. If there is no Network Specialist Dentist
in the Covered Person’s Service Area, we will refer the Covered Person
to a Non-Participating Specialist of our choice. Except for Emergency
Dental Services, in no event will we cover dental care provided to a
Covered Person by a specialist not preauthorized by us to provide such
services.
• Covered Person’s financial responsibility is limited to applicable
Copayments. Copayments are listed in the Covered Person’s Schedule
of Covered Dental Services.
6
400-5793 - Contrib
4/2014
©2013-2014 United HealthCare Services, Inc.
This plan is underwritten by Dental Benefit Providers of California, Inc.
Exclusion of Benefits
21. Any implant procedures performed which are not listed as Covered implant
procedures in the Schedule of Covered Dental Services.
22. Treatment which requires the services of a pediatric specialist, after the
Covered Person’s 6th birthday.
The following procedures and services are excluded and not Covered
Services, unless otherwise specifically listed as a covered benefit on this
Plan’s Schedule of Benefits:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Orthodontic Exclusions & Limitations
Dental Services that are not Necessary.
Any Dental Services or Procedures not listed in the Schedule of
CoveredDental Services.
Any Dental Procedure not performed in a dental setting. This will not apply
to Covered Emergency Dental Services.
Any Dental Procedure not directly associated with dental disease.
Procedures related to the reconstruction of a patient’s correct vertical
dimension of occlusion (VDO).
Any service done for cosmetic purposes that is not listed as a Covered
cosmetic service in the Schedule of Covered Dental Services.
Costs for non-dental services related to the provision of dental services
in hospitals, extended care facilities, or Member’s home are not covered.
When deemed necessary by the Primary Care Dentist, the Member’s
physician, and authorized by the Plan, covered dental services that are
delivered in an inpatient or outpatient hospital setting are covered as
indicated in the Schedule of Benefits
Setting of facial bony fractures and any treatment associated with the
dislocation of facial skeletal hard tissue.
Replacement of a lost, missing or stolen appliance or prosthesis or the
fabrication of a spare appliance or prosthesis.
Removable Prosthetics/Fixed Prosthetics/Crowns, Inlays and Onlays
(Major Restorative Services) - The plan provides for the use of noble
metals for inlays, onlays, crowns and fixed bridges. When high noble metal
is used, the Covered Person must pay: (a) the Copayment for the inlay,
onlay, crown or fixed bridge; and (b) an added charge equal to the actual
laboratory cost of the high noble metal.
Placement of fixed partial dentures solely for the purpose of achieving
periodontal stability.
Fixed or removable prosthodontic restoration procedures or implant
services for complete oral rehabilitation or reconstruction.
Services for injuries or conditions covered by Worker’s Compensation or
employer liability laws, and services that are provided without cost to the
Covered Person by any municipality, county, or other political subdivision.
This exclusion does not apply to any services covered by Medicaid or
Medicare.
Dental Services otherwise Covered under the Contract, but rendered after
the date individual Coverage under the Contract terminates, including
Dental Services for dental conditions arising prior to the date individual
Coverage under the Contract terminates.
Treatment of benign neoplasms, cysts, or other pathology involving benign
lesions, except excisional removal. Treatment of malignant neoplasms or
Congenital Anomalies of hard or soft tissue, including excision.
Any Covered Person request for: (a) specialist services or treatment which
can be routinely provided by a Participating Dentist; or (b) treatment by a
specialist without referral from a Participating Dentist and our approval.
Drugs/medications, obtainable with or without a prescription, unless they
are dispensed and utilized in the dental office during the patient visit.
Services related to the temporomandibular joint (TMJ), either bilateral or
unilateral. Upper and lower jaw bone surgery (including that related to
the temporomandibular joint). No Coverage is provided for orthognathic
surgery, jaw alignment, or treatment for the temporomandibular joint.
Any endodontic, periodontal, crown or bridge abutment procedure or
appliance requested, recommended or performed for a tooth or teeth with a
guarded, questionable or poor prognosis.
Dental Services received as a result of war or any act of war, whether
declared or undeclared or caused during service in the armed forces of any
country.
If you require the services of an orthodontist, a referral must first be obtained. If a
referral is not obtained prior to the commencement of orthodontic treatment, the
Covered Person will be responsible for all costs associated with any orthodontic
treatment. Orthodontic services Copayments are valid for authorized services
rendered.
If you terminate Coverage after the start of orthodontic treatment, you will be
responsible for any additional charges incurred for the remaining orthodontic
treatment.
1. The following are not covered orthodontic benefits:
• Replacement or repair of lost, stolen or broken appliances or appliances
damaged due to the neglect of the Covered Person
• Treatment in progress prior to the effective date of this coverage
• Extractions required for orthodontic purposes
• Surgical orthodontics or jaw repositioning
• Myofunctional therapy
• Cleft palate
• Micrognathia
• Macroglossia
• Hormonal imbalances
• Orthodontic retreatment when initial treatment was rendered under this
plan or for changes in orthodontic treatment necessitated by any kind of
treatment of accident
• Palatal expansion appliances
• Services performed by outside laboratories
2. If a treatment plan is for less than 24 months, then a prorated portion of the
full copayment shall apply.
3. If Covered Person’s dental eligibility ends, for whatever reason, and the
Covered Person is receiving orthodontic treatment under the plan, the remaining
cost for that treatment will be prorated at the orthodontist’s usual fees over
the number of months of treatment remaining. The Covered Person will be
responsible for the payment of this balance under the terms and conditions prearranged with the orthodontist.
4. If the Covered Person has the orthodontist perform a “diagnostic work-up” (a
consultation and diagnosis) and then decides to forgo the treatment program,
the Covered Person will be charged a $50 consultation fee, plus any lab costs
incurred by the orthodontist.
5. One orthodontic benefit under this plan is available per lifetime, per Covered
Person. A Covered Person may access this Comprehensive Orthodontic
Treatment. If comprehensive treatment is necessary, and is completed within
a 24 month period, the Copayments listed will apply. If necessary and active
treatment extends beyond 24 months, the provider is obligated to accept the
plan Copayment only for the first 24 months of active therapy. The provider may
charge usual and customary fees for active treatment extending beyond the 24
month benefit period.
7
400-5793 - Contrib
4/2014
©2013-2014 United HealthCare Services, Inc.
This plan is underwritten by Dental Benefit Providers of California, Inc.