The following is a partial listing of scheduled benefit allowances. If you choose Dental Plan B, you may go to any dentist and you will be reimbursed according to the schedule listed below up to a maximum benefit of $2,000 per calendar year. The $2,000 annual maximum does not apply to Preventative and Minor Restorations for dependent children under the age of 18. Under Dental Plan B, your out-of-pocket will be the difference between the charge made by the dentist and the scheduled allowance. For a complete listing of benefits, limitations and exclusions, please refer to the official Plan booklet. You will save money when you choose a dentist who is in the Delta Dental network because the dentists in the network charge a discounted rate for dental services. For a complete listing of benefits, limitations and exclusions, please refer to the official Plan booklet.
Benefit Category | Scheduled Benefit |
Procedural/Diagnostic | |
Examinations (two per year) Periodic oral exam | $45 |
Complete mouth intramural x-rays, including bitewings (once each calendar year) | $104 |
Bitewing x-rays – two films | $35 |
Preventative | |
Prophy (cleaning and scaling) (two each calendar year) age 14 and over | $89 |
Minor Restorations | |
Amalgam – two surface | $120 |
Composite resin – two surface | $138 |
Major Restorations | |
Crown – Porcelain with metal (gold) | $658 |
Crown – Gold | $651 |
Endodontics | |
Pulpotomy | $103 |
Root Canal – includes entire treatment plan except final restoration – bi-rooted | $663 |
Periodontics | |
Periodontal prophy (limited to one every 3 months) | $118 |
Oral Surgery | |
Extractions (includes local anesthesia and routine post-operative care) | |
Single tooth (uncomplicated) | $106 |
Erupted tooth ( surgically removed) | $201 |
Impacted tooth – soft tissue | $205 |
Prosthodontics | |
Complete upper dentures | $1121 |
Complete lower dentures | $1015 |
Bridgework/porcelain fused to gold pontic | $667 |
Other Dental Procedures | |
General Anesthesia, first 30 minutes | $276 |
Space Maintainers/fixed, band type | $221 |
