BLUE SHIELD INDIVIDUAL DENTAL PLANS MONTHLY RATES DENTAL PPO DENTAL HMO Individual $34 $16 Two Party $65 $30 Family $101 $50
| SERVICE | |||
|---|---|---|---|
| Diagnostic Services | Comprehensive Oral Exams | $0 | $0 |
| Preventive Care | Cleanings every 6 months | $0 | $0 |
| Restorative Services ² | One-Surface Amalgam (filling) | $35 | $15 |
| Crown | $320 | $300 | |
| Endodontics ² | Anterior Root Canal | $156 | $155 |
| Molar Root Canal | $234 | $290 | |
| Periodontics ² | Osseous Surgery | $263 | $303 |
| Periodontal Root Planing | $65 | $75 | |
| Prosthetics ² | Bridge (per unit) | $320 | $300 |
| Complete Denture (U or L) | $388 | $400 | |
| Oral Surgery ² | Extraction (single tooth) | $37 | $30 |
| Removal of Impacted Tooth | $113 | $125 | |
| Orthodontics ² ³ | Fully banded (two year) case-child | $2350 | $2350 |
| Fully banded (two year) case-adult | $2650 | $2650 | |
| Annual maximum benefit | |||
| $1,000 per member | No Max | ||
| Annual deductible | |||
| $50 per member | No Ded |
² Dental PPO members have a three month waiting period for minor restorative services and procedures. Dental PPO & HMO members have a twelve month waiting period for major restorative services and procedures (such as crowns and orthodontics).
³ Orthodontics services are on a fixed patient copayment and do not apply to your $1,000 in-Network maximum.
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Download Blue Shield Dental HMO .pdf Application
Blue Shield HMO Dentist Network Database
(You must choose a primary dentist to put on our HMO application.)
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