our time ~ your piece of mind!
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Group Dental
& Vision Plan
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Monthly Rate Schedule:
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Monthly Billing Fee:
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| Dental Expense Benefit Program | |
| Type I - Plan Pays 100% | Type III - Plan Pays 50% |
| Preventive Services | After Deductible |
| Oral Exams (non emergency) |
Major Services |
| Dental Cleaning | Crowns |
| X-rays | Dentures |
| Fluoride Treatment (under age 15) | Bridge Work |
| Space Maintainers (under age 15) | |
| Type II - Plan Pays 80% | Type IV - Plan Pays 50% |
| After Deductible | Orthodontia |
| Basic services | Bands / Appliances |
| Emergency Oral Examinations | Cephalometric X-Rays |
| Repairs for Dentures, Crown, Bridges | Treatment Study Models |
| Fillings, Extractions | |
| Non-surgical Periodontics | |
| Scaling / Root Planning | No Deductible Type I |
| Periodontics (Surgical) | Deducible for Types II and II .................$50 |
| Gingivectomy | Calendar Year Maximum for |
| Gingival Curettage | Types I, II, III.................................$1000 |
| Endodontics | Lifetime Maximum for |
| Palliative Treatment | Orthodontia.....................................$1000 |
| Consultations | |
| Annual Vision Plan | |
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| Lenses, Frames and Contacts are limited to either one pair of contacts, or one pair of lenses and /or frames per calendar year. | |
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| Maximum Allowances for Vision Services | |
| Vision analysis - MD | $75.00 |
| Vision analysis-OD | $60.00 |
| Single vision lens | $18.75 |
| Single vision lenses | $37.50 |
| Bifocal lens | $35.00 |
| Bifocal lenses | $70.00 |
| Trifocal lens | $45.00 |
| Trifocal lenses | $90.00 |
| Lenticular lens | $56.26 |
| Lenticular lenses | $112.50 |
| One contact lens | $25.00 |
| Two contact lenses | $50.00 |
| Frames | $50.00 |
| Consultations | |
1 September 2001