Curious about the fees covered by your patient's BeneCare Dental Plan? Interested in participating but need more information? Use the form below to submit your office's usual and customary fees and we will send back an analysis of the coverage for a specific patient or group. Since coverage differs by plan, please submit this form separately for each patient covered under a different group.

Please take the time to completely fill out the upper boxed-in portion of the form. After you have completed filling in your office's information, enter your office's usual and customary fee in the "Office's U & C Fee" column. Once you have finished, please press the submit button at the bottom of the page to send your fee comparison.

Sponsor Name:
Patient SSN:
Office Name:
Contact Person:
Fax Number: Phone:
Office Email Address:
Office Address:
Address:
City: State: Zip:

Procedure Code Service Description Office's U & C Fee
110 initial oral examination $
120 periodic oral examination $
210 complete x-ray series $
220 periapical film $
272 bitewings-two films $
1110 prophylaxis-adult $
1120 prophylaxis-child $
2120 amalgam-primary two surfaces $
2150 amalgam-permanent two surfaces $
2330 anterior one surface composite $
2386 posterior two surface composite $
2752 porcelain to noble metal crown $
3310 anterior root canal therapy $
4341 scaling & root planing per quad $
5110 complete upper denture $
5213 partial upper denture $
6252 pontic-resin w/ noble metal $
6722 crown-resin w/ noble metal $
7110 extraction - single tooth $
$
$
$
$
 

 

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