Benefits - Page 2

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Benefits
Page 2
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BlueDental Choice

Combined Life Dental

Preventive ServicesBlue Cross Blue Shield Logo

Oral Evaluations Exams
Prophylaxes (Cleanings)- Adult/Child
Fluoride Treatment-Child
Bite wing X-rays
Intraoral/Complete
Series/Panoramic Sealants

Pays 100% In-Network, 100% Out-of-Network

Basic Services

Space Maintainers
Amalgam Restorations (Silver Fillings)
Resin-Based Restorations - Anterior and Posterior
Extractions - Routine and Surgical
Root Canal Therapy
Periodontal Treatment

Pays 100% In-Network, 80% Out-of-Network

Major Services

Crowns- Single Restorations
Osseous Surgery
Complete Dentures
Partial Dentures
Fixed partial dentures (Bridges)

Pays 60% In-Network, 50% Out-of-Network

Rates as of 10-01-2013 - 09-30-2014

Employees Only

$28.33/Month

Employee + Family

$79.76/Month

Employee + Children

$51.83/Month

Employee + Spouse

$56.28/Month

The Finance Office will provide your deduction for 24 pay periods.



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