Services & Benefit Options

PPO Schedule Plan
Calendar Year deductibles 4
$50
Calendar Year maximum Benefit
Select $1,000 , $1,500, or $2,000
Preventative & Diagnostic Services
Type I Services
  • Clinical oral examinations (limited to two exams per calendar year)
  • Bitewing X-rays (no less than six months apart)
  • Prophlyaxis (limited to two cleanings per calendar year)
  • Topical Fluoride treatment for children up to age 19,or 23 if a full-time student (0nce per calendar year)
  • Sealants for children under age 14 5
  • Space maintainers for children up to the age of 19 (23 if full-time student)
  • Emergency treatment (If no other service was rendered except x-rays)
Your choice of the following
In Network
Out of Network
100%
100%
Type II Basic Services
Type II Services
  • Extractions (non-orthodontic)
  • Oral Surgery
  • Restorative-type fillings
  • General anesthetic when administered with oral surgery.
  • Endodontics treatment (pulp capping , pulpotomy, and root canal treatment) 6
  • Periodontics 6
In Network
Out of Network
80%
80%
Type III Major Services
Type III Services
  • Crowns, Inlays and Onlays (Single Restorations)
  • Installation Prosthodontics (Bridges and Dentures)
  • maintenance Prosthodontics (adjustments within six months after installation) 7
In Network
Out of Network
50%
50%
Type IV Orthodontia Services
Type IV Services
  • Lifetime Benefit Maximum $1,000 or $1,500
  • For Children under the age 19 only
  • Only available to groups of five or more 7

 
In Network
Out of Network
50%
50%

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