Page 8 - GDP - Provider Reimbursement Guide B 2022

GROUP NUMBER
402
228
420
369
16
450
409
408
13
84
42
36
448
437
21
25
436
428
363
364
414
22
OFFICE VISIT FEE
None***
None***
None***
None***
$5.00
None***
$5.00
$5.00
None***
None***
None***
None***
$10.00
None***
None***
None***
None***
None***
None***
None*** 50%
$5.00
$5.00
$5.00
CLASS 1
100%
100%
100%
100%
100%
100%
100%
100%
100%
*100% 50%
100%
100%
100%
100%
100%
100%
100%
100%
*100% 50%
*100%
See Benefit Schedule
See Benefit Schedule
100%
CLASS II
50%
90%
90%
50%
100%
100%
75%
75%
100%
50%
100%
75%
80%
100%
75%
50%
100%
100%
50%
50%
See Benefit Schedule
See Benefit Schedule
75%
CLASS III
50%
75%
75%
50%
80%
80%
75%
75%
70%
50%
80%
50%
75%
80%
75%
50%
80%
85%
50%
50%
See Benefit Schedule
See Benefit Schedule
50%
CLASS IV
**30%
50%
50%
50%
70%
70%
75%
75%
70%
**30%
70%
50%
75%
70%
50%
50%
70%
85%
**30%
**30%
See Benefit Schedule
See Benefit Schedule
50%
BENEFITS
GENERAL ANESTHESIA COVERAGE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No None - Adult
Yes
See Benefit Schedule
Yes
See Benefit Schedule
CLASS V ORTHODONTICS
$800 - Child $800 - Sub/Spouse
$3,000 - Child $1,500 - Sub/Spouse
$3,000 - Child $1,500 Sub/Spouse
$500 - Child $500 - Sub/Spouse
$3,000 Child $3,000 Sub/Spouse
$3,000 Child $3,000 Sub/Spouse
$1,750 - Child $1,000 Sub/Spouse
$3,000 - Child $1,000 Sub/Spouse
$1,250 Child $1,250 Sub/Spouse
$500 - Child None - Sub/Spouse
None
None
$3000 - Child $1500- Sub/Spouse
$3,000 - Child $3,000 Sub/Spouse
$1,800 Child $1,800 Adult
$500 Child None Adult
$3,000 - Child $3,000 Sub/Spouse
No Co-pay - Child $1250.00 Co-pay - Sub/Spouse
$500 - Child None - Adult
$800 - Child
$1,800 - Child
$1,200 - Sub/Spouse
$1,800 - Child
$1,200 - Sub/Spouse
$1,500 Child
6
404
367
17
449
None***
None***
$5.00
*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.
100%
See Benefit Schedule
100%
90%
See Benefit Schedule
80%
75%
See Benefit Schedule
60%
50%
See Benefit Schedule
50%
No
No
Yes
No
$750 Sub/Spouse
$1,250 - Child None - Adult
$3,000 - Child $3,000 Sub/Spouse
$1,800 Child $1,800 Sub/Spouse