Understand the components of a dental plan to verify correctly and communicate cost to the patient.
Key components
Component
Definition
Typical example
Annual Maximum
Max insurance will pay per year
$1,500 / $2,000 / $3,000
Lifetime Maximum (ortho)
Ortho only — total lifetime max
$1,500 / $2,500
Deductible
What patient pays before insurance starts
$50 individual / $150 family
Coinsurance %
% insurance covers per category
Preventive 100% · Basic 80% · Major 50%
Copay
Fixed amount patient pays per service (HMO)
$10 cleaning · $50 RCT
Waiting period
Time before a service is covered
6m basic · 12m major
Missing tooth clause
Doesn't cover replacement of teeth lost before plan effective date
Excludes pre-existing missing teeth
Typical coverage by category
Category
Typical coverage
Example codes
Preventive / Diagnostic
80-100%
D0120, D0150, D0210, D1110, D1208
Basic / Restorative
50-80%
D2140-D2394 (fillings), D3310, D4341
Major / Prosthodontic
30-50%
D2740 (crown), D5110, D6010, D3330
Orthodontics
50% (lifetime max + age limit)
D80xx-D89xx
Cosmetic
0% (not covered)
D2960-D2962 (veneers), Whitening
Frequency Limits — the critical detail
Service
Typical frequency
Prophylaxis (D1110)
2 per year (every 6 months)
FMX (D0210)
1 every 3-5 years
BWX (D0274)
1 every 12 months
SRP (D4341/D4342)
1 every 24 months
Perio maintenance (D4910)
Every 90 days (Plan Variant) or 2×/year
Crown (D2740)
1 every 5-7 years per tooth
Plan Variant: When a plan has different frequencies or rules than typical (e.g. D4910 every 90 days vs. 2×/year), it's called a "Plan Variant". Always document.
