Health & Welfare Plan
Comparison of Dental Plan Benefits
The following examples help to show the difference between plans.
| Your estimated cost if you select: | ||||||
|---|---|---|---|---|---|---|
| Description | Average Charge | Non-PPO Dentist* | United Concordia Preferred* | H&W PPO Dentist* | Delta Care USA | Western Dental (MIB) |
| Periodic Oral Exam (D0120) | $55 | $37 | $0 | $0 | $0 | $0 |
| Teeth cleaning (D1110) | $100 | $61 | $0 | $0 | $0 | $0 |
| X-Rays, complete series (D0210) | $150 | $74 | $0 | $0 | $0 | $0 |
| 2-surface filling (D2150) | $200 | $144 | $0 | $0 | $0 | $0 |
| Porcelain/Metal Crown (D2750) | $1,300 | $900 | $0 | $0 | $0 | $0 |
| Extraction, erupted tooth (D7140) | $200 | $148 | $0 | $0 | $0 | $0 |
| Extraction, impacted tooth, completely bony (D7240) | $525 | $348 | $0 | $0 | $0 | $0 |
| Periodontal scaling/root planning, per quad (D4341) | $300 | $196 | $0 | $0 | $0 | $0 |
| Root Canal – 3 roots (D3330) | $1,150 | $750 | $0 | $0 | $60 | $0 |
| Full denture (D5110/5120) | $2,000 | $1,555 | $0 | $0 | $65 | $0 |
| Full cast partial denture (D5213/5214) | $2,000 | $1,422 | $0 | $0 | $75 | $0 |
| * After $25 deductible is satisfied. | No Deductible | |||||
The sample table above is a small selection of common procedures. The average charges will vary based on the location of your dentist.