Plan Information

Starmount Value Plan + Vision
Schedule of Covered Services
and Copayments

The Starmount Individual Dental plan pays a flat dollar amount per covered dental procedure outlined in the policy. You can visit any provider, and we will pay the lesser of the provider’s actual charge or the amount listed on the Schedule of Covered Dental Procedures.† Visit a network dentist and see your benefit dollars stretched even further.

Schedule of Covered Services and Copayments
Note: Please see benefit schedule below for more details.
Preventive/Diagnostic
No waiting periods
  • Routine exams (2 per 12 months)
  • Prophylaxis (simple cleaning) (2 per 12 months)
  • Full mouth x-ray (1 per 5 years) (D0210, D0277, D0330)
  • Bitewing x-rays (max 4 films per 12 months)
  • Services for children to age 16
    • Space maintainers (1 per lifetime, per quadrant or arch)
    • Fluoride (1 per 12 months)
    • Sealants (permanent molars, 1 per 36 months)
  • Oral cancer screening (max 1 per 12 months for age 40+)
Schedule Amounts Apply
Other Services
12 month waiting period*
  • Fillings (12 month waiting period does not apply to fillings)
  • Simple extractions
  • Oral surgery (surgical extractions & impactions)
  • Emergency pain (1 per 12 months)
  • Periodontics
  • Crowns, bridges, and dentures
  • Inlays and onlays
  • Endodontics (root canals)
Schedule Amounts Apply
Deductible
(Does not apply to preventive services)
Per person, per benefit year. $50 Annual. Maximum 3 per family.
Vision Services**
Once per 12 months
Exams
Materials
$15 Co-pay
$20 Co-pay
 

Standard Plastic Lenses:

  • Single Vision
  • Bifocal
  • Trifocal
  • Lenticular
  • Progressive


Covered by Co-pay
Covered by Co-pay
Covered by Co-pay
$80 allowance
$70 allowance
  Frames $120 retail frame allowance
 

Contact Lenses (includes fit, follow-up and materials and are in lieu of frames and lenses)

  • Elective
  • Medically Necessary



$120 retail allowance
$210 retail allowance
Plan Features
Diagnostic
Clinical Oral Evaluation Plan Pays
D0120 periodic oral evaluation - established patient $19
D0140 limited oral evaluation - problem focused $29
D0145 oral evaluation for a patient under three years of age and counseling with primary caregiver $26
D0150 comprehensive oral evaluation - new or established patient $31
D0170 re-evaluation - limited, problem focused (established patient; not post-operative visit) $24
D0180 comprehensive periodontal evaluation - new or established patient $41
Radiographs/Diagnostic Imaging (Including Interpretation) Plan Pays
D0210 intraoral - complete series (including bitewings) $53
D0220 intraoral - periapical first film $11
D0230 intraoral - periapical each additional film $9
D0240 intraoral - occlusal film $15
D0250 extraoral - first film $22
D0260 extraoral - each additional film $19
D0270 bitewing - single film $11
D0272 bitewings - two films $17
D0273 bitewings - three films $21
D0274 bitewings - four films $25
D0277 vertical bitewings - 7 to 8 films $37
D0330 panoramic film $43
Tests and Examinations Plan Pays
D0431 adjunctive pre-diagnostic test that aids in dection of mucosal abnormalities including premalignant and malignant lesions, not to incluede cytology or biopsy procedures $21
Oral Pathology Laboratory Plan Pays
D0472 accession of tissue, gross examination, preparation and transmission of written report $31
D0473 accession of tissue, gross and microscopic examination, preparation and transmission of written report $70
D0474 accession of tissue, gross and microscopic examination, including assessment of surgical margins for presence of disease, preparation and transmission of written report $114
D0486 accession of transepithelial cytologic sample, microscopic examination, preparation and transmission of written report $66
Preventive
Dental Prophylaxis Plan Pays
D1110 prophylaxis - adult $36
D1120 prophylaxis - child $26
Topical Fluoride Treatment (Office Procedure) Plan Pays
D1203 topical application of fluoride - child $14
D1206 topical fluoride varnish; therapeutic application for moderate to high caries risk patients $15
Other Preventive Services Plan Pays
D1351 sealant - per tooth $21
Space Maintenance (Passive Appliances) Plan Pays
D1510 space maintainer - fixed - unilateral $132
D1515 space maintainer - fixed - bilateral $197
D1520 space maintainer - removable - unilateral $158
D1525 space maintainer - removable - bilateral $234
D1550 re-cementation of space maintainer $28
D1555 removal of fixed space maintainer $28
Restorative
Amalgam Restorations (Including Polishing) Plan Pays
D2140 amalgam - one surface, primary or permanent $39
D2150 amalgam - two surfaces, primary or permanent $48
D2160 amalgam - three surfaces, primary or permanent $58
D2161 amalgam - four or more surfaces, primary or permanent $68
Resin - Based Composite Restorations - Direct Plan Pays
D2330 resin-based composite - one surface, anterior $45
D2331 resin-based composite - two surfaces, anterior $55
D2332 resin-based composite - three surfaces, anterior $67
D2335 resin-based composite - four or more surfaces or involving incisal angle (anterior) $81
D2390 resin-based composite crown, anterior $98
D2391 resin-based composite - one surface, posterior $50
D2392 resin-based composite - two surfaces, posterior $66
D2393 resin-based composite - three surfaces, posterior $80
D2394 resin-based composite - four or more surfaces, posterior $90
Inlay/Onlay Restorations Plan Pays
D2510 inlay - metallic - one surface $90
D2520 inlay - metallic - two surfaces $122
D2530 inlay - metallic - three or more surfaces $152
D2542 onlay - metallic-two surfaces $163
D2543 onlay - metallic-three surfaces $171
D2544 onlay - metallic-four or more surfaces $177
D2610 inlay - porcelain/ceramic - one surface $126
D2620 inlay - porcelain/ceramic - two surfaces $148
D2630 inlay - porcelain/ceramic - three or more surfaces $158
D2642 onlay - porcelain/ceramic - two surface $168
D2643 onlay - porcelain/ceramic - three surfaces $171
D2644 onlay - porcelain/ceramic - four or more surfaces $177
D2650 inlay - resin-based composite - one surface $68
D2651 inlay - resin-based composite - two surfaces $117
D2652 inlay - resin-based composite - three or more surfaces $126
D2662 onlay - resin-based composite - two surfaces $132
D2663 onlay - resin-based composite - three surfaces $153
D2664 onlay - resin-based composite - four or more surfaces $158
Crowns - Single Restorations Only Plan Pays
D2710 crown - resin-based composite (indirect) $65
D2720 crown - resin with high noble metal $167
D2721 crown - resin with predominantly base metal $135
D2722 crown - resin with noble metal $135
D2740 crown - porcelain/ceramic substrate $178
D2750 crown - porcelain fused to high noble metal $167
D2751 crown - porcelain fused to predominantly base metal $149
D2752 crown - porcelain fused to noble metal $158
D2780 crown - 3/4 cast high noble metal $176
D2781 crown - 3/4 cast predominantly base metal $54
D2782 crown - 3/4 cast noble metal $171
D2783 crown - 3/4 porcelain/ceramic $177
D2790 crown - full cast high noble metal $163
D2791 crown - full cast predominantly base metal $158
D2792 crown - full cast noble metal $166
Other Restorative Services Plan Pays
D2910 recement inlay, onlay, or partial coverage restoration $15
D2920 re-cement crown $15
D2930 prefabricated stainless steel crown - primary tooth $39
D2931 prefabricated stainless steel crown - permanent tooth $44
D2932 prefabricated resin crown $46
D2950 core buildup, including any pins $39
D2951 pin retention - per tooth, in addition to restoration $7
D2952 post and core in additon to crown, indirectly fabricated $59
D2954 prefabricated post and core in addition to crown $50
D2980 crown repair, by report $33
Endodontics
Pulpotomy Plan Pays
D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament $26
D3221 pulpal debridement, primary and permanent teeth $28
Endodontic Therapy on Primary Teeth Plan Pays
D3230 pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) $36
D3240 pulpal therapy (resorbable filling) - posterior, primary tooth (excluding final restoration) $37
Endodontic Therapy (Including Treatment Plan, Clinical Procedures and Follow-Up Care) Plan Pays
D3310 endodontic therapy, anterior tooth (excluding final restoration) $114
D3320 endodontic therapy, bicuspid tooth (excluding final restoration) $134
D3330 endodontic therapy, molar (excluding final restoration) $171
D3332 incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $59
D3333 internal root repair of perforation defects $45
Endodontic Retreatment Plan Pays
D3346 retreatment of previous root canal therapy - anterior $131
D3347 retreatment of previous root canal therapy - bicuspid $151
D3348 retreatment of previous root canal therapy - molar $188
Apexification/Recalcification Procedures Plan Pays
D3351 apexification/recalcification/pulpal regeneration - initial visit (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $50
D3352 apexification/recalcification/pulpal regeneration - interim medication replacement (apical closure/calcific repair of perforations, root resorption, pulp space disinfection, etc.) $29
D3353 apexification/recalcification - final visit (includes completed root canal therapy -apical closure/calcific repair of perforations, root resorption, etc.) $81
Apicoectomy/Periradicular Services Plan Pays
D3410 apicoectomy/periradicular surgery - anterior $133
D3421 apicoectomy/periradicular surgery - bicuspid (first root) $144
D3425 apicoectomy/periradicular surgery - molar (first root) $158
D3426 apicoectomy/periradicular surgery (each additonal root) $50
D3430 retrograde filling - per root $36
D3450 root amputation - per root $81
Other Endodontic Procedures Plan Pays
D3920 hemisection (including any root removal), not including root canal therapy $59
Periodontics
Surgical Services (Including Usual Postoperative Care) Plan Pays
D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant $89
D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant $35
D4240 gingival flap procedure, including root planing - four or more contiguous teeth or tooth bounded spaces per quardant $113
D4241 gingival flap procedure, including root planing - one to three contiguous teeth or tooth bounded spaces per quardant $83
D4249 clinical crown lengthening - hard tissue $135
D4260 osseous surgery (including flap entry and closure) - four or more contiguous teeth or tooth bounded spaces per quadrant $170
D4261 osseous surgery (including flap entry and closure) - one to three teeth contiguous teeth or tooth bounded spaces per quadrant $149
D4263 bone replacement graft - first site in quadrant $72
D4264 bone replacement graft - each additonal site in quadrant $45
D4265 biologic materials to aid in soft and osseous tissue regeneration $66
D4270 pedicle soft tissue graft procedure $137
D4271 free soft tissue graft procedure (including donor site surgery) $149
D4273 subepithelial connective tissue graft procedures, per tooth $171
D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $81
D4275 soft tissue allograft $140
D4276 combined connective tissue and double pedicle graft, per tooth $176
Non-Surgical Periodontal Service Plan Pays
D4341 periodontal scaling and root planing - four or more teeth per quadrant $38
D4342 periodontal scaling and root planing - one to three teeth per quadrant $25
D4381 localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $9
Other Periodontal Services Plan Pays
D4910 periodontal maintenance $22
Prosthodontics (removable)
Complete Dentures (Including Routine Post-Delivery Care) Plan Pays
D5110 complete denture - maxillary $189
D5120 complete denture - mandibular $189
D5130 immediate denture - maxillary $210
D5140 immediate denture - mandibular $210
Partial Dentures (Including Routine Post-Delivery Care) Plan Pays
D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth) $150
D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth) $166
D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $214
D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $214
D5281 removable unilateral partial denture - one piece cast metal (including clasps and teeth) $122
Adjustments to Dentures Plan Pays
D5410 adjust complete dentures - maxillary $12
D5411 adjust complete dentures - mandibular $12
D5421 adjust partial denture - maxillary $12
D5422 adjust partial denture - mandibular $12
Repairs to Complete Dentures Plan Pays
D5510 repair broken complete denture base $27
D5520 replace missing or broken teeth - complete denture (each tooth) $23
Repairs to Partial Dentures Plan Pays
D5610 repair resin denture base $26
D5620 repair cast framework $32
D5630 repair or replace broken clasp $32
D5640 replace broken teeth - per tooth $23
D5650 add tooth to existing partial denture $28
D5660 add clasp to existing partial denture $32
D5670 replace all teeth and acrylic on cast metal framework (maxillary) $86
D5671 replace all teeth and acrylic on cast metal framework (mandibular) $90
Denture Rebase Procedures Plan Pays
D5710 rebase complete maxillary denture $72
D5711 rebase complete mandibular denture $72
D5720 rebase maxillary partial denture $72
D5721 rebase mandibular partial denture $72
Denture Reline Procedures Plan Pays
D5730 reline complete maxillary denture (chairside) $48
D5731 reline complete mandibular denture (chairside) $46
D5740 reline maxillary partial denture (chairside) $45
D5741 reline mandibular partial denture (chairside) $45
D5750 reline complete maxillary denture (laboratory) $63
D5751 reline complete mandibular denture (laboratory) $63
D5760 reline maxillary partial denture (laboratory) $63
D5761 reline mandibular partial denture (laboratory) $63
Interim Prosthesis Plan Pays
D5810 interim complete denture (maxillary) $99
D5811 interim complete denture (mandibular) $101
D5820 interim partial denture (maxillary) $82
D5821 interim partial denture (mandibular) $87
Other Removable Prosthetic Services Plan Pays
D5850 tissue conditioning, maxillary $23
D5851 tissue conditioning, mandibular $23
Implant Services
Implant Supported Prosthetics Plan Pays
D6058 abutment supported porcelain/ceramic crown $223
D6059 abutment supported porcelain fused to metal crown (high noble metal) $219
D6060 abutment supported porcelain fused to metal crown (predominantly base metal) $198
D6061 abutment supported porcelain fused to metal crown (noble metal) $207
D6062 abutment supported cast metal crown (high noble metal) $216
D6063 abutment supported cast metal crown (predominantly base metal) $189
D6064 abutment supported cast metal crown (noble metal) $243
D6065 implant supported porcelain/ceramic crown $234
D6066 implant supported porcelain fused to metal crown (titanium, titanium alloy, high noble metal) $234
D6067 implant supported metal crown (titanium, titanium alloy, high noble metal) $233
D6068 abutment supported retainer for porcelain/ceramic FPD $202
D6069 abutment supported retainer for porcelain fused to metal FPD (high noble metal) $216
D6070 abutment supported retainer for porcelain fused to metal FPD (predominantly base metal) $214
D6071 abutment supported retainer for porcelain fused to metal FPD (noble metal) $216
D6072 abutment supported retainer for cast metal FPD (high noble metal) $186
D6073 abutment supported retainer for cast metal FPD (predominantly base metal) $198
D6074 abutment supported retainer for cast metal FPD (noble metal) $202
D6075 implant supported retainer for ceramic FPD $216
D6076 implant supported retainer for porcelain fused to metal FPD (titanium, titanium alloy, or high noble metal) $225
D6077 implant supported retainer for cast metal FPD (titanium, titanium alloy, or high noble metal) $176
Other Implant Services Plan Pays
D6092 recement implant/abutment supported crown $16
D6093 recement implant/abutment supported fixed partial denture $23
Prosthodontics, fixed
Fixed Partial Denture Pontics Plan Pays
D6210 pontic - cast high noble metal $158
D6211 pontic - cast predominantly base metal $146
D6212 pontic - cast noble metal $161
D6240 pontic - porcelain fused to high noble metal $163
D6241 pontic - porcelain fused to predominantly base metal $146
D6242 pontic - porcelain fused to noble metal $156
D6245 pontic - porcelain/ceramic $176
D6250 pontic - resin with high noble metal $162
D6251 pontic - resin with predominantly base metal $144
D6252 pontic - resin with noble metal $153
Fixed Partial Denture Retainers-Inlays/Onlays Plan Pays
D6545 retainer - cast metal for resin bonded fixed prosthesis $72
D6548 retainer - porcelain/ceramic for resin bonded fixed prosthesis $86
D6600 inlay - procelain/ceramic, two surfaces $135
D6601 inlay - porcelain/ceramic, three or more surfaces $171
D6602 inlay - cast high noble metal, two surfaces $126
D6603 inlay - cast high noble metal, three or more surfaces $144
D6604 inlay - cast predominantly base metal, two surfaces $117
D6605 inlay - cast predominantly base metal, three or more surfaces $162
D6606 inlay - cast noble metal, two surfaces $125
D6607 inlay - cast noble metal, three or more surfaces $161
D6608 onlay - porcelain/ceramic, two surfaces $161
D6609 onlay - porcelain/ceramic, three or more surfaces $171
D6610 onlay - cast high noble metal, two surfaces $144
D6611 onlay - cast high noble metal, three or more surfaces $171
D6612 onlay - cast predominantly base metal, two surfaces $135
D6613 onlay - cast predominantly base metal, three or more surfaces $170
D6614 onlay - cast noble metal, two surfaces $138
D6615 onlay - cast noble metal, three or more surfaces $173
Fixed Partial Denture Retainers-Crowns Plan Pays
D6720 crown - resin with high noble metal $162
D6721 crown - resin with predominantly base metal $148
D6722 crown - resin with noble metal $149
D6740 crown - porcelain/ceramic $178
D6750 crown - porcelain fused to high noble metal $166
D6751 crown - porcelain fused to predominantly base metal $149
D6752 crown - porcelain fused to noble metal $158
D6780 crown - 3/4 cast high noble metal $162
D6781 crown - 3/4 cast predominantly base metal $153
D6782 crown - 3/4 cast noble metal $164
D6783 crown - 3/4 porcelain/ceramic $180
D6790 crown - full cast high noble metal $161
D6791 crown - full cast predominantly base metal $149
D6792 crown - full cast noble metal $162
Other Fixed Partial Denture Services Plan Pays
D6930 re-cement fixed partial denture $22
D6940 stress breaker $45
D6970 post and core in addition to fixed partial denture retainer, indirectly fabricated $57
D6972 prefabricated post and core in addition to fixed partial denture retainer $48
D6980 fixed partial denture repair, by report $36
Oral and Maxillofacial Surgery
Extractions (Includes Local Anesthesia, Suturing, if Needed, and Routine Postoperative Care) Plan Pays
D7111 extraction, coronal remnants - deciduous tooth $34
D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal) $44
Surgical Extractions (Includes Local Anesthesia, Suturing, If Needed, and Routine Postoperative Care Plan Pays
D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth. $41
D7220 removal of impacted tooth - soft tissue $49
D7230 removal of impacted tooth - partially bony $63
D7240 removal of impacted tooth - completely bony $72
D7241 removal of impacted tooth - completely bony, with unusual surgical complications $86
D7250 surgical removal of residual tooth roots (cutting procedure) $45
Other Surgical Prodecures Plan Pays
D7260 oroantral fistula closure $161
D7261 primary closure of a sinus perforation $108
D7270 tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $70
D7272 tooth transplantation (includes reimplantation from one site to another and splinting and/or stabilization) $99
D7280 surgical access of an unerupted tooth $81
Periodontics
Surgical Services (Including Usual Postoperative Care) Plan Pays
D7281 Surgical exposure of impacted or unerupted tooth to aid eruption $81
Oral and Maxillofacial Surgery
Other Surgical Prodecures Plan Pays
D7282 mobilization of erupted or malpositioned tooth to aid eruption $41
D7285 biopsy of oral tissue - hard (bone, tooth) $79
D7286 biopsy of oral tissue - soft $54
D7287 exfoliative cytological sample collection $23
Alveoloplasty-Surgical Preparation of Ridge for Dentures Plan Pays
D7310 alveoloplasty in conjunction with extractions - four or more teeth or tooth spaces, per quadrant $39
D7320 alveoloplasty not in conjuction with extractions - four or more teeth or tooth spaces, per quadrant $54
Vestibuloplasty Plan Pays
D7340 vestibuloplasty - ridge extension (secondary epithelialization) $153
Surgical Excision of Soft Tissue Lesions Plan Pays
D7410 excision of benign lesion up to 1.25 cm $68
D7411 excision of benign lesion greater than 1.25 cm $108
D7412 excision of benign lesion, complicated $171
D7413 excision of malignant lesion up to 1.25 cm $94
D7414 excision of malignant lesion greater than 1.25 cm $163
Surgical Excision of Intra-Osseous Lesions Plan Pays
D7440 excision of malignant tumor - lesion diameter up to 1.25 cm $179
D7441 excision of malignant tumor - lesion diameter greater than 1.25 cm $180
D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm $81
D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm $135
D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm $80
D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm $119
Surgical Excision of Soft Tissue Lesions Plan Pays
D7465 destruction of lesion(s) by physical or chemical method, by report $45
Excision of Bone Tissue Plan Pays
D7471 removal of lateral exostosis (maxilla or mandible) $90
D7472 removal of torus palatinus $117
D7473 removal of torus mandibularis $100
D7485 surgical reduction of osseous tuberosity $82
Surgical Incision Plan Pays
D7510 incision and drainage of abscess - intraoral soft tissue $33
D7520 incision and drainage of abscess - extraoral soft tissue $113
D7530 removal of foreign body from mucosa, skin, or subcutaneous alveolar tissue $45
D7540 removal of reaction producing foreign bodies, musculoskeletal system $68
D7550 partial ostectomy/sequestrectomy for removal of non-vital bone $48
D7560 maxillary sinusotomy for removal of tooth fragment or foreign body $216
Repair of Traumatic Wounds Plan Pays
D7910 suture of recent small wounds up to 5 cm $27
Other Repair Procedures Plan Pays
D7960 frenulectomy (frenectomy or frenotomy) - separate procedure $65
D7970 excision of hyperplastic tissue - per arch $59
D7972 surgical reduction of fibrous tuberosity $54
D7980 sialolithotomy $86
D7983 closure of salivary fistula $217
Orthodontics
Minor Treatment to Control Harmful Habits Plan Pays
D8210 removable appliance therapy $84
D8220 fixed appliance therapy $84
Adjunctive General Services
Unclassified Treatment Plan Pays
D9110 palliative (emergency) treatment of dental pain-minor procedure $16
D9120 fixed partial denture sectioning $18
Anesthesia Plan Pays
D9220 deep sedation/general anesthesia-first 30 minutes $61
D9221 deep sedation/general anesthesia-each additional 15 minutes $23
D9241 intravenous conscious sedation/analgesia-first 30 minutes $57
D9242 intravenous conscious sedation/analgesia-each additional 15 minutes $19
Professional Visits Plan Pays
D9440 office visit-after regularly scheduled hours $21
Miscellaneous Services Plan Pays
D9911 application of desensitizing resin for cervical and/or root surface, per tooth $8
D9930 treatment of complications (post-surgical) - unusual circumstances, by report $13

This is a brief description of the individual dental plan. A full explanation of benefits, limitations and exclusions is contained in the policy issued when coverage becomes effective. Policy Form Series IDN-2009. Underwritten and administered by Starmount Life Insurance Company.

*Subject to policy deductible, annual maximum and limitations and exclusions. Waiting periods do not apply in Washington.