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University Benefits Student Insurance

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Monday-Friday, 8 a.m.-5 p.m.

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
Co-Insurance 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
Co-Insurance 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
Co-Insurance 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
Co-Insurance 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
Co-Insurance 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
Co-Insurance 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.