Sample Schedule of Benefits of how much the insurance will pay

Standard

Royal

Deductible—$50 Calendar Year-Per Person Deductible for Basic and Major Services ONLY!

Elimination Period—12 Month Waiting Period on Major Procedures

Plan Maximum Per Calendar Year-Per Person

$1,000

$1,000

$1,000

Preventive * - NO DEDUCTIBLE

Two evaluations per calendar year

$13 each

$16 each

$20 each

Two cleanings per calendar year - Adult

$33 each

$40 each

$50 each

Two cleanings per calendar year - Child

$22 each

$27 each

$34 each

Fluoride for Children (Under age 19)

$13

$15

$19

Basic

X-rays - complete series (including bitewings)

$40

$48

$60

$15

$18

$22

Amalgam restoration (silver fillings)—one surface, primary or permanent

$35

$42

$53

Extraction—Erupted tooth or exposed root (elevation and/or forceps removal)

$40

$48

$60

Surgical removal of tooth (completely bony)

$83

$100

$125

Deep sedation/general anesthesia

$116

$140

$175

Major

Maxillary partial denture—resin base

$248

$300

$375

Denture repair-Repair Broken Base

$30

$36

$45

Endodontics—root canal, anterior

$132

$160

$200

Periodontal scaling and root planning, limited (per quadrant). Each quadrant is eligible for consideration once in a 2 year period

$43

$52

$65

Crown—full cast noble metal

$185

$224

$280

Crown repair

$50

$60

$75

Pontics—porcelain fused to noble metal

$185

$224

$280