Physicians Mutual Insurance Company®

Over 400 covered
Dental
Procedures

Over 400 covered
Dental
Procedures

This affordable dental insurance helps pay for over 400 covered procedures.

View some of the most common procedures and what percentage each plan helps cover — or browse the full list of covered procedures below.

Covered procedures at a glance

Take a quick look at what percentage each dental plan pays for commonly used services.
This chart shows examples of some of the most-commonly used dental procedures and what percentage each plan covers when receiving care from an in-network provider. See the full list of covered procedures beneath this chart.
Covered procedure TypeWaiting PeriodEconomy Plan CoverageStandard Plan CoveragePreferred Plan CoveragePremier Plan Coverage
CleaningsNone100%100%100%100%
Routine ExamsNone100%100%100%100%
Dental X-raysNone100%100%100%100%
Fillings for cavitiesNone25%40%55%70%
Minor oral surgery procedures and sedationNone25%40%55%70%
Simple tooth extractionsNone25%40%55%70%
Root canals12 months25%40%55%70%
Crowns12 months25%40%55%70%
Dentures12 months25%40%55%70%

100% coverage for preventive care is only available when you see an in-network dentist.
The 25%/40%/55% are averages of the maximum allowable charge. 70% is what we’ll pay of the maximum allowable charge.

See list of all covered procedures

Looking for specific dollar amounts? Browse our comprehensive list of all covered procedures.
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.
  • Each plan pays 100% for preventive (type I) services when you see an in-network provider.
  • The Premier Plan (Schedule 4) pays 70% of the maximum allowable charge for basic (type II) and major (type III) services.
  • The other three plans – Preferred (Schedule 3), Standard (Schedule 2) and Economy (Schedule 1) – pay a set dollar amount, for basic and major services. With these three plans, the amounts shown for basic and major services are the same regardless of provider participation.
  • 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 at 1-800-228-9100.

Type I - Preventive

100% covered preventive care only at network providers.
Code
D0120
Description
Periodic oral evaluation – established patient.
ECO
STA
PRE
PRM
100%
Code
D0145
Description
Oral evaluation for a patient under three years of age and counseling with primary caregiver.
ECO
STA
PRE
PRM
100%
Code
D0150
Description
Comprehensive oral evaluation – new or established patient.
ECO
STA
PRE
PRM
100%
Code
D0180
Description
Comprehensive periodontal evaluation – new or established patient.
ECO
STA
PRE
PRM
100%
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
PRM
100%
Code
D0330
Description
Panoramic radiographic image.
ECO
STA
PRE
PRM
100%
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
PRM**
$11
$18
$25
70%
Code
D0170
Description
Re-evaluation - limited, problem focused (established patient; not post-operative visit).
ECO
STA
PRE
PRM**
$11
$18
$25
70%
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
PRM**
$18
$28
$38
70%

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
PRM**
$23
$36
$49
70%
Limited to the treatment of primary teeth:
Code
D3221
Description
Pulpal debridement, primary and permanent teeth.
ECO
STA
PRE
PRM**
$23
$36
$49
70%
Code
D3222
Description
Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development.
ECO
STA
PRE
PRM**
$38
$61
$84
70%
Code
D3230
Description
Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration).
ECO
STA
PRE
PRM**
$38
$61
$84
70%
Code
D3240
Description
Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration).
ECO
STA
PRE
PRM**
$38
$61
$84
70%

Type I - Preventive

100% covered preventive care only at network providers.

Maximum Covered Expense

CodeEconomy Schedule 1Standard Schedule 2Preferred Schedule 3Premier Schedule 4
D0120Periodic oral evaluation – established patient.100% Covered
D0145Oral evaluation for a patient under three years of age and counseling with primary caregiver.100% Covered
D0150Comprehensive oral evaluation – new or established patient.100% Covered
D0180Comprehensive periodontal evaluation – new or established patient.100% Covered
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.100% Covered
D0330Panoramic radiographic image.100% Covered
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 Schedule 1Standard Schedule 2Preferred Schedule 3Premier Schedule 4**
D0140Limited oral evaluation - problem focused.$11$18$2570%
D0170Re-evaluation - limited, problem focused (established patient; not post-operative visit).$11$18$2570%
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.$18$28$3870%

See all Type II - Basic covered procedures

Type III - Major

Maximum Covered Expense

CodeEconomy Schedule 1Standard Schedule 2Preferred Schedule 3Premier Schedule 4**
D3220Therapeutic pulpotomy (excluding final restoration) – removal of pulp coronal to the dentinocemental junction and application of medicament.$23$36$4970%
Limited to the treatment of primary teeth:
D3221Pulpal debridement, primary and permanent teeth.$23$36$4970%
D3222Partial pulpotomy for apexogenesis – permanent tooth with incomplete root development.$38$61$8470%
D3230Pulpal therapy (resorbable filling) – anterior, primary tooth (excluding final restoration).$38$61$8470%
D3240Pulpal therapy (resorbable filling) – posterior, primary tooth (excluding final restoration).$38$61$8470%

See all Type III - Major covered procedures