SCHEDULE A Description of Benefits and Copayments DHMO-901

DELTA DENTAL PPO EPO PLAN DESIGN CP070

DELTA DENTAL PPO EPO PLAN DESIGN CP070 SCHEDULE OF BENEFITS AND The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations and exclusions of the program.

Newport News Public Schools Summary Schedule of Services Delta Dental PPO EPO Plan

Newport News Public Schools Summary of Services Delta Dental PPO EPO Plan Services In-Network Out-of-Network PPO Premier All Other Diagnostic & Preventive Oral Exams & Teeth Cleanings Fluoride Applications

Delta Dental of Colorado EXCLUSIVE PANEL OPTION (EPO) Schedule EPO 1B List of Patient Co-Payments. * See Special Provisions on Last Page

List of Co-Payments Code edure Code Definition Co-Pay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation

RETIREE DENTAL PLAN. RETIREE DENTAL PLAN FEE SCHEDULE Page 1 of 8

D0120 periodic oral evaluation $ 30.50 D0140 limited oral evaluation problem focused $ 30.50 D0150 comprehensive oral evaluation - new or established patient $ 30.50 D0160 detailed and extensive oral evaluation

General Dentist Fee Schedule

General Dentist Fee Schedule ADA Diagnostic D0120 Periodic oral evaluation $0 $72 $72 D0140 Limited oral evaluation problem focused $77 $107 $30 D0150 Comprehensive oral evaluation new or established patient

General Dentist Fee Schedule

General Dentist Fee Schedule Diagnostic D0120 Periodic oral evaluation $0 $59 $59 D0140 Limited oral evaluation problem focused $71 $88 $17 D0150 Comprehensive oral evaluation new or established patient

Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #

Exclusive Panel Option (EPO 1-B) a feature of the Delta Dental PPO Denver Public Schools- Group #6694 7.2011 MAXIMUM BENEFIT Calendar Year Orthodontic Lifetime CALENDAR YEAR DEDUCTIBLE WHO CAN BE COVERED

Delta Dental of Colorado DENVER HEALTH AND HOSPITAL AUTHORITY GROUP #587. EXCLUSIVE PANEL OPTION (EPO) List of Patient Copayments

List of Copayments Code edure Code Definition Copay DIAGNOSTIC CODES D0120 Periodic oral evaluation - established patient $10.00 D0140 Limited oral evaluation - problem focused $10.00 D0145 Oral evaluation

SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE

DentiCare of Alabama, Inc. 3595 Grandview Parkway, Suite 650 Birmingham, AL 35243 SECURE CHOICE INDIVIDUAL COPAYMENT SCHEDULE SECTION I: PLAN DENTIST SERVICES (Subject to Exclusions and Limitations Listed

MDG Dental Plan Comparison

D0999 Office visit during regular hours, general dentist only Evaluations D0120 Periodic oral examination - established patient D0140 Limited oral evaluation - problem focused D0145 Oral evaluation for

Access Dental Family DHMO

866-569-9900 HTTPS://MYDENTAL.GUARDIANLIFE.COM SCHEDULE OF BENEFITS Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Access Dental Individual & Family

Delta Dental EPO City & County of Denver Group #6791 EPO

MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule

SCHEDULE A Description of Benefits and Copayments DHMO-500

Dental and Vision 888.326.3210 WWW.PREMIERLIFE.COM SCHEDULE A Description of Benefits and Copayments DHMO-500 The benefits shown below are performed as deemed appropriate by the attending Primary Care

Delta Dental EPO City & County of Denver Group #6791 EPO

MAXIMUM BENEFIT - Calendar Year Maximum Delta Dental EPO City & County of Denver Group #6791 EPO Unlimited See copayment schedule for additional details. Orthodontic Lifetime Unlimited See copayment schedule

Employee Benefit Fund July 2018 ADA Codes and Plan Fees

CSEA Employee Benefit Fund July 2018 ADA Codes and Plan Fees DIAGNOSTIC D0120 periodic oral examination 40 34 42 45 48 38 30 32 31 D0140 limited oral examination (Does not look at 9110) 40 34 42 45 48

Managed DentalGuard Texas

Page 1 of 5 0120 0120 0140 0140 0150 0150 0460 0470 0999 9310 9310 9430 9440 0210 0220 0230 0240 0270 0272 0274 0330 1110 1120 1999 1201 1203 1204 1310 1330 1351 9999 1510 1515 1550 2110 2120 2130 2131

Concordia Plus Schedule of Benefits

Concordia Plus Schedule of Benefits Plan MD/DC 6 IMPORTANT INFORMATION ABOUT YOUR PLAN This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment,

LOUISIANA MEDICAID PROGRAM ISSUED: 08/18/14 REPLACED: 09/15/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16

APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.

Scheduled Dental Benefit Plan Schedule of Dental Allowances

Diagnostic Scheduled Dental Benefit Plan Schedule of Dental Allowances 0120 Periodic Oral Evaluation (once in 5 months after comprehensive) 20.00 0140 Limited Oral Evaluation 20.00 0150 Comprehensive Oral

LOUISIANA MEDICAID PROGRAM ISSUED: 09/15/13 REPLACED: 03/28/13 CHAPTER 16: DENTAL SERVICES APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE PAGE(S) 16

APPENDIX A: FEE SCHEDULE DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program.

APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE

: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures

Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM

Delta Dental PPO EPO PLAN DESIGN THE NORFOLK CONSORTIUM SCHEDULE OF BENEFITS AND COPAYMENTS/ The benefits shown below are performed as deemed appropriate by the attending Dentist subject to the limitations

APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE

: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures

Schedule of Benefits Access Dental Family DHMO

Schedule of Benefits Access Dental Family DHMO This Schedule of Benefits lists the services available to you under your Premier Access Individual & Family Plan, as well as the Copayments associated with

Schedule of Benefits (GR-9N S )

Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2016 Effective Date: January 1, 2016 Schedule: 1A Cert Base: 1 For: DMO - All

Managed DentalGuard - Plan Schedule

D0999 Office visit during regular hours, general dentist only * $5 Evaluations D0120 Periodic oral examination established patient 0 D0140 Limited oral evaluation problem focused 0 D0145 Oral evaluation

Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE

Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: BNSF Railway Company GROUP AGREEMENT: 727796 PLAN EFFECTIVE: January 1, 2016 The benefits

APPENDIX A: EPSDT DENTAL PROGRAM FEE SCHEDULE

: EPSDT DENTAL PROGRAM FEE SCHEDULE Provided in the table on the following pages are the reimbursable dental procedure codes and fees for the Medicaid of Louisiana, EPSDT Dental Program. All procedures

Schedule of Benefits (GR-9N S )

Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: Roman Catholic Diocese Of Dallas GP-870560-WI Issue Date: February 9, 2015 Effective Date: January 1, 2015 Schedule: 7A Cert Base:

CDT updates on this schedule are subject to approval by regulatory agencies in the following states: CA, FL, MD, MO, NY, OK, TX, VA and WA

CDT updates on this schedule are subject to approval by regulatory agencies in the following states: CA, FL, MD, MO, NY, OK, TX, VA and WA SCHEDULE A Description of Benefits and Copayments The Benefits

Staywell FL Child Medicaid Plan Benefits

The following is a complete list of dental procedures for which benefits are payable under this Plan. For beneficiaries under age 21, additional coverage may be available with documentation of medical

SCHEDULE A Description of Benefits and Copayments DHMO-PA3

SCHEDULE A Description of Benefits and s DHMO-PA3 855.280.2882 WWW.PREMIERLIFE.COM The benefits shown below are performed as deemed appropriate by the attending Primary Care Dentist subject to the limitations

Schedule of Benefits (GR-9N S )

Schedule of Benefits (GR-9N S-01-001-01) Employer: Group Policy Number: BNSF Railway Company GP-727796 Issue Date: January 1, 2014 Effective Date: January 1, 2014 Schedule: 1A Cert Base: 1 For: DMO - All

MDG-FP-U10NYI04-SCH-NY-OFF-17

SECTION XVI MANAGED DENTALGUARD SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under Age 19 Two (2) or More Members under Age 19 Participating

DINA Dental. Prepaid Plan Highlights. Prepaid Plan Bi-weekly Premiums $ 7.00 $10.76 $ Employee Only Employee + One Employee + Family

DINA Dental Prepaid Plan Highlights NO Claim Forms NO Maximums NO Deductibles NO Waiting Period - Some Preventive and Diagnostic Services Provided at NO CHARGE - Over 180 procedures covered by co-payments

SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS

SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental SCHEDULE OF BENEFITS COST-SHARING PEDIATRIC DENTAL CARE ESSENTIAL HEALTH BENEFIT Deductible One (1) Member under age 19 Two (2) or more Members

LIST OF COVERED DENTAL SERVICES

LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental Services which will be considered for payment by Constitution Life Insurance Company after the expiration of any applicable

Aetna Dental Inc. One Prudential Circle Sugar Land, TX SUMMARY OF COVERAGE

Aetna Dental Inc. One Prudential Circle Sugar Land, TX 77478 1-877-238-6200 SUMMARY OF COVERAGE CONTRACT HOLDER: Clear Creek ISD GROUP AGREEMENT: 620318 PLAN EFFECTIVE: September 1, 2014 The benefits shown

Plan CA15B DeltaCare USA Description of Benefits and Copayments

SCHEDULE A Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program.

SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits

COST-SHARING SECTION XVI. EssentialSmile Ped 111, ST, INN, Pediatric Dental Schedule of Benefits Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx Member Services:

Fee Schedule Detail Procedure Procedure Description Code Fee

Fee Schedule Detail Procedure Procedure Description Code Fee D0120 PERIODIC ORAL EVALUATION - ESTABLISHED PATIENT $ 32.29 D0140 LIMITED ORAL EVALUATION-PROBLEM FOCUSED $ 53.02 D0150 COMPREHENSIVE ORAL

Covered Dental Services and Patient Charges U10TXI04

The services covered by this Plan are named in this list. If a service, treatment or procedure is not on this list, it is not a covered service. All services must be provided by the assigned PCD. The Member

EssentialSmile Ped 221 Schedule of Benefits

EssentialSmile Ped 221 Schedule of Benefits P.O. Box 19199 Plantation, FL 33318 Telephone: 877-760-2247 Fax: 954-370-1701 www.mysolstice.net Members can search for a Network Provider at www.solsticecare.com/provider-search.aspx

GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual

Effective: January 1, 2016 Eligibility: (866) 436-3093 GUARANTY ASSURANCE COMPANY Dina Dental of Louisiana Pre-Paid Group & Individual Diagnostic D0999 Office Visit Copay - Per Person, Per Visit $9.00

EssentialSmile Ped 221 Schedule of Benefits

EssentialSmile Ped 221 Schedule of Benefits P.O. Box 9 Plantation, FL 33318 Telephone: 877 760 2247 Fax: 954 370 1701 www.mysolstice.net Members can search for a Network Provider atwww.solsticecare.com/provider

SCHEDULE A. Description of Benefits and Copayments

SCHEDULE A Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program.

DIAGNOSTIC/PREVENTIVE SERVICES

DIAGNOSTIC/PREVENTIVE SERVICES Diagnostic Services D0120 Periodic oral evaluation 100% 100% D0140 Limited oral evaluation problem focused 100% 100% D0150 Comprehensive oral evaluation 100% 100% D0160 Detailed

Concordia Plus ScheduleofofBenefits

Concordia Plus ScheduleofofBenefits Benefits Concordia Plus Schedule Plan 931 Plan CACA 1131 IMPORTANT INFORMATION ABOUT YOUR PLAN ÂÂ This Schedule of Benefits provides a listing of procedures covered

GUARANTY ASSURANCE COMPANY - DINA Dental Plan SCHEDULED BENEFITS RIDER

OSHA Charge for disposables for patients protection, per person, per visit* $5.00 120 Periodic oral exam $5.00 140 Limited oral exam $30.00 150 Comprehensive oral evaluation $20.00 180 Comprehensive Perio

SCHEDULE A. Description of Benefits and Copayments

SCHEDULE A Description of Benefits and Copayments The benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions of the program.

Improve your smile and overall well-being with. Dental Health Services. Dental Health Services. Difference today!

Improve your smile and overall well-being with Dental Health Services Great oral health is essential for your overall well-being. With a Dental Health Services plan, you can achieve a healthy smile while

The. Dental Plan. Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation

The Dental Plan Underwritten by: DENTA-CHEK of Maryland, Inc. A Not-for-Profit Corporation Now you can have comprehensive DENTAL coverage at a cost you can afford! Since 1981, Denta-Chek has been providing

Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits

Anthem Blue Dental PPO Voluntary Option 2V Summary of Benefits Annual Benefit Limit: $1500 Annual Member Deductible: $50 PPO Dentist $50 Non-PPO Dentist Family Coverage Deductible Limit 3 times Annual

Senior Dental Insurance Scheduled Allowance

Senior Dental Insurance Scheduled Allowance LIST OF COVERED DENTAL SERVICES The following is a complete list of those dental services which will be considered for payment by The American Progressive Life

This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General

This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this schedule is to establish the maximum fee that a General

IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation

D0120 IRON WORKERS BENEFIT TRUST SCHEDULE OF DENTAL SERVICES AND SUPPLIES D0100-D0999 I. Diagnostic Clinical Oral Evaluations periodic oral evaluation established patient* $ 66.50 D0140 limited oral evaluation

BOSTON TEACHERS UNION PARAPROFESSIONAL HEALTH AND WELFARE FUND Schedule of Covered Dental Procedures for the Dental Plan - Effective January 1, 2009

TYPE 1 D0120 Periodic oral evaluation 27.81 D0140 Limited oral evaluation - problem focused 43.15 D0145 Oral evaluation for a patient under three years of age and 22.20 counseling with primary caregiver

CIGNA Dental Care (*DHMO) Patient Charge Schedule

A2O07 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered

MY SMILE DENTAL PLAN FEE SCHEDULE

D0120 periodic oral evaluation D0140 limited oral evaluation problem focused D0145 exam under 3 years D0150 comprehensive oral evaluation - new or established patient D0160 detailed and extensive oral

California Family Dental HMO

California Family Dental HMO This Schedule of Benefits lists the services available to you under your Access Dental Individual Plan, as well as the Copayments associated with each procedure. Please review

FEE SCHEDULE. Complete Dental Plan is a discount plan offered and administered by our organization at:

FEE SCHEDULE Complete Dental Plan is a discount plan offered and administered by our organization at: 7801 CORAL WAY SUITE # 106, MIAMI, FL 33144 (786) 326-6873 F (305) 6979785 COMPLETE DENTAL PLAN HIGHLIGHTS

CCPOA PRIMARY DENTAL. CCPOA s Fee-for-Service. Procedure Code List

CCPOA PRIMARY DENTAL CCPOA s Fee-for-Service Procedure Code List Effective December 2017 We have provided these payment allowances for informational purposes only and not as a guarantee of payment. All

DHMO 400, 500, 600 Copayment Schedule

, 500, 600 ment Schedule www.premierlife.com Description Office visit - per visit (including all fees for sterilization and/or infection control) 0120 0140 0145 0150 0160 0170 0180 0210 0220 0230 0240

DeltaCare USA (DHMO) Standard Plan

SCHEDULE A Description of Benefits and Copayments DeltaCare USA (DHMO) The Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject to the limitations and exclusions

DeltaCare. USA provided by Alpha Dental of Nevada, Inc. Convenience. Predictable costs. Quality

DeltaCare USA provided by Alpha Dental of Nevada, Inc. We ll do whatever it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted general

D0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive

D0120 Periodic Oral Examination $31 D0140 Limited Oral Evaluation Problem Focused $41 D0145 Oral Evaluation Patient Under 3 $28 D0150 Comprehensive Oral Examination $43 D0160 Detailed And Extensive Oral

All Participants and Beneficiaries in the Health and Benefit Trust Fund of the International Union

SUMMARY OF MATERIAL MODIFICATIONS TO THE HEALTH AND BENEFIT TRUST FUND OF THE INTERNATIONAL UNION OF OPERATING ENGINEERS LOCAL UNION NO. 94 94A 94B, AFL CIO To: From: All Participants and Beneficiaries

SCHEDULE OF BENEFITS. Tests and Examinations D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0

SCHEDULE OF BENEFITS DENTAL PLAN This sample Schedule of Benefits lists the services available to you under your SafeGuard plan as well as the copayments associated with each procedure. There are other

Concordia Plus Schedule of Benefits

Concordia Plus Schedule of Benefits Plan TX IMPORTANT INFORMATION ABOUT YOUR PLAN The pays a $ office visit Copayment per visit in addition to the Copayments listed on this Schedule of Benefits. This schedule

Summary of Benefits Dental Coverage - New Dental Option

Summary of Benefits Dental Coverage - New Dental Option Managed Dental Plan MET225 - Texas Code Description Co-Payment Diagnostic Treatment D0120 Periodic Oral Evaluation established patient $0 D0150 Comprehensive

DeltaCare. USA provided by Delta Dental of California. Quality. Predictable costs. Convenience

DeltaCare USA provided by Delta Dental of California We ll do whatever it takes and then some. Welcome to DeltaCare USA quality, convenience, predictable costs Find a DeltaCare USA dentist Select from

CIGNA DENTAL CARE (*DHMO)

B1-05 CIGNA DENTAL CARE (*DHMO) PATIENT CHARGE SCHEDULE This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies

Careington Corporation Care PPO Schedule CI-10

Careington Corporation Care PPO Schedule Page 1 of 5 This schedule applies to services provided by a participating General Dentist and is an extensive list of most common procedures. The purpose of this

Summary of Benefits - Dental HMO Deluxe Plan

Office visit Office visit $5 per visit Diagnostic (exams and x-rays) D0120 Periodic oral evaluation You pay nothing D0140 Limited oral evaluation - problem focused You pay nothing D0145 Oral evaluation

PLEASE READ IMPORTANT PLAN INFORMATION AT THE END OF THIS SCHEDULE

Careington Corporation Care POS Schedule CI-4 Please Call 800-290-0523 for Customer Service ***Discount plans are not insurance*** This schedule applies to services provided by a participating General

Code Description Cap Freq D5660 ADD CLASP TO EXISTING PARTIAL DENTURE - PER TOOTH 4 1

Code Description Cap Freq D5660 ADD CLASP TO EXISTING PARTIAL DENTURE - PER TOOTH D5650 ADD TOOTH TO EXISTING PARTIAL DENTURE D5411 ADJUST COMPLETE DENTURE - MANDIBULAR D5410 ADJUST COMPLETE DENTURE -

Delta Dental PPO SM Platinum, Gold and Silver

Delta Dental PPO SM Platinum, Gold and Silver Plans offered with 2- and 3-tier rate options. Summary of Coverages Platinum Option Gold Option Silver Option Coverage A Diagnostic: Routine exams twice per

SCHEDULE OF BENEFITS Self-Referral Dental Plan

SCHEDULE OF BENEFITS Self-Referral Dental Plan SG245D-IP This Schedule of Benefits lists the services available to you under your SafeGuard plan as well as the co-payments associated with each procedure.

LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule

LIBERTY Dental Plan of Florida, Inc. FL800NS Copayment Schedule Members must select, and be assigned to, a LIBERTY Dental Plan contracted dental office to utilize covered benefits. LIBERTY Dental Plan

2018 fee schedule. Georgia. Diagnostic Services (Performed by a General Dentist)

Diagnostic Services (Performed by a General Dentist) page 1 of 12 IS NOT A REGISTERED INSURANCE PLAN. It is a savings plan offered exclusively by Coast Dental practices to patients who do not have dental

DHMO500 Benefits.

Dental and Vision DHMO500 Benefits DESCRIPTION Preventive Services Periodic Oral Exam Comprehensive Exam Full Mouth Series ( FMX) Panoramic Periapical X-rays Bitewings- four films Adult Cleanings Child

cigna dental care (*DHMO) patient charge schedule

C15V9 Subject to regulatory approval cigna dental care (*DHMO) patient charge schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights

State of Tennessee. Prepaid Plan. Dental Benefit Option. Sponsored by the. State of Tennessee

State of Tennessee Prepaid Plan Dental Benefit Option Sponsored by the State of Tennessee 2011 Products and services marketed by Assurant Employee Benefits are underwritten and/or provided by Union Security

GUARDIAN MANAGED DENTALGUARD FOR INDIVIDUALS AND FAMILIES TEXAS

GUARDIAN MANAGED DENTALGUARD FOR INDIVIDUALS AND FAMILIES TEXAS Plan Year 2017 Guardian DHMO plans allow you to choose to receive care from any participating dentist in the network, and pay set co-pays

ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or

ADA CODE ADA DESCRIPTION NV FEES PREVENTATIVE D0120 Periodic oral evaluation - established patient 50 D0150 Comprehensive oral evaluation - new or established patient(initial exam) 0 D0160 Detailed and

Plan highlights. Welcome to DeltaCare USA. KAISER PERMANENTE SENIOR ADVANTAGE Group # Quality. Convenience. Cost savings

KAISER PERMANENTE SENIOR ADVANTAGE Group #1228-1 Plan highlights Welcome to DeltaCare USA DeltaCare (administered by Delta Dental Insurance Company) provides you with quality dental benefits at an affordable

DENTAL GRID - SCMEBF Page 1 of 8 Vol. 1 #7 as of 1/16/18

0120 Periodic oral evaluation - established patient $25 0140 Limited oral evaluation - problem focused $30 0150 Comprehensive oral eval.-new or established patient $35 0160 0180 Detailed & extensive oral

DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008

DELTA DENTAL OF CALIFORNIA Client Name: University of Southern California Student Health Plan Group No.: 05008 BENEFIT HIGHLIGHTS FOR DELTA DENTAL PPO TABLE OF ALLOWANCE The Delta Dental PPO table plan

AmeriPlan Lime Fee Zip: 78411

AmeriPlan Lime Fee Zip: 78411 SPECIALIST FEE SCHEDULE Any AmeriPlan /Dental Plans of America member receiving treatment from a participating specialist provider (advanced degree), shall receive a 15% discount

TX Prepaid DHMO Dental

TX Prepaid DHMO Dental Good news about dental benefits for employees of Pearland Independent School District A Dental Plan Means Healthy Smiles Because you are a valued employee, we are pleased to offer

USA provided by Delta Dental of California. DeltaCare

DeltaCare USA provided by Delta Dental of California We ll do do whatever it it takes and then some. Find a DeltaCare USA dentist Select from among the many conveniently located DeltaCare USA contracted

DELTA DENTAL PPO sm AGREEMENT SUPPLEMENT TO DELTA DENTAL PREMIER PARTICIPATING DENTIST S AGREEMENT

DELTA DENTAL PPO sm AGREEMENT SUPPLEMENT TO DELTA DENTAL PREMIER PARTICIPATING DENTIST S AGREEMENT This agreement (the "Supplement") supplements the Delta Dental Premier Participating Dentist s Agreement

23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company

www.bcbsla.com 23XX2293 R3/08 Blue Cross and Blue Shield of Louisiana incorporated as Louisiana Health Service & Indemnity Company 1 Blue Cross and Blue Shield of Louisiana and HMO Louisiana, Inc. are

CIGNA Dental Care (*DHMO) Patient Charge Schedule

G1-07 CIGNA Dental Care (*DHMO) Schedule This Schedule lists the benefits of the Dental Plan including covered procedures and patient charges. Important Highlights This Schedule applies only when covered

Service Office visit - per visit (including all fees for sterilization and/or infection control) Diagnostic Treatment

SCHEDULE OF BENEFITS Benefits provided by SafeGuard Health Plans, Inc., a MetLife company Direct Referral Dental Plan* CITY OF DALLAS This SCHEDULE OF BENEFITS lists the Covered Services available to You