Use these dental charts to compare the three plans you can choose from!
These charts are examples of frequently used services, to help you make a
choice for your family's dental coverage.
For a more complete list of services you may log on to CompBenefits'
Web site at www.compbenefits.com or call Customer Service at 1-800-
303-6347.
BENEFIT
COMPBENEFITS PLAN MANAGED CARE S-320
Choose a panel dentist
Deductible
(Calendar Year is January 1 - December 31)
None
Calendar Year Maximum
None
Claim Forms
None
PROCEDURES
Office visit
$3 per visit
Routine Exams
No Charge
Prophylaxis (cleaning) - basic
No Charge (1 per 6 months)
Emergency Treatment
No Charge
X-ray and complete series including bitewings**
No charge (1 per 36 months)
Fluoride application
No charge - child (1 per 6 months) No charge - adult (1 per 6 months)
BASIC RESTORATIVE PROCEDURES
Simple extractions
No charge (single tooth extraction)
Amalgam fillings - 1 surface permanent
No Charge
Root canal (1 canal)
$80
Root canal (3 canals)
$185
Sealants
No Charge
MAJOR PROCEDURES
Crowns - porcelain, base metal
$200
Dentures - upper/lower
$220
Bridges - porcelain base metal
$200 per unit
PERIODONTICS
Scaling and root planing
$40 per quadrant (limit 4 per year)
ORTHODONTICS
Pre-orthodontic treatment visit
$225
Comprehensive treatment of adolescent dentition
$1400 per unit
Comprehensive treatment of adult dentition
$1950 per unit
Please refer to your Certificate of Coverage for a complete list of
benefits, limitations and exclusions.
If you have dental coverage, your co-pays or uninsured, out-of-pocket
expenses may be eligible for reimbursement through your Health Care Expense FSA. Call
FBMC Customer Service at 1-800-342-8017 for eligible expenses.
FILLINGS
Amalgams (Silver Fillings)
No Co-payment - Covered at 100%
Verify that Amalgam Fillings
are provided by your treating dentist; If your dentist does
not offer amalgam fillings you will receive a resin (white
filling) and you will be responsible for a co-payment.
If your treatment dentist offers amalgam fillings,
the following co-payments and costs would apply;
