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Health

State PPO

HMO

Life Insurance

Dental

Vision

Supplemental

   

Prepaid Dental Plans (In-Network Only)

The Prepaid Dental Plans pay benefits only when you use network providers. These plans do not have a deductible and cover most preventive care at no charge. You pay a specific dollar amount for other care you receive.

Use the chart below to see costs for basic services for each Prepaid dental plan. The rows show the monthly premium and the amount or percentage you pay for the common dental services listed. The columns list the costs by plan.

 

 

Humana
(CompBenefits)
Network Plus
4004
UnitedHealthCare
Solstice S700
4014
Assurant Employee Benefits Prepaid 225
(Heritage Plus)
4025
CIGNA Dental
4034
Humana
(CompBenefits)
Select 15
4044
  Monthly Premiums
 

      Employee Only
      Employee + Spouse
      Employee + Child(ren)
      Employee + Spouse +
        Child(ren)

$23.58
$46.48
$55.42
$70.80


$10.91
$23.95
$29.90
$41.98


$14.93
$25.17
$33.26
$43.54


$27.38
$49.22
$57.92
$70.26


$12.64
$21.20
$23.00
$32.98


 

      Calendar Year Deductible

$0

$0

$0

$0

$0

 

      Calendar Year Maximum

$0

$0

$0

$0

$0

ADA Code Exams You Pay You Pay You Pay You Pay You Pay

D0120

      Periodic Checkup

$0

$0

$0

$0

$0

D0140

      Limited

$0

$0

$0

$0

$0

D0150

      Comprehensive Initial

$0

$0

$0

$0

$0

  X-Rays          

D0230

      Additional Intraoral

$0

$2

$0

$0

$0

D0272

      2 Bite Wings

$01

$0

$0

$0

$0

D0330

      Panoramic

$0

$50

$0

$0

$0

  Preventive Services          

D1110

      Prophy (adult cleaning)

$01

$01

$0

$0

$01

D1120

      Prophy (child cleaning)

$01

$01,2

$0

$0

$01

D1203

      Fluoride (Child)

$0

$02

$0

$0

$02

D1351

      Sealant

$03

$02

$0

$11

$7

  Silver Fillings          

D2140

      Amalgam, 1 surface

$6

$0

$10

$0

$0

D2150

      Amalgam, 2 surfaces

$8

$0

$15

$0

$0

  White Fillings, Front Teeth          

D2330

      Anterior Composite, 1 surface

$8

$30

$25

$0

$30

D2331

      Anterior Composite, 2 surfaces

$10

$37

$35

$0

$37

  White Fillings, Back Teeth          

D2391

      Posterior Composite, 1 surface

$6

$65

$60

$45

75%

D2392

      Posterior Composite, 2 surfaces

$8

$75

$70

$57

75%

  Onlays and Crowns          

D2740

      Crown, All Porcelain

$280

$2455

$2255

$490 (all inclusive)

75%

D2750

      Crown, Porcelain fused to High Noble

$300
(includes metal)

$2455

$2255

$450 (all inclusive)

$240
(plus metal)

D2950

      Core Build Up

$59

$70

$75

$130

$40

  Periodontal Care (for gums)          

D4341

      Periodontal Therapy, 4+ teeth/quadrant

$14

$50

$759

$83

$45

D4910

      Periodontal Maintenance

$91

$50

$45

$50

$45

  Extractions          

D7140

      Extraction, Erupted Tooth or Exposed Root

$8

$20

$18

$12

$0

D7210

      Extraction, Surgical

$14

$30

$699

$50

$25

  Orthodontia Treatment6          

D8080

Comprehensive orthodontic treatment of adolescent dentition (full treatment case up to 24 months - including fixed/removable appliances)

$1,580

$2,250

$2,000

$2,045

75%

D8090

Comprehensive orthodontic treatment of adult dentition (full treatment case up to 24 months - including fixed/removable appliances)

$1,580

$2,350

$2,200

$2,385

75%

None

Bracketing (for above procedures D8080 or D8090)

Included

Included

$300

$515

Included

D8660

Pre-orthodontic treatment visit (consult/records/exam)

$80

$35

$100

$67

75%

D8680

Orthodontic retention (removal of applicances, construction and placement of retainer(s))

$250

$300

$250

$345

75%

D8999

Unspecified Orthodontic Procedure - By Report (Orthodontic Treatment Plan and Records)

Included

$250

Included under D8660

$195

Included

1Limited to once every six months
2Only for children under age 16
3Only for children under age 14
4Only for children under age 13
5Services require separate payment for laboratory charges
6Copays do not include pre-exam and retention
775% during first year; 50% for 2nd and subsequent years of continuous coverage
8Plan payments for covered preventive procedures are not deducted from your annual maximum benefit.
9Copayment for General Dentist or Specialist is the same