Page 9 - GDP - Provider Reimbursement Guide B 2022

Schedule of Benefits and Monthly Payments
ANNUAL MAXIMUM
$1,200
$3,000
$3,000
$1,250
$3,500
$1,600
$1,500
$1,500
$1,200
$1,200
$1,600
$1,200
$3,000.00
$1,600
$1,500
$1,200
$1,600
Unlimited
$1,200
$1,200
$2,500 General
$1,000 Specialty
Unlimited General
SINGLE
$5.84
$8.66
$8.66
$7.02
$18.00
$8.67
$13.80
$13.80
$23.08
$7.50
$14.63
$6.84
$18.00
$9.49
$17.66
$10.70
$8.67
$17.08
$6.25
$7.50
$7.50
$5.67
FAMILY OF 2
$11.46
$17.07
$17.07
$11.80
$18.00
$14.73
$22.89
$22.89
$23.08
$10.00
$14.63
$6.84
$18.00
$15.53
$17.66
$10.70
$14.73
$27.90
$10.00
$11.46
$13.00
MONTHLY CAP RATES
FAMILY OF 3-5
$18.00
$22.57
$22.57
$15.17
$18.00
$22.07
$34.16
$34.16
$23.08
$13.50
$14.63
$6.84
$18.00
$22.87
$17.66
$10.70
$22.07
$47.64
$13.50
$18.00
$18.50
FAMILY OF 6
$14.50
$14.50
$19.00
FAMILY OF 7
$15.50
$15.50
$20.00
FAMILY OF 8
$16.50
$16.50
$21.00
$18.88 +4 >
$1,000 Specialty
$1,500 General
$8.25
$11.23 Couple
$9.60 w/1 minor
$12.22 w/2 minor
$15.17 Sp, 2 dep
$21.00
$22.00
$500 Specialty
$1,500
$1,800
$2,000
$11.28
$22.37
$8.42
$14.00
$19.94
$22.37
$15.84
$19.00
$27.17
$22.37
$22.28
$20.00
For a complete list of all Schedule of benefits go to https://providers.goldendentalplans.com
7