Dentcare Benefit Plan Covered Dental Services ... - CWA Local 1180

Dentcare Benefit PlanCovered Dental ServicesDiagnostic & Preventive ServicesOral ExaminationFull Mouth X-RaySingle Films (periapical or bitewing)Bitewing SeriesCleaning of Teeth (prophylaxis & polishing)Fluoride TreatmentSpecialty ConsultationTreatment in case of dental emergencyPatient Co-paymentNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeRestorative DentistrySilver Amalgam, One SurfaceSilver Amalgam, Two SurfacesSilver Amalgam, Three Surfaces or moreComposite Filling, One SurfaceComposite Filling, Two SurfacesComposite Filling, Three Surfaces or moreNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeOral SurgeryRoutine Extractions - per toothSurgical ExtractionsSoft Tissue ImpactionsBony ImpactionsAlveolectomy - per quadrantNo ChargeNo ChargeNo ChargeNo ChargeNo ChargeRoot Canal TherapyPulp Capping, DirectPulpotomyRoot Therapy - AnteriorRoot Therapy - BicuspidRoot Therapy - MolarNo ChargeNo ChargeNo ChargeNo ChargeNo Charge

PeriodonticsScaling of Teeth, per quadNo ChargePedicle Soft Tissue Graft 150.00Free Soft Tissue Graft 150.00Gingivectomy, per quadOsseous surgery, per quadProsthetics - CrownsAcrylic with Metal CrownPorcelain CrownNo ChargeNo ChargeNo ChargeNo ChargePorcelain with Metal Crown. 50.00PostRecementation, per CrownNo ChargeNo ChargeProsthetics - Fixed BridgesAcrylic w/ Metal Bridge Crown or Pontic 50.00Porcelain w/ Metal Bridge Crown or Pontic 50.00Recementation, BridgeNo ChargeProsthetics - RemovableFull Upper or Lower Denture, w/adjustments 50.00Partial Upper or Lower Denture, cast base 50.00Denture RepairsBroken Body of DentureNo ChargeNo ChargeOrthodontia - Maximum case fee – 24 monthsDependent Children* 300.00Adult 300.00*Children covered up to age 19, 23 if full-time student.