WWW UDHI

CWA Disctrict 6
SBC SW Bell-Patient Benefit Page
Yearly Insurance Maximum For General Dental: $1300.00
Orthodontic Lifetime Maximum: $1600.00
Lifetime Deductible: $50.00 (provided you have your teeth cleaned at least 1 time each year.)

Dental Services	Patient Pays
PREVENTATIVE PROCEDURES Teeth Cleaning (2 times per year) X-rays Examinations	$0.00 -You Pay Nothing!*
Periodontal Procedures Perio Maintenence Deep Cleanings	$0.00 -You Pay Nothing!*
Fillings: Composite “Tooth Colored” Fillings	Small out of pocket expense on back teeth
Root Canal Procedures	$150.00 Pre-set Co-Payment
Crowns (Caps)	$150.00 Pre-set Co-Payment Higher co-pay applies for specialty crowns
Bridges (Permanently placed to fill in for missing teeth)	$150.00 per number of teeth involved in bridge
Partial Dentures (Removable appliance to fill in for missing teeth)	$150.00 Pre-set Co-Payment
Full Dentures (Removable appliance to replace all missing teeth)	$150.00 Pre-set Co-Payment

All Benefits Are Subject To Patient Eligibility And Plan Provisions. Always-Contact Insurance For Details

*Exclusions and limitations apply