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
*Deductible is waived for all providers in this category| | 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.