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Health

State PPO

HMO

Life Insurance

Dental

Vision

Supplemental

   

Indemnity Dental Plan

With the Indemnity Dental option, 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.

Use the 2011 Dental Plans Rate Chart to see your monthly premium rates and costs for basic services for each dental plan.

 

Indemnity

 

CompBenefits (formerly ADP) Schedule B
4084

Monthly Premiums
Employee
Employee + Spouse
Employee + Child(ren)
Employee + Spouse + Child(ren)


$14.74
$21.96
$23.30
$37.10

Calendar Year Deductible

$50/person
3 per family

Calendar Year Maximum

$1,000/person

***Preventive Care (no deductible)

Periodic oral exam (ADA 120)

Cost above $11.70

Bite-wing X-rays four films (ADA 274)

Cost above $16.20

Cleanings - Dental Prophylaxis Adult (ADA 1110)

Cost above $18.90

Fluoride treatment, child (ADA 1203)

Cost above $15.30

Sealant, per tooth (ADA 1351)

Cost above $6.30

Space maintainers - fixed bilateral (ADA 1515)

Cost above $108

***Basic and Major Care (for PPO and Indemnity plans, deductible applies)

X-rays - intraoral - complete series including bitewings (ADA 210)

Cost above $30.60

Amalgam fillings - 2 surfaces, primary or permanent (ADA 2150)

Cost above $18

Resin-based composite - 2 surfaces, anterior (ADA 2331)

Cost above $22.50

Root canal - endodontic therapy - molar, excluding final restoration (ADA 3330)

Cost above $243

Periodontal surgery – gingivecotomy/gingivoplasty - 4 or more contiguous teeth per quadrant (ADA 4210)

Cost above $243

Periodontal scaling and root planing, 4 or more contiguous teeth per quadrant (ADA 4341)

Cost above $14.40

Surgical extraction of tooth, including wisdom teeth (ADA 7240)

Cost above $61.60

General anesthesia, first 30 minutes (ADA 9220)

Cost above $30.60

Porcelain Crowns fused to high noble metal (ADA 2750)++

Cost above $180

Fixed bridges - pontic, pocelain fused to high noble metal (ADA 6240)++

Cost above $180

Full lower denture (ADA 5120)++

Cost above $129.60

Metalic inlay - 2 surfaces (ADA 2520)++

Cost above $79.20

Lower partial dentures, cast metal - acrylic (ADA 5214)++

Cost above $134.10

Re-cement crowns (ADA 2920)

Cost above $11.70

Relining complete upper denture - chairside (ADA 5730)

Cost above $32.40

Repairs to broken denture base (ADA 5510)++

Cost above $26.10

***Orthodontia Care

Comprehensive orthodontic treatment of the adolescent dentition (full treatment case up to 24 months – including fixed/removable appliances) (ADA 8080)

100%

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