PPO / Indemnity Plan$50.00 Deductible - Starting 2nd year, no deductible for preventative care
Calendar Year Maximums:
1st year $750.00, 2nd year $1,000.00, 3rd year and later $1,500.00
|
|
PREVENTATIVE AND DIAGNOSTIC - 100% of Scheduled Charge
| Scheduled
Charge |
Periodic oral evaluation *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Comprehensive oral evaluation *. . . . . . . . . . . . . . . . . . . . . . . . .. . . . .
Routine Teeth Cleaning - Adult *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-Rays - Bitewing - 2 films * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
X-Rays - Bitewing - 4 films *. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Flouride treatment - child ^. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . .
Sealant - each tooth +. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* once in any 6 month period
^ once in any 12 month period
+once in any 36 month period | 21.00
35.00
44.00
17.00
25.00
15.00
20.00
|
BASIC RESTORATIVE - Pays 80% of scheduled charge
| Scheduled
Charge
|
Amalgam
filling – 1 surface – permanent . . . . . . . . . . . . . . .
. . . . . . . .
Amalgam filling – 2 surface – permanent . . . . . . . . . . . .
. . . . . . . . . . .
Amalgam filling – 3 surface – permanent . . . . . . . . . . . .
. . . . . . . . . . .
Resin filling – 1 surface – anterior . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Resin filling – 4 surface – anterior . . . . . . . . . . . . . . . .
. . . . . . . . . . . .
Extraction – single tooth . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
Extraction – soft tissue . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
Removal of impacted tooth – bony . . . . . . . . . . . . . . . . . .
. . . . . . . . .
| 52.00
68.00
98.00
70.00
175.00
75.00
159.00
229.00
|
MAJOR RESTORATIVE - Pays 50% of scheduled charge
After 12 month waiting period (unless switching from another plan)
| Scheduled
Charge
|
Crown – porcelain – fused to high noble metal . . . . . . . . .
. . . . . . . . .
Crown – porcelain – predom. base metal . . . . . . . . . . . . . . . . . . . . . . .
Crown – full cast – predom. Base metal . . . . . . . . . . . . . . . . . . . . . . . .
Core buildup – including any pins . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cast pore and core – in addition to crown . . . . . . . . . .
. . . . . . . . . . .
Root canal – anterior . . . . . . . . . . . . . . . . . . . .
. . . . . . .. . . . . . . . . . .
Root canal – Molar . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
Gingivectomy – per tooth . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
Scaling / root planning – per quadrant . . . . . . . . . . . . . . .
. . . . . . . . .
Periodontal maintenance (following therapy) . . . . . . . . . . . . . . . . . . . .
Denture – complete upper or lower . . . . . . . . . . . . . . . . . . . . . . . . . .
Partial – complete upper or lower – resin base . . . . . . . . . . . . . . . . . .
| 550.00
500.00
420.00
101.00
173.00
430.00
540.00
79.00
120.00
70.00
690.00
600.00
|
PLEASE NOTE:
The Scheduled Charge is the maximum amount which benefits will be
paid. If your dentist charges less than the scheduled charge, the
benefit will be paid on the lower amount. If your dentist charges
more, you will pay the normal co-payment plus the amount over the
scheduled charge.
You can use any dentist, but if you choose
one of our preferred providers, they will charge based on our
scheduled charge. If you go outside the system and your dentist
charges higher than the scheduled charge you just pay the
difference.
PPO/Indemnity Plan
| Semi-monthly premium |
| Individual | 9.20
|
| Individual + 1 Dependent | 17.48
|
| Family | 27.60
|