Building Trades Employers Insurance Fund
Insurance Forms
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BTEIF Indemnity Dental Program
"The actual insurance contract shall prevail in the event of any conflict with the employee benefit summaries listed within the BTEIF's website."
(adminstered by EBS Benefit Solutions)
(updated for 2006)
Click here to print plan details.
Schedule B: Basic Benefits
| Procedures | |
|---|---|
| Examinations | $25.00 |
| X-Rays | |
| Intra-oral, complete series (including bitewings) | $31.00 |
| Intra-oral, first film | $5.00 |
| Intra-oral, each additional | $3.00 |
| Bitewing, first film | $5.00 |
| Bitewing, each additional | $4.00 |
| Tests & Laboratory Examinations | |
| Biopsy and exam of oral tissue | $50.00 |
| (hard or soft) | |
| Dental Prophylaxis (teeth cleaning) | |
| Adults | $35.00 |
| Children | $25.00 |
| Adults-Initial Exam-Cleaning, 2 bitewings | $39.00 |
| Children-Initial exam, Cleaning-2 bitewings | $34.00 |
| Fluoride Treatments | |
| Topical sodium fluoride(4 treatments) w/cleaning | $35.00 |
| Topical stannous fluoride(1 treatment) w/ cleaning | $25.00 |
| Fillings (Silver including polishing) | |
| Amalgam, one surface, primary | $20.00 |
| Amalgam, two surfaces, primary | $25.00 |
| Amalgam, three surfaces, primary | $30.00 |
| Amalgam, one surface, permanent | $20.00 |
| Amalgam, two surfaces, permanent | $26.00 |
| Amalgam, three surfaces, permanent | $32.00 |
| Reinforced Amalgam, first pin | $8.00 |
| Reinforced Amalgam, additional pin | $6.00 |
| (Additional allowances for Sillicate, Acrylic and Plastic restorations) | |
| Pulpotomy | |
| Pulp cap, direct (excluding final restoration) | $10.00 |
| Vital Pulpotomy | $30.00 |
| Root Canal | |
| One canal (Excludes restoration) | $150.00 |
| Two canals (Excludes restoration) | $200.00 |
| Three canals (Excludes restoration) | $250.00 |
| Repairs to Dentures | |
| Repair broken complete or partial denture, no teeth damage | $30.00 |
| Repair denture and replace one broken tooth | $35.00 |
| Adding tooth to partial denture to replace extracted tooth | $40.00 |
| Adding one tooth to partial (plus clasp to abutment tooth) | $40.00 |
| Simple Extractions | |
| First tooth | $25.00 |
| Each additional tooth | $25.00 |
Schedule A: Supplemental Basic Benefit Rider
| Space maintainers | |
|---|---|
| Fixed, unilateral | $65.00 |
| Fixed, bilateral | $85.00 |
| Gold Inlay Restorations | |
| Inlay, gold-one surface | $100.00 |
| Inlay, gold-two surfaces | $150.00 |
| Inlay, gold-three surfaces | $165.00 |
| Crowns (Not part of Bridges) | |
| (One per 12 month period) | |
| Jacket, acrylic, cast gold lingual | $175.00 |
| Jacket, porcelain, cast gold lingual | $245.00 |
| Crown, jacket, porcelain with metal thimble | $200.00 |
| Gold, full cast | $175.00 |
| Gold, ¾ cast | $150.00 |
| Porcelain-with metal | $225.00 |
| Surgical Extractions | |
| Extraction, erupted | $30.00 |
| Extraction, completely bony impacted | $85.00 |
| Oral antra root recovery | $120.00 |
| Alveopasty (Preparation of Gum Ridge for Dentures) | |
| Per quadrant, in connection w/extractions | $30.00 |
| Per quadrant, not in connection w/extractions | $50.00 |
| Treatment if Fractures | |
| Simple | $520.00 |
| Compound | $520.00 |
| Other Procedures | |
| Excisions of tumors | $50.00 |
| Tooth replantation | $120.00 |
| Tooth implantation | $120.00 |
* Full time students to age 25
The Basic Benefits and Supplemental Basic Benefit Rider are all inclusive with the Indemnity Program.
Click here to print plan details.