Plan Information

Dental Value Plan C Series Benefit Schedule

This Schedule of Benefits lists your copayments for most common procedures. The following co-payments apply only when services are performed by your selected HumanaOne participating dentist. If a procedure is not listed below, you’ll get a 25% discount when you see one of our participating dentists. And you’ll also get a 25% discount when you see one of our participating specialists.

Plan Features
Diagnostic
Clinical Oral Evaluation You Pay
D0120 periodic oral evaluation - established patient no charge
D0140 limited oral evaluation - problem focused no charge
D0150 comprehensive oral evaluation - new or established patient no charge
D0160 detailed and extensive oral evaluation - problem focused, by report no charge
D0180 comprehensive periodontal evaluation - new or established patient $25
Radiographs/Diagnostic Imaging (Including Interpretation) You Pay
D0210 intraoral - complete series (including bitewings) no charge
D0220 intraoral - periapical first film no charge
D0230 intraoral - periapical each additional film no charge
D0270 bitewing - single film no charge
D0272 bitewings - two films no charge
D0274 bitewings - four films no charge
D0330 panoramic film no charge
Tests and Examinations You Pay
D0460 pulp vitality tests no charge
D0470 diagnostic casts no charge
Preventive
Dental Prophylaxis You Pay
D1110 prophylaxis - adult no charge
D1120 prophylaxis - child no charge
Topical Fluoride Treatment (Office Procedure) You Pay
D1201 topical application of fluoride (including prophylaxis) - child no charge
D1203 topical application of fluoride - child no charge
Other Preventive Services You Pay
D1330 oral hygiene instructions no charge
D1351 sealant - per tooth $20
Space Maintenance (Passive Appliances) You Pay
D1510 space maintainer - fixed - unilateral $65**
D1515 space maintainer - fixed - bilateral $65**
D1520 space maintainer - removable - unilateral $105**
D1525 space maintainer - removable - bilateral $105**
D1550 re-cementation of space maintainer $20
Restorative
Amalgam Restorations (Including Polishing) You Pay
D2140 amalgam - one surface, primary or permanent $30
D2150 amalgam - two surfaces, primary or permanent $35
D2160 amalgam - three surfaces, primary or permanent $40
D2161 amalgam - four or more surfaces, primary or permanent $50
Resin - Based Composite Restorations - Direct You Pay
D2330 resin-based composite - one surface, anterior $50
D2331 resin-based composite - two surfaces, anterior $55
D2332 resin-based composite - three surfaces, anterior $65
D2391 resin-based composite - one surface, posterior $90
D2392 resin-based composite - two surfaces, posterior $110
D2393 resin-based composite - three surfaces, posterior $130
D2394 resin-based composite - four or more surfaces, posterior $150
Inlay/Onlay Restorations You Pay
D2510 inlay - metallic - one surface $155
D2520 inlay - metallic - two surfaces $165
D2530 inlay - metallic - three or more surfaces $190
Crowns - Single Restorations Only You Pay
D2740 crown - porcelain/ceramic substrate $370**
D2750 crown - porcelain fused to high noble metal $370*
D2751 crown - porcelain fused to predominantly base metal $370
D2752 crown - porcelain fused to noble metal $370*
D2790 crown - full cast high noble metal $370*
D2791 crown - full cast predominantly base metal $370
D2792 crown - full cast noble metal $370*
Other Restorative Services You Pay
D2910 recement inlay, onlay, or partial coverage restoration $30
D2920 re-cement crown $30
D2930 prefabricated stainless steel crown - primary tooth $120
D2940 protective restoration $30
D2950 core buildup, including any pins $60
D2951 pin retention - per tooth, in addition to restoration $30
D2952 post and core in additon to crown, indirectly fabricated $120**
D2953 each additonal indirectly fabricated post - same tooth $120**
D2954 prefabricated post and core in addition to crown $120
D2962 labial veneer (porcelain laminate) - laboratory $370**
Endodontics
Pulpotomy You Pay
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $50
D3221 pulpal debridement, primary and permanent teeth $130
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) You Pay
D3310 endodontic therapy, anterior tooth (excluding final restoration) $250
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $350
D3330 endodontic therapy, molar (excluding final restoration) $450
Apicoectomy/Periradicular Services You Pay
D3410 apicoectomy/periradicular surgery - anterior $200
Periodontics
Surgical Services (Including Usual Postoperative Care) You Pay
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $200
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $55
Non-Surgical Periodontal Service You Pay
D4341 periodontal scaling and root planing - four or more teeth per quadrant $65
D4342 periodontal scaling and root planing - one to three teeth per quadrant $65
D4355 full mouth debridement to enable comprehensive evaluation and diagnosis $60
D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $60
Other Periodontal Services You Pay
D4910 periodontal maintenance $65
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) You Pay
D5110 complete denture - maxillary $375**
D5120 complete denture - mandibular $375**
D5130 immediate denture - maxillary $375**
D5140 immediate denture - mandibular $375**
Partial Dentures (Including Routine Post-Delivery Care) You Pay
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $375**
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $375**
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $375**
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $375**
Adjustments to Dentures You Pay
D5410 adjust complete dentures - maxillary $30
D5411 adjust complete dentures - mandibular $30
D5421 adjust partial denture - maxillary $30
D5422 adjust partial denture - mandibular $30
Repairs to Complete Dentures You Pay
D5510 repair broken complete denture base $30**
D5520 replace missing or broken teeth - complete denture (each tooth) $30**
Repairs to Partial Dentures You Pay
D5610 repair resin denture base $30**
D5630 repair or replace broken clasp $30**
D5640 replace broken teeth - per tooth $30**
D5650 add tooth to existing partial denture $45**
Denture Reline Procedures You Pay
D5730 reline complete maxillary denture (chairside) $65
D5731 reline complete mandibular denture (chairside) $65
D5740 reline maxillary partial denture (chairside) $65
D5741 reline mandibular partial denture (chairside) $65
D5750 reline complete maxillary denture (laboratory) $50**
D5751 reline complete mandibular denture (laboratory) $50**
D5760 reline maxillary partial denture (laboratory) $50**
D5761 reline mandibular partial denture (laboratory) $50**
Other Removable Prosthetic Services You Pay
D5850 tissue conditioning, maxillary $45
D5851 tissue conditioning, mandibular $45
Prosthodontics, fixed
Fixed Partial Denture Pontics You Pay
D6210 pontic - cast high noble metal $370*
D6211 pontic - cast predominantly base metal $370
D6212 pontic - cast noble metal $370*
D6240 pontic - porcelain fused to high noble metal $370*
D6241 pontic - porcelain fused to predominantly base metal $370
D6242 pontic - porcelain fused to noble metal $370*
Fixed Partial Denture Retainers-Crowns You Pay
D6750 crown - porcelain fused to high noble metal $370*
D6751 crown - porcelain fused to predominantly base metal $370
D6752 crown - porcelain fused to noble metal $370*
D6790 crown - full cast high noble metal $370*
D6791 crown - full cast predominantly base metal $370
D6792 crown - full cast noble metal $370*
Other Fixed Partial Denture Services You Pay
D6930 re-cement fixed partial denture $25
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) You Pay
D7111 extraction, coronal remnants - deciduous tooth $35
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $35
Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care You Pay
D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. $55
D7220 removal of impacted tooth - soft tissue $100
D7230 removal of impacted tooth - partially bony $125
D7240 removal of impacted tooth - completely bony $150
D7250 surgical removal of residual tooth roots (cutting procedure) $65
Alveoloplasty-Surgical Preparation of Ridge for Dentures You Pay
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $65
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $100
Surgical Incision You Pay
D7510 incision and drainage of abscess - intraoral soft tissue $40
Orthodontics
Limited Orthodontic Treatment You Pay
D8020 limited orthodontic treatment of the transitional dentition 75%
D8030 limited orthodontic treatment of the adolescent dentition 75%
D8040 limited orthodontic treatment of the adult dentition 75%
Comprehensive Orthodontic Treatment You Pay
D8070 comprehensive orthodontic treatment of the transitional dentition 75%
D8080 comprehensive orthodontic treatment of the adolescent dentition 75%
D8090 comprehensive orthodontic treatment of the adult dentition 75%
Other Orthodontic Services You Pay
D8660 pre-orthodontic treatment visit 75%
D8680 orthodontic retention (removal of appliances, construction and placement of retainer(s)) 75%
Adjunctive General Services
Anesthesia You Pay
D9215 local anesthesia no charge
D9230 analgesia, anxiolysis, inhalation of nitrous oxide $30
Professional Consultation You Pay
D9310 consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician $30
Professional Visits You Pay
D9430 office visit for observation (during regularly scheduled hours)-no other services performed $10
D9440 office visit-after regularly scheduled hours $35
D9450 case presentation, detailed and extensive treatment planning no charge
Miscellaneous Services You Pay
D9951 occlusal adjustment - limited $40
D9952 occlusal adjustment - complete $225
*The above copayments do not include the additional cost of precious (high noble) and semi-precious (noble) metal.  The additional cost of precious metal shall not exceed $125 per unit and $75 per unit for semi-precious metal.
 
**The above copayments do not include additional lab fees.