Professional Dental Care is an Absolute Necessity for Living a Healthy, Happy and Productive Lifestyle

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HIGHLIGHTS OF THE Q-DENT PLAN

  Fully complies with all Louisiana Insurance Laws.

  Louisiana owned, administered and underwritten.

  No waiting periods.

  No annual or lifetime maximums.

  No claim forms.

  No deductible.

  Most pre-existing conditions
are covered.

  Doctor supported.

Membership Summary

Membership Agreement

Subscription Instructions

Participating Dentists

Benefit Schedule

Rate Schedule

Benefit Schedule for Q-Dent Plan

Description: Q-Dent Member
Out of Pocket
Clinical Oral Exams
D0110Initial Oral ExamNone
D0120Periodic Oral ExamNone
D0150Evaluation Comprehensive OralNone
D0180Evaluation Comprehensive Perio

14.00
X-Rays
D0210X-Ray, Intraoral, Complete SetNone
D0220Periapical, SingleNone
D0230Periapical, Additional FilmNone
D0270Bitewing, Single FilmNone
D0272Bitewing, Two FilmsNone
D0330PanoramicNone
D0340Cephalometric (Ortho only)66.00

Dental Prophylaxis
D1110Adult Prophy (Limit 2/year)None
D1120Child Prophy (Limit 2/year)None
D1203Topical Application (Child)None
D1351Sealant - Per Tooth21.00

Restorations
D2140Amalgam, Permanent, 1 Surface29.00
D2150Amalgam, Permanent, 2 Surface33.00
D2160Amalgam, Permanent, 3 Surface42.00
D2161Amalgam, Permanent, 4 Surface51.00
D2951Amalgam, Pin Retention (2 Max.)10.00
D2330Resin Composite 1 Surface Anterior44.00
D2331Resin Composite 2 Surface Anterior52.00
D2332Resin Composite 3 Surface Anterior75.00
D2335Resin Composite 4 Surface Anterior102.00
D2391Resin Composite 1 Surface Posterior52.00
D2392Resin Composite 2 Surface Posterior64.00
D2393Resin Composite 3 Surface Posterior79.00
D2394Resin Composite 4 Surface Posterior102.00

Crowns
D2750Crown, Gold (Gold cost extra)550.00
D2751Crown, Porcelain550.00
D2930Crown, Stainless Steel (Child)77.00
D2931Crown, Stainless Steel (Adult)124.00
D2954Post and Core Including pin77.00

Other Restorative Services
D2940Zoe Sedative Base (Per Tooth)32.00
D2950Core build Up (Including Pin)64.00

Pulp Capping
D3110Direct Pulp Cap16.00
D3120 Pulp Cap Indirect13.00
D3220Vital Pulpotomy53.00

Root Canal Therapy
D3310Endodontics, 1 Canal426.00
D3320Endodontics, 2 Canals479.00
D3330Endodontics, 3 Canals556.00

Periodontal Services
D4210Gingivectomy (Per Quad)356.00
D4342Root Planning/Perio Scale (Per Quad) 120.00
D4910Periodontal Maintenance51.00

Dentures
D5110Complete Upper Denture607.00
D5120Complete Lower Denture607.00
D5211Acrylic Partial, Treatment335.00
D5212Acrylic Partial, Permanent335.00
D5730Reline Denture Chair Side109.00
D6751Bridge Abutment Porcelain550.00

Oral Surgery
D7140Extraction, Erupted Tooth63.00
D7210Surgical Extraction107.00
D7220Impaction Soft Tissue158.00
D7230Impaction Partial Bony222.00
D7240Impaction Complete Bony188.00
D7510Incision and Drain of Abcess63.00

Orthodontics All Ages
D8660Ortho Records177.00
D8690Ortho Class 1, 2 and 34056.00


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