Dentcare Benefit Plan Covered Dental Services - CWA Local 1180
Dentcare Benefit Plan Covered Dental Services - CWA Local 1180
Dentcare Benefit Plan Covered Dental Services - CWA Local 1180
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<strong>Dentcare</strong> <strong>Benefit</strong> <strong>Plan</strong><br />
<strong>Covered</strong> <strong>Dental</strong> <strong>Services</strong><br />
Procedure<br />
Diagnostic & Preventive <strong>Services</strong><br />
Full month x-ray<br />
Single Films (periapical or bitewing)<br />
Bitewing Series<br />
Oral Examination<br />
Specialty Consultation<br />
Cleaning of Teeth (prophylaxis & polishing)<br />
Fluoride Treatment<br />
Treatment in case of dental emergency<br />
Restorative Dentistry<br />
Silver amalgam, one surface<br />
Silver amalgam, two surfaces<br />
Silver amalgam, three surfaces or more<br />
Composite filling, one surface<br />
Composite filling, two surfaces<br />
Composite filling, three surfaces or more<br />
Oral Surgery<br />
Routine Extractions – per tooth<br />
Surgical extractions<br />
Soft tissue impactions<br />
Bony impactions<br />
Alveolectomy, per quadrant<br />
Root Canal Therapy<br />
Pulp Capping, Direct<br />
Pulpotomy<br />
Root Therapy – anterior<br />
Root Therapy – bicuspid<br />
Root Therapy – molar<br />
Patient Co-payment<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge<br />
No Charge
Periodontics<br />
Scaling of teeth, per quad<br />
No Charge<br />
Pedicle Soft Tissue Graft $150.00<br />
Free Soft Tissue Graft $150.00<br />
Gingivectomy, per quad<br />
No Charge<br />
Osseous surgery, per quad<br />
No Charge<br />
Prosthetics – Crowns<br />
Acrylic with metal crowns<br />
No Charge<br />
Porcelain crowns<br />
No Charge<br />
Porcelain with metal crown $50.00<br />
Post<br />
No Charge<br />
Recementation, per crown<br />
No Charge<br />
Prosthetics – Fixed Bridges<br />
Acrylic w/ metal bridge crown or pontic $50.00<br />
Porcelain w/ metal bridge crown or pontic $50.00<br />
Recementation, bridge<br />
No Charge<br />
Prosthetics – Removable<br />
Full upper denture, w/ adjustments $50.00<br />
Full lower denture, w/ adjustments $50.00<br />
Partial lower denture, cast base $50.00<br />
Partial upper denture, cast base $50.00<br />
Denture repairs<br />
No Charge<br />
Broken body of denture<br />
No Charge<br />
Orthodontia<br />
Maximum case fee – 24 months<br />
Dependent Children* $300.00<br />
Adult $300.00<br />
* Children covered up to age 26
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