Benefit |
In
Network |
Out
of Network |
|
|
|
|
No
charge |
Not
Applicable |
|
No
charge |
Not
Applicable |
|
No
charge |
Not
Applicable |
- X-rays,
each additional
film
|
No
charge |
Not
Applicable |
|
No
charge |
Not
Applicable |
|
No
charge |
Not
Applicable |
|
Not
covered |
Not
Applicable |
|
$10 |
Not
Applicable |
- Intial
charting with
pocket depth
summary
|
$5 |
Not
Applicable |
|
$10 |
Not
Applicable |
|
$20 |
Not
Applicable |
|
|
|
|
|
|
|
$15 |
Not
Applicable |
|
$20 |
Not
Applicable |
|
$26 |
Not
Applicable |
- Resin
restorations,
per tooth
|
$25 |
Not
Applicable |
|
$28 |
Not
Applicable |
|
$5 |
Not
Applicable |
|
$7 |
Not
Applicable |
|
$16 |
Not
Applicable |
- Extraction,
each additional
|
$10 |
Not
Applicable |
|
$50 |
Not
Applicable |
|
Not
covered |
Not
Applicable |
- Completely
bony impaction
|
Not
covered |
Not
Applicable |
- Biopsy
of bony tissue
(soft)
|
$10 |
Not
Applicable |
- Biopsy
of bony tissue
(hard)
|
$16 |
Not
Applicable |
- Surgical
removal or erupted
tooth
|
$40 |
Not
Applicable |
|
$90 |
Not
Applicable |
- Alveoloplasty
with extractions,
per quadrant
|
$80 |
Not
Applicable |
|
$30 |
Not
Applicable |
|
$30 |
Not
Applicable |
|
$50 |
Not
Applicable |
|
|
|
|
$10 |
Not
Applicable |
|
$24 |
Not
Applicable |
|
$22 |
Not
Applicable |
|
$100 |
Not
Applicable |
|
$130 |
Not
Applicable |
|
$175 |
Not
Applicable |
|
$50 |
Not
Applicable |
|
$65 |
Not
Applicable |
|
|
|
- Gingival
curettage, per
quadrant
|
$40 |
Not
Applicable |
- Gingivectomy,
per quadrant
|
$115 |
Not
Applicable |
|
$20 |
Not
Applicable |
|
|
|
|
|
|
- Stainless
steel, primary
tooth
|
$30 |
Not
Applicable |
|
$85 |
Not
Applicable |
|
$145 |
Not
Applicable |
|
$140 |
Not
Applicable |
|
$130 |
Not
Applicable |
- Porcelain
with metal crown
|
$165 |
Not
Applicable |
- Cast
post and core,
in addition
to crown
|
$65 |
Not
Applicable |
|
$20 |
Not
Applicable |
- Pontic,
cast metal (base)
|
$145 |
Not
Applicable |
- Pontic,
porcelain with
metal
|
$165 |
Not
Applicable |
|
$12 |
Not
Applicable |
|
$12 |
Not
Applicable |
|
$18 |
Not
Applicable |
|
|
|
|
$12 |
Not
Applicable |
|
$22.50 |
Not
Applicable |
|
$28 |
Not
Applicable |
|
$35 |
Not
Applicable |
|
$65 |
Not
Applicable |
|
$60 |
Not
Applicable |
- Partial
denture, upper
or lower
|
$255 |
Not
Applicable |
- Complete
upper or lower
denture
|
$250 |
Not
Applicable |
- Teeth
and or clasps
extra, per unit
|
$31 |
Not
Applicable |
|
$55 |
Not
Applicable |
- Removable
acrylic space
maintainer
|
$55 |
Not
Applicable |
|
|
|
- Class
I (teeth straightening)
|
$1895 |
Not
Applicable |
- Class
II (correction
or overbite)
|
$1895 |
Not
Applicable |
- Class
III (correction
of underbite)
|
$1895 |
Not
Applicable |