Individual Dental Plan
Georgia - Sample Copayments
Select Plan
The following is a sample of some of the most frequently used dental procedures. When you enroll for the DentiCare plan, you will pay discounted fees called copayments. These discounts are only available from providers who participate in our network. After you enroll, a complete list of copayments will be mailed to your home along with your Individual Prepaid Dental Plan Agreement. The sample below demonstrates potential savings with the DentiCare plan and may not reflect your actual results.
Dental Treatment |
With The Select Plan |
Average Retail Charges* |
||
|---|---|---|---|---|
Appointments |
||||
Periodic Oral Evaluation |
$5.00 |
$27.00 |
||
Limited Oral Exam |
$25.00 |
$45.00 |
||
Comprehensive Oral Evaluation |
$5.00 |
$47.00 |
||
Diagnostic Dentistry |
||||
Complete X-Ray Series, Including Bitewings |
No Charge |
$84.00 |
||
Preventive Dentistry |
||||
Routine Cleaning - Adult (once every 6 mos.) |
$5.00 |
$54.00 |
||
Routine Cleaning - Child (once every 6 mos.) |
$5.00 |
$41.00 |
||
Application Of Fluoride (up to 18 years of age) |
No Charge |
$21.00 |
||
Oral Hygiene Instruction |
No Charge |
$27.00 |
||
Application Of Sealant, Per Tooth |
$15.00 |
$33.00 |
||
Fixed Space Maintainer |
$70.00* |
$203.00 |
||
Fillings/Crowns |
||||
Silver Fillings |
||||
One Surface |
$25.00 |
$71.00 |
||
Two Surfaces |
$30.00 |
$87.00 |
||
Three Surfaces |
$40.00 |
$99.00 |
||
White Fillings |
||||
One Surface, Anterior |
$40.00 |
$94.00 |
||
Two Surfaces, Anterior |
$50.00 |
$114.00 |
||
Three Surfaces, Anterior |
$60.00 |
$141.00 |
||
One Surface, Posterior |
$40.00 |
$91.00 |
||
Two Surfaces, Posterior |
$50.00 |
$113.00 |
||
Three Surfaces, Posterior |
$60.00 |
$135.00 |
||
Crowns - Porcelain To High Noble Metal (cost of precious & semi-precious metal is additional) |
$320.00 |
$730.00 |
||
Core Buildup |
$225.00* |
$347.00 |
||
Root Canals |
||||
Anterior |
$225.00 |
$501.00 |
||
Bicuspid |
$345.00 |
$594.00 |
||
Molar |
$545.00 |
$751.00 |
||
Periodontics |
||||
Periodontal Scaling And Root Planing, Per Quadrant |
$75.00 |
$169.00 |
||
Full Mouth Debridement (complicated cleaning) |
$95.00 |
$101.00 |
||
Dentures |
||||
Complete Denture - Upper |
$350.00 |
$923.00 |
||
Complete Denture - Lower |
$350.00 |
$984.00 |
||
Partial Denture - Upper |
$395.00 |
$616.00 |
||
Partial Denture - Lower |
$395.00 |
$620.00 |
||
Oral Surgery |
||||
Single Tooth Extraction |
$30.00 |
$85.00 |
||
Removal Of Impacted Tooth |
||||
Soft Tissue |
$80.00 |
$207.00 |
||
Partial Bony |
$90.00 |
$276.00 |
||
Complete Bony |
$115.00 |
$320.00 |
||
Complete Bony with complications |
$165.00 |
$370.00 |
||
Orthodontics |
||||
Orthodontic treatment for children and adults is provided at 25% reduction from the Plan Specialist or Plan Dentist's list charges. |
||||
The Plan Dentist you select may not perform all procedures listed. The copayments shown apply to those Plan Dentists who perform those services. Therefore, you are encouraged to discuss availability of the scheduled services with your Plan Dentist. Charges for procedures not listed on the Copayment Schedule that are performed by your Plan Dentist are not covered under your Plan with DentiCare.
Should you require dental services that your Plan Dentist is unable to provide, you may obtain those services from a Plan Specialist at a discounted rate. No referral is needed from your Plan Dentist in order for you to obtain services from Plan Specialist. There is no applicable copayment schedule for Plan Specialist services. Instead, the following discounts will apply. For treatment provided by an Endodontist you will receive 15% off his/her list charges. For treatment provided by an Oral Surgeon, Orthodontist, Periodontist or Pedodontist you will receive 25% off his/her list charges. You will be responsible for paying the entire discounted charge at the time the service is received, or in accordance with the Plan Specialists' billing procedures.
*Members are responsible for additional lab fees for these services.
1The charges listed in this column were developed from charges dentists in Georgia submitted to Fortis Benefits Insurance Company in 2002. The listed charges represent a mean average of those submitted charges rounded to the nearest dollar