Schedule of Dental Benefits

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Pre-authorization required for services amounting to $500 or more. Benefits are limited to $2,000 per covered patient per calendar year. If both husband and wife are Fund members, this limit is $4,000 per covered patient per calendar year. Crown and Bridge Work covered once every 3 years.

*** Crowns & Dentures Are Payable Once Per Three Years
*** Dental Implants: Lifetime Maximum = $2,000/personmaximum allowance = $1000 per implant, not included in dental yearly maximum.
*** General Anesthesia and Intravenous Anesthesia only covered if used in conjunction with oral surgery.

ADA Fund # and Covered Service Payment
0120 Periodic Oral Evaluation 25.00
0140 Limited oral evaluation - problem focused 25.00
0150 Comprehensive oral evaluation - Only 2 examination (0120,0140 or 0150) per year combined 25.00
0210 Intraoral- complete series including bitewings (once per 3 yrs) 40.00
0220 Intraoral, Periapical, first film 2.00
0230 Intraoral, Periapical, each additional film 2.00
0240 Intraoral, Occlusal film 7.00
0250 Extraoral - first film 10.00
0260 Extraoral - each additional film 2.00
0270 Bitewings, single film - max 4 per year 2.50
0272 Bitewings, two films - max 2 per year 5.00
0274 Bitewings, four films - max I per year 10.00
0290 Posterior-anterior or lateral skull & facial bone survey film 15.00
0310 Sialography 5.00
0320 TMJ arthrogram, including injection 21.00
0330 Panoramic film (once every 3 years) 40.00
0340 Cephalometric film 20.00
0460 Pulp vitality tests 5.00
0470 Diagnostic casts 10.00
1110 Prophylaxis - Adult - 2 per calendar year 10.00
1120 Prophylaxis - Child (under 12) - 2 per calendar year 10.00
1203 Topical application fluoride excl. prophy (child) -2 per calendar year 10.00
1204 Topical application fluoride excl. prophy (adult) -2 per calendar year 10.00
1510 Space Maintainer- fixed - unilateral 50.00
1515 Space Maintainer- fixed - bilateral 50.00
1520 Space Maintainer- removable - unilateral 40.00
1525 Space Maintainer- removable bilateral 40.00
2110 Amalgam - one surface, primary 15.00
2120 Amalgam - two surfaces, primary 20.00
2130 Amalgam- three surfaces, primary 30.00
2131 Amalgam - four or more surfaces, primary 35.00
2140 Amalgam - I surface, permanent 30.00
2150 Amalgam - 2 surfaces, permanent . 40.00
2160 Amalgam - 3 surfaces, permanent 50.00
2161 Amalgam - 4 or more surfaces, permanent 55.00
2330 Resin, I surface, anterior 30.00
2331 Resin, 2 surfaces, anterior 50.00
2332 Resin, 3 surfaces, anterior 50.00
2335 Resin, 4 or more surface or involving incisal angle (anterior) 50.00
2385 Resin, I Surface, Posterior - Permanent 30.00
2386 Resin, 2 Surfaces, Posterior - Permanent 50.00
2387 Resin, 3 or more Surfaces, Posterior - Permanent 50.00
2410 Gold foil - one surface 20.00
2420 Gold foil - two surfaces 20.00
2430 Gold foil - three surfaces 20.00
2510 Inlay - Metallic - I Surface* 70.00
2520 Inlay - Metallic - 2 Surfaces* 110.00
2530 Inlay - Metallic - 3 Surfaces* 140.00
2610 Inlay - Porcelain/Ceramic - I Surface* 70.00
2710 Crown - Resin (laboratory)* 110.00
2720 Crown - Resin with high noble metal* 170.00
2721 Crown - Resin with predominantly base metal* 110.00
2722 Crown - Resin with noble metal* 110.00
2740 Crown - Porcelain/ceramic substrate* 160.00
2750 Crown - Porcelain fused to high noble metal* 250.00
2751 Crown - Porcelain fused to predominantly base 250.00
2752 Crown - Porcelain fused to noble metal* 250.00
2780 Crown - Gold, full 3/4 cast 170.00
2790 Crown - Full Cast high noble metal 220.00
2791 Crown - Full Cast predominantly base metal* 220.00
2792 Crown - Full Cast noble in metal* 220.00
2810 Crown - 3/4 cast metallic* 170.00
2910 Recement inlay 15.00
2920 Recement crown 15.00
2940 Sedative filling 5.00
2950 Core buildup, including any pins* 20.00
2952 Cast post and core in addition to crown* 65.00
2954 Prefabricated post and core in addition to crown* 50.00
2970 Temporary crown (fractured tooth) . 35.00
3110 Pulp cap - direct (excluding final restoration) 10.00
3120 Pulp cap - indirect ( excluding final restoration) 10.00
3220 Therapeutic Pulpotomy (excluding final restoration) 25.00
3310 Anterior Root Canal (excluding fainl restoration) 200.00
3320 Bicuspid Root Canal (excluding final restoration) 250.00
3330 Molar Root Canal (excluding final restoration) 300.00
3346 Retreatment of previous root canal therapy- anterior 200.00
3347 Retreatment of previous root canal therapy- bicuspid 250.00
3348 Retreatment of previous root canal therapy 300.00
3410 Apicoectomy/Periradicular surgery- anterior 130.00
3421 Apicoectomy/periradicular surgery - bicuspid (first root) 110.00
3425 Apicoectomylperiradicular surgery - molar (first root) 125.00
3426 Apicoectomy/periradicular surgery - (each add'l root) 75.00
3430 Retrograde filling -per root 75.00
3450 Root amputation - per root 35.00
4210 Gingivectomy or Gingivoplasty - per quadrant 85.00
4211 Gingivectomy or Gingivoplasty, per tooth 15.00
4240 Gingival flap procedure incl. root planing - per quadrant 160.00
4249 Clinical crown lengthening - hard tissue 75.00
4260 Osseous Surgery (incl. flap entry & clos.) per quadrant - once every 3 years 225.00
4263 Bone replacement graft - first site in quadrant 200.00
4264 Bone replacement graft - each additional site in quadrant 100.00
4266 Guided tissue regeneration - resorbable barrier - per site 150.00
4267 Guided tissue regeneration - nonresorbable barrier - per site 150.00
4270 Pedicle soft tissue graft procedure 125.00
4271 Free soft tissue graft procedure 125.00
4910 Perio-Preventive Procedures 25.00
5110 Complete upper dentures* 600.00
5120 Complete lower dentures* 600.00
5130 Immediate upper dentures* 600.00
5140 Immediate lower dentures* 600.00
5211 Maxillary Partial Denture - Resin Base* 600.00
5212 Mandibular Partial Denture - Resin Base* 600.00
5213 Maxillary Partial Denture - Cast Metal Frame* 600.00
5214 Mandibular Partial Denture - Cast Metal Frame* 600.00
5281 Removable unilateral partial denture - one piece cast metal (including clasps & pontics)* 275.00
5421 Adjust partial denture - maxillary 10.00
5422 Adjust partial denture - mandibular 10.00
5610 Repair resin saddle or base 25.00
5620 Repair cast framework 14.00
5630 Repair or replace broken clasp 15.00
5640 Replace broken teeth - per tooth 20.00
5650 Add tooth to existing partial denture 30.00
5660 Add clasp to existing partial denture 30.00
5730 Reline complete upper denture (chairside) 50.00
5731 Reline complete lower denture (chairside) 50.00
5740 Reline upper partial denture (chairside) 50.00
5741 Reline lower partial denture (chairside) 50.00
5750 Reline complete upper denture (laboratory) 65.00
5751 Reline complete lower denture (laboratory) 65.00
5760 Reline upper partial denture (laboratory) 65.00
5761 Reline lower partial denture (laboratory) 65.00
6010 Surgical placement of implant body- endosteal implant 1000.00
6210 Pontic - Cast high noble metal* 170.00
6211 Pontic - Cast predominantly base metal* 170.00
6212 Pontic - Cast noble metal* 170.00
6240 Pontic - porcelain fused to high noble metal* . 200.00
6241 Pontic - porcelain fused to predominantly base metal* 200.00
6242 Pontic - porcelain fused to noble metal* 200.00
6250 Pontic - Resin with high noble metal* 160.00
6251 Pontic - Resin with predominantly base metal* 160.00
6252 Pontic - Resin with noble mtale* 160.00
6520 Inlay - metallic - two surfaces* 110.00
6530 Inlay - metallic - three or more surfaces 140.00
6540 Onlay - metallic per tooth - in addition to inlay 60.00
6720 Crown - Resin with high noble metal* 125.00
6721 Crown - Resin with predominantly base metal* 110.00
6722 Crown - Resin with noble metal* 110.00
6740 Crown - porcelain/ceramic* 155.00
6750 Crown - porcelain fused to high noble metal* 250.00
6751 Crown - porcelain fused to predominantly base metal* 250.00
6752 Crown - porcelain fused to noble metal* 250.0
6780 Crown - 3/4 cast high noble metal* 175.00
6790 Crown - full cast high noble metal* 220.00
6791 Crown - full cast predominantly base metal* 220.00
6792 Crown - full cast noble metal* 220.00
6930 Recement bridge 15.00
6940 Stress breaker 15.00
7110 Extraction - single tooth 50.00
7120 Extraction - each additional tooth 45.00
7210 Surgical removal of erupted tooth requiring elevation mucoperiosteal flap & removal of bone and/or section of tooth 75.00
7220 Removal of impacted tooth - soft tissue 100.00
7230 Removal of impacted tooth - partially bony 150.00
7240 Removal of impacted tooth - completely bony 200.00
7241 Removal of impacted tooth - completely bony with unusual surgical complications 225.00
7250 Surgical removal of residual roots (cutting procedure) 40.00
7280 Surgical exposure of impacted or erupted tooth for unerupted orthodontic reasons (including orthodontic attachments) 70.00
7285 Biopsy of oral tissue - hard 50.00
7286 Biopsy of oral tissue - soft 50.00
7290 Surgical repositioning of teeth 50.00
7310 Alveoloplasty in conjunction with extractions - per quadrant 60.00
7320 Alveoloplasty not in conjunction with extractions - per quadrant 60.00
7340 Vestibuloplasty - ridge extension (secondary epithelialization)..70.00
7350 Vestibuloplasty - ridge extension (including soft tissue grafts, muscle reattachment, revision of soft tissue attachment and management of hypertrophied and hyperplastic tissue) 100.00
7410 Radical excision - lesion diameter up to 1.25 cm 60.00
7420 Radical excision - lesion diameter over 1.25 cm 60.00
7430 Excision of benign tumor - lesion diameter up to 1.25 cm 60.00
7431 Excision of benign tumor - lesion diameter over 1.25 cm 60.00
7440 Excision of malignant tumor - lesion diameter up to 1.25 cm ..60.00
7441 Excision of malignant tumor - lesion diameter over 125 cm 60.00
7450 Remove odontogenic cyst/tumor/lesion diameter up to 1.25 cm 60.00
7451 Remove odontogenic cyst/tumor/lesion diameter over 1.25 cm. 60.00
7460 Remove nonodontogenic cyst/tumor/lesion diameter up to 1.25 cm. 60.00
7461 Remove nonodontogenic cyst/tumor/lesion diameter over 1.25 cm 60.00
7471 Removal of exostosis - per site 75.00
7480 Partial ostectomy 50.00
7490 Radical resection of mandible with bone graft 500.00
7510 Incision & drainage of abscess - intraoral soft tissue 20.00
7550 Sequestrectomy for osteomyelitis 40.00
7960 Frenulectomy - separate procedure 60.00
7970 Excision of hyperplastic tissue - per arch 50.00
7980 Sialolithotomy 35.00
8460 Orthodontic diagnosis and initial appliance - child 500.00
8461 Active visits - monthly - child (up to 30 months) 60.00
8462 Passive treatment, every 6 months - child 30.00
8463 Orthodontic passive treatment (1) month - child 5.00
8560 Orthodontic diagnosis and initial appliance - adult 500.00
8561 Active visits - monthly - adult (up to 24 consecutive months) 60.00
8562 Passive treatment, every 6 months - adult 30.00
8563 Orthodontic passive treatment (1) month) - adult 5.00
9110 Palliative (emergency) treatment of dental pain 20.00
9220 General anesthesia - first 30 minutes*** 100.00
9221 General anesthesia - each additional 15 minutes*** 50.00
9241 Intravenous sedation/analgesia - first 30 minutes*** 80.00
9242 Intravenous sedation/analgesia - each additional 15 minutes*** 40.00
9310 Specialist Consultation - 2 per calender year 20.00
9910 Application of desensitizing medicament - once per year 5.00
9951 Occlusal adjustment, limited - twice per year 15.00

Social Service Employees Union Local 371
AFSCME, AFL—CIO
817 Broadway, New York, NY 10003
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