|
Services
|
Percentage Paid
|
|
Preventative Services
|
In-Network (%)
|
Out-of-Network (%)
|
| Emergency Pallative Treatment |
100% |
100% |
| Oral Exmination - Every 6 months |
100% |
100% |
| X-Rays-4 bitewings every 12 months, full mouth series every 5 years |
100% |
100% |
| Teeth cleaning - every 6 months |
100% |
100% |
| Flouride treatments for Children - every 6 months under age 14 |
100% |
100% |
| Space Maintainers for Children - under age 16 |
100% |
100% |
| Topical Sealants for unrestored molar teeth - one treatment for child(ren) under 16 in a 3-year period |
100% |
100% |
| Teeth cleaning - every 6 months |
100% |
100% |
|
Basic Services
|
In-Network (%)
|
Out-of-Network (%)
|
| Laboratory Test |
100% |
80% |
| Diagnositic Consulation - One per year |
100% |
80% |
| Fillings: Amalgam, Silicate, Acrylic |
100% |
80% |
| Crowns: Stainless Steel |
100% |
80% |
| Repairs of dentures, bridgework, crowns, etc. |
100% |
80% |
| Endodontic services/root canal therapy |
100% |
80% |
| Periodontic Services |
100% |
80% |
| Oral Surgery-Uncomplicated extractions |
100% |
80% |
| General Anesthesia - Surgical procedures only |
100% |
80% |
| Injectable Antibiotics - Treatment for a dental condition only |
100% |
80% |
|
Major Services
|
In-Network (%)
|
Out-of-Network (%)
|
| Dental Implants |
60% |
50% |
| Bridges Installation-Fixed and removable |
60% |
50% |
| Dentures-Full and partial |
60% |
50% |
| Crowns: Acrylic Metal, Porcelain |
60% |
50% |
| Inlays |
60% |
50% |
| Onlays |
60% |
50% |
| Posts |
60% |
50% |
|
Orthodontic Services
|
In-Network (%)
|
Out-of-Network (%)
|
| $1000.00 Lifetime Maximum for child(ren) under 19 |
50% |
50% |
|
|
| |