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Individual dental plan

Missouri - sample copayments

Secure Choice

The following is a sample of some frequently used dental procedures. When you enroll for the plan, you will pay reduced fees called copayments. These reduced fees 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 Dental Service Agreement. The sample below demonstrates potential savings with the Secure Choice plan and may not reflect your actual results.

Dental Treatment

With Secure Choice

Average Retail Charges1

Appointments

Periodic Oral Evaluation

No Charge

$36

Limited Oral Exam

$25

$55

Comprehensive Oral Evaluation

No Charge

$58

Diagnostic Dentistry

Complete X-Ray Series, Including Bitewings

$10

$103

Preventive Dentistry

Routine Cleaning - Adult (once every 6 mos.)

$10

$70

Routine Cleaning - Child (once every 6 mos.)

$10

$50

Application Of Fluoride (up to 18 years of age)

No Charge

$27

Oral Hygiene Instruction

No Charge

$35

Application Of Sealant, Per Tooth

$20

$41

Fixed Space Maintainer

$85**

$384

Fillings/Crowns

Silver Fillings

One Surface

$25

$100

Two Surfaces

$30

$123

Three Surfaces

$45

$148

White Fillings

One Surface, Anterior

$50

$114

Two Surfaces, Anterior

$65

$139

Three Surfaces, Anterior

$80

$169

One Surface, Posterior

$85

$125

Two Surfaces, Posterior

$100

$163

Three Surfaces, Posterior

$105

$200

Crowns - Porcelain To High Noble Metal

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

$295**

$866

Core Buildup

$55

$194

Root Canals

Anterior

$145

$577

Bicuspid

$225

$667

Molar

$295

$858

Periodontics

Periodontal Scaling And Root Planing, Per Quadrant

$90

$188

Full Mouth Debridement (complicated cleaning)

$90

$118

Dentures

Complete Denture - Upper

$385**

$1,008

Complete Denture - Lower

$385**

$981

Partial Denture - Upper

$410**

$739

Partial Denture - Lower

$410**

$814

Oral Surgery

Single Tooth Extraction

$25

$84

Removal Of Impacted Tooth

Soft Tissue

$105

$247

Partial Bony

$140

$316

Complete Bony

$165

$368

Complete Bony with complications

$205

$432

Orthodontics

Orthodontic treatment for children and adults is provided at a 25% reduction from Plan Specialist's normal retail 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 the Secure Choice Plan.

Should you require dental services that your selected Plan Dentist is unable to provide, you may obtain those services from a Plan Specialist at a reduced rate.  No referral is needed from your Plan Dentist in order for you to obtain services from a Plan Specialist.  There is no applicable copayment schedule for Plan Specialist services.  Instead, the following reductions off the Plan Specialist's normal retail charges apply to all services received from a Plan Specialist.  A 15% reduction applies if the Plan Specialist is an endodontist.  A 25% reduction applies if the Plan Specialist is any other type of specialist, including but not limited to an orthodontist.  You are responsible for paying the entire reduced charge at the time the service is received, or in accordance with the Plan Specialist's billing procedures.

Payment for each service of a Non-Plan Dentist or Non-Plan Specialist (at the provider's normal retail charge) is your responsibility, except for limited Plan Benefits for covered dental Emergency Services for temporary pain relief.

** Members are responsible for additional lab fees for these services.

1 The Average Retail Charges were determined by Assurant Employee Benefits claims analysis for the year 2006.  The Retail Charges represent a mean average rounded to the nearest dollar representing what you may pay without the plan services.

 

Missouri plan information

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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