Florida Sample Co-Payments

Secure Choice Plan

The following is a sample of some frequently used dental procedures. When you enroll for the plan, you will pay reduced fees called co-payments. These reduced fees are only available from providers who participate in our network. After you enroll, a complete list of copayments will be mailed to your home along with your Individual Dental Service Agreement. The sample below demonstrates potential savings with the Secure Choice plan and may not reflect your actual results.

Dental Treatment			With Secure Choice	Average Retail Charges**
Appointments
	Periodic Oral Evaluation		No Charge	$30
	Limited Oral Exam		$25	$51
	Comprehensive Oral Evaluation		No Charge	$52
Diagnostic Dentistry
	Complete X-Ray Series, Including Bitewings		$5	$86
Preventive Dentistry
	Routine Cleaning - Adult (once every 6 mos.)		$5	$63
	Routine Cleaning - Child (once every 6 mos.)		$5	$45
	Application Of Fluoride (up to 18 years of age)		No Charge	$23
	Oral Hygiene Instruction		No Charge	$33
	Application Of Sealant, Per Tooth		$15	$33
	Fixed Space Maintainer		$70*	$334
Fillings/Crowns
	Silver Fillings
		One Surface	$20	$94
		Two Surfaces	$25	$115
		Three Surfaces	$50	$143
	White Fillings
		One Surface, Anterior	$45	$106
		Two Surfaces, Anterior	$55	$129
		Three Surfaces, Anterior	$75	$159
		One Surface, Posterior	$80	$113
		Two Surfaces, Posterior	$90	$144
		Three Surfaces, Posterior	$100	$182
		Crowns - Porcelain To High Noble Metal (cost of precious & semi-precious metal is additional)	$280*	$765
		Core Buildup	$85	$174
Root Canals
		Anterior	$155	$558
		Bicuspid	$225	$641
		Molar	$275	$799
Periodontics
	Periodontal Scaling And Root Planing, Per Quadrant		$55	$178
	Full Mouth Debridement (complicated cleaning)		$85	$97
Dentures
	Complete Denture - Upper		$325*	$937
	Complete Denture - Lower		$410*	$927
	Partial Denture - Upper		$390*	$658
	Partial Denture - Lower		$390*	$792
Oral Surgery
	Single Tooth Extraction		$30	$81
	Removal Of Impacted Tooth
		Soft Tissue	$75	$232
		Partial Bony	$100	$285
		Complete Bony	$140	$332
		Complete Bony with complications	$170	$396
Orthodontics
	Orthodontic treatment for children and adults is provided at a 25% reduction from Plan Specialist's normal retail charges.

Click Here For Full Schedule Of Benefits

The Plan Dentist you select may not perform all procedures listed.  The co-payments shown apply to those Plan Dentists who perform those services. Therefore, you are encouraged to discuss availability of the scheduled services with your Plan Dentist. Charges for procedures not listed on the Co-payment Schedule that are performed by your Plan Dentist are not covered under the Secure Choice Plan.

Should you require dental services that your selected Plan Dentist is unable to provide, you may obtain those services from a Plan Specialist at a reduced rate.  No referral is needed from your Plan Dentist in order for you to obtain services from a Plan Specialist.  There is no applicable copayment schedule for Plan Specialist services.  Instead, the following reductions off the Plan Specialist's normal retail charges apply to all services received from a Plan Specialist.  A 15% reduction applies if the Plan Specialist is an endodontist.  A 25% reduction applies if the Plan Specialist is any other type of specialist, including but not limited to an orthodontist.  You are responsible for paying the entire reduced charge at the time the service is received, or in accordance with the Plan Specialist's billing procedures.

Payment for each service of a Non-Plan Dentist or Non-Plan Specialist (at the provider's normal retail charge) is your responsibility, except for limited Plan Benefits for covered dental Emergency Services for temporary pain relief.

* Members are responsible for additional lab fees for these services.

**The Average Retail Charges were determined by Assurant Employee Benefits claims analysis for the year 2005.  The Retail Charges represent a mean average rounded to the nearest dollar representing what you may pay without the plan services.

*Lab Fees Additional - See Schedule Of Benefits

 

 

Click Here For Full Schedule Of Benefits

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