PLAN BENEFIT DETAILS
Q-Dent Plan
Q-DENT DENTAL CARE
Benefit Schedule
Description
Out of Pocket for
Q-Dent Member
Clinical Oral Exams
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D0110: Initial Oral Exam None
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D0120: Periodic Oral Exam None
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D0150: Evaluation Comprehensive Oral None
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D0180: Evaluation Comprehensive Perio $14.00
X-Rays
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D0210: X-Ray, Intraoral, Complete Set None
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D0220: Periapical, Single None
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D0230: Periapical, Additional Film None
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D0270: Bitewing, Single Film None
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D0272: Bitewing, Two Films None
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D0330: Panoramic None
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D0340: Cephalometric (Ortho only) $66.00
Dental Prophylaxis
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D1110: Adult Prophy (Limit 2/year) None
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D1120: Child Prophy (Limit 2/year) None
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D1203: Topical Application (Child) None
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D1351: Sealant - Per Tooth $21.00
Restorations
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D2140: Amalgam, Permanent, 1 Surface $64.00
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D2150: Amalgam, Permanent, 2 Surface $83.00
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D2160: Amalgam, Permanent, 3 Surface $96.00
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D2161: Amalgam, Permanent, 4 Surface $115.00
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D2951: Amalgam, Pin Retention (2 Max.) $10.00
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D2330: Resin Composite 1 Surface Anterior $85.00
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D2331: Resin Composite 2 Surface Anterior $106.00
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D2332: Resin Composite 3 Surface Anterior $123.00
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D2335: Resin Composite 4 Surface Anterior $135.00
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D2391: Resin Composite 1 Surface Posterior $87.00
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D2392: Resin Composite 2 Surface Posterior $115.00
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D2393: Resin Composite 3 Surface Posterior $146.00
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D2394: Resin Composite 4 Surface Posterior $174.00
Crowns
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D2750: Crown, Gold (Gold cost extra) $665.00
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D2751: Crown, Porcelain $665.00
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D2930: Crown, Stainless Steel (Child) $178.00
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D2931: Crown, Stainless Steel (Adult) $272.00
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D2954: Post and Core Including pin $175.00
Other Restorative Services
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D2940: Zoe Sedative Base (Per Tooth) $79.00
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D2950: Core build Up (Including Pin) $163.00
Pulp Capping
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D3110: Direct Pulp Cap $43.00
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D3120: Pulp Cap Indirect $40.00
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D3220: Vital Pulpotomy $137.00
Root Canal Therapy
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D3310: Endodontics, 1 Canal $521.00
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D3320: Endodontics, 2 Canals $602.00
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D3330: Endodontics, 3 Canals $714.00
Periodontal Services
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D4210: Gingivectomy (Per Quad) $349.00
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D4342: Root Planning/Perio Scale (Per Quad) $169.00
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D4910: Periodontal Maintenance $93.00
Dentures
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D5110: Complete Upper Denture $1062.00
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D5120: Complete Lower Denture $1062.00
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D5211: Acrylic Partial, Treatment $696.00
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D5212: Acrylic Partial, Permanent $696.00
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D5730: Reline Denture Chair Side $199.00
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D6751: Bridge Abutment Porcelain $655.00
Oral Surgery
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D7140: Extraction, Erupted Tooth $120.00
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D7210: Surgical Extraction $182.00
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D7220: Impaction Soft Tissue $198.00
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D7230: Impaction Partial Bony $236.00
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D7240: Impaction Complete Bony $282.00
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D7510: Incision and Drain of Abcess $163.00
Orthodontics All Ages
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D8660: Ortho Records $177.00
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D8690: Ortho Class 1, 2 and 3 $4056.00
General Benefit Exclusions
- All dental services performed by a non participating dentist.
- Dental service benefits for injuries covered by workman’s compensation or any other liability dental services.
- Dental services that are not determined by selected dentist to be necessary services.
- Any expenses incurred for dental services prior to the effective date or during any waiting period.
- All charges in connection with the completion of claim forms or reports.
- Dental Services for setting fracture, dislocations, or treatment of malignancies.
- The cost of all drugs, all charges for dispensing drugs, all hospital costs.
- Dental services caused by disasters, epidemics, or military services.
- Benefits that you are entitled to receive at no cost through any government or privately funded program.
- Cosmetic Dentistry.
- Any tempora mandibular joint (TMJ) problems or craniomandibular joints or syndromes.
- Orthognathic surgery or treatment.
- Replacement of appliances, crowns, bridges due to loss or damage.
Q-DENT DENTAL CARE
Plan Coverage
No Charge Services
A member does not pay an extra charge to a chosen dentist for dental services that are fully prepaid by Q-Dents monthly capitation payments. The Dental Service contract schedule of benefits list NONE on the same line that describes the Dental service contract fully prepaid dental services.
Co-Payment Services
A member pays an extra charge (Co-Payment to a chosen dentist for dental services that are fully prepaid by Q-Dents monthly capitation payments.) The Dental service contract schedule of benefits lists the amount of the Co-Payment needed to cover the remainder of the cost for dental services that are not fully prepaid. The members pay all CO-PAYMENTS to the dentist the member chooses.
Usual Charge Services
Most dental services a member will usually need are covered by the Dental service contract In those cases when dental services are not covered by the Dental service contract, such dental services are also available to a patient at the chosen dentists USUAL CHARGE.
Higher Benefit Level
For Q-Dent members, as patients of the dentist they choose, there are no deductible or annual maximums that apply to the benefits of the plans prepaid dental insurance policy. The Dental service contracts benefits for pre-existing conditions, orthodontia for children and adults, and other specialist dental services are all available for the patients on the eligibility date of the Dental service contract.
Q-Dent encourages utilization of the Dental Service contract by offering preventative treatments (such as periodic exams and routine cleaning twice per year) at no extra charge. There are no claim forms or pre-authorization forms for the patient or the chosen dentist to complete.
When compared to indemnity plans, A Dental service contract offer more benefits for less cost, without any paperwork for a patient or the chosen dentist.
