Dental Plan

Chiave Dentale
Plan Benefits
Exams & Diagnostics
Office Exam
Teeth Cleaning
Bite-Wing X-Ray
Oral Surgery
Removal of
Uncomplicated
Single Tooth
Removal of
Impacted Tooth
Restorative
Cavities
Amalgam
Cavities
Porcelain
Endodontics
Single Root Canal
Bi-Root Canal
Molar Root Canal

Plan A

No charge
No charge
No charge

No charge
No charge
No charge

$12/10.73
Copay

No charge

No charge

$40/35.77
Copay

$12/10.73
Copay
$95/84.95
Copay

$5/4.47 Copay
$60/53.66
Copay

$100/89.43
Copay
$120/107.31
Copay
$140/125.20
Copay

$50/44.71
Copay
$60/53.66
Copay
$80/71.54
Copay

$40/35.77
Copay

No charge

$230/205.68
Copay

$180/160.97
Copay

$160/143.08
Copay

$80/71.54
Copay

$1900/1699.09
Copay
$2150/1922.66
Copay

$1900/1699.09
Copay
$2150/1922.66
Copay

Periodontics
Gingivectomy
Per Tooth
Crowns
Porcelain Base
Metal
Full Cast Nobel
Metal
Orthodontics
Children (up to 18
yrs)
Adult

Plan B

Monthly Cost:
Employee
Employee + 1
Employee & Family

$12/10.73
$24/21.46
$36/32.19

$21/18.78
$35/31.30
$50/44.71