Diagnostic
and Preventative
In-Network
- 100% of the Allowable Amount.
Out-of-Network - 80% of the Allowable Amount. Not
subject to deductible:
- Initial exam
- Periodic exams
- Emergency exams
- X-rays (diagnostic)
- Cleanings (one in a 6 month period)
- Pulp vitality test
- Child fluoride treatment (up to age 19)
- Space maintainers (for children)
- Emergency treatment (relief of pain) |
Minor
Services
In-Network
- 50% of the Allowable Amount.
Out-of-Network - 30% of the Allowable Amount. Subject
to deductible:
- Silver fillings (in permanent and primary teeth)
- Anterior resin fillings (tooth colored filling)
- Stainless steel crown
- Sedative filling
- Pin retention
- Crown repair
- Denture repair
- Some oral surgery (excluding any impacted teeth)
- Root canal and pulp therapy (excluding final restoration)
|
Major
Services
In-Network
- 50% of the Allowable Amount.
Out-of-Network - 30% of the Allowable Amount. Subject
to deductible:
- Crowns (permanent)
- Recement crown
- Crown build-up
- Periodontal procedures, dentures (complete and partial)
- Denture/ partial repair
- Bridges
12
month waiting period applies. Replacement of teeth
missing prior to the effective dates are not covered.
|
