Page 8 - GDP - Provider Reimbursement Guide 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