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Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for IIIIIHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionPeriodic oral evaluation (maximum of two per calendar year)*Limited oral evaluation - problem focused (maximum of two per calendar year)Oral Evaluation under three years of age, over three years of age will be disallowedComprehensive oral evaluation - new or established patient (maximum of two per calendar year)*Detailed and extensive oral evaluation - problem focused, by report.Comprehensive periodontal evaluationIntraoral - complete series (including bitewings) (once in 36 months)Intraoral - periapical first filmIntraoral - periapical each additional filmIntraoral - occlusal filmExtra oral - 2D radiographic imageBitewing - single filmBitewings - two filmsBitewings - three filmsBitewings - four filmsVertical bitewings - 7 to 8 filmsOther temporomandibular joint films, by reportPanoramic film.Cephalometric FilmOral/Facial Photographic ImagesLab processing for microbial specimenBacteriologic studies for determination of pathologic agentsPulp Vitality Tests - Only for diagnostic and emergency %100%100%100%100%100%100%100%100%100%100%100%
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for Implants:High Plan 3,000.00 3,000.00 2,000.00Fund IIIID4346D4355D4910IIID2140D2150IIIIDiagnostic castsProphylaxis - adult, maximum of two per calendar year*Prophylaxis - child, maximum of two per calendar year*Topical fluoride varnishTopical application of fluoride, maximum of two per calendar yearSealant - per tooth (applied to unrestored permanent molars, once per tooth every four years through agePreventive resin restoration is a moderate to high caries risk patient permanent tooth conservativeSilver Diamine Fluoride: Application of caries arresting medicament, per toothSpace maintainer - fixed - unilateral (before age 19)Space maintainer - fixed - bilateral (before age 19), maxillarySpace maintainer - fixed - bilateral (before age 19), mandibularSpace maintainer - removable - unilateralSpace maintainer - removable - bilateral maxillarySpace maintainer - removable - bilateral mandibularRe-cement or re-bond space maintainer-maxillaryRe-cement or re-bond space maintainer-mandibularRe-cement or re-bond space maintainer-per quadrantRemoval of unilateral fixed bilateral space maintainer-per quadrantRemoval of fixed bilateral space maintainer-maxillaryRemoval of fixed bilateral space maintainer-mandibularDistal Shoe Space Maintainer - fixed unilateral (for first molars only for premature loss of second primarymolars (A, J, K and T)Scaling in the presence of generalized moderate or severe gingival inflammation-full mouth after overallFull Mouth Debridement to enable comprehensive evaluationPeriodontal maintenance (following active periodontal therapy - Four periodontal cleanings per calendaryear, not to exceed two periodontal cleanings per calendar year if combined with preventative cleanings).Amalgam - one surface, primary or permanentAmalgam - two surfaces, primary or 0% 77.31 97.40 98.43 133.14
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for igh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionAmalgam - three surfaces, primary or permanentAmalgam - four or more surfaces, primary or permanentResin-based composite - one surface, anteriorResin-based composite - two surfaces, anteriorResin-based composite - three surfaces, anteriorResin-based composite - four or more surfaces or involving incisal angle (anterior)Resin-based composite crown, anteriorResin-based composite - one surface, posteriorResin-based composite - two surfaces, posteriorResin-based composite - three surfaces, posteriorResin-based composite - four or more surfacesRecement inlayRecement or re-bond indirectly fabricated or Prefabricated Post and CoreRecement crownPrefabricated stainless steel crown - primary toothSedative fillingInterim therapeutic restoration - primary toothPin retention - per tooth, in addition to restorationPulp cap - direct (excluding final restoration)Pulp cap - indirect (excluding final restoration)Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocementaljunction and application of medicamentPulpal Debridement, primary and permanent teeth, disallowed when endodontic treatment is completedby the same dentist/dental officeAnterior (excluding final restoration)Bicuspid (excluding final restoration)Molar (excluding final restoration)Retreatment of previous root canal therapy - anterior3 115.00 132.00 92.29 114.89 140.41 177.41 217.23 99.09 147.42 172.63 188.48 60.97 60.97 60.97 181.41 66.16 66.16 32.20 39.63 39.63 110.52 141.46 180.43 126.16 157.03 191.93 242.46 296.91 135.42 196.21 235.96 257.62 83.33 83.33 83.33 247.95 90.41 90.41 44.03 57.39 57.39 156.52 130.05 184.14 679.79 766.71 909.53 707.48 800.62 975.61 1255.60 832.14
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for D4266IID4267IID4270D4273D4274IIIIIIHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionRetreatment of previous root canal therapy - bicuspidRetreatment of previous root canal therapy - molarApicoectomy/periradicular surgery - anteriorApicoectomy/periradicular surgery - bicuspid (first root)Apicoectomy/periradicular surgery - molar (first root)Apicoectomy/periradicular surgery (each additional root)Retrograde filling - per rootHemisection, not including root canal therapy, only per posterior tooth per lifetimeGingivectomy or gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrantGingivectomy or gingivoplasty - one to three teeth, per quadrantGingival flap procedure, including root planing - four or more contiguous teeth or bounded teeth spacesGingival flap procedure, including root planing - one to three teeth, per quadrantApically positioned flapClinical crown lengthening - hard tissueOsseous surgery (including flap entry and closure) - four or more contiguous teeth or bounded teethspaces per quadrantOsseous surgery (including flap entry and closure) - 1-3 teeth/quadrantBone replacement graft - first site in quadrantBone replacement graft - each additional site in quadrantBiologic Materials to aid soft/osseous. tissue regeneration, once per site on natural teeth, not to exceedtwo sites/tooth per quadrant per 36 monthsGuided tissue regeneration-resorb barrier, per site, once per site on natural teeth, not to exceed twosites/tooth per quadrant per 36 monthGuided tissue regeneration-nonresorb barrier, per site, once per site on natural teeth, not to exceed twosites/tooth per quadrant per 36 monthsPedicle soft tissue graft procedureSubepithelial connective tissue graft proceduresDistal or Proximal Wedge procedure4 804.04 965.61 463.73 568.27 591.95 394.93 130.05 266.26 382.54 189.12 542.00 344.29 364.32 632.29 877.74 972.26 1237.36 653.89 697.14 809.09 653.89 177.75 356.21 475.06 258.49 728.26 436.98 443.81 864.22 1199.69 671.95 390.09 177.81 169.77 918.44 533.20 228.99 228.99 368.12 488.77 368.12 457.98 595.67 845.23 390.91 814.18 1155.26 534.31
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for Implants:High Plan 3,000.00 3,000.00 2,000.00Fund 12IID5520D5611D5612D5621IIIIIIIISoft tissue allograftCombined connective tissue and double pedicle graftFree Soft Tissue Graft Procedure (including donor site surgery), first tooth or edentulous tooth position inFree Soft Tissue Graft Procedure (including donor site surgery, each additional contiguous tooth oredentulous tooth position in same graft siteAutogenous connective tissue graft procedure each additional contiguous tooth - two graphs per 36month, per quadrantNon-autogenous connective tissue graft each additional contiguous tooth, position in same graft site - twographs per 36 month, per quadrantSplint – intra-coronal; natural teeth or prosthetic crownsSplint – extra-coronal; natural teeth or prosthetic crownsPeriodontal scaling and root planing - four or more contiguous teeth or bounded teeth spaces perquadrant. Two quadrants are allowed on the same date of service. Additional quadrants will deny.Periodontal scaling and root planing - one to three teeth/ quadrantLocalized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue,Unscheduled dressing change (by someone other than treating dentist)Adjust complete denture - maxillaryAdjust complete denture - mandibularAdjust partial denture - maxillaryAdjust partial denture - mandibularRepair of broken complete denture base, mandibular (lower arch) - Once per 12 months (after 6 monthsfrom insertion)Repair of broken complete denture base, maxillary (upper arch) - Once per 12 months (after 6 monthsfrom insertion)Replace missing or broken teeth - complete denture (each tooth)Repair resin partial denture base, mandibular (lower arch). Once per 12 months (after 6 months fromRepair resin partial denture base, maxillary (upper arch). Once per 12 months (after 6 months fromRepair cast partial framework, mandibular (lower arch). Once per 12 months (after 6 months from5 785.94 845.23 754.56 377.29 952.35 1155.26 1031.37 515.67 507.14 693.16 471.56 571.41 241.37 271.41 160.84 247.43 278.23 208.17 118.99 45.76 43.08 61.48 61.48 61.48 61.48 113.78 198.95 76.51 73.73 84.04 84.04 84.04 84.04 155.51 113.78 155.51 97.54 136.63 136.63 148.92 133.31 186.73 186.73 203.54
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for 7220IIHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionRepair cast partial framework, maxillary (upper arch). Once per 12 months (after 6 months fromRepair or replace broken claspReplace broken teeth - per toothAdd tooth to existing partial dentureAdd clasp to existing partial dentureReplace all teeth and acrylic on cast metal framework (maxillary)Replace all teeth and acrylic on cast metal framework (mandibular)Rebase complete maxillary denture (once in three years)Rebase complete mandibular denture (once in three years)Rebase maxillary partial denture (once in three years)Rebase mandibular partial denture (once in three years)Rebase hybrid prosthesisReline complete maxillary denture (chairside)Reline complete mandibular denture (chairside)Reline maxillary partial denture (chairside)Reline mandibular partial denture (chairside)Reline complete maxillary denture (laboratory)Reline complete mandibular denture (laboratory)Reline maxillary partial denture (laboratory)Reline mandibular partial denture (laboratory)Soft liner for complete or partial removable denture – indirectRecement fixed partial dentureFixed partial denture repair, by reportCoronal remnants, deciduous toothExtraction, erupted tooth or exposed root (elevation and/or forceps removal)Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/orsection of toothRemoval of impacted tooth - soft tissue6 148.92 129.57 100.76 136.63 152.20 460.15 460.15 346.34 346.34 282.94 282.94 282.94 273.24 273.24 273.24 273.24 291.44 291.44 257.49 257.49 257.49 89.47 167.35 75.91 84.70 179.59 203.54 177.08 137.75 186.73 186.73 610.63 610.63 466.83 466.83 386.74 386.74 386.74 373.47 373.47 373.47 373.47 358.12 358.12 330.76 330.76 330.76 122.29 228.75 107.12 115.77 219.82 243.23 313.69
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for Implants:High Plan 3,000.00 3,000.00 2,000.00Fund IIIRemoval of impacted tooth - partially bonyRemoval of impacted tooth - completely bonyRemoval of impacted tooth - completely bony, with unusual surgical complicationsSurgical removal of residual tooth roots (cutting procedure)Surgical access of an unerupted toothBiopsy of oral tissue - hard (bone, tooth)Biopsy of oral tissue - soft (all others)Brush Biopsy-transepithelial sample collectionSurgical Repositioning of teeth, covered only if the group has an ortho riderCorticomy-one to three teeth spaces per quadrant. Once per lifetime per quadrant. Subject to OrthodontiamaximumCorticomy-four or more teeth spaces per quadrant. Once per lifetime per quadrant. Subject toOrthodontia maximumAlveoloplasty in conjunction with extractions - per quadrantAlveoloplasty in conjunction with extractions 1 to 3 teeth or tooth spaces per quadAlveoloplasty not in conjunction with extractions - per quadrantAlveoloplasty not in conjunction with extractions 1 to 3 teeth or tooth spaces per quadExcision of Benign Lesion up to 1.25 cm covered only with a pathology report with claim - medical planIncision and drainage of abscess - intraoral soft tissueIncision and drainage of abscess - extraoral soft tissueOsseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, byreport, maybe be covered if the group has an implant rider.Sinus augmentation via a vertical approach, maybe be covered if the group has an implant rider.Bone replacement graft for ridge preservation - per site, maybe be covered if the group has an implantBuccal / labial frenectomy (frenulectomy) - Two per lifetime for patients over age 6Lingual frenectomy (frenulectomy) - Once per lifetime per arch for patients over age 6Non-surgical siaolithitomy. Once per lifetimePalliative treatment of dental pain, minor procedure7 362.62 409.87 432.64 191.79 422.60 274.31 333.70 88.81 182.16 344.29 403.18 514.23 541.54 262.16 577.64 323.63 396.82 121.38 186.73 436.98 542.00 728.26 162.33 96.80 297.83 163.94 268.69 143.46 182.16 1821.60 221.86 132.30 407.09 224.09 408.95 196.08 186.73 1867.36 2660.58 315.14 321.82 321.82 318.79 64.27 2727.41 425.77 439.89 439.89 326.80 70.23
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for Implants:High Plan 3,000.00 3,000.00 2,000.00Fund ep sedation/general anesthesia - first 15 minutes (pre-set up time). Covered in conjunction withimpacted teeth only up to one hour.Deep sedation /general anesthesia-each subsequent 15 minute increment, allowed with covered surgicalimpacted teeth only (up to one hour)Analgesia, anxiolysis, inhalation of nitrous oxide. If documented as necessary on patient record tocomplete treatment, then covered once per patient per date of service (for children under age 19 only)Intravenous moderate (conscious) sedation/analgesia- first 15 minutes (pre-set up time) covered inconjunction with impacted teeth only (up to one hour)Intravenous moderate (conscious) sedation/analgesia-each subsequent 15 minute increment, allowed withcovered surgical impacted teeth only (up to one hour)Non-intravenous conscious sedation (Only for eligible dependent children age 19 and under)Treatment of Complications (post-surgical)-unusual circumstances, individual considerationFabrication of Athletic Mouth GuardOcclusal Guard - Hard appliance, full archOcclusal Guard - Soft appliance, full archOcclusal Guard - Hard appliance, partial archOcclusal adjustment - limitedOcclusal adjustment - completeExternal bleaching, per toothInlay - metallic - one surfaceInlay - metallic - two surfacesInlay - metallic - three or more surfacesOnlay - metallic-two surfacesOnlay - metallic-three surfacesOnlay - metallic-four or more surfacesInlay - porcelain/ceramic - one surfaceInlay - porcelain/ceramic - two surfacesInlay - porcelain/ceramic - three or more surfaces8 99.34 139.85 87.79 124.85 46.73 64.16 106.10 145.02 94.54 129.23 109.29 61.48 182.16 270.33 67.58 108.13 89.88 286.00 255.03 489.12 491.42 502.90 505.20 507.49 560.08 502.90 491.42 489.12 112.04 84.04 186.73 369.50 92.38 147.80 148.40 353.86 291.50 654.24 660.54 674.40 674.40 681.96 823.90 674.40 660.54 654.24
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionOnlay - porcelain/ceramic - two surfacesOnlay - porcelain/ceramic - three surfacesOnlay - porcelain/ceramic - four or more surfacesInlay - resin-based composite - one surfaceInlay - resin-based composite - two surfacesInlay - resin-based composite - three or more surfacesOnlay - resin-based composite - two surfacesOnlay - resin-based composite - three surfacesOnlay - resin-based composite - four or more surfacesCrown - resin (indirect)Crown- ¾ resin based composite (indirect)Crown - resin with high noble metalCrown - resin with predominantly base metalCrown - resin with noble metalCrown - porcelain/ceramic substrateCrown - porcelain fused to high noble metalCrown - porcelain fused to predominantly base metalCrown - porcelain fused to noble metalCrown - porcelain fused to titanium alloysCrown - 3/4 cast high noble metalCrown - 3/4 cast predominantly base metalCrown - 3/4 cast noble metalCrown - 3/4 porcelain/ceramicCrown - full cast high noble metalCrown - full cast predominantly base metalCrown - full cast noble metalCrown - titaniumProvisional crown 505.20 507.49 526.73 509.79 369.71 420.23 505.20 507.49 518.98 555.72 555.72 555.72 555.72 555.72 555.72 555.72 555.72 555.72 555.72 555.72 555.72 555.72 569.03 555.72 555.72 555.72 555.72 555.729 674.40 688.08 774.82 681.96 496.66 566.00 674.40 681.96 695.83 743.73 743.73 743.73 743.73 743.73 817.22 785.79 743.73 743.73 743.73 798.95 743.73 743.73 837.04 798.95 743.73 743.73 798.95 743.73
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionCore buildup, including any pinsCast post and core in addition to crownEach additional indirectly fabricated post - samePrefabricated post and core in addition to crownLabial veneer (resin laminate) - chairsideLabial veneer (resin laminate) - laboratoryLabial veneer (porcelain laminate) - laboratoryCrown Repair, by report, once per year per tooth after 24 months of crown insertionComplete denture, upper (maxillary)Complete denture, lower (mandibular)Immediate denture, upper (maxillary)Immediate denture, lower (mandibular)Maxillary partial denture -resin baseMandibular partial denture - resin baseMaxillary partial denture - cast medal framework with resin basesMandibular partial denture - cast metal framework with resin basesImmediate maxillary partial denture – resin baseImmediate mandibular partial denture – resin baseImmediate maxillary partial denture – cast metal framework with resin denture basesImmediate mandibular partial denture – cast metal framework with resin denture basesMaxillary partial denture - flexible baseMandibular partial denture - flexible baseImmediate maxillary partial denture - flexible baseImmediate mandibular partial denture - flexible baseRem. unilateral partial denture-1 piece cast metal (including clasps and teeth), maxillaryRem. unilateral partial denture-1 piece cast metal (including clasps and teeth), mandibularPartial Denture - removable unilateral – one piece flexible base (including clasps and teeth) – perPartial Denture - removable unilateral – one piece resin (including clasps and teeth) – per quadrant10 124.44 218.15 135.48 169.93 349.05 427.35 485.11 99.52 712.25 712.25 712.25 712.25 567.20 578.68 714.16 711.87 572.87 584.93 721.30 719.55 642.88 667.59 642.88 667.59 302.78 302.78 302.78 302.78 183.06 293.71 182.78 226.90 466.41 526.92 713.59 130.02 942.94 942.94 942.94 942.94 760.12 776.51 956.77 951.73 767.72 784.73 966.34 962.02 880.09 880.09 880.09 880.09 445.39 445.39 445.39 445.39
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for 064D6065D6066D6067D6068D6069D6072D6082TypeHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionIII Interim partial denture (maxillary), to replace anterior permanent teeth during the healing period after anextraction, also in children 16 years of age and under for missing anterior teethIII Interim partial denture (mandibular) to replace anterior permanent teeth during the healing period after anextraction, also in children 16 years of age and under for missing anterior teethIII Precision attachment, by reportIII Overdenture - complete, upper archIII Overdenture - partial, upper archIII Overdenture - complete, lower archIII Overdenture - partial, lower archIII Surgical placement of Implant body (once per tooth in 60 months)III Surgical placement of Mini-Implant body (once per tooth in 60 months)III Prefabricated Abutment (once per tooth in 60 months)III Custom Abutment (if a cast post and core was performed on the tooth within 60 months of the implantabutment, the implant abutment will be denied)III Implant abutment supported porcelain/ceramic crownIII Abutment supported porcelain fused to metal crown (high noble metal)III Abutment supported porcelain fused to metal crown (predominantly base metal)III Abutment supported porcelain fused to metal crown (noble metal)III Abutment supported cast metal crown (high noble metal)III Abutment supported cast metal crown (predominantly base metal)III Abutment supported cast metal crown (noble metal)III Implant supported porcelain/ceramic crownIII Implant supported porcelain fused to metal crownIII Implant supported metal crownIII Abutment Supported Retainer Porc/Ceramic FPD, alternate benefit of a partial denture or bridgeIII Abutment supported retainer for porcelain fused to metal FPD (high noble metal).III Abutment supported retainer for cast metal FPD (high noble metal).III Implant supported crown – porcelain fused to predominantly base alloys11 209.37 292.30 209.37 292.30 284.89 712.25 688.34 712.25 688.34 908.72 454.35 274.87 398.86 376.91 942.94 942.94 942.94 942.94 1206.18 603.09 329.35 502.91 679.15 679.15 619.22 621.08 679.16 555.72 619.34 679.16 761.13 621.08 679.16 679.15 679.16 609.08 837.65 867.57 753.72 807.72 787.99 743.73 753.72 949.83 1005.81 822.25 949.83 867.57 787.99 872.68
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for IIIIIIIIIIIIIIIIIIIIIIIIIHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionImplant supported crown – porcelain fused to noble alloysImplant supported crown – porcelain fused to titanium and titanium alloysProvisional Implant crownImplant supported crown – predominantly base alloysImplant supported crown – noble alloysImplant supported crown – titanium and titanium alloysRepair Implant Supported Prosthesis, by reportRecement implant/abutment supported crownRecement implant/abutment supported fixed partial denture (once per tooth after 6 month have elapsedfrom the initial seating date by the same dentist/dental office)Repair implant abutment, by report (once per 12 months after 24 months have elapsed from the initialinsertion date of the crown)Abutment supported crown – porcelain fused to titanium and titanium alloysImplant supported retainer – porcelain fused to predominantly base alloysImplant supported retainer for FPD – porcelain fused to noble alloysImplant removal (once per tooth per lifetime)Bone graft for repair of peri-implant defect – does not include flap entry and closure.Bone graft at time of implant placementImplant/Abutment Complete Denture-Removable Upper ArchImplant/Abutment Complete Denture-Removable Lower ArchImplant/Abutment Partial Denture-Removable Upper ArchImplant/Abutment Partial Denture-Removable Lower ArchImplant supported retainer – porcelain fused to titanium and titanium alloysImplant supported retainer for metal FPD – predominantly base alloysImplant supported retainer for metal FPD – noble alloysImplant supported retainer for metal FPD – titanium and titanium alloysAbutment supported retainer – porcelain fused to titanium and titanium alloysPontic - cast high noble metal12 646.44 609.08 555.72 555.72 555.72 555.72 113.96 42.74 64.10 926.21 872.68 743.73 743.73 765.69 789.57 125.72 62.86 94.30 106.83 157.17 555.72 609.38 646.44 103.08 237.62 237.62 806.04 806.04 806.04 806.04 609.38 609.38 609.38 609.38 609.38 656.76 746.81 872.68 926.21 134.53 349.55 349.55 959.29 959.29 956.77 956.77 872.68 815.50 815.50 815.50 815.50 882.40
Dental Plan Maximums:Massachusetts State Health Care Professionals' Dental FundGroup Number: 0006570000Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022StandardPlan 1,500.00 2,500.00 1,000.00Orthodontia Benefit Lifetime Maximum:Annual Plan Maximum (Excluding Orthodontia):Separate Annual Maximum for IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHigh Plan 3,000.00 3,000.00 2,000.00Fund Payment**DescriptionPontic - cast predominantly base metalPon
Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022. Dental Plan Maximums: Orthodontia Benefit Lifetime Maximum: Separate Annual Maximum for Implants: Fund Payment** . Massachusetts State Health Care Professionals' Dental Fund Group Number: 0006570000 Schedule of Dental Benefits (Maximum Payments) Effective July 1, 2022 .
