|
Type
1 Preventive & Diagnostic
|
Plan
Pays
|
|
a.
Oral exams, including prophylaxis
|
$48.00
|
|
b.
Bitewings, per film
|
$6.40
|
|
c.
X-ray, panoramic or cephalometric
|
$48.00
|
|
d.
Sealants/topical fluoride
|
$13.60
|
|
e.
Space maintainers
|
$144.00
|
| |
|
|
Type
2 Major Restorative
|
Plan
Pays
|
|
a.
Crowns, bridges and dentures
|
$240.00
|
| b.
Pre-fabricated crowns |
$80.00 |
| c.
Crown build-up procedures |
$64.00 |
| |
|
| Type
3 Minor Restorative |
Plan
Pays |
| a.
Fillings |
$56.00 |
| b.
Crown, bridge and denture repairs |
$32.00 |
| c.
Relining or rebasing dentures |
$80.00 |
| |
|
| Type
4 Endodontics |
Plan
Pays |
| a.
Root canals, apicoectomies |
$256.00 |
| b.
Root amputation |
$128.00 |
| c.
Therapeutic pulpotomy, retrograde fillings, apexification, and hemisection |
$64.00 |
| |
|
| Type
5 Periodontics ($500 Lifetime Maximum) |
Plan
Pays |
| a.
Tissue grafts or bone surgery |
$128.00 |
| b.
Gingival curettage (per quadrant) |
$80.00 |
| c.
Gingivectomy (per tooth) |
$48.00 |
| d.
Gingivectomy (per quadrant), periodontal scaling, periodontal
splinting, and root planing |
$32.00 |
| |
|
| Type
6 Oral Surgery |
Plan
Pays |
| a.
Surgeries Level 1 (removal of exostosis) |
$160.00 |
| b.
Surgeries Level 2 (removal of impacted tooth) |
$88.00 |
| c.
Surgeries Level 3 (simple extraction) |
$48.00 |
| |
|
| Type
7 Anesthesia |
Plan
Pays |
| a.
Intravenous sedation |
$96.00 |
| b.
General anesthesia, first half-hour and each additional quarter-hour |
$96.00 |
| |
|
|
Type
8 Orthodontia
(Adult
or Child - Per Course of Treatment)
|
Plan
Pays |
| Annual
Maximum |
|
| Types
1 through 7 |
$1,500.00 |
| |
|
| Waiting
Period |
|
| 12-month
waiting period applicable to Types 2, 5, 6a, 7 and 8 |
