Page 8 - SEARCH Day Program Benefit Guide 2020-2021

A GUIDE TO YOUR BENEFITS | 2020

Dental Choice Fee Schedule

Covered Services All exams Out-of-Pocket Costs
with no out-of-pocket costs Fluoride treatment (child) $0
Exams and Preventive Services* Sealant application $0
X-Rays* Prophylaxis $0
Restorations and Repairs Panoramic $0
Full-mouth X-Rays $0
Endodontics $0
Amalgam restorations
Periodontics Composite restorations (other than for Out-of-Pocket Costs
molars)
Oral Surgery
Covered Services Pulp cap
with out-of-pocket costs Pulpotomy
Root canal therapy – anterior, bicuspid

Scaling and root planning
Gingivectomy
Soft tissue grafts
Periodontal maintenance

Routine extractions
Soft tissue surgical extractions
Incision and drainage of abscess

Major Restorations Crowns 50% of charges

Periodontics Osseous surgery 50% of charges

Endodontics Root canal therapy – molar 50% of charges

Oral Surgery Surgical extractions – impacted 50% of charges
Dentures 50% of charges
Fixed Bridges Complete and partial dentures 50% of charges
Space Maintainers Denture adjustments and repairs 50% of charges

Orthodontic Procedures Retainers and pontics 50% of charges

Fixed unilateral and bilateral space
maintainers
Children only
Limited to one complete orthodontic
treatment per lifetime

$25 fee for appointments broken with less than 24 hours’ notice.

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