PREPAID PLAN- No Annual
Maximums
- No Deductibles
- No Claim Forms
- No Waiting Periods
|
|
| PREVENTATIVE AND DIAGNOSTIC SERVICES | YOU
PAY |
Periodic oral evaluation * . . . . . . . . . . . . . . . . . . . .
. . . .
Comprehensive oral evaluation * . . . . . . . . . . . . . . . . . .
Routine Teeth Cleaning – Adult * . . . . . . . . . . . . . . . . .
.
X-Rays – bitewing – 2 films * . . . . . . . . . . . . . . . . . .
. . .
X-Rays – bitewing – Complete series + . . . . . . . . . . . . .
Fluoride treatment – child ^ . . . . . . . . . . . . . . . . . . .
. . .
Sealant – each tooth + . . . . . . . . . . . . . . . . . . . . . .
. . .
*
once in any 6 month period
^ once in any 12 month period
+ once in any 36 month period
| 5.00
20.00
15.00
10.00
24.00
5.00
8.00
|
BASIC RESTORATIVE
| YOU
PAY
|
Amalgam
filling – 1 surface – primary . . . . . . . . . . . . . . . . . . .
Amalgam filling – 2 surface – primary . . . . . . . . . .
. . . . . . . . .
Amalgam filling – 3 surface – permanent. . . . . . . . . .
. . . . . . .
Resin filling – 1 surface – anterior. . . . . . . . . . . .
. . . . . . . . . .
Resin filling – 2 surfaces – anterior. . . . . . . . .
. . . . . . . . . . . .
Extraction – single tooth . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .
Extraction – soft tissue . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
| 20.00
30.00
40.00
50.00
60.00
50.00
75.00
|
MAJOR RESTORATIVE
| YOU
PAY
|
Crown –
porcelain – fused to high noble metal . . . . . . . .
Crown – porcelain – predominately based metal . . . . . . .
Crown – full cast – predominately based metal . . . . . . . .
Core buildup – including any pins . . . . . . . . . . . . . . . .
. .
Root canal – anterior . . . . . . . . . . . . . . . . . . . . . . . . . . ..
Scaling / root planning – per quadrant . . . . . . . . . . . . . .
Denture – complete upper or lower . . . . . . . . . . . . . . . .
.
Partial – complete upper or lower – resin base . . . . . . . .
| 450.00
420.00
400.00
90.00
225.00
90.00
450.00
375.00
|