Transcription of Effective date - January 1, 2018. Coverage for eligible ...
1 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.
2 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 $3, $ 331411, $ up to maximum of $3, $ up to maximum of $3, $ Maximum 16 units per calendar year01901 (Exam) $ $ $ Exam allowance includes models, x-rays, $ diagnostics records and case $ 01902 (Specific) $ 16101(Finishing restorations) $ $ 16511(Occlusal Adjustments) $ Denturist Services20111/9 (Caries Trauma/pain) up $ Dentures01701 (Exam) $ 32221/2 (Pulpotomy) $ Complete upper and lower + labComplete or Partial - Upper/Lower39201/02 (Open and Drain) $ 51101/02 (Standard)1, $ dentures + lab (each) $ 41301 (Desensitize) $ 51301/02 (Immediate)1, $ 56211/41 (Relines) $ 91111 (Emergency Pain Treatment) $ Partial upper and lower+ lab56511/12/21/22(tissue cond) $ 96101 (Prescription) $ 53101/021, $ Effective date - January 1, 2018.
3 Coverage for eligible members of the ACAW Health & Wellness PlanMaximum Payable per Calendar year is $3, Major dental treatment over $1, -- preauthorization recommended.
