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 1-800-342-5209. |
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| BENEFIT |
IN-NETWORK |
OUT-OF-NETWORK** |
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(Use dentist of choice) |
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Deductible
(Calendar Year is January 1 -December 31) |
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| Type I |
None |
None |
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| Type II, III |
$50 per year, individual |
$50 per year, individual |
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| Calendar Year Maximum |
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| Type I, II, III |
$1000 per person |
$1000 per person |
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PROCEDURES |
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| Office Visit |
100% |
80% |
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| Routine exams |
100% |
80% |
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Prophylaxis (cleaning) - basic
(1 per 6 months) |
100% |
80% |
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X-ray and complete series
(limitations may apply) |
100% |
80% |
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Sealants
(once per 3 years for children under age 16, for non-carious molars
only) |
100% |
80% |
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Fluoride application
(children under 16, once per 12 months) |
100% |
80% |
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BASIC/RESTORATIVE
PROCEDURES |
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| Emergency treatment |
50% |
40% |
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| Simple extractions |
50% |
40% |
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| Amalgam fillings synthetic or composite |
50% |
40% |
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| Root canals (endodontics) |
50% |
40% |
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| Periodontics (includes treatment of
diseases of the gums) |
50% |
40% |
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| MAJOR PROCEDURES |
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| Crowns, inlays, onlays |
50% |
40% |
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| Dentures |
50% |
40% |
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| Bridges |
50% |
40% |
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| Denture Repairs |
50% |
40% |
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** Out-of-Network Dentists may balance bill for amounts
over CompBenefits' UCR fee.
Please ask your dentist if she/he offers amalgam (silver) fillings
before treatment.
Please refer to your Certificate of Coverage booklet for a complete
list of benefits, limitations, and exclusions. |
