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Dental:   Outline of Benefits | Sampling of Covered Dental Procedures
How the DENTAL plan works:
Each plan pays a flat dollar amount per dental procedure based on the fee schedule in your policy. Visit one of our in-network providers for additional savings. We will pay the lesser of the provider’s actual charge or the amount listed on the Schedule of Covered Dental Procedures, subject to policy year deductible, annual maximum, and limitations and exclusions. The following is a partial listing of the 300+ insured covered dental procedures and schedule amounts. Choose the right plan for you and your family – Value, Standard or Preferred!

SAMPLING OF COVERED DENTAL PROCEDURES SCHEDULE AMOUNT
PROCEDURE CODE DESCRIPTION VALUE
PLAN		 STANDARD
PLAN		 PREFERRED
PLAN
Oral Evaluations



D0120 Periodic Oral Evaluation $19 $27 $35
D0150 Comprehensive Oral Evaluation $31 $44 $57
 
Prophylaxis (Simple Cleaning)



D1110 Prophylaxis - Adult $36 $52 $67
D1120 Prophylaxis - Child $26 $37 $48
 
Radiographs



D0210 Intraoral - Complete Series (Including Bitewings) $53 $75 $98
D0272 Bitewings - Two Films $17 $24 $31
D0330 Panoramic Film $43 $61 $79
 
Sealants



D1351 Sealant - Per Tooth $21 $30 $39
 
Space Maintainer



D1510 Space Maintainer - Fixed - Unilateral $132 $187 $242
 
Fillings



D2140 Amalgam - One Surface, Primary or Permanent $39 $56 $72
D2150 Amalgam - Two Surfaces, Primary or Permanent $48 $68 $88
D2331 Resin - Two Surfaces, Anterior $55 $79 $102
 
Palliative (Emergency Treatment)*



D9110 Palliative Treatment of Dental Pain - Minor Procedure $16 $23 $29
 
Oral Surgery*



D7140 Extraction - Erupted or Exposed Root $44 $62 $81
D7230 Removal of Impacted Tooth - Partially Bony $63 $89 $116
 
Endodontics* (Emergency Treatment)*



D3310 Root Canal, Anterior $114 $162 $209
D3330 Root Canal, Molar $171 $242 $313
 
Periodontics*



D4260 Osseous Surgery - Per Quadrant $170 $241 $312
D4341 Periodontal Scaling and Root Planing - Per Quadrant $38 $54 $70
 
Single Tooth Restorations*



D2750 Crown - Porcelain Fused to High Noble Metal $167 $237 $306
D2950 Core Build-up, Including Any Pins $39 $56 $72
D2952 Post and Core in Addition to Crown, Indirectly Fabricated $59 $83 $108
 
Prosthodontics*



D5110 Complete Denture - Maxillary $189 $268 $347
D5213 Maxillary Partial Denture - Cast Metal $214 $303 $393
D6210 Pontic - Cast High Noble Metal $158 $223 $289
D6721 Crown - Resin with Predominantly Base Metal $148 $209 $271
* Waiting period applies. Not applicable in Washington.

How much does it cost?
Click Here for rates and more information on when coverage starts.


Product not yet available in all states.

Administered by: AlwaysCare Benefits, Inc.
Underwritten by: Starmount Life Insurance Company
Policy Form Series IDN-2009
Dental:   Outline of Benefits | Sampling of Covered Dental Procedures

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