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Specialty Benefit Copayment Schedule - Heritage Series

How Your Specialty Benefit (SB) Works

Should you need the services of a specialty dentist, you may receive those services without a referral from your Plan Dentist.

To find a Plan Specialty Dentist, go to Find a Dentist. For more information about the SB plan or for assistance in finding a Plan Specialty Dentist, call Member Customer Service at 800.443.2995 (hours of operation 7:00 am – 5:30 pm CT, Monday-Friday).  If you use an SB Plan Specialty Dentist (a specialty dentist who is a part of the plan provider network and accepts SB copayments) for a service listed on the schedule below, you will pay the corresponding Member Copayment shown in the “SB Specialty Dentist Copayment” column at the time of service.

All other services obtained from an SB Plan Specialty Dentist, and all services obtained from a Non-SB Plan Speciality Dentist (a specialty dentist who is a part of the plan provider network but does not accept SB copayments), will be provided to you at a reduction in that Plan Specialty Dentist’s normal retail charges. A 15% reduction applies if that dentist’s specialty is endodontics. A 25% reduction applies if that dentist has any other type of specialty, including but not limited to orthodontics. You will be responsible for paying the entire reduced charge at the time of service or in accordance with that Plan Specialty Dentist’s billing procedures.

If you choose to go to a Non-Plan Specialty Dentist (a specialty dentist who is not part of the plan provider network), you may still receive benefits!

If you obtain a service listed on the schedule below from a Non-Plan Specialty Dentist, you will be responsible for paying that specialty dentist’s entire normal retail charge for the service at the time of service or in accordance with that specialty dentist’s billing procedures. You may then submit a completed claim form with an itemized bill attached to United Dental Care of Texas, Inc. (You may obtain claim forms by contacting Customer Service at 800.443.2995.) You will be reimbursed the lesser of (a) the corresponding amount shown in the “Maximum Reimbursement with a Non-Plan Specialty Dentist” column of the schedule below or (b) the amount charged by that specialty dentist for service.

Payment for any other service of a Non-Plan Specialty Dentist, at that specialty dentist’s normal retail charge, is your responsibility, except for Plan Benefits for covered dental Emergency Services.

Annual Maximum Benefit

There is no annual maximum benefit for services of an SB or Non-SB Plan Specialty Dentist. For services of a Non-Plan Specialty Dentist, there is a $2,000 annual maximum benefit.

Sample Schedule

$ADA Code** Service Description SB Plan Specialty Dentist Copayment Maximum Reimbursement with A Non-Plan Specialty Dentist
Appointments
D0140 Limited oral evaluation - problem focused $35 $20
D0150 Comprehensive oral evaluation - new or established patient‡ (once in any 6 calendar months) $45 $25
D0160 Detailed and extensive oral evaluation - problem focused, by report $67 $45
D0170 Re-evaluation - limited, problem focused (established patient; not post-operative visit) $35 $25
D0180 Comprehensive periodontal evaluation - new or established patient $80 $50
Endodontics
D3320 Bicuspid (excluding final restoration) $280 $320
D3330 Molar (excluding final restoration) $395 $405
D3346 Retreatment of previous root canal therapy - anterior $360 $230
D3347 Retreatment of previous root canal therapy - bicuspid $525 $265
D3348 Retreatment of previous root canal therapy - molar $545 $345
D3410 Apicoectomy/periradicular surgery - anterior $265 $335
D3421 Apicoectomy/periradicular surgery - bicuspid (first root) $280 $420
D3425 Apicoectomy/periradicular surgery - molar (first root) $310 $390
D3430 Retrograde filling - per root $90 $85
Periodontics
D4210 Gingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant $355 $195
D4211 Gingivectomy or gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant $100 $65
D4260 Osseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teeth spaces per quadrant $495 $395
D4261 Osseous surgery (including flap entry and closure) - one to three contiguous teeth or bounded teeth spaces per quadrant $215 $170
D4341 Periodontal scaling and root planing - four or more teeth per quadrant $100 $90
D4342 Periodontal scaling and root planing - one to three teeth per quadrant $70 $65
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $80 $50
Oral Surgery
D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $80 $120
D7220 Removal of impacted tooth - soft tissue $105 $125
D7230 Removal of impacted tooth - partially bony $135 $155
D7240 Removal of impacted tooth - completely bony $200 $130
D7241 Removal of impacted tooth - completely bony, with unusual surgical complications $220 $180
D7250 Surgical removal of residual tooth roots (cutting procedure) $75 $125
D7310 Alveoloplasty in conjunction with extractions - per quadrant $180 $70
D7320 Alveoloplasty not in conjunction with extractions - per quadrant $130 $150
D7510 Incision and drainage of abscess - intraoral soft tissue $105 $55
D7960 Frenulectomy (frenectomy or frenotomy) - separate procedure $185 $145
Other Services
D9241 Intravenous conscious sedation/analgesia - first 30 minutes $170 $115

This is a sample schedule only. It is not an Evidence of Coverage. Please see the Group Dental Service Agreement, Evidence of Coverage, and Copayment Schedule, which determine all rights, benefits, and applicable limitations and exclusions.

Listed copayments apply only to SB Specialty Dentists who perform the corresponding listed services.  Plan Specialty Dentists may not perform or offer all services listed.  Availability and participation of SB and Non-SB Plan Specialty Dentists are subject to change.

**Current and prior versions of the Current Dental Terminology (CDT) codes (in the ADA Code column) and descriptors (in the Service Description column) are copyrighted by the American Dental Association (ADA) and are used by permission. © 2004 American Dental Association.  All rights reserved.

‡More often if medically necessary as determined by attending Plan Dentist.

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