|
Benefits
|
In Network
|
Out of Network
|
|
Annual Maximum
|
$1,500
|
$1,500
|
|
Deductible
|
$50 Annual
|
$50 Annual
|
|
Deductible Limit
|
Max 3 per family
|
Max 3 per family
|
Preventative Services
|
Plan Pays
100%
Deductible Waived
|
Plan Pays
100%
Deductible Waived
|
|
Cleanings (2 per year)
|
|
Exams
|
|
Floride (under age 16)
|
|
Sealants under age 16)
|
|
Space Maintainers (under age 16)
|
|
Oral Cancer Screening (Age 40+)
|
|
Radiographs - Bitewings
|
|
Radiographs - FMX
|
Basic Services
|
Plan Pays
90% |
Plan Pays
90% |
|
Emergency Pain
|
|
Restorations (Amalgams & Interior Resin)
|
|
Restorations (Posterior Resin)
|
|
Simple Extractions
|
|
Surgical Extractions
|
|
Endodontics
|
|
Periodontal Maintenance
|
|
Non-Surgical Periodontics
|
|
Crown Repairs
|
|
Bridge Repairs
|
|
Denture Repairs
|
|
Anethesia
|
Major Services
|
Plan Pays
60%
|
Plan Pays
50%
|
|
Inlays
|
|
Onlays
|
|
Crowns
|
|
Bridges
|
|
Dentures
|
|
Implants
|
Orthodontics (child only)
|
50%
|
50%
|
Orthodontics Lifetime Maximum
|
$1,500
|
$1,500
|