What You’ll Pay For Your Dental Care

Select a type of plan to find out how much you’ll pay.

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$50 Deductible for Adults $75 for Children
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No Annual Benefit Limit for Children $1,500 Annual Benefit Limit for Adults
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$350 Individual Out-of-Pocket Maximum (child only)
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$700 Family Out-of-Pocket Maximum (two or more children only)
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$0 Office Copay
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Six-Month Waiting Period For Major Services for Adults


Service Price
Diagnostic and Preventive (includes x-rays, exams, cleaning and sealants) Free
Amalgam Filling: One Surface Pay 20% of bill
Root Canal: Molar Pay 50% of bill
Gingivectomy, Per Tooth Pay 50% of bill
Extraction: Single Tooth, Exposed Root or Erupted Pay 50% of bill
Extraction: Complete Bony Pay 50% of bill
Crown: Porcelain With Metal Pay 50% of bill
Medically Necessary Orthodontia Children – pay 50% of bill
Not Covered for Adults

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