Annual
Maximum Benefit |
Participating
provider
|
$1,000 per person per calendar year;
benefits listed
are after the deductible and applicable waiting
periods are satisfied |
Non-participating
provider
|
$1,000 per person per calendar year;
benefits listed
are after the deductible and applicable waiting
periods are satisfied |
Major
Restorative Services |
Participating
provider
|
Oral surgery (extractions): All
charges except $49 per single tooth, $46 each additional tooth,
3-month waiting period |
Non-participating
provider
|
Oral surgery (extractions): All
charges except $49 per single tooth, $46 each additional tooth,
3-month waiting period |
Endodontics |
Participating
provider
|
Root canal therapy: All charges
except $154-$242, depending on tooth, excluding final
restoration,
12-month waiting period |
Non-participating
provider
|
Root canal therapy: All charges
except $154-$242, depending on tooth, excluding final
restoration,
12-month waiting period |
Periodontics |
Participating
provider
|
Gingivectomy: All charges except
$145 per quadrant; Osseous surgery: All charges except $277 per
quadrant; 12-month waiting period for all services |
Non-participating
provider
|
Gingivectomy: All charges except
$145 per quadrant; Osseous surgery: All charges except $277 per
quadrant; 12-month waiting period for all services |
Prosthodontics |
Participating
provider
|
Pontic: All charges except $264;
Post and Core: All charges except $75; Complete denture: All
charges except $343; Partial denture: All charges except $308;
Denture reline (chairside): All charges except $75; Denture
reline (lab): All charges except $106 |
Non-participating
provider
|
Pontic: All charges except $264;
Post and Core: All charges except $75; Complete denture: All
charges except $343; Partial denture: All charges except $308;
Denture reline (chairside): All charges except $75; Denture
reline (lab): All charges except $106 |
Orthodontic
Services |
Participating
provider
|
Not covered |
Non-participating
provider
|
Not covered |
Annual
Deductible |
Participating
provider
|
$50 per person, limited to three
deductibles
per family |
Access
to Providers |
Participating
provider
|
Dentist of your choice3 |
Non-participating
provider
|
Dentist of your choice3 |
Annual
Deductible |
Non-participating
provider
|
$50 per person, limited to three
deductibles
per family |
Preventive
Services |
Participating
provider
|
No charge |
Non-participating
provider
|
Office visits: All charges except
$25; Cleaning: All charges except $39/adult, $30/child up to two
times in 12 consecutive months; Fluoride application (child
only): All charges except $14 up to twice per year |
Diagnostic
Services |
Participating
provider
|
No charge |
Non-participating
provider
|
Oral exams: All charges except $25;
x-rays (full-mouth): All charges except $60, limited to once
every 3 years |
Minor
Restorative Services |
Participating
provider
|
Fillings: All charges except
$38-$84, depending on tooth
and number of surfaces, 3-month waiting period; Crowns
(stainless steel): All charges except $57, 12-month waiting
period |
Non-participating
provider
|
Fillings: All charges except
$38-$84, depending on tooth
and number of surfaces, 3-month waiting period; Crowns
(stainless steel): All charges except $57, 12-month waiting
period |