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HealthState PPO HMO
Life InsuranceDentalVisionSupplemental |
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Indemnity Dental Plans
With the Indemnity Dental options, you may receive care from any dentist. You have a deductible to meet and then pay part of the cost for the services you receive. None of these plans cover adult orthodontia; Assurant does cover child orthodontia. Premiums shown do not include the 2% administrative fee.
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Indemnity |
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CompBenefits (formerly ADP) Schedule B |
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Monthly Premiums |
$14.74 |
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Calendar Year Deductible |
$50/person |
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Calendar Year Maximum |
$1,000/person |
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***Preventive Care (no deductible) |
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Periodic oral exam (ADA 120) |
Cost above $11.70 |
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Bite-wing X-rays four films (ADA 274) |
Cost above $16.20 |
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Cleanings - Dental Prophylaxis Adult (ADA 1110) |
Cost above $18.90 |
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Fluoride treatment, child (ADA 1203) |
Cost above $15.30 |
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Sealant, per tooth (ADA 1351) |
Cost above $6.30 |
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Space maintainers - fixed bilateral (ADA 1515) |
Cost above $108 |
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***Basic and Major Care (for PPO and Indemnity plans, deductible applies) |
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X-rays - intraoral - complete series including bitewings (ADA 210) |
Cost above $30.60 |
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Amalgam fillings - 2 surfaces, primary or permanent (ADA 2150) |
Cost above $18 |
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Resin-based composite - 2 surfaces, anterior (ADA 2331) |
Cost above $22.50 |
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Root canal - endodontic therapy - molar, excluding final restoration (ADA 3330) |
Cost above $243 |
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Periodontal surgery – gingivecotomy/gingivoplasty - 4 or more contiguous teeth per quadrant (ADA 4210) |
Cost above $243 |
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Periodontal scaling and root planing, 4 or more contiguous teeth per quadrant (ADA 4341) |
Cost above $14.40 |
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Surgical extraction of tooth, including wisdom teeth (ADA 7240) |
Cost above $61.60 |
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General anesthesia, first 30 minutes (ADA 9220) |
Cost above $30.60 |
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Porcelain Crowns fused to high noble metal (ADA 2750)++ |
Cost above $180 |
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Fixed bridges - pontic, pocelain fused to high noble metal (ADA 6240)++ |
Cost above $180 |
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Full lower denture (ADA 5120)++ |
Cost above $129.60 |
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Metalic inlay - 2 surfaces (ADA 2520)++ |
Cost above $79.20 |
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Lower partial dentures, cast metal - acrylic (ADA 5214)++ |
Cost above $134.10 |
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Re-cement crowns (ADA 2920) |
Cost above $11.70 |
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Relining complete upper denture - chairside (ADA 5730) |
Cost above $32.40 |
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Repairs to broken denture base (ADA 5510)++ |
Cost above $26.10 |
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***Orthodontia Care |
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Comprehensive orthodontic treatment of the adolescent dentition (full treatment case up to 24 months – including fixed/removable appliances) (ADA 8080) |
100% |
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Comprehensive orthodontic treatment of the adult dentition (full treatment case up to 24 months – including fixed/removable appliances) (ADA 8090) |
100% |
*75% for first year; 50% for subsequent years of consecutive coverage
**limited to children under age 16
***A sample of American Dental Association (ADA) codes are shown to help
you more easily compare costs across plans.
++With some plans, these services may also require a separate payment
for metal and/or laboratory charges
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