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Humana — HumanaOne Dental Value Plan (HI215)

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Plan Details

Humana

The HumanaOne Dental Value Plan HI215 plan is affordable, dependable coverage that helps you get the dental treatment you need, when you need it. Whether you need routine care or a major dental procedure, you know what to expect from HumanaOne Dental Value Plan. No waiting periods, no claim forms to file, no annual maximum and no dental fee surprises.

Code Services Member Pays
 

Appointments

D9310 Consultation (diagnostic service provided by dentist other than practitioner providing treatment). $45.00
D9430 Office visit (normal hours) $15.00
D9440 Office visit (after regularly scheduled hours) $55.00
D9999 Emergency visit during regularly scheduled hours, by report. $20.00
D9999 Broken appointments (without 24 hr. notice, per 15 min) —maximum $40 per broken appointment. No charge will be made due to emergencies $10.00
     
Code

Diagnostic

Member Pays
D0120 Periodic oral examination no charge
D0140 Limited/comprehensive/detailed and extensive oral eval no charge
D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver no charge
D0150 Limited/comprehensive/detailed and extensive oral eval no charge
D0160 Limited/comprehensive/detailed and extensive oral eval no charge
D0170 Re-evaluation—problem focused (not post-operative visit) no charge
D0180 Comprehensive periodontal evaluation $35.00
D0210 X-ray intraoral—complete series including bitewings no charge
D0220 X-ray intraoral—periapical, first film no charge
D0230 X-ray intraoral—periapical, each additional film no charge
D0240 X-rays intraoral—occlusal film no charge
D0250 Extraoral—first film no charge
D0260 Extraoral—each additional film no charge
D0270 X-ray bitewing—single film no charge
D0272 X-ray bitewings—two films no charge
D0273 X-ray bitewings—three films (two per calendar year) no charge
D0274 Bitewings—four films no charge
D0277 X-ray bitewings, vertical—seven to eight films (two per calendar year). no charge
D0330 Panoramic film no charge
D0350 Oral/facial photography images no charge
D0415 Collect microorganisms culture & sensitivity no charge
D0425 Caries susceptibility tests no charge
D0431 Oral cancer screening using a special light source $70.00
D0460 Pulp vitality tests no charge
D0470 Diagnostic casts no charge
D0472 Pathology report—gross examination of lesion no charge
D0473 Pathology report—microscopic examination of lesion no charge
D0474 Pathology report—microscopic examination of lesion and area no charge
     
Code

Preventive

Member Pays
D1110 Prophylaxis—adult, routine (two per calendar year, by primary care dentist) no charge
D1120 Prophylaxis—child, routine (two per calendar year) no charge
D1203 Topical application of fluoride (not including prophylaxis)—child (up to 16 years of age) (two per calendar year) no charge
D1204 Topical application of fluoride—adult (two per calendar year, by primary care dentist) no charge
D1206 Topical fluoride varnish (for child <16) (two per calendar year) no charge
D1310 Nutrition counseling for the control or avoidance of dental disease no charge
D1320 Tobacco counseling services for the control or prevention of oral disease no charge
D1330 Oral hygiene instruction no charge
D1351 Sealant—per tooth (permanent teeth only to age 16) $20.00
D1510 Space maintainer—fixed, unilateral (through age 14) $95.00
D1515 Space maintainer—fixed, bilateral (through age 14) $135.00
D1520 Space maintainer—removable, unilateral (through age 14) $105.00
D1525 Space maintainer—removable, bilateral (through age 14) $115.00
D1550 Recementation of space maintainer $20.00
     
Code

Restorative

Member Pays
D2140 Amalgam—one surface, primary or permanent $30.00
D2150 Amalgam—two surfaces, primary or permanent $35.00
D2160 Amalgam—three surfaces, primary or permanent $40.00
D2161 Amalgam—four or more surfaces, primary or permanent. $45.00
D2940 Sedative filling $25.00
     
Code

Resin Restorative

Member Pays
D2330 Resin based composite—one surface, anterior $45.00
D2331 Resin based composite—two surfaces, anterior $60.00
D2332 Resin based composite—three surfaces, anterior $75.00
D2335 Resin based composite—four or more surfaces or involving incisal angle (anterior) $95.00
D2390 Resin based composite crown, anterior $90.00
D2391 Resin based composite—one surface, posterior $70.00
D2392 Resin based composite—two surfaces, posterior $90.00
D2393 Resin based composite—three surfaces, posterior $110.00
D2394 Resin based composite—four or more surfaces, posterior $130.00
D2510 Inlay—metallic, one surface $345.00
D2520 Inlay—metallic, two surfaces $355.00
D2530 Inlay—metallic, three or more surfaces $365.00
D2542* Onlay—metallic, two surfaces $370.00
D2543* Onlay—metallic, three surfaces $380.00
D2544* Onlay—metallic, four or more surfaces $390.00
D2610* Inlay—porcelain/ceramic, one surface $370.00
D2620* Inlay—porcelain/ceramic, two surfaces $380.00
D2630* Inlay—porcelain/ceramic, three or more surfaces $390.00
D2642* Onlay—porcelain/ceramic, two surfaces $395.00
D2643* Onlay—porcelain/ceramic, three surfaces $405.00
D2644* Onlay—porcelain/ceramic, four or more surfaces $415.00
D2650* Inlay—resin based composite, one surface $345.00
D2651* Inlay—resin based composite, two surfaces $355.00
D2652* Inlay—resin based composite, three or more surfaces $365.00
D2662* Onlay—resin based composite, two surfaces $370.00
D2663* Onlay—resin based composite, three surfaces $380.00
D2664* Onlay—resin based composite, four or more surfaces $410.00
     
Code

Crown and Bridge

Member Pays
D2710* Crown—resin based composite, indirect $410.00
D2712* Crown—3/4 resin based composite, indirect $410.00
D2720* Crown—resin with high noble metal $410.00
D2721 Crown—resin with predominantly base metal $410.00
D2722* Crown—resin with noble metal $410.00
D2740 Crown—porcelain/ceramic substrate $410.00
D2750* Crown—porcelain fused to high noble metal $410.00
D2751 Crown—porcelain fused to predominantly base metal $410.00
D2752* Crown—porcelain fused to noble metal $410.00
D2780* Crown—3/4 cast high noble metal $410.00
D2781 Crown—3/4 cast predominantly base metal $410.00
D2782* Crown—3/4 cast noble metal $410.00
D2783* Crown—3/4 porcelain/ceramic $410.00
D2790* Crown—full cast high noble metal $410.00
D2791 Crown—full cast predominantly base metal $410.00
D2792* Crown—full cast noble metal $410.00
D2794* Crown—titanium $410.00
D2799 Provisional crown no charge
D2910 Recement inlay $25.00
D2915 Recement cast or prefabricated post and core no charge
D2920 Recement crown $25.00
D2930 Prefabricated stainless steel crown—primary tooth $110.00
D2931 Prefabricated stainless steel crown—permanent tooth $35.00
D2932 Prefabricated resin crown $110.00
D2933 Prefabricated stainless steel crown with resin window $110.00
D2934 Prefabricated esthetic coated stainless steel crown—primary tooth $110.00
D2950 Core buildup, including any pins $80.00
D2951 Pin retention—per tooth, in addition to restoration $25.00
D2952 Cast post and core in addition to crown $175.00
D2953 Each additional cast post—same tooth $140.00
D2954 Prefabricated post and core in addition to crown $120.00
D2955 Post removal $20.00
D2957 Each additional prefabricated post—same tooth, base metal post $45.00
D2960 Labial veneer (resin laminate)—chairside $290.00
D2961* Labial veneer (resin laminate)—laboratory $425.00
D2962* Labial veneer (porcelain laminate)—laboratory $475.00
D2971 Additional procedure—new crown existing partial denture $70.00
D2980 Crown repair $25.00
D6940 Stress breaker $170.00
D6950 Precision attachment $220.00
D6970* Cast post and core, in addition to fixed partial denture retainer $120.00
D6972 Prefabricated post and core in addition to fixed partial denture retainer, base metal post $120.00
D6976* Each additional cast post—same tooth $100.00
D6977 Each additional prefabricated post—same tooth $100.00
     
Code

Prosthodontics (fixed)

Member Pays
D6210* Pontic—cast high noble metal $410.00
D6211 Pontic—cast predominantly base metal $410.00
D6212* Pontic—cast noble metal $410.00
D6240* Pontic—porcelain fused to high noble metal $410.00
D6241 Pontic—porcelain fused to predominantly base metal $410.00
D6242* Pontic—porcelain fused to noble metal $410.00
D6750* Crown—porcelain fused to high noble metal $410.00
D6751 Crown—porcelain fused to predominantly base metal $410.00
D6752* Crown—porcelain fused to noble metal $410.00
D6790* Crown—full cast high noble metal $410.00
D6791 Crown—full cast predominantly base metal $410.00
D6792* Crown—full cast noble metal $410.00
D6794* Crown—titanium $410.00
D6930 Recement fixed partial denture (per unit) $45.00
D6973 Core buildup for retainer, including any pins $70.00
     
Code

Prosthodontics

Member Pays
D5110* Complete denture—maxillary $550.00
D5120* Complete denture—mandibular $550.00
D5130* Immediate denture—maxillary $550.00
D5140* Immediate denture—mandibular $550.00
D5211* Maxillary partial denture—resin base $495.00
D5212* Mandibular partial denture—resin base $495.00
D5213* Maxillary partial denture—cast metal framework, resin denture bases $525.00
D5214* Mandibular partial denture—cast metal framework, resin denture bases $525.00
D5225* Maxillary partial denture—flexible (including clasps, rests and teeth) $525.00
D5226* Mandibular partial denture—flexible (including clasps, rests and teeth) $525.00
D5281* Removable partial denture—one piece cast metal $445.00
D5410 Adjust complete denture—maxillary $25.00
D5411 Adjust complete denture—mandibular $25.00
D5421 Adjust partial denture—maxillary $25.00
D5422 Adjust partial denture—mandibular $25.00
D5660* Add clasp to existing partial denture $110.00
     
Code

Endodontics

Member Pays
D3110 Pulp cap—direct (excluding final restoration) $25.00
D3120 Pulp cap—indirect (excluding final restoration) $20.00
D3220 Therapeutic pulpotomy $65.00
D3221 Pulpal debridement, primary and permanent teeth $135.00
D3230 Pulpal therapy (resorbable filling)—anterior, primary tooth (excluding final restoration) $65.00
D3240 Pulpal therapy (resorbable filling)—posterior, primary tooth (excluding final restoration) $100.00
D3310 Root canal therapy—anterior (excluding final restoration) $175.00
D3320 Root canal therapy—bicuspid (excluding final restoration) $270.00
D3330 Root canal therapy—molar (excluding final restoration) $390.00
D3331 Treatment of root canal obstruction—non-surgical access. $110.00
D3332 Incomplete endodontic therapy—inoperable or fractured tooth $110.00
D3333 Internal root repair of perforation defects $120.00
D3351 Apexification/recalcification—initial visit $140.00
D3352 Apexification/recalcification—interim $100.00
D3353 Apexification/recalcification—final visit $140.00
D3410 Apicoectomy/periradicular surgery—anterior $210.00
D3421 Apicoectomy/periradicular surgery—bicuspid (first root) $220.00
D3425 Apicoectomy/periradicular surgery—molar (first root) $220.00
D3426 Apicoectomy/periradicular surgery (each additional root) $90.00
D3430 Retrograde filling—per root $55.00
D3450 Root amputation—per root (not covered in conjunction with procedure D3920) $130.00
D3910 Surgical procedure to isolate tooth with rubbed dam $50.00
D3920 Hemisection not included in root canal therapy $120.00
D3950 Root canal prepare and fit preformed dowel/post $25.00
     
Code

Peridontics (gum treatment)

Member Pays
D4210 Gingivectomy/gingivoplasty—four or more teeth, per quadrant $195.00
D4211 Gingivectomy/gingivoplasty per tooth—one to three teeth, per quadrant $100.00
D4240 Gingival flap, including root planing—four or more teeth, per quadrant $220.00
D4241 Gingival flap, including root planing—one to three teeth, per quadrant $150.00
D4245 Apically positioned flap $225.00
D4249 Clinical crown lengthening—hard tissue $220.00
D4260 Osseous surgery—four or more teeth or bounded spaces, per quadrant $425.00
D4261 Osseous surgery—one to three teeth, per quadrant $400.00
D4263 Bone replacement graft—first site in quadrant $290.00
D4264 Bone replacement graft—each additional site in quadrant bone $200.00
D4265 Biological materials which can aid soft and osseous tissue regeneration $135.00
D4266 Guided tissue regeneration—resorbable barrier, per site $360.00
D4267 Guided tissue regeneration—nonresorbable barrier, per site (includes membrane removal) $425.00
D4270 Pedicle soft tissue graft procedure $335.00
D4271 Free soft tissue graft procedure (including donor site surgery) $340.00
D4273 Subeptithelial connective tissue graft, tooth $425.00
D4274 Distal or proximal wedge procedure $120.00
D4275 Soft tissue allograft $460.00
D4320 Provisional splinting—intracoronal $135.00
D4321 Provisional splinting—extracoronal $115.00
D4341 Periodontal scaling and root planing, per quadrant $85.00
D4342 Periodontal scaling and root planing 1 to 3 teeth per quadrant $70.00
D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $80.00
D4381 Localized delivery of chemotherapeutic agents (per tooth) $70.00
D4910 Periodontal maintenance $70.00
     
Code

Extractions/oral and maxillofacial surgery

Member Pays
D7111 Coronal remnants, deciduous tooth no charge
D7140 Extraction, erupted tooth or exposed tooth $55.00
D7210 Surgical removal of erupted tooth $60.00
D7220 Removal of impacted tooth—soft tissue $75.00
D7230 Removal of impacted tooth—partially bony $95.00
D7240 Removal of impacted tooth—completely bony $135.00
D7241 Removal of impacted tooth—completely bony, unusual complications by report $175.00
D7250 Surgical removal of residual tooth roots $50.00
D7260 Oroantral fistula closure $450.00
D7261 Primary closure of a sinus perforation $275.00
D7270 Tooth stabilization of accidentally avulsed or displaced tooth $95.00
D7280 Surgical access of an unerupted tooth (excluding wisdom teeth) $160.00
D7282 Mobilization of erupted or malposed tooth to aid eruption $120.00
D7285 Biopsy of oral tissue—hard (bone, tooth) $450.00
D7286 Biopsy of oral tissue—soft (all others) $155.00
D7287 Exfoliative cytological sample collection $70.00
D7288 Brush biopsy—transepithelial sample collection $75.00
D7310 Alveoloplasty in conjunction with extractions—per quadrant $50.00
D7311 Alveoloplasty in conjunction with extractions—one to three teeth or tooth spaces, per quadrant $25.00
D7320 Alveoloplasty not in conjunction with extractions—per quadrant $90.00
D7321 Alveoloplasty not in conjunction with extractions—one to three teeth or tooth spaces, per quadrant $65.00
D7450 Removal of benign odontogenic cyst or tumor—up to 1.25 cm $210.00
D7451 Removal of benign odontogenic cyst or tumor—greater than 1.25 cm $285.00
D7471 Removal of lateral exostosis (maxilla or mandible) $130.00
D7472 Removal of torus palatinus $80.00
D7473 Removal of torus mandibularis $80.00
D7485 Surgical reduction of osseous tuberosity $75.00
D7510 Incision and drainage of abscess—intraoral soft tissue $45.00
D7970 Excision hyperplastic tissue—per arch $100.00
D7971 Excision of pericoronal gingival $65.00
     
Code

Repairs to prosthetics

Member Pays
D5510* Repair broken complete denture base $65.00
D5520* Replace missing or broken teeth—complete denture (each tooth) $65.00
D5610* Repair resin denture base $65.00
D5620* Repair cast framework $65.00
D5630* Repair or replace broken clasp $65.00
D5640* Replace broken teeth—per tooth $65.00
D5650* Add tooth to existing partial denture $60.00
D5670* Replace all teeth and acrylic framework—maxillary $255.00
D5671* Replace all teeth and acrylic framework—mandibular $350.00
D5710* Rebase complete maxillary denture $230.00
D5711* Rebase complete mandibular denture $230.00
D5720* Rebase maxillary partial denture $230.00
D5721* Rebase mandibular partial denture $230.00
D5730 Reline complete maxillary denture (chairside) $110.00
D5731 Reline complete mandibular denture (chairside) $110.00
D5740 Reline maxillary partial denture (chairside) $110.00
D5741 Reline mandibular partial denture (chairside) $110.00
D5750* Reline complete maxillary denture (laboratory) $180.00
D5751* Reline complete mandibular denture (laboratory) $180.00
D5760* Reline maxillary partial denture (laboratory) $180.00
D5761* Reline mandibular partial denture (laboratory) $180.00
D5810* Interim complete denture (maxillary) $300.00
D5811* Interim complete denture (mandibular) $300.00
D5820* Interim partial denture (maxillary) $210.00
D5821* Interim partial denture (mandibular) $210.00
D5850 Tissue conditioning, maxillary $45.00
D5851 Tissue conditioning, mandibular $45.00
D6214* Pontic titanium $410.00
D6245* Pontic—porcelain/ceramic $410.00
D6250* Pontic—resin with high noble metal $410.00
D6251 Pontic—resin with predominantly base metal $410.00
D6252* Pontic—resin with noble metal $410.00
D6253* Provisional pontic no charge
D6545* Retainer—cast metal, resin bonded fixed prosthesis $300.00
D6548* Retainer—porcelain/ceramic, resin bonded fixed prosthesis $300.00
D6600* Inlay—porcelain/ceramic, two surfaces $410.00
D6601* Inlay—porcelain/ceramic, three or more surfaces $410.00
D6602* Inlay—cast high noble metal, two surfaces $410.00
D6603* Inlay—cast high noble metal, three or more surfaces $410.00
D6604 Inlay—cast predominantly base metal, two surfaces $410.00
D6605 Inlay—cast predominantly base metal, three or more surfaces $410.00
D6606* Inlay—cast noble metal, two surfaces $410.00
D6607* Inlay—cast noble metal, three or more surfaces $410.00
D6608* Onlay—porcelain/ceramic, two surfaces $410.00
D6609* Onlay—porcelain/ceramic, three or more surfaces $410.00
D6610* Onlay—cast high noble metal, two surfaces $410.00
D6611* Onlay—cast high noble metal, three or more surfaces $410.00
D6612 Onlay—cast predominantly base metal, two surfaces $410.00
D6613 Onlay—cast predominantly base metal, three or more surfaces $410.00
D6614* Onlay—cast noble metal, two surfaces $410.00
D6615* Onlay—cast noble metal, three or more surfaces $410.00
D6624* Inlay titanium $410.00
D6634* Onlay titanium $410.00
D6710* Crown—indirect resin based composition $410.00
D6720* Crown—resin with high noble metal $410.00
D6721 Crown—resin with predominantly base metal $410.00
D6722* Crown—resin with noble metal $410.00
D6740* Crown—porcelain/ceramic $410.00
D6780* Crown—3/4 cast high noble metal $410.00
D6781 Crown—3/4 cast predominantly base metal $410.00
D6782* Crown—3/4 cast noble metal $410.00
D6783* Crown—3/4 porcelain/ceramic, denture $410.00
     
Code

Adjunctive general services

Member Pays
D9110 Palliative (emergency) treatment of dental pain—minor procedure. $25.00
D9215 Local anesthesia no charge
D9220 General anesthesia—first 30 minutes (limited to the removal of partial, or complete bony impacted teeth) $205.00
D9221 General anesthesia—additional 15 minutes (limited to the removal of partial, or complete bony impacted teeth) $95.00
D9230 Analgesia (nitrous oxide), per 15 minutes $45.00
D9241 I.V. conscious sedation—first 30 minutes (limited to the removal of partial, or complete bony impacted teeth) $205.00
D9242 I.V. conscious sedation—additional 15 minutes (limited to the removal of partial, or complete bony impacted teeth) $90.00
D9450 Case presentation, detailed and extensive treatment planning no charge
D9951 Occlusal adjustment—limited $45.00
D9952 Occlusal adjustment—complete $205.00
     
 

Orthodontics

 
  NOTE: Members can receive a 25 percent savings by visiting an in-network orthodontist.  
     
     
     
  Current Dental Technology © 2007 American Dental Association. All rights reserved.  

* 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..


NOTE:
Waiting Periods on Types of Services
   
Preventive None
Diagnostic None
Basic None
Major None

Preventive care
  • Routine oral exams
  • Prophylaxis (routine cleanings) – two per calendar year
  • Topical fluoride application (up to age 16) – two per calendar year
  • Topical fluoride application (adult) – two per calendar year, by primary care dentist
Diagnostic care
  • Intra-oral occlusal film
  • Bitewing X-rays (up to a set of four) – two per calendar year
  • Full-mouth X-rays (panoramic film) – once per three calendar years
Endodontics care
  • Root canal therapy
  • Pulpal debridement, primary and permanent teeth
  • Apexification/recalcification
  • Apicoectomy/periradicular surgery
Periodontics care
  • Gingivectomy/gingivoplasty
  • Osseous surgery
  • Pedicle/free soft tissue grafts
  • Periodontal scaling and root planing
Orthodontia
  • NOTE: Members can receive a 25 percent savings by visiting an in-network orthodontist.

 

Limitations and exclusions may apply.

Offered or administered by HumanaDental Insurance Company, the Dental Concern, Inc., CompBenefits Insurance Company, CompBenefits Company, CompBenefits Dental, Inc., CompBenefits of Alabama, Inc., CompBenefits of Georgia, Inc., American Dental Providers of Arkansas, Inc., American Dental Plan of North Carolina, Inc., or DentiCare, Inc. d/b/a CompBenefits.