My Benefits
Sample List of Covered Procedures
With two plan options available, you can choose the coverage that best meets your individual needs.
| |
Plan CAA54 |
Plan CAA55 |
| Read the full plan detail, list of covered procedures, copayments, limitations and exclusions. |
CAA54 |
CAA55 |
| |
You Pay |
You Pay |
| Office Visit (D0999) |
$10.00 |
$15.00 |
| Exam (D0150, D0120) |
No Cost |
No Cost |
| Bitewing X-rays (D0270, D0274) |
No Cost |
No Cost |
| Full Mouth X-rays (D0210, D0330) |
No Cost |
$25.00 |
| Cleaning (once every 6 months) (D1110, D1120) |
$20.00 |
$25.00 |
| Silver (Amalgam) Fillings (D2150) |
$40.00 |
$45.00 |
| Crown (upgrade applies for porcelain on molars) (D2751) |
$325.00 |
$325.00 |
| Tooth Extraction (D7140) |
$40.00 |
$45.00 |
| Teeth Whitening (per arch) (D9972) |
$125.00 |
$125.00 |
| Periodontal Scaling (D4341) |
$80.00 |
$85.00 |
| Child Orthodontics (D8070, D8080) |
$2,600.00 |
$2,700.00 |
| Adult Orthodontics (D8090) |
$2,800.00 |
$2,900.00 |
Carefully review the Description of Benefits and Copayments in Schedule A and Limitations of Benefits in Schedule B of the contract to determine which plan is right for you.
Disclosure Form/Contract
Detailed disclosure of plan copayments, limitations and exclusions.
|
