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Summary Plan Description (SPD)
Summary of Benefits
| Safeguard Dental Plan – 4950-DI | ||
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| Code: | Service: | Member Co-payment |
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DIAGNOSTIC TREATMENT |
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| 00110 | Initial oral examination | No Charge |
| 00120 | Periodic oral examination | No Charge |
| 00130 | Emergency oral examination | No Charge |
| 09491 | Office visit fee - per visit | $5.00 |
| 00210 | Intraoral - complete series (including bitewings) | No Charge |
| 00220 | Intraoral - periapical first film | No Charge |
| 00230 | Intraoral - periapical - each additional film | No Charge |
| 00240 | Intraoral - occlusal film | No Charge |
| 00250 | Extraoral - first film | No Charge |
| 00260 | film Extraoral - each additional | No Charge |
| 00270 | Bitewings - single film | No Charge |
| 00272 | Bitewings - two films | No Charge |
| 00274 | Bitewings - four films | No Charge |
| 00321 | Temporo mandibular laminogram-bite wing films, including exam | No Charge |
| 00330 | Panoramic film | No Charge |
| 00460 | Pulp vitality tests | No Charge |
| 00470 | Diagnostic casts (study models) | No Charge |
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PREVENTIVE SERVICES |
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| 01110 | Prophylaxis – adult | No Charge |
| 01110 | Prophylaxis - adult (third cleaning within 12 month period) | $15.00 |
| 01120 | Prophylaxis – child | No Charge |
| 01201 | Fluoride (including prophylaxis) - child | No Charge |
| 01203 | Fluoride (excluding prophylaxis) - child | No Charge |
| 01330 | Oral hygiene instruction (preventive dental education) | No Charge |
| 01351 | Sealant - per tooth | No Charge |
| 01510 | Space maintainer - fixed - unilateral | No Charge |
| 01515 | Space maintainer - fixed - bilateral | No Charge |
| 01520 | Space maintainer – removable - unilateral | No Charge |
| 01525 | Space maintainer – removable - bilateral | No Charge |
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RESTORATIVE TREATMENT |
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| 02110 | Amalgam - one surface, primary | No Charge |
| 02120 | Amalgam - two surfaces, primary | No Charge |
| 02130 | Amalgam - three surfaces, primary | No Charge |
| 02131 | Amalgam - four or more surfaces, primary | No Charge |
| 02140 | Amalgam - one surface, permanent | No Charge |
| 02150 | Amalgam - two surfaces, permanent | No Charge |
| 02160 | Amalgam - three surfaces, permanent | No Charge |
| 02161 | Amalgam - four or more surfaces, permanent | No Charge |
| 02210 | Silicate cement - per restoration | No Charge |
| 02330 | Resin - one surface, anterior | No Charge |
| 02331 | Resin - two surfaces, anterior | No Charge |
| 02332 | Resin - three surfaces, anterior | No Charge |
| 02335 | Resin - four or more surfaces, anterior | No Charge |
| 02336 | Composite restoration - CR. anterior - primary | No Charge |
| 02340 | Etchant procedures for cliv or larger restoration | No Charge |
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CROWNS
Per Unit:
Plus Additional Cost Of Noble/High Nobel Metal (Gold) |
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| 02510 | Inlay - metallic - 1 surface | $45.00 |
| 02520 | Inlay - metallic - 2 surfaces | $45.00 |
| 02530 | Inlay - metallic - 3 or more surfaces | $45.00 |
| 02740 | Porcelain/ceramic substrate | $45.00 |
| 02750 | Porcelain fused to high noble metal (gold)* | $45.00 |
| 02751 | Porcelain fused to predominantly base metal* | $45.00 |
| 02752 | Porcelain fused to noble metal* | $45.00 |
| 02753 | Acrylic | $8.00 |
| 02754 | Acrylic with metal | $45.00 |
| 02780 | Crown - ¾ cast high noble metal** | $45.00 |
| 02781 | Crown – ¾ cast predominantly base metal | $45.00 |
| 02782 | Crown – ¾ cast noble metal** | $45.00 |
| 02790 | Full cast high noble metal (gold)** | $45.00 |
| 02791 | Full cast predominantly base metal | $45.00 |
| 02792 | Full cast noble metal | $45.00 |
| 02910 | Re-cement inlay | No Charge |
| 02920 | Re-cement crown | No Charge |
| 02930 | Prefab. SS. CR. - primary tooth | No Charge |
| 02931 | Prefab. SS. CR. - permanent tooth | No Charge |
| 02940 | Sedative filling | No Charge |
| 02950 | Core buildup, including any pins | No Charge |
| 02951 | Pin retention - per tooth - add, to restoration | No Charge |
| 02952 | Cast post & core in addition to crown | No Charge |
| 02954 | Prefab post & core in addition to crown | No Charge |
| 02980 | Crown repair | No Charge |
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*Additional $75 fee for porcelain on a molar |
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ENDODONTICS |
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| 03110 | Pulp cap - direct (excluding final restoration) | No Charge |
| 03120 | Pulp cap - indirect (excluding final restoration) | No Charge |
| 03220 | Therapeutic or vital pulpotomy/pulpectomy | No Charge |
| 03310 | Anterior (excluding final restoration, per canal) | No Charge |
| 03320 | Bicuspid (excluding final restoration, per canal) | No Charge |
| 03330 | Molar (excluding final restoration, per canal) | No Charge |
| 03340 | Molars (2nd or 3rd molars only - per canal) | No Charge |
| 03346 | Retreat - anterior, by report, per canal | No Charge |
| 03347 | Retreat - bicuspid, by report, per canal | No Charge |
| 03348 | Retreat - molar, by report, per canal | No Charge |
| 03349 | Retreat - molar (2nd or 3rd molar, per canal) | No Charge |
| 03410 | Apicoectomy – anterior (per root) (periapical services) | No Charge |
| 03411 | Apicoectomy – per tooth, each additional root | No Charge |
| 03420 | Apicoectomy – with retro fill, per root | No Charge |
| 03421 | Apicoectomy – bicuspid (per root) (periapical services) | No Charge |
| 03425 | Apicoectomy – molar (per root) (periapical services) | No Charge |
| 03426 | Apicoectomy - each additional root (periapical services) | No Charge |
| 03430 | Retrograde filling - per root | No Charge |
| 03499 | Apicoectomy in conjunction with root canal therapy (per root) | No Charge |
| 03940 | Recalcification | No Charge |
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PERIODONTICS |
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| 04110 | Perio examination and treatment plan | $12.00 |
| 04210 | Gingivectomy or Gingivoplasty - per quadrant | No Charge |
| 04211 | Gingivectomy or Gingivoplasty - per tooth | No Charge |
| 04220 | Gingival curettage - per quadrant, dentist | No Charge |
| 04240 | Gingival flap procedure, including root planing - per quadrant | No Charge |
| 04250 | Mucogingival surgery - per quadrant | No Charge |
| 04260 | Osseous surgery (including flap entry/closure per quadrant) | No Charge |
| 04271 | Free soft tissue graft procedure - per procedure | $50.00 |
| 04320 | Provisional splinting (2-6 teeth) | $50.00 |
| 04341 | Periodontal scaling and root planing - per quadrant | No Charge |
| 04345 | Periodontal scaling with gingival inflammation | No Charge |
| 04910 | Periodontal maintenance procedure | No Charge |
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PROSTHETICS |
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| 05110 | Full upper denture | $75.00 |
| 05120 | Full lower denture | $75.00 |
| 05130 | Immediate upper denture | $75.00 |
| 05140 | Immediate lower denture | $75.00 |
| 05211 | Upper partial - resin base (includes any conventional clasps and rests) | $40.00 |
| 05212 | Lower partial - resin base (includes any conventional clasps and rests) | $40.00 |
| 05213 | Upper partial - cast metal base w/resin saddles (including any conventional clasps and rests) | $75.00 |
| 05214 | Lower partial - cast metal base w/resin saddles (including any conventional clasps and rests) | $75.00 |
| 05282 | Partial denture (designed) | $265.00 |
| 05410 | Adjustment full denture - upper | No Charge |
| 05411 | Adjustment full denture - lower | No Charge |
| 05421 | Adjust partial denture - upper | No Charge |
| 05422 | Adjust partial denture - lower | No Charge |
| 05510 | Repair broken full denture base | No Charge |
| 05520 | Replace missing or broken teeth, full denture (each tooth) | No Charge |
| 05610 | Repair resin acrylic saddle or base | No Charge |
| 05620 | Repair cast framework | No Charge |
| 05630 | Repair or replace broken clasp | No Charge |
| 05640 | Replace broken teeth - per tooth | No Charge |
| 05650 | Add tooth to existing partial denture | No Charge |
| 05660 | Add clasp to existing partial denture | No Charge |
| 05710 | Rebase full upper denture | $75.00 |
| 05711 | Rebase full lower denture | $75.00 |
| 05720 | Rebase partial upper denture | $75.00 |
| 05721 | Rebase partial lower denture | $75.00 |
| 05730 | Reline full upper denture (chair side) | No Charge |
| 05731 | Reline full lower denture (chair side) | No Charge |
| 05740 | Reline upper partial denture (chair side) | No Charge |
| 05741 | Reline lower partial denture (chair side) | No Charge |
| 05750 | Reline full upper denture (lab) | $30.00 |
| 05751 | Reline full lower denture (lab) | $30.00 |
| 05760 | Reline upper partial denture (lab) | $30.00 |
| 05761 | Reline lower partial denture (lab) | $30.00 |
| 05820 | Stayplate - upper or lower | No Charge |
| 05850 | Tissue conditioning, maxillary | No Charge |
| 05851 | Tissue conditioning, mandibular | No Charge |
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BRIDGES Per unit: plus additional cost of noble/high noble metal (gold) |
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| 06210 | Pontic - cast high noble metal | $45.00 |
| 06211 | Pontic - cast predominantly base metal | $45.00 |
| 06212 | Pontic - cast noble metal | $45.00 |
| 06240 | Pontic - porcelain fused to high noble metal (gold) | $45.00 |
| 06241 | Pontic - porcelain fused to predominantly base metal | $45.00 |
| 06242 | Pontic - porcelain fused to noble metal | $45.00 |
| 06250 | Pontic - resin fused to noble metal | $45.00 |
| 06251 | Pontic - resin with predominantly base metal | $45.00 |
| 06252 | Pontic - resin with noble metal | $45.00 |
| 06720 | Crown - resin with high noble metal (gold) | $45.00 |
| 06721 | Crown - resin with predominantly base metal | $45.00 |
| 06722 | Crown - resin with noble metal | $45.00 |
| 06750 | Crown - porcelain fused to high noble metal (gold)* | $45.00 |
| 06751 | Crown - porcelain fused to predominantly base metal* | $45.00 |
| 06752 | Crown - porcelain fused to noble metal* | $45.00 |
| 06780 | Crown - 3/4 cast high noble metal (gold) | $45.00 |
| 06790 | Crown - full cast high noble metal (gold) | $45.00 |
| 06791 | Crown - full cast predominantly base metal | $45.00 |
| 06792 | Crown - full cast noble metal | $45.00 |
| 06930 | Recement bridge | No Charge |
| 06940 | Stress breaker | No Charge |
| 06970 | Cast post and core in addition to bridge retainer | No Charge |
| 06971 | Cast post as part of bridge retainer | No Charge |
| 06972 | Prefabricated post and core in addition to bridge retainer | No Charge |
| 06973 | Core build up for retainer – including any pins | No Charge |
| 06980 | Bridge repair | No Charge |
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*Additional $75 fee for porcelain on a molar |
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ORAL SURGERY |
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| 07110 | Single tooth (simple extraction) | No Charge |
| 07120 | Each additional tooth (simple extraction) | No Charge |
| 07130 | Root removal - exposed roots | No Charge |
| 07210 | Surgical removal of erupted tooth | No Charge |
| 07220 | Removal of impacted tooth – soft tissue | No Charge |
| 07230 | Removal of impacted tooth – partial bony | No Charge |
| 07240 | Removal of impacted tooth – complete bony | No Charge |
| 07250 | Surgical removal of residual tooth roots | No Charge |
| 07260 | Oral antral fistula closure (maxillary sinus) | No Charge |
| 07272 | Tooth transplantation (tooth or tooth bud) | No Charge |
| 07280 | Surg. expo. of impltd/unerupted tooth for ortho | No Charge |
| 07285 | Biopsy of oral tissue – hard | No Charge |
| 07286 | Biopsy of oral tissue – soft | No Charge |
| 07310 | Alveolectomy/alveoplasty in conjunction with extractions - per quadrant | No Charge |
| 07320 | Alveolectomy/alveoplasty not in conjunction with extractions - per quadrant | No Charge |
| 07450 | Exclusion of cysts and neoplasms | No Charge |
| 07471 | Removal of torus (palatal or mandibular) | No Charge |
| 07510 | Incision & drainage of abscess - intraoral soft tissue | No Charge |
| 07520 | Incision & drainage of abscess - extraoral soft tissue | No Charge |
| 07530 | Incision & drainage of foreign body from soft tissue | No Charge |
| 07550 | Sequestomy | No Charge |
| 07910 | Sunture of soft tissue injury | No Charge |
| 07960 | Frenulectomy (frenectomy or frenotomy) separate procedure | No Charge |
| 07970 | Excision of hyperplastic tissue - per arch | No Charge |
| 07971 | Excision of pericoronal gingiva | No Charge |
| 07980 | Sialolithotomy (removal of salivary calculus) | No Charge |
| 07982 | Sialolithotomy (dilation of salivary duct) | No Charge |
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ADJUNCTIVE GENERAL SERVICES |
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| 09110 | Palliative (emergency) treatment of dental pain minor procedures | No Charge |
| 09215 | Local anesthesia | No Charge |
| 09241 | Sedative base | No Charge |
| 09310 | Consultation - (diagnostic service provided by dentist other than practitioner providing treatment) | No Charge |
| 09430 | Office visit for observation (during regularly scheduled hours)-no other services performed | No Charge |
| 09440 | Office visit - after regularly scheduled hours | $20.00 |
| 09951 | Occlusal adjustment – limited | No Charge |
| 09952 | Occlusion adjustment – complete | No Charge |
| 09999 | Broken appointment (less than 24-hour notice) per 15 minute appointment | $10.00 |
| 08755 | Office visit after 24 months of treatment, per visit | $25.00 |
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ORTHODONTICS |
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| 08000 | Full banded case – adult | $1000.00 |
| 08001 | Full banded case – child | $1000.00 |
| 08004 | Ortho treatment plan (records and models) | $35.00 |
| 08755 | Office visit after 24 months of treatment, per visit | $25.00 |