Dental Codes

Dental claims are reimbursed based on a Schedule of Benefits. The following subsets of the Select and Basic Plan Schedules include the most commonly used procedure codes. Note: the Basic Plan provides coverage for a limited range of services including diagnostic, and preventive. The Schedule dollar amount is the maximum reimbursement for the specified procedure code.

Covered individuals are responsible for the difference (if any) between the provider’s charge and the
Schedule reimbursement amount. See Summary Plan Description for listing



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