Managed DentalGuard Guardian HMO

Managed DentalGuard
Guardian HMO
Plan Schedule 38-M
Orthodontic Plan Schedule 1
MDG Codes++
Covered Services
Patient Charge
0120
0140
0150
0460
0470
0999
9310
9430
9440
Appointments & Diagnostic Services
Periodic oral evaluation
Limited oral evaluation - problem focused
Comprehensive oral evaluation
Pulp vitality tests
Diagnostic casts
Office visit - during regular hours - participating general dentist only
Consultation (by dentist other than practitioner providing treatment)
Office visit for observation - regular hours - no other service performed
Emergency office visit - after regularly scheduled office hours
No Charge
No Charge
No Charge
No Charge
No Charge
$5.00
No Charge
No Charge
$50.00
0210
0220
0230
0240
0270
0272
0274
0330
Radiographs
Intraoral - complete series (including bitewings)
Intraoral - periapical - single film
Intraoral - periapical - each additional film
Intraoral - occlusal - each film
Bitewing - single film
Bitewings - two films
Bitewings - four films
Panoramic film
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
1110
1120
1999
Preventive & Space Maintenance
Prophylaxis - adult (first 2 services in any 12 month period) +
Prophylaxis - child (first 2 services in any 12 month period) +
Prophylaxis - adult or child (with or without fluoride)(each additional
service in same 12 month period) +
No Charge
No Charge
$60.00
1201
Topical application of fluoride (including prophylaxis) - child (first 2
services in any 12 month period) +
No Charge
1203
Topical application of fluoride (prophylaxis not included) – child (first 2
services in any 12 month period) +
No Charge
1204
Topical application of fluoride (prophylaxis not included) – child (each
additional service in same 12 month period) +
$20.00
1310
1330
1351
9999
1510
1515
1550
Nutritional counseling for control of dental disease
Oral hygiene instruction
Sealant - per tooth - molars only
Sealant - per tooth - non-molars only
Space maintainer - fixed - unilateral
Space maintainer - fixed - bilateral
Recementation of space maintainer
No Charge
No Charge
$10.00
$35.00
$80.00
$80.00
$10.00
2110
2120
2130
Restorative
Amalgam - one surface - primary
Amalgam - two surfaces - primary
Amalgam - three surfaces - primary
No Charge
No Charge
No Charge
2131
2140
2150
2160
2161
2210
2330
2331
2332
2335
2336
2380
2381
2382
2385
2386
2387
Amalgam - four or more surfaces - primary
Amalgam - one surface - permanent
Amalgam - two surfaces - permanent
Amalgam - three surfaces - permanent
Amalgam - four or more surfaces - permanent
Silicate cement - per restoration
Resin/composite - one surface, anterior
Resin/composite - two surfaces, anterior
Resin/composite - three surfaces, anterior
Resin/composite - four or more surfaces or incisal angle, anterior
Composite resin crown, anterior - primary
Resin/composite - one surface, posterior - primary
Resin/composite - two surfaces, posterior - primary
Resin/composite - three or more surfaces, posterior - primary
Resin/composite - one surface, posterior - permanent
Resin/composite - two surfaces, posterior - permanent
Resin/composite - three or more surfaces, posterior - permanent
2510
2520
2530
2543
2544
2740
2750
2751
2752
2790
2791
2792
2810
2999
6199
Crown, Bridge & Other Cast Restorations
Inlay - metallic - one surface ^ **
Inlay - metallic - two surfaces ^ **
Inlay - metallic - three or more surfaces ^ **
Onlay - metallic - three surfaces ^ **
Onlay - metallic - four or more surfaces ^ **
Crown - porcelain/ceramic substrate ^
Crown - porcelain fused to high noble metal ^ **
Crown - porcelain fused to predominantly base metal ^
Crown - porcelain fused to noble metal ^
Crown - full cast high noble metal ^ **
Crown - full cast predominantly base metal ^
Crown - full cast noble metal ^
Crown - 3/4 cast metallic ^ **
Crown supporting existing partial denture, in addition to crown
Dental lab service - per inlay, onlay, crown or bridge unit
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
No Charge
$70.00
$70.00
$30.00
$40.00
$50.00
$30.00
$40.00
$50.00
$225.00
$230.00
$240.00
$250.00
$260.00
$290.00
$280.00
$210.00
$270.00
$280.00
$210.00
$270.00
$280.00
$125.00
$75.00
6210
Pontic - cast high noble metal ^ **
$280.00
6211
6212
6240
6241
6242
6520
6530
6543
6544
6750
6751
6752
6780
6790
Pontic - cast metal predominantly base metal ^
Pontic - cast noble metal ^
Pontic - porcelain fused to high noble metal ^ **
Pontic - porcelain fused to predominantly base metal ^
Pontic - porcelain fused to noble metal ^
Inlay - abutment - metallic - two surfaces ^ **
Inlay - abutment - metallic - three or more surfaces ^ **
Onlay - abutment - metallic - three surfaces ^ **
Onlay - abutment - metallic - four or more surfaces ^ **
Crown - abutment - porcelain fused to high noble metal ^ **
Crown - abutment - porcelain fused to predominantly base metal ^
Crown - abutment - porcelain fused to noble metal ^
Crown - abutment - 3/4 cast metallic ^ **
Crown - abutment - full cast high noble metal ^ **
$210.00
$270.00
$280.00
$210.00
$270.00
$230.00
$240.00
$250.00
$260.00
$280.00
$210.00
$270.00
$280.00
$280.00
6791
6792
6999
Crown - abutment - full cast predominantly base metal ^
Crown - abutment - full cast noble metal ^
Multiple crown and bridge unit treatment plan - per unit
$210.00
$270.00
$125.00
2910
2920
2930
2931
2932
2940
2950
2951
2952
2954
2960
6930
6970
6972
6973
Other Restorative Services
Recement inlay
Recement crown
Prefabricated stainless steel crown
Prefabricated stainless steel crown - permanent tooth
Prefabricated resin crown
Sedative filling
Core buildup, including any pins
Pin retention - per tooth, in addition to restoration
Cast post & core
Prefabricated post & core
Labial veneer (laminate) - chairside
Recement bridge
Cast post & core, in addition to abutment
Prefabricated post & core, in addition to abutment
Core buildup for abutment, including any pins
$20.00
$20.00
$70.00
$70.00
$110.00
$5.00
$110.00
$10.00
$140.00
$110.00
$105.00
$20.00
$140.00
$110.00
$110.00
3110/3120
3220
3310
3320
3330
3346
3347
3348
3410
3421
3425
3426
3430
4210
4211
4220
4240
4249
4260
4270
4271
4341
4355
4910
4920
4999
Endodontics
Pulp cap
Therapeutic pulpotomy
Root canal - anterior
Root canal - bicuspid
Root canal - molar
Root canal - retreatment - anterior
Root canal - retreatment - bicuspid
Root canal - retreatment - molar
Apicoectomy/periradicular surgery – anterior
Apicoectomy/periradicular surgery - bicuspid - first root
Apicoectomy/periradicular surgery - molar - first root
Apicoectomy/periradicular surgery - each additional root
Retrograde filling - per root
Periodontics
Gingivectomy or gingivoplasty - per quadrant
Gingivectomy or gingivoplasty - per tooth
Gingival curettage, surgical - per quadrant - by report
Gingival flap procedure-including root planing - per quadrant
Clinical crown lengthening - hard tissue
Osseous surgery - including flap entry, closure - per quadrant - five to
eight teeth
Pedicle soft tissue graft procedure
Free soft tissue graft procedure (including donor site surgery)
Periodontal scaling & root planing - per quadrant
Full mouth debridement to enable evaluation & diagnosis
Periodontal maintenance procedures (following active therapy)
Unscheduled dressing change (by other than treating dentist)
Osseous surgery - including flap entry, closure - per quadrant - one to
four teeth
No Charge
$45.00
$90.00
$160.00
$230.00
$105.00
$195.00
$280.00
$140.00
$140.00
$140.00
$70.00
$30.00
$100.00
$40.00
$45.00
$130.00
$110.00
$290.00
$165.00
$170.00
$45.00
$40.00
$35.00
No Charge
$175.00
9951
5110/5120
5130/5140
5211/5212
5213/5214
5410/11/21/22
5510/5610
5520/5640
5630
5650
5660
5710/11/20/21
5730/31/40/41
5750/51/60/61
5820/5821
5850/5851
5899
5999
Occlusal adjustment - limited - per visit
Prosthodontics (Removable)
Complete denture (including routine post delivery care) ^ ^
Immediate denture (including routine post delivery care) ^ ^
Partial dentures (including routine post delivery care):
Resin base - including clasps, rests, teeth ^ ^
Cast metal framework with resin base - including clasps, rests, teeth ^ ^
Repairs & adjustments:
Denture adjustments
Repair denture base ^ ^ ^
Replace missing or broken teeth - per tooth ^ ^ ^
Repair or replace clasp ^ ^ ^
Add tooth to existing partial ^ ^ ^
Add clasp to existing partial ^ ^ ^
Rebase denture ^ ^ ^
Reline denture (chairside)
Reline denture (laboratory) ^ ^ ^
Interim partial denture (stayplate)
Tissue conditioning
Dental lab service - each new complete, immediate, or partial denture per denture
Dental lab service - denture repair, rebase or reline - per denture
$25.00
$260.00
$260.00
$250.00
$260.00
$15.00
$25.00
$25.00
$35.00
$25.00
$35.00
$100.00
$85.00
$100.00
$150.00
$30.00
$165.00
$35.00
7280
7281
7285
7286
7310
7320
Oral Surgery
Extraction - single tooth
Extraction - each additional tooth
Root removal - exposed roots
Surgical removal of erupted tooth
Removal of impacted tooth - soft tissue
Removal of impacted tooth - partially bony
Removal of impacted tooth - completely bony
Removal of impacted tooth - completely bony, with unusual surgical
complications
Surgical removal of residual tooth roots (cutting procedure)
Tooth reimplantation and/or stabilization of accidentally evulsed tooth
Surgical exposure of impacted or unerupted tooth for orthodontic
reasons
Surgical exposure of impacted or unerupted tooth to aid eruption
Biopsy of oral tissue - hard
Biopsy of oral tissue - soft
Alveoplasty in conjunction with extractions - per quadrant
Alveoplasty not in conjunction with extractions - per quadrant
7450
Removal of odontogenic cyst/tumor - up to 1.25cm
$95.00
7451
Removal of odontogenic cyst/tumor - over 1.25cm
$165.00
7470
Removal of exostosis - maxilla or mandible
$130.00
7510
Incision & drainage of intraoral abscess
$45.00
Frenulectomy (separate procedure)
$95.00
7110
7120
7130
7210
7220
7230
7240
7241
7250
7270
7960
Orthodontic Treatment (covers 24 months active treatment)
No Charge
No Charge
No Charge
$35.00
$25.00
$60.00
$75.00
$75.00
$35.00
$90.00
$115.00
$90.00
$60.00
$55.00
$40.00
$55.00
8070/8080/8090
8070/8080/8090
8660
Comprehensive orthodontic treatment, including fabrication and insertion
of fixed banding appliance and periodic visits, up to 24 months;
dependent child to age 18 (as determined by the Member’s age on the
date of banding)
Comprehensive orthodontic treatment, including fabrication and insertion
of fixed banding appliance and periodic visits, up to 24 months;
employee, spouse, or dependent child over age 18 (as determined by
the Member’s age on the date of banding)
Orthodontic evaluation and consultation
8670
Periodic comprehensive orthodontic treatment visit
8680
Orthodontic retention
Orthodontic treatment plan and records, including x-rays, study models
and photos
8999
$2,285.00
$2,285.00
$100.00
No Charge
$415.00
$150.00
Miscellaneous Services
++
+
^
^^
^^
^
**
9110
Palliative (emergency) treatment - per visit
No Charge
9215
Local anesthesia
No Charge
9972
External bleaching - per arch - take home bleaching only
$165.00
Covered Services are subject to exclusions, limitations and Plan provisions. Other codes may be used to
describe Covered Services.
The patient charges for codes 1110, 1120, 1201 and 1203 are limited to the first two services in any 12 month
period. For each additional service in the same 12 month period, see codes 1204 and 1999 for the applicable
patient charge.
There is an additional dental lab service patient charge for these procedures. See code 6199 for the applicable
patient charge.
There is an additional dental lab service patient charge for these procedures. See code 5899 for the applicable
patient charge.
There is an additional dental lab service patient charge for these procedures. See code 5999 for the applicable
patient charge.
If high noble metal is used, there may be an additional patient charge for the actual cost of the high noble metal.
The total patient charge for high noble metal plus the applicable dental lab service charge may not exceed the
general dentist’s actual lab bill for the service.
Plan Schedule 38-M is only valid for Covered Services rendered by Participating Dentists in the State of Texas.
Orthodontic Plan Schedule 1 is only valid for Authorized Services rendered by Participating Orthodontic Specialty
Care Dentists in the State of Texas.
Orthodontic Plan Schedule
1
This chart lists some common dental procedures, along with the average fee charged by dentists in your
service area. We also show the patient charge you pay for these services under this plan.
Patient Charge
Average
Fee*
General
Dentist
Specialty
Care Dentist
Diagnostic and Preventive Services
Office visit
Full mouth x-rays
42.00
76.00
$5.00
No Charge
Teeth cleaning (prophylaxis) - adult (first 2 services)
56.00
No Charge
Not
Covered
No Charge
Not
Covered
82.00
No Charge
No Charge
107.00
No Charge
No Charge
Porcelain with noble metal crown ***
694.00
$270.00
Not
Covered
Full cast noble metal crown ***
682.00
$270.00
Endodontics
Root canal therapy, bicuspid
Root canal therapy, molar
558.00
716.00
$160.00
$230.00
$160.00
$230.00
Periodontics
Gingivectomy/gingivoplasty, per quadrant
Osseous surgery, per quadrant
Periodontal scaling and root planing, per quadrant
401.00
694.00
157.00
$100.00
$290.00
$45.00
$100.00
$290.00
$45.00
Restorative Services
Amalgam filling, 1 surface
Amalgam filling, 2 surfaces
Crown and Bridge Services
"
Prosthodontics
Complete upper denture ***
Partial denture with metal framework ***
Repair or replace broken denture clasp ***
925.00
916.00
156.00
$260.00
$260.00
$35.00
Not
Covered
"
"
Oral Surgery
Simple extraction - single tooth
Extraction of impacted tooth, completely bony
84.00
288.00
No Charge
$75.00
No Charge
$75.00
Orthodontics
Evaluation and consultation
Treatment plan, x-rays and models
Comprehensive treatment, up to 24 months
Child to age 18
Member over age
18
Retention
**
**
Not
Covered
"
100.00
150.00
3800.00
"
2,285.00
4200.00
**
"
"
2,285.00
415.00
Covered Services are subject to exclusions, limitations and Plan provisions as described in the Certificate of
Coverage.
*
Derived from December 2000 Health Insurance Association of America (HIAA) fee data for Texas.
**
These charges are usually included in the comprehensive treatment fee.
***
There is an additional dental lab service patient charge for these procedures.
The Managed DentalGuard plan is underwritten by Managed DentalGuard, Inc. (MDG). MDG is a wholly owned
subsidiary of The Guardian Life Insurance Company of America, New York, NY.
Managed DentalGuard, Inc., 13455 Noel Rd., Dallas, TX 75240