Page 10 - GDP - Provider Reimbursement Guide B 2022

8
GROUP NUMBER
401
44
49
444
34
425
426
43
442 - Active
442 - Retirees
214
63
393
51
43 -Active
43 -Pension
441
419
395
406
407
174
374
417
23
29
375
410
439
OFFICE VISIT
None***
100%
None***
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
$5.00
None***
None***
$5.00
$5.00
$5.00
None***
$5.00
None***
$5.00
$10.00
None***
None***
$5.00
None***
None***
None***
None***
$10.00
*100% coverage on exams, 50% coverage on x-rays, cleanings and fluoride. **30% Discount on UCR Fees
*** GDP does not prohibit providers from charging PPE or Sterilization Fees.
CLASS I
100%
90%
100%
100%
100%
100%
100%
100%
100%
100%
100%
*100% 50%
100%
100%
100%
100%
100%
100%
100%
100%
**100% 50%
100%
100%
100%
100%
100%
100%
100%
100%
CLASS II
50%
80%
100%
75%
90%
90%
90%
90%
75%
75%
75%
50%
75%
75%
100%
100%
100%
90%
80%
75%
50%
75%
100%
75%
75%
100%
100%
75%
50%
CLASS III
50%
80%
85%
50%
75%
75%
75%
75%
50%
60%
50%
50%
60%
50%
80%
80%
80%
75%
75%
50%
50%
50%
90%
50%
50%
85%
85%
50%
50%
CLASS IV
50%
No
80%
50%
75%
75%
75%
75%
50%
50%
50%
**30%
50%
50%
50%
50%
70%
75%
75%
50%
*30% Pedo not cover
50%
70%
50%
50%
85%
85%
50%
50%
BENEFITS
GENERAL ANESTHESIA COVERAGE
No
No
No
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
ORTHODONTICS CLASS V
$800 - Child $800 - Sub/Spouse
$2,000 - Child $2,000 - Sub/Spouse
$650 Co-pay - Child $650.00 Co-pay - Sub/Spouse
$2,000 - Child $750 - Sub/Spouse
$2,200 - Child $1,800 - Sub/Spouse
$2,200 - Child $1,800 Sub/Spouse
$2,200 - Child $1,800 Sub/Spouse
$2,200 - Child $1,800 Sub/Spouse
$3,000 Child $1,800 Sub/Spouse
$1,800 Child $1,200 Sub/Spouse
$2,000 Child $1,000 Sub/Spouse
$500 - Child None - Sub/Spouse
$1,800 - Child $1,800 - Sub/Spouse
$1,000 - Child $1,000 - Sub/Spouse
$1,500 - Child $1,500 - Sub/Spouse
$1,500 - Child $1,500 - Sub/Spouse
$3,000 Child $3,000 Sub/Spouse
$2,200 - Child $1,800 Sub/Spouse
$2,000 - Child $2,000 - Sub/Spouse
$2,000 Child $750 Sub/Spouse
$1,500 Child $500 Sub/Spouse
None
$1,000 - Child $1,000 - Sub/Spouse
$1,500 Child $750 Sub/Spouse
None
No Co-pay - Child $1250.00 Co-pay - Adult
No Co-pay - Child $1250.00 Co-pay - Adult
None
$1,800 Child $1,500 Sub/Spouse