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| Dental Plan Options |
| Your dental plan is a Preferred Provider Plan administered by Delta Dental of Kansas. |
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| Two levels of coverage are offered: |
Provides benefits for diagnostic, preventive & basic care eligible charges (including exams, cleanings, fillings and X-rays). |
Deductible |
$50 Per Person/$150 Per Family |
Preventive/Diagnostic |
100% (Not subject to deductible) |
Basic Services |
80% (After deductible) |
Major Services |
Not Covered |
Annual Benefit Maximum |
$750 Per Person |
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Provides all of the above preventive/diagnostic and basic coverage, plus offers coverage for a more extensive range of dental care including orthodontia. |
Deductible |
$100 Per Person/$300 Per Family |
Preventive/Diagnostic |
100% (Not subject to deductible) |
Basic Services |
80% (After deductible) |
Major Services |
50% (After Deductible) |
Annual Benefit Maximum |
$1,500 Per Person |
| Orthodontia |
50% (After deductible) |
| Orthodontia Lifetime Maximum |
$2,000 Per Person |
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- Routine Dental Examinations
Twice per calendar year
- Cleaning
Twice per calendar year
- Topical fluoride application for children under age 19
Twice per calendar year
- Total mouth x-ray
Once every 36 months
- Bitewing x-rays
Twice per calendar year
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- Restorations (fillings)
Amalgam, silicate cement, acrylic and composite
- Oral Surgery
Extractions (uncomplicated surgical removal of an erupted tooth), incision/drainage of abscess, cyst or tumor removal
- General anesthesia and postoperative care
- Periodontics
Root planning/scaling, gingivectomy/gingivoplasty
- Endodontics
Root canals (including necessary x-rays/cultures, excluding final restoration), denture or bridge work repairs
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- Inlays and crowns
- Artificial teeth
- Removable bridge
- Dentures
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