How Much an Individual Pays for Dental Services
Check-ups and Teeth Cleaning (Diagnostic and Preventative Services)
- Dental Cleaning
- Oral Evaluations
- Fluoride Applications
- X-rays
- Sealant Applications
- Space Maintainers
- Diagnostic Tests
- Biopsy of Oral Tissue
- Maintenance Therapy
| PPO | PREMIER | NON-PARTICIPATING | |
|---|---|---|---|
| Deductible* | $0 | $0 | $0 |
| Coinsurance | 0% | 0% | 0% |
| Annual Maximum | $1,000 | $1,000 | $1,000 |
Cavity Repair and Tooth Extractions (Routine and Restorative Services)
- Emergency Treatment for Pain
- General Anesthesia/Sedation Anesthesia or Analgesia
- Restoration of Decayed or Fractured Teeth
- Limited Occlusal Adjustment
- Routine Oral Surgery
- Consultations
- Antibiotic Drug Injections
| PPO | PREMIER | NON-PARTICIPATING | |
|---|---|---|---|
| Deductible (Single / Family) | $15 / $45 | $25 / $75 | $25 / $75 |
| Coinsurance | 10% | 20% | 20% |
| Annual Maximum | $1,000 | $1,000 | $1,000 |
Root Canals (Endodontic Services)
- Apicoectomy
- Direct Pulp Cap
- Pulpotomy
- Retrograde Fillings
- Root Canal Therapy
| PPO | PREMIER | NON-PARTICIPATING | |
|---|---|---|---|
| Deductible (Single / Family) | $15 / $45 | $25 / $75 | $25 / $75 |
| Coinsurance | 20% | 20% | 20% |
| Annual Maximum | $1,000 | $1,000 | $1,000 |
Gum and Bone Diseases (Periodontal Services)
- Conservative Procedures
- Complex Procedures
| PPO | PREMIER | NON-PARTICIPATING | |
|---|---|---|---|
| Deductible (Single / Family) | $15 / $45 | $25 / $75 | $25 / $75 |
| Coinsurance | 20% | 20% | 20% |
| Annual Maximum | $1,000 | $1,000 | $1,000 |
High-Cost Restorations (Cast Restorations)
- Crowns
- Inlays
- Onlays
- Posts and Cores
| PPO | PREMIER | NON-PARTICIPATING | |
|---|---|---|---|
| Deductible (Single / Family) | $15 / $45 | $25 / $75 | $25 / $75 |
| Coinsurance | 50% | 50% | 50% |
| Annual Maximum | $1,000 | $1,000 | $1,000 |
Dentures and Bridges (Prosthetics)
- Bridges
- Dentures
- Denture Relining
- Implants
| PPO | PREMIER | NON-PARTICIPATING | |
|---|---|---|---|
| Deductible (Single / Family) | $15 / $45 | $25 / $75 | $25 / $75 |
| Coinsurance | 50% | 50% | 50% |
| Annual Maximum | $1,000 | $1,000 | $1,000 |
The benefit period is the same as a calendar year. It begins the day your coverage goes into effect and starts over each January 1. This is true for as long as you have coverage.
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Our website's information describes only the highlights of the plans and does not constitute official plan documents. Additional terms and conditions may apply. If there are any discrepancies between the information contained herein and the official plan documents, the plan documents will govern.