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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 Charges1

Appointments

Periodic Oral Evaluation

$5

$34

Limited Oral Exam

$25

$53

Comprehensive Oral Evaluation

$5

$55

Diagnostic Dentistry

Complete X-Ray Series, Including Bitewings

No Charge

$98

Preventive Dentistry

Routine Cleaning - Adult (once every 6 mos.)

$5

$64

Routine Cleaning - Child (once every 6 mos.)

$5

$69

Application Of Fluoride (up to 18 years of age)

No Charge

$26

Oral Hygiene Instruction

No Charge

$33

Application Of Sealant, Per Tooth

$15

$39

Fixed Space Maintainer

$70*

$385

Fillings/Crowns

Silver Fillings

One Surface

$25

$103

Two Surfaces

$30

$126

Three Surfaces

$40

$149

White Fillings

One Surface, Anterior

$40

$114

Two Surfaces, Anterior

$50

$139

Three Surfaces, Anterior

$60

$169

One Surface, Posterior

$40

$125

Two Surfaces, Posterior

$50

$160

Three Surfaces, Posterior

$60

$196

Crowns - Porcelain To High Noble Metal

(cost of precious & semi-precious metal is additional)

$320*

$866

Root Canals

Anterior

$225

$608

Bicuspid

$345

$703

Molar

$545

$895

Periodontics

Periodontal Scaling And Root Planing, Per Quadrant

$75

$190

Full Mouth Debridement (complicated cleaning)

$95

$122

Dentures

Complete Denture - Upper

$350*

$940

Complete Denture - Lower

$350*

$875

Partial Denture - Upper

$395*

$663

Partial Denture - Lower

$395*

$660

Oral Surgery

Single Tooth Extraction

$30

$88

Removal Of Impacted Tooth

Soft Tissue

$80

$251

Partial Bony

$90

$320

Complete Bony

$115

$369

Complete Bony with complications

$165

$440

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 Assurant Employee Benefits in 2006. The listed charges represent a mean average of those submitted charges rounded to the nearest dollar representing what you pay with out the plan services.

 

Additional information

  • Find a dentist
  • To inquire about our prepaid dental product prior to enrolling, call 888.882.8233.
  • To inquire about your enrollment, submission or billing, call 800.380.6347.

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