Transcription of Effective date - January 1, 2018. Coverage for eligible ...
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Effective date - January 1, 2018. Coverage for eligible ...
ExamsBridgeworkRestorations (Fillings)01103 (Adult complete ) $ 67201/11 (Abutment)+lab1, $ 01101 (Child complete ) $ 62501 (Pontic)+ $ Group 101202 (Recall) $ 29101/09 (Removal) $ $ $ $ 02111 (Single PA) $ 71101 $ $ 02142 (Bitewings) $ 71201 $ $ 02601 (Panorex) $ 72111 $ 02101 (Full mouth series) $ $ Group $ $ Polish and $ $ $ $ $ $ Covered in conjunction with oral surgery $ Scaling92411 $ Maximum 16 units per calendar year92412 $ Group $ 92413 $ $ $ 92414 $ $ $ 92415 $ $ $ 92416 $ $ 92212 $ $ Sealants92213 $ $ 92214 $ Group $ 92215 $ $ $ Bruxism Appliance (Nightguard) $ 14611/12 $ For dependent children age 6 up to and $ age 18. Lifetime maximum payable is $3, $ CrownsRemovable appliances23601 (Build-up) $ 81111/12 + $ Group 525731 (Post) $ Observation and $ 27211 (Crown) +lab1, $ 80601 $ $ Stainless steel crownsFull $ 22201 $ Fixed $ 22202 $ up to maximum of $3, $ up to maximum of $3, (Root Canal) up to maximum of $3, $ 85101/85201(see 84101 & 84201) $ 331211, $ 85301 (see 84301) $ 331311, $ Removable $ 331341, $ up to maximum of
Exams Bridgework Restorations (Fillings) 01103 (Adult complete) $ 137.39 67201/11 (Abutment)+lab $ 1,157.83 01101 (Child complete) $ 88.57 62501 (Pontic)+lab $ 531.44 Group 1
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