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Dental Plan B

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

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