Provider Search Dental Plans Direct Access Plans Individual Plans Group Plans Association Plans Employers Why Dentist Direct Administration Information Frequently Asked Questions Current Members Member Login Frequently Asked Questions Refer a Provider Administration Information Claims Information Producers Why Dentist Direct Frequently Asked Questions Request Producer Kit Providers Why Dentist Direct Claims Information Refer a Patient or Group Become a Provider Refer a Colleague Request a Fee Schedule Check Eligibility Contact dentistDIRECT 75 South 500 West Bountiful, UT 84010 Phone: 801.292.0100 Fax: 801.299.8365 info@usdentistdirect.com The following is a partial listing of insured covered dental procedures (and an insured vision benefit), with applicable limitations and reimbursement amounts. Benefits will be paid as listed in the schedule of Covered Procedures in your policy, subject to the policy year deductible, annual maximum, and limitations and exclusions. Access to discount networks is also included. Procedure Code Description Limitations Plan Pays Oral Evaluations D0120 Periodic Oral Evaluation j 16 D0150 Comprehensive Oral Evaluation   j 24 Prophylaxis (simple Cleaning) D0110 Prophylaxis - Adult a 31 D0120 Prophylaxis - Child   a 21 Radiographs D0210 Intraoral - complete series (7 or more films including bitewings) p 45 D0272 Bitewings - two films k 13 D0330 Panoramic Film   p 36 Sealants D1351 Sealant - per tooth   b, l, d 14 Space Maintainers D1510 Space Maintainer - fixed - unilateral   l, n 89 Fillings D2140 Amalgam - one surface primary or permanent h, g 34 D2150 Amalgam - two surfaces primary or permanent h, g 43 D2331 Resin Two Surfaces - Anterior   h, g 48 Extractions D7140 Extraction Single erupted tooth or exposed root (evaluation and/or forceps removal) i 39 D7230 Removal of impacted tooth - partially bony (6 month waiting period)   67 Palliative (emergency Treatment) D9110 Palliative Treatment of Dental Pain-Minor Procedure   c 30 Endodontics D3310 Root Canal-Anterior (excluding final restoration) 127 D3330 Root Canal-Molar (excluding final restoration) 189 Periodontics (12 month waiting period) D4260 Osseous Surgery (including flap entry and closure) per quadrant f 200 D4341 Periodontal Scaling and Root Planing per quadrant   e 43 Single Tooth Restorations (12 month waiting period) D2750 Crown Porcelain Fused to High Noble Metal m, o 189 D2950 Crown Buildup, Including any pins m, o 43 D2952 Cast Post and Core in Addition to Crown   m, o 70 Prosthodontics (24 month waiting period) D5110 Complete upper Denture m, o 223 D5213 Upper Removable Partial Denture - cast Metal (framework with resin denture base)   m, o 260 Orthodontia 08000-08999   Network discounts apply Vision Eye Exam (not applicable in WA) c 35 (per year) Key to Limitations: a) Maximum of 2 procedures per 12 months b) Maximum of 1 procedure per 36 months c) Maximum of 1 procedure per 12 months d) Applications made to permanent molar teeth only e) Maximum of 1 each quadrant per 24 months f) Maximum of 1 each per quadrant per 36 months g) Maximum of 1 per tooth surface per 24 months h) Replacement of existing only if in place for 24 months i) Maximum 1 time per tooth j) Limited to 2 oral evaluation procedures per 12-month period in any combination k) Limited to 1 bitewing x-ray procedure per 12-month period-up to 4 films l) Limited to dependent children under age 16 m) Maximum of 1 per 7-year period n) Maximum of 1 per lifetime, per quadrant or arch o) Limited to patients age 16 and over p) Limited to 1 x-ray procedure in any combination per 5-year period