| Dental Services |
Basic Option |
Premium Option |
PREVENTATIVE PROCEDURES
Teeth Cleaning (2 times per year) |
$0.00 -You Pay Nothing!
|
$0.00 -You Pay Nothing! |
| X-Rays
Examinations
Fluoride Treatments |
Small out of pocket. Exclusions
and limitations apply |
Small out of pocket. Exclusions
and limitations apply |
Periodontal Procedures
Perio Maintenence
Deep Cleanings |
Small out of pocket. Exclusions
and limitations apply |
Percentage benefit applies |
Fillings:
Composite “Tooth
Colored” Fillings |
Difference between insurance
and dentist charge |
Difference between insurance
and dentist charge |
| Inlays
Onlays |
Exclusions and limitations apply. |
Percentage benefit applies |
| Root Canal Procedures |
$200 Co-Pay applies if covered
- Exclusions and limitations apply |
Percentage benefit applies |
| Crowns (Caps) |
$165 Co-Pay applies if covered
- Exclusions and limitations apply |
Percentage benefit applies |
| Bridges (Permanently
placed to fill in for missing teeth) |
$165 Co-Pay (per unit) applies
if covered - Exclusions and limitations apply |
Percentage benefit applies |
| Partial Dentures (Removable
appliance to fill in for missing teeth) |
$165 Co-Pay applies if covered
plus percision attachments |
Percentage benefit applies |
| Full Dentures (Removable
appliance to replace all missing teeth) |
$165 Co-Pay (per unit) applies
if covered - Exclusions and limitations apply |
Percentage benefit applies |
