Dental Plan 1
High Option*
Zero Deductible
Maximum Annual Benefit - $1500 per covered person
| Members Services | Pay amount |
|---|---|
|
Oral Examinations 0110 Initial Oral Examination |
17.00 26.00 |
|
X-rays
0210 Intraoral- Complete Series |
43.00 11.00 37.00 |
|
Dental Prophylaxis (routine cleaning) 1110 Adults |
33.00 |
|
Fluoride Treatments 1231 Application of Fluoride |
28.00 |
|
Restorative Dentistry 2150 Amalgam- Two surfaces, Permanent |
33.00 45.00 |
|
Acrylic or Plastic Restorations 2310
Acrylic or Plastic |
21.00 33.00 33.00 47.00 |
|
Other Restorative Services 2910 Recement Inlays / Crowns |
13.00 |
|
Endodontic Treatment 3320 Two Canals (excludes final
restoration) |
173.00 223.00 |
| Adjunctive Periodontal Services
4340 Periodontal scaling and root plng (entire mouth)
|
63.00 44.00 |
*Major Benefits- Prosthetics/Crowns/Periodontics are covered after twelve months of continuous coverage
