100%/80%/0% $750 Type 3 Major Services 0% Annual Deductible (calendar year) $50 Type 2, Waived Type 1, Family max. $150 Calendar Year Maximum (per person) $750 Endodontics Periodontics Anesthesia Type 1 Type 2 Routine Exam (1 in 6 months) Sealants (age 13 and under) Bitewing X-rays (1 in 12 months) Space Maintainers Full Mouth/Panoramic X-rays (1 in 5 years) Restorative Amalgams Periapical X-rays Restorative Composites Cleaning (1 in 6 months) Periodontics (nonsurgical) Fluoride for Children 13 and under (1 in 12 months) Simple Extractions
100%/50%/50% $750 Type 2 Basic Services 50% Calendar Year Maximum (per person) $750 Endodontics 50% Periodontics 50% Anesthesia 50% Cleaning (1 in 6 months) Periodontics (nonsurgical) Endodontics (surgical) Fluoride for Children 13 and under Periodontics (surgical) (1 in 12 months) Simple Extractions Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 10 years)
Active PPO 100%/80%/50% $1,000 In-Network Out-of-Network 80% 60% 50% Annual Deductible (calendar year) $50 Type 2 & 3, Waived Type 1, $50 Type 2 & 3, Waived Type 1, Family max. $150 Family max. $150 Calendar Year Maximum (per person) $1,000 $1,000 Contracted Fee 80% 80% Endodontics 50% 50% Periodontics 50% 50% Anesthesia 50% 50% Periapical X-rays Crown Repair Cleaning (1 in 6 months) Simple Extractions Endodontics (nonsurgical) Fluoride for Children 13 and under Endodontics (surgical) (1 in 12 months) Periodontics (nonsurgical) Periodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial dentures) (1 in 10 years)
100%/80%/50% $1,000 Calendar Year Maximum (per person) $1,000 Endodontics 80% Periodontics 80% Anesthesia 50% Ameritas Rewards Included. See description at cbia.com. Cleaning (1 in 6 months) Endodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial Fluoride for Children 13 and under Periodontics (nonsurgical) dentures) (1 in 10 years) (1 in 12 months) Periodontics (surgical) Simple Extractions
100%/80%/50% $1,500 with Ortho Calendar Year Maximum (per person) $1,500 Endodontics 80% Periodontics 80% Anesthesia 80% Ameritas Rewards Covered 50% of U&C to $1,000 max. (lifetime max. per person). No waiting period. Included. See description at cbia.com. Cleaning (1 in 6 months) Endodontics (surgical) Prosthodontics (fixed bridge; removable complete/partial Fluoride for Children 13 and under Periodontics (nonsurgical) dentures) (1 in 10 years) (1 in 12 months) Periodontics (surgical) Simple Extractions ; Rev. 2.15