Dental Plan 500B
Low Option- Your Own Dentist
Zero Deductible
| Members Services | Plan pays amount listed |
| Oral Examinations 0110 Initial Oral Examination |
7.00 9.00 |
| X-rays 0210 Intraoral- Complete Series |
17.00 4.00 14.00 |
| Dental Prophylaxis (routine cleaning 1110 Adults |
16.00 |
| Fluoride Treatments 1231 Application of Fluoride |
11.00 |
| Restorative Dentistry 2150 Amalgam- Two surfaces, Permanent |
18.00 23.00 |
| Acrylic or Plastic Restorations
2310 Acrylic or Plastic |
18.00 23.00 22.00 33.00 |
| Other Restorative
Services 2910 Recement Inlays / Crowns |
10.00 |
| Endodontic Treatment 3320 Two Canals (excludes final restoration) |
92.00 121.00 |
| Adjunctive Periodontal
Services 4341 Periodontal scaling and root plgn (per quad) |
21.00 |
