1-800-469-81381-800-469-8138

Physicians Mutual Insurance Company®

Over 350 covered
Dental
Procedures

Below is a complete list of all covered procedures provided by our dental insurance.

That product is not available in your state. To find out about the products that are available please call 1-800-469-81381-800-469-8138.

The chart below shows the covered dental procedures Physicians Mutual Insurance Company pays benefits for, as well as the maximum expense paid for each. Customers with this coverage have access to discounts through the Ameritas Classic PPO Network. The amounts shown are the same regardless of provider participation. There are no penalties for seeing a Non-Participating Provider. Only the procedures listed receive benefits for the schedule (A, D or E) for the plan option selected. For Participating Providers, the amount paid will not exceed the Maximum Allowable Charge. For Non-Participating Providers, the amount paid will not exceed the amount of the actual charge for the procedure. Covered procedures may vary by state and are subject to change. No benefits are payable for a procedure that is not listed. If you have any questions, give us a call us at 1-800-469-81381-800-469-8138.
Type I - Preventive
Code
D0120
Description
Periodic oral evaluation – established patient.
ECO +
STA +
PRE +
$34
$39
$44
Code
D0145
Description
Oral evaluation for a patient under three years of age and counseling with primary caregiver.
ECO +
STA +
PRE +
$31
$34
$38
Code
D0150
Description
Comprehensive oral evaluation – new or established patient.
ECO +
STA +
PRE +
$41
$49
$57
Code
D0180
Description
Comprehensive periodontal evaluation – new or established patient.
ECO +
STA +
PRE +
$41
$49
$57
Two evaluations will be allowed in a Policy Year. A D0120, D0145, D0150 or D0180 counts toward this maximum allowance. D0150 and D0180 will be limited to once per provider.
Code
D0210
Description
Intraoral – complete series of radiographic images.
ECO +
STA +
PRE +
$44
$60
$77
Code
D0330
Description
Panoramic radiographic image.
ECO +
STA +
PRE +
$45
$59
$72
D0210 or D0330: One of these procedures will be allowed in a 5-year period.*
Type II - Basic
Code
D0140
Description
Limited oral evaluation - problem focused.
ECO +
STA +
PRE +
$19
$25
$32
Code
D0170
Description
Re-evaluation - limited, problem focused (established patient; not post-operative visit).
ECO +
STA +
PRE +
$19
$25
$32
D0140 and D0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a D0120 and count toward this maximum allowance.
Code
D0472
Description
Accession of tissue, gross examination, preparation and transmission of written report.
ECO +
STA +
PRE +
$22
$30
$38
Type III - Major
Code
D3220
Description
Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament.
ECO +
STA +
PRE +
$29
$40
$49
Code
D3221
Description
Pulpal debridement, primary and permanent teeth.
ECO +
STA +
PRE +
$29
$40
$49
Code
D3222
Description
Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development.
ECO +
STA +
PRE +
$44
$60
$73
Code
D3230
Description
Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration).
ECO +
STA +
PRE +
$39
$53
$65
Code
D3240
Description
Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration).
ECO +
STA +
PRE +
$34
$46
$56
Type I - Preventive

Maximum Covered Expense

CodeEconomy
Plus
Schedule A
Standard
Plus
Schedule D
Preferred
Plus
Schedule E
D0120Periodic oral evaluation – established patient. $34$39$44
D0145Oral evaluation for a patient under three years of age and counseling with primary caregiver. $31$34$38
D0150Comprehensive oral evaluation – new or established patient. $41$49$57
D0180Comprehensive periodontal evaluation – new or established patient. $41$49$57
Two evaluations will be allowed in a Policy Year. A D0120, D0145, D0150 or D0180 counts toward this maximum allowance. D0150 and D0180 will be limited to once per provider.
D0210Intraoral – complete series of radiographic images. $44$60$77
D0330Panoramic radiographic image. $45$59$72
D0210 or D0330: One of these procedures will be allowed in a 5-year period.*

See all Type I - Preventive covered procedures

Type II - Basic

Maximum Covered Expense

CodeEconomy
Plus
Schedule A
Standard
Plus
Schedule D
Preferred
Plus
Schedule E
D0140Limited oral evaluation - problem focused. $19$25$32
D0170Re-evaluation - limited, problem focused (established patient; not post-operative visit). $19$25$32
D0140 and D0170: Coverage is limited to accidental injury only. If not due to an accident, will be considered as a D0120 and count toward this maximum allowance.
D0472Accession of tissue, gross examination, preparation and transmission of written report. $22$30$38

See all Type II - Basic covered procedures

Type III - Major

Maximum Covered Expense

CodeEconomy
Plus
Schedule A
Standard
Plus
Schedule D
Preferred
Plus
Schedule E
D3220Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament.
Limited to treatment of primary teeth.
$29$40$49
D3221Pulpal debridement, primary and permanent teeth. $29$40$49
D3222Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development. $44$60$73
D3230Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration). $39$53$65
D3240Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration). $34$46$56

See all Type III - Major covered procedures