Dentcare Benefit Plan Covered Dental Services - CWA Local 1180

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Dentcare Benefit Plan Covered Dental Services - CWA Local 1180

Dentcare Benefit Plan

Covered Dental Services

Procedure

Diagnostic & Preventive Services

Full month x-ray

Single Films (periapical or bitewing)

Bitewing Series

Oral Examination

Specialty Consultation

Cleaning of Teeth (prophylaxis & polishing)

Fluoride Treatment

Treatment in case of dental emergency

Restorative Dentistry

Silver amalgam, one surface

Silver amalgam, two surfaces

Silver amalgam, three surfaces or more

Composite filling, one surface

Composite filling, two surfaces

Composite filling, three surfaces or more

Oral Surgery

Routine Extractions – per tooth

Surgical extractions

Soft tissue impactions

Bony impactions

Alveolectomy, per quadrant

Root Canal Therapy

Pulp Capping, Direct

Pulpotomy

Root Therapy – anterior

Root Therapy – bicuspid

Root Therapy – molar

Patient Co-payment

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

No Charge


Periodontics

Scaling of teeth, per quad

No Charge

Pedicle Soft Tissue Graft $150.00

Free Soft Tissue Graft $150.00

Gingivectomy, per quad

No Charge

Osseous surgery, per quad

No Charge

Prosthetics – Crowns

Acrylic with metal crowns

No Charge

Porcelain crowns

No Charge

Porcelain with metal crown $50.00

Post

No Charge

Recementation, per crown

No Charge

Prosthetics – Fixed Bridges

Acrylic w/ metal bridge crown or pontic $50.00

Porcelain w/ metal bridge crown or pontic $50.00

Recementation, bridge

No Charge

Prosthetics – Removable

Full upper denture, w/ adjustments $50.00

Full lower denture, w/ adjustments $50.00

Partial lower denture, cast base $50.00

Partial upper denture, cast base $50.00

Denture repairs

No Charge

Broken body of denture

No Charge

Orthodontia

Maximum case fee – 24 months

Dependent Children* $300.00

Adult $300.00

* Children covered up to age 26

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