Dental Plan Chart, plan 1 High option

Dental Plan

High Option- Your Own Dentist

Plan 1

Zero Deductible

Maximum Annual Benefit - $1000 per covered person

Members Services	Plan pays amount listed
Oral Examinations 0110 Initial Oral Examination 0130 Emergency Oral Examination	17.00 26.00
X-rays 0210 Intraoral- Complete Series 0270 Bitewing- Single, First Film 0330 Panoramic- Maxilla & Mandible, Single	43.00 11.00 37.00
Dental Prophylaxis (routine cleaning) 1110 Adults	33.00
Fluoride Treatments 1231 Application of Fluoride	28.00
Restorative Dentistry 2150 Amalgam- Two surfaces, Permanent 2161 Amalgam- Four or more surfaces	33.00 45.00
Acrylic or Plastic Restorations 2310 Acrylic or Plastic 2331 Composite Resin- Two surfaces 2338 Composite with Ultra- Violet, Two surfaces 2339 Composite with Ultra-Violet, Three surfaces	21.00 33.00 33.00 47.00
Other Restorative Services 2910 Recement Inlays / Crowns	13.00
Endodontic Treatment 3320 Two Canals (excludes final restoration) 3330 Three Canals (excludes final restoration)	173.00 223.00
Adjunctive Periodontal Services 4341 Periodontal scaling and root plng (per quad)	44.00

Considerable effort went into preparing the on-line materials on this WWW server, and we try to keep the information correct and up-to-date. However, Benefits Unlimited and its agents shall not be held liable for any damages, however caused, by errors or omissions that may have occurred in the preparation of these pages. Prices and conditions subject to change and are only a brief summary of the complete benefits.

Copyright 1997. No information contained in this document may be reproduced without express written consent of the author.
Last revised: December 09, 2002.