HumanaDental - Florida
HumanaDentalState of Florida EmployeesFLHHB32HH 0914
2 - HumanaDental
Four plans to choose fromDental care is animportant partof keeping youryour goodoverall health.Humana is pleased to offer you four dental plans to choose from this year.While some of the benefits are similar, others are distinct to each plan. Be sureto review the features in this book to make the right choice for your dentalhealth and budget. Information on each plan is here.Plans to choose from are: Two managed care plans, Network Plus Prepaid or Select 15 Prepaid A preferred provider dental plan, Preferred Plus DPPO An indemnity plan, Schedule BYour cost in monthly premiumPeople First4004Benefit Plan Code404440544084Network PlusPrepaidSelect 15PrepaidPreferred PlusDPPOSchedule BIndemnityEmployee only 24.06 12.64 32.40 14.74Employee Spouse 47.42 21.20 59.94 21.96Employee Child(ren) 56.54 23.00 66.98 23.30Employee Family 72.22 32.98 97.24 37.10If you have questions, visit our website atwww.humanadental.com/custom/fl/ or call us between8 a.m. and 6 p.m. Eastern time, Monday through Friday. Call 1-800-943-6880 for the Network Plus Prepaid andPreferred Plus DPPO plans Call 1-866-879-3630 for the Select 15 Prepaid and Schedule B plansWe will also have representatives available at all Department of ManagementServices (DMS) benefit fairs.HumanaDental - 3
How do the plans work?Network Plus and Select 15 Prepaid cover preventive care and other dentalprocedures as listed when you’re treated by your selected primary care dentist.If your dentist decides you need more specialized treatment, you’ll be referredto a participating specialist. With the Network Plus plan, the copayment listingin this brochure applies at both the participating general dentist and specialist.With the Select 15 plan, the participating specialist’s fees will be discounted at25 percent. General dentistry and specialty services are available only in areaswhere Humana has a participating general dentist and/or specialist.Preferred Plus DPPO and Schedule B cover preventive care and other dentalprocedures as listed when you’re treated by any dentist you choose. But withthe Preferred Plus DPPO plan, a greater portion of your dental expenses will becovered for treatment performed by an in-network dentist who has agreed notto balance bill above the contracted fees. You’ll be responsible for deductiblesand there are benefit maximums.Do I have to file a claim form?Network Plus Prepaid and Select 15 Prepaid: No, all treatment will becoordinated by your primary care dentist. You’re only responsible for thecopayment listed on the benefit schedule.Preferred Plus DPPO and Schedule B: Yes, you must submit a claim form tobe reimbursed for your dental expenses. Most Preferred Plus DPPO dentists willagree to file the claim form on your behalf.Submit claim forms to:HumanaP.O. Box 14284Lexington, KY 40512-4284PredeterminationIf covered dental expenses for a procedure are expected to be more than 200,it’s recommended that you send a dental treatment plan before beginningtreatment. You and/or your dentist will be notified of the benefits payablebased on the dental treatment plan.4 - HumanaDental
How do I know which dentist to see?Network Plus Prepaid and Select 15 Prepaid: For participating dentistinformation, visit www.humanadental.com/custom/fl/. Once you enroll in yourplan, you’ll need to select a primary care dentist by registering atwww.mycompbenefits.com.Preferred Plus DPPO and Schedule B: You can choose any dentist. However,your costs may be lower when you choose an in-network dentist. For a listingof participating DPPO dentists, visit www.humanadental.com/custom/fl/.Does everyone in my family need to use the same dentist?Humana’s plansencouragepreventivetreatment, helpingyou to better oralhealth andkeeping yourcosts down.No, each family member can have a different dentist. For instance, a spousemight choose to a dentist close to a workplace, a dependent college studentliving away from home (in Florida) might pick a dentist near school, andparents might choose to send their children to pediatric dentists who are morecomfortable treating young children. Please note Network Plus limitations andexclusions regarding pediatric dentists.What should I do if I have a question or concern?Contact Humana between 8 a.m. and 6 p.m. Eastern time, Mondaythrough Friday. Call 1-800-943-6880 for the Network Plus Prepaid andPreferred Plus DPPO plans Call 1-866-879-3630 for the Select 15 Prepaid and Schedule B plansHumanaDental - 5
Network Plus Prepaid planPeople First Plan Code #4004Selecting a dentistFor participating dentist information, you may visit our website at www.humanadental.com/custom/fl/ or call our dedicated Customer Care number at 1-800-943-6880. Once you become enrolled in the Network Plus Prepaid plan, you will need to select a primarycare dentist by registering at www.mycompbenefits.com or by calling our dedicated Customer Care number at 1-800-943-6880.The schedule of benefits below represents your copayments for treatment provided by participating general dentists and specialists.Please note limitations and exclusions apply. Refer to the Network Plus Prepaid Plan Limitations & Exclusions section for more details.Schedule of benefitsADACode 1110D1110D1120D1120D1203MemberPaysPeriodic oral evaluation . . . . . . . . . . . . . . . . . . . . . . . . 0Limited oral evaluation - problem focused . . . . . . . 0Oral evaluation for a patientunder three years of age . . . . . . . . . . . . . . . . . . . . . . . 0Comprehensive oral evaluation . . . . . . . . . . . . . . . . . 0Detailed & extensive oral evaluation –problem focused . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Re-evaluation - limited, problem focused . . . . . . . . 0Comprehensive periodontal evaluation . . . . . . . . . . 0Intraoral - complete series . . . . . . . . . . . . . . . . . . . . . 0Intraoral - periapical first film . . . . . . . . . . . . . . . . . . . 0Intraoral - periapical each additional film . . . . . . . . 0Intraoral - occlusal film . . . . . . . . . . . . . . . . . . . . . . . . 0Extraoral - first film . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Extraoral - each additional film . . . . . . . . . . . . . . . . . 0Bitewing - single film . . . . . . . . . . . . . . . . . . . . . . . . . . 0Bitewings - two films . . . . . . . . . . . . . . . . . . . . . . . . . . 0Bitewings - three films . . . . . . . . . . . . . . . . . . . . . . . . . 0Bitewings - four films . . . . . . . . . . . . . . . . . . . . . . . . . . 0Vertical bitewings - 7 to 8 films . . . . . . . . . . . . . . . . . 0Panoramic film . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Oral/facial photographic images . . . . . . . . . . . . . . . . 0Collection of microorganisms for culture& sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Caries susceptibility tests . . . . . . . . . . . . . . . . . . . . . . . 0Adjunctive pre-diagnostic test that aids in thedetection of mucosal abnormalities . . . . . . . . . . . . 50Pulp vitality tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Diagnostic casts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Accession of tissue, gross exam, prep & report . . 50Accession of tissue, gross and microscopicexam, prep & report . . . . . . . . . . . . . . . . . . . . . . . . . . 50Accession of tissue, gross and microscopicexam, including assesment of surgical margins,prep & report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50Prophylaxis - adult . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Additional prophylaxis - adult . . . . . . . . . . . . . . . . . . 25Prophylaxis - child . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Additional prophylaxis - child . . . . . . . . . . . . . . . . . . 20Topical fluoride - child . . . . . . . . . . . . . . . . . . . . . . . . . . 06 - HumanaDentalADACode l fluoride - adult . . . . . . . . . . . . . . . . . . . . . . . . . 0Topical fluoride varnish . . . . . . . . . . . . . . . . . . . . . . . . . 0Nutritional counseling . . . . . . . . . . . . . . . . . . . . . . . . . 0Tobacco counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Oral hygiene instructions . . . . . . . . . . . . . . . . . . . . . . . 0Sealant - per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0Space maintainer - fixed - unilateral . . . . . . . . . . . . . 0Space maintainer - fixed - bilateral . . . . . . . . . . . . . . 0Space maintainer - removable - unilateral . . . . . . . . 0Space maintainer - removable - bilateral . . . . . . . . . 0Recementation of space maintainer . . . . . . . . . . . . . 0Amalgam - one surface, primary or permanent . . . 6Amalgam - two surfaces, primary or permanent . . 8Amalgam - three surfaces, primary or permanent . 9Amalgam - four or more surfaces, primaryor permanent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Resin-based composite - one surface, anterior . . . . 8Resin-based composite - two surfaces, anterior . . 10Resin-based composite - three surfaces, anterior 13Resin-based composite - four or more surfacesor involving incisal angle, anterior . . . . . . . . . . . . . . 15Resin-based composite crown, anterior . . . . . . . . . 30Resin-based composite - one surface, posterior . . . 6Resin-based composite - two surfaces, posterior . . 8Resin-based composite - three surfaces, posterior . 9Resin-based composite - four or more surfaces,posterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Inlay - metallic - one surface . . . . . . . . . . . . . . . . . 105Inlay - metallic - two surfaces . . . . . . . . . . . . . . . . 115Inlay - metallic - three or more surfaces . . . . . . . 125Onlay - metallic - two surfaces . . . . . . . . . . . . . . . . 175Onlay - metallic - three surfaces . . . . . . . . . . . . . . 185Onlay - metallic - four or more surfaces . . . . . . . . 195Inlay - porcelain/ceramic - one surface . . . . . . . . 202Inlay - porcelain/ceramic - two surfaces . . . . . . . 214Inlay - porcelain/ceramic - three ormore surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227Onlay - porcelain/ceramic - two surfaces . . . . . . . 221Onlay - porcelain/ceramic - three surfaces . . . . . 238Current Dental Terminology 2006 American Dental Association. All rights reserved.
Network Plus Prepaid planPeople First Plan Code #4004Schedule of benefitsADACode 2955MemberPaysOnlay - porcelain/ceramic - four ormore surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253Inlay - resin-based composite - one surface . . . . 166Inlay - resin-based composite - two surfaces . . . 198Inlay - resin-based composite - three surfaces . . 208Onlay - resin-based composite - two surfaces . . 180Onlay - resin-based composite - three surfaces . 212Onlay - resin-based composite - four ormore surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228Crown - resin-based composite (indirect) . . . . . . . 228Crown - 3 4 resin-based composite (indirect) . . . 228Crown - resin with high noble metal . . . . . . . . . . . 150Crown - resin with predominantly base metal . . 150Crown - resin with noble metal . . . . . . . . . . . . . . . . 150Crown - porcelain/ceramic substrate . . . . . . . . . . . 280Crown - porcelain fused to high noble metal . . . . 150Crown - porcelain fused to predominantlybase metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Crown - porcelain fused to noble metal . . . . . . . . 150Crown - 3 4 cast high noble metal . . . . . . . . . . . . . 150Crown - 3 4 cast predominantly base metal . . . . 150Crown - 3 4 cast noble metal . . . . . . . . . . . . . . . . . 150Crown - 3 4 porcelain/ceramic . . . . . . . . . . . . . . . . 280Crown - full cast high noble metal . . . . . . . . . . . . . 150Crown - full cast predominantly base metal . . . . 150Crown - full cast noble metal . . . . . . . . . . . . . . . . . 150Crown - titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Provisional crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Recement inlay, onlay . . . . . . . . . . . . . . . . . . . . . . . . . 6Recement cast or prefabricated post and core . . . . 6Recement crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Prefabricated stainless steel crown primary tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63Prefabricated stainless steel crown permanent tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72Prefabricated resin crown . . . . . . . . . . . . . . . . . . . . . 78Prefabricated stainless steel crown withresin window . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88Sedative filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Core buildup, including any pins . . . . . . . . . . . . . . . . 59Pin retention - per tooth, in addition torestoration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Cast post and core in addition to crown . . . . . . . . . 86Cast post and core each additional same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86Prefabricated post and core in additionto crown . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Post removal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50ADACode 3430D3450D3910D3920D3950D4210MemberPaysEach additional prefabricated post same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Labial veneer (resin laminate) - chairside . . . . . . . 250Labial veneer (resin laminate) - laboratory . . . . . 300Labial veneer (porcelain laminate) - laboratory . 350Additional procedures to construct new crownunder existing partial denture framework . . . . . . . 50Crown repair, by report . . . . . . . . . . . . . . . . . . . . . . . . 50Pulp cap - direct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Pulp cap - indirect . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Therapeutic pulpotomy . . . . . . . . . . . . . . . . . . . . . . . 10Pulpal debridement, primary andpermanent teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Pulpal therapy - anterior, primary tooth . . . . . . . . . 15Pulpal therapy - posterior, primary tooth . . . . . . . . 15Root canal therapy - anterior . . . . . . . . . . . . . . . . . . 41Root canal therapy - bicuspid . . . . . . . . . . . . . . . . . . 50Root canal therapy - molar . . . . . . . . . . . . . . . . . . . . 64Treatment of root canal obstruction;non-surgical access . . . . . . . . . . . . . . . . . . . . . . . . . . . 85Incomplete endodontic therapy; inoperable,unrestorable or fractured tooth . . . . . . . . . . . . . . . 105Internal root repair of perforation defects . . . . . . . 85Retreatment of previous root canal therapy anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Retreatment of previous root canal therapy bicuspid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65Retreatment of previous root canal therapy molar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78Apexification/recalcification - initial visit . . . . . . . . . 65Apexification/recalcification - interim visit . . . . . . . 65Apexification/recalcification - final visit . . . . . . . . . . 65Apicoectomy/periradicular surgery - anterior . . . . 47Apicoectomy/periradicular surgery - bicuspid(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51Apicoectomy/periradicular surgery - molar(first root) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58Apicoectomy/periradicular surgery each additional root . . . . . . . . . . . . . . . . . . . . . . . . . . 19Retrograde filling - per root . . . . . . . . . . . . . . . . . . . . 14Root amputation - per root . . . . . . . . . . . . . . . . . . . . 29Surgical procedure for isolation of toothwith rubber dam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Hemisection, not including root canal therapy . . . 90Canal preparation and fitting of preformeddowel or post . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Gingivectomy or gingivoplasty - four or morecontiguous teeth per quadrant . . . . . . . . . . . . . . . . . 39Current Dental Terminology 2006 American Dental Association. All rights reserved.HumanaDental - 7
Network Plus Prepaid planPeople First Plan Code #4004Schedule of benefitsADACode y or gingivoplasty - one to threecontiguous teeth per quadrant . . . . . . . . . . . . . . . . . 10Gingival flap procedure - four or morecontiguous teeth per quadrant . . . . . . . . . . . . . . . . 150Gingival flap procedure - one to threecontiguous teeth per quadrant . . . . . . . . . . . . . . . . 115Apically positioned flap . . . . . . . . . . . . . . . . . . . . . . 165Clinical crown lengthening - hard tissue . . . . . . . . 140Osseous surgery, four or more contiguousteeth per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Osseous surgery, one to three contiguousteeth per quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Bone replacement graft - first site in quadrant . . 180Bone replacement graft - each additionalsite in quadrant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Biologic materials to aid in soft and osseoustissue regeneration . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Guided tissue regeneration - resorbablebarrier, per site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Guided tissue regeneration - nonresorbablebarrier, per site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Pedicle soft tissue graft procedure . . . . . . . . . . . . . . 55Free soft tissue graft procedure . . . . . . . . . . . . . . . . 57Subepithelial connective tissue graft, per tooth . . 75Distal or proximal wedge procedure . . . . . . . . . . . . 70Soft tissue allograft . . . . . . . . . . . . . . . . . . . . . . . . . . 265Provisional splinting - intracoronal . . . . . . . . . . . . . . 95Provisional splinting - extracoronal . . . . . . . . . . . . . 85Periodontal scaling and root planing four or more contiguous teeth per quadrant . . . . . 14Periodontal scaling and root planing one to three teeth per quadrant . . . . . . . . . . . . . . . . 14Full mouth debridement . . . . . . . . . . . . . . . . . . . . . . . 9Localized delivery of antimicrobial agents,per tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35Periodontal maintenance . . . . . . . . . . . . . . . . . . . . . . 9Unspecified periodontal procedure, by report . . . . . 0Complete denture - maxillary . . . . . . . . . . . . . . . . . 320Complete denture - mandibular . . . . . . . . . . . . . . . 320Immediate denture - maxillary . . . . . . . . . . . . . . . 349Immediate denture - mandibular . . . . . . . . . . . . . 349Maxillary partial denture - resin base . . . . . . . . . . 292Mandibular partial denture - resin base . . . . . . . . 292Maxillary partial denture - cast metalframework with resin . . . . . . . . . . . . . . . . . . . . . . . . 354Mandibular partial denture - cast metalframework with resin . . . . . . . . . . . . . . . . . . . . . . . . 354Maxillary partial denture - flexible base . . . . . . . . 3658 - HumanaDentalADACode 6214D6240D6241D6242MemberPaysMandibular part denture - flexible base . . . . . . . . 365Removable unilateral partial denture one piece cast metal . . . . . . . . . . . . . . . . . . . . . . . . 250Adjust complete denture - maxillary . . . . . . . . . . . . 18Adjust complete denture - mandibular . . . . . . . . . . 18Adjust partial denture - maxillary . . . . . . . . . . . . . . 18Adjust partial denture - mandibular . . . . . . . . . . . . 18Repair broken complete denture base . . . . . . . . . . . 9Replace missing or broken teeth complete denture (each tooth) . . . . . . . . . . . . . . . . . 7Repair resin denture base . . . . . . . . . . . . . . . . . . . . . 10Repair cast framework . . . . . . . . . . . . . . . . . . . . . . . . 10Repair or replace broken clasp . . . . . . . . . . . . . . . . . 13Replace broken teeth - per tooth . . . . . . . . . . . . . . . . 8Add tooth to existing partial denture . . . . . . . . . . . 11Add clasp to existing partial denture . . . . . . . . . . . . 13Replace all teeth and acrylic on cast metalframework (maxillary) . . . . . . . . . . . . . . . . . . . . . . . 165Replace all teeth and acrylic on cast metalframework (mandibular) . . . . . . . . . . . . . . . . . . . . . 165Rebase complete maxillary denture . . . . . . . . . . . . 31Rebase complete mandibular denture . . . . . . . . . . 31Rebase maxillary partial denture . . . . . . . . . . . . . . . 31Rebase mandibular partial denture . . . . . . . . . . . . . 31Reline complete maxillary denture (chairside) . . . 18Reline complete mandibular denture (chairside) . 18Reline maxillary partial denture (chairside) . . . . . . 18Reline mandibular partial denture (chairside) . . . . 18Reline complete maxillary denture (laboratory) . . 24Reline complete mandibular denture (laboratory) 24Reline maxillary partial denture (laboratory) . . . . . 24Reline mandibular partial denture (laboratory) . . . 24Interim complete denture (maxillary) . . . . . . . . . . 225Interim complete denture (mandibular) . . . . . . . 225Interim partial denture (maxillary) . . . . . . . . . . . . 225Interim partial denture (mandibular) . . . . . . . . . . 225Tissue conditioning, maxillary . . . . . . . . . . . . . . . . . . 30Tissue conditioning, mandibular . . . . . . . . . . . . . . . 30Precision attachment, by report . . . . . . . . . . . . . . . 180Pontic - cast high noble metal . . . . . . . . . . . . . . . . 150Pontic - cast predominantly base metal . . . . . . . . 150Pontic - cast noble metal . . . . . . . . . . . . . . . . . . . . . 150Pontic - titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Pontic - porcelain fused to high noble metal . . . . 150Pontic - porcelain fused to predominantlybase metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Pontic - porcelain fused to noble metal . . . . . . . . 150Current Dental Terminology 2006 American Dental Association. All rights reserved.
Network Plus Prepaid planPeople First Plan Code #4004Schedule of benefitsADACode PaysPontic - porcelain/ceramic . . . . . . . . . . . . . . . . . . . . 280Pontic - resin with high noble metal . . . . . . . . . . . 150Pontic - resin with predominantly base metal . . . 150Pontic - resin with noble metal . . . . . . . . . . . . . . . . 150Provisional pontic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75Retainer - cast metal for resin bondedfixed prosthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Inlay - porcelain/ceramic, two surfaces . . . . . . . . 214Inlay - porcelain/ceramic, three or moresurfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227Inlay - cast high noble metal, two surfaces . . . . . 115Inlay - cast high noble metal, three or moresurfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Inlay - cast predominantly base metal,two surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115Inlay - cast predominantly base metal,three or more surfaces . . . . . . . . . . . . . . . . . . . . . . . 125Inlay - cast noble metal, two surfaces . . . . . . . . . 115Inlay - cast noble metal, three or moresurfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Onlay - porcelain/ceramic, two surfaces . . . . . . . . 221Onlay - porcelain/ceramic, three or moresurfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238Onlay - cast high noble metal, two surfaces . . . . 175Onlay - cast high noble metal, three or moresurfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Onlay - cast predominantly base metaltwo surfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Onlay - cast predominantly base metalthree or more surfaces . . . . . . . . . . . . . . . . . . . . . . . 185Onlay - cast noble metal, two surfaces . . . . . . . . 175Onlay - cast noble metal, three or moresurfaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185Crown - indirect resin based composite . . . . . . . . 228Crown - resin with high noble metal . . . . . . . . . . . 150Crown - resin with predominantly base metal . . 150Crown - resin with noble metal . . . . . . . . . . . . . . . . 150Crown - porcelain/ceramic . . . . . . . . . . . . . . . . . . . . 280Crown - porcelain fused to high noble metal . . . . 150Crown - porcelain fused to predominantlybase metal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Crown - porcelain fused to noble metal . . . . . . . . 150Crown - 3 4 cast high noble metal . . . . . . . . . . . . . 150Crown - 3 4 cast predominantly base metal . . . . 150Crown - 3 4 cast noble metal . . . . . . . . . . . . . . . . . 150Crown - 3 4 porcelain/ceramic . . . . . . . . . . . . . . . . 150Crown - full cast high noble metal . . . . . . . . . . . . . 150Crown - full cast predominantly base metal . . . . 150Crown - full cast noble metal . . . . . . . . . . . . . . . . . 150ADACode rown - titanium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150Recement fixed partial denture . . . . . . . . . . . . . . . . . 8Stress breaker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110Precision attachment . . . . . . . . . . . . . . . . . . . . . . . . 195Cast post and core in addition to fixedpartial denture retainer . . . . . . . . . . . . . . . . . . . . . . . 89Prefabricated post and core in addition tofixed partial denture retainer . . . . . . . . . . . . . . . . . . 81Core build up for retainer, including any pins . . . . . 59Each additional cast post - same tooth . . . . . . . . . 89Each additional prefabricated post same tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81Fixed partial denture repair, by report . . . . . . . . . . . 45Extraction, coronal remnants - deciduous tooth . . 8Extraction, erupted tooth or exposed root . . . . . . . . 8Surgical removal of erupted tooth . . . . . . . . . . . . . . 14Removal of impacted tooth - soft tissue . . . . . . . . 17Removal of impacted tooth - partially bony . . . . . 23Removal of impacted tooth - completely bony . . . 27Removal of impacted tooth - completely bonywith surgical complications . . . . . . . . . . . . . . . . . . . . 34Surgical removal of residual tooth roots . . . . . . . . . 15Tooth reimplantation and/or stabilization ofaccidentally evulsed or displaced tooth . . . . . . . . . 50Surgical access of an unerupted tooth . . . . . . . . . . 33Mobilization of erupted or malpositioned toothto aid eruption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Placement of devise to facilitate eruptionof impacted tooth . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Biopsy of oral tissue - hard . . . . . . . . . . . . . . . . . . . 150Biopsy of oral tissue - soft . . . . . . . . . . . . . . . . . . . . . 75Exfoliative cytological sample collection . . . . . . . . 50Brush biopsy - transepithelial sample collection . . 50Alveoloplasty in conjunction with extractions four or more teeth per quadrant . . . . . . . . . . . . . . . 16Alveoloplasty in conjunction with extractions one to three teeth per quadrant . . . . . . . . . . . . . . . . 16Alveoloplasty not in conjunction withextractions - four or more teeth per quadrant . . . 72Alveoloplasty not in conjunction withextractions - one to three teeth per quadrant . . . . 72Removal of lateral exostosis
D2332 Resin-based composite - three surfaces, anterior 13 D2335 Resin-based composite - four or more surfaces or involving incisal angle, anterior. 15 D2390 Resin-based composite crown, anterior. 30 D2391 Resin-based composite - one surface, posterior . 6 D2392 Resin-based composite - two surfaces, posterior . 8
FLORIDA WETLAND PLANTS, AN mENTIFICATION MANUAL can be purchased from the University of Florida, Food and Agricultural Sciences. 1-800-226-1764, P.O. Box 110011, University of Florida, Gainesville, Florida 32611-0011. Introduction For use the the manual: FLORIDA WETLAND PLANTS, AN mENTIFICATION MANUAL
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The offering company(ies) listed below, severally or collectively, as the content may require, are referred to in this application as "Humana." Medical and Life products insured by Humana Health Insurance Company of Florida, Inc. Dental products insured by HumanaDental Insurance Company Primary Applicant Information
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