Page 21 - Prestige

Prestige
Network Access Plan 3

PPO Dental Claims Reimbursement

Sample Member Experience

Dentist Average Charge Plan Pays You Pay
Non‐ Non‐ Non‐
Procedure Network Network Network Network Network Network *
Deductible is waived for Preventive Waived Waived

Preventive:
Bitewings X‐Rays ‐ Two Films $27 $38 100% 100% $0 $0

Preventive:
Teeth Cleaning ‐ Adult $57 $82 100% 100% $0 $0

Preventive:
Periodic Oral Examination $31 $44 100% 100% $0 $0
Deductible is waived for Preventive, but applies to Basic & Major services $50 $50
Basic:
Filling ‐ Two Surfaces 80% after 80% after
Permanent and Primary $102 $145 $50 Ded $50 Ded $60 $69

Major: 50% after 50% after
Root Canal Therapy ‐ Molar $706 $1,008 $50 Ded $50 Ded $353 $504
Total $922 $1,317 $413 $573
Savings $160

► Illustration assumes national average charges and a 30% network discount
► Actual out-of-network reimbursement basis is limited to 90th Percentile of Usual, Customary, and
Resonable charges (UCR). * The dentist can bill the patient for the difference between the fee
schedule and the 90th Percentile.

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