United Food & Commercial Workers

Unions and Employers

Midwest Health and Pension Funds

UFCW Calumet Region Insurance Fund

Dental Schedule of Benefits

Your eligible dependents are covered only if you elected Family Coverage and are working enough hours to qualify for full-time coverage.

 

Maximum Allowance for Most Common Procedures

          (ADA Procedure Code is listed in third column for each procedure)
 
Diagnostic and Palliative Treatment—No Deductible Required

Prophylaxis—Adult (maximum two treatments in any calendar year) $ 83.00 1110
Prophylaxis—Child (maximum two treatments in any calendar year) 65.00 1120
Oral Examination 43.00 0120
Topical application of fluoride 31.00 1203
Topical sealant, per tooth 50.00 1351
Radiographs
   Complete series, including bitewings (once each calendar year) 113.00 0210
   Periapical—single, first film 25.00 0220
   Periapical—each additional film 20.00 0230
   Bitewings—two films 38.00 0272
   Bitewings—four or more films 55.00 0274
   Panoramic x-ray (once each calendar year) 105.00 0330
Palliative treatment (emergency) 83.00 9110
Diagnostic casts 80.00 0470

 
Basic Dental Benefits

Surgical Extractions (including routine post-operative visits)
   Each single uncomplicated extraction $ 73.00 7140
   Surgical extraction, erupted 128.00 7210
   Removal of impacted tooth (soft tissue) 162.00 7220
   Removal of impacted tooth (partially bony) 195.00 7230
   Removal of impacted tooth (completely bony) 225.00 7240
Surgical placement of implant 677.00 6010
Alveoplasty with extractions (per quadrant) 107.00 7310
General anesthesia (in or out of hospital) 248.00 9220
General analgesia 24.00 9230

 
Restorative Dentistry

Amalgam Restorations
   One surface $ 57.00 2140
   Two surfaces 63.00 2150
   Three surfaces 83.00 2160
   Four or more surfaces 88.00 2161
Composite Resin Restorations
   One surface 69.00 2330
   Two surfaces 83.00 2331
   Three surfaces 93.00 2332
   Four surfaces or incisal angle 130.00 2335
Inlay Restorations—Non-Abutment
   One surface, gold 316.00 2510
   One surface, porcelain 362.00 2610
   One surface, composite 339.00 2650
   Two surfaces, gold 384.00 2520
   Two surfaces, porcelain 407.00 2620
   Two surfaces, composite 362.00 2651
   Three surfaces, metallic 388.00 2530
   Three surfaces onlay, metallic 407.00 2543
   Four or more surfaces onlay, metallic 429.00 2544
   Four or more surfaces onlay, porcelain 474.00 2644
   Four or more surfaces onlay, composite 429.00 2664
Crowns—Non-Abutment
   Plastic prefabricated 125.00 2932
   Porcelain 483.00 2740
   Porcelain with gold 483.00 2750
   Porcelain with nonprecious metal 425.00 2751
   Porcelain with semiprecious metal 468.00 2752
   Gold full cast 468.00 2790
   Metal full cast 488.00 2792
   Stainless steel crown 170.00 2930
   Steel post and amalgam core 138.00 2954
   Cast post and gold core 170.00 2952
   Recement inlays 30.00 2910
   Recementation of crown 44.00 2920
   Sedative filling 48.00 2940
   Crown buildup-pin retention 123.00 2950


Endodontics

Pulp capping, direct $ 33.00 3110
Pulp capping, indirect 23.00 3120
Vital pulpotomy 88.00 3220
Root Canal Therapy
   Anterior (excludes final restoration) 327.00 3310
   Bi-cuspid (excludes final restoration 388.00 3320
   Molar (excludes final restoration) 459.00 3330
   Apicoectomy (separate procedure) 338.00 3410


Periodontics

Osseous surgery (per quadrant; minimum 4 teeth) $ 407.00 4260
Periodontal scaling (full-mouth debridement
prior to periodontal therapy)
74.00 4355
Periodontal scaling and root planing (per quadrant;
minimum of 4 teeth)
100.00 4341
Maintenance periodontal prophylaxis (following
periodontal therapy)
60.00 4910

 
Prosthetic Replacements

Fixed Bridgework
   Crowns—Abutment Teeth
      Porcelain, gold $ 308.00 6750
      Porcelain, nonprecious 282.00 6751
      Porcelain, semiprecious 287.00 6752
      Gold (full cast) 269.00 6790
      Nonprecious cast 241.00 6791
      Semiprecious cast 254.00 6792
   Pontics
      Cast gold (sanitary) 269.00 6210
      Cast nonprecious metal 241.00 6211
      Cast semiprecious metal 254.00 6212
      Porcelain, gold 308.00 6240
      Porcelain, nonprecious 282.00 6241
      Porcelain, semiprecious 287.00 6242
   Recement bridge 47.00 6930
Complete Denture
   Upper (Maxillary) 367.00 5110
   Lower (Mandibular) 367.00 5120
Removable Partial Denture
   Upper, resin base 367.00 5211
   Lower, resin base 367.00 5212
   Upper, cast framework, resin base 424.00 5213
   Lower, cast framework, resin base 424.00 5214
   Removable unilateral partial, 1 piece cast metal 282.00 5281
Reline—Rebase
   Office reline (chairside), full denture 62.00 5730
   Office reline (chairside), partial denture 43.00 5741
   Laboratory reline, full denture 107.00 5750
   Laboratory reline, partial denture 85.00 5760
   Full denture rebase 107.00 5710
   Partial denture rebase 127.00 5720
Space Maintainers
   Removable, unilateral 181.00 1520
   Removable, bilateral 275.00 1525
   Recementation 40.00 1550

 

(Updated 11/09/15)