Latin Chamber of Commerce - Dental
 

		PPO PLAN
PREVENTIVE & DIAGNOSTIC (Type 1)		PCN¹	PPO²	OON³
Cleanings & Exams		100% (Co-Pay Applies)	100%	100%
Fluoride Treatments
All X-Rays
BASIC (Type II)
Fillings (Amalgams)		100% (Co-Pay Applies)	80%	80%
Posterior Composites (White Fillings)
Sealants
Simple Extractions
Periodontics
Endodontics
Major (Type III)
Inlays and Onlays		100% (Co-Pay Applies)	50%	50%
Crowns & Posts
Fixed Bridges and/or Dentures
ORTHODONTIA
Adult & Child (Available for groups with 10 or more employees only)		50% $1,500 Lifetime Maxiumum
CALENDAR YEAR DEDUCTIBLE
(Waived for Preventive)		N/A	$50 - Employee Only $100 - Emp. +1 $150 - Emp. +2
CALENDAR YEAR MAXIUMUM		$1,500
		3 to 9 Employees
Employee Only		$25.96
Employee + 1 Dependent		$50.60
Employee + 2 Dependents		$77.90
		10 or More Employees
Employee Only		$24.96
Employee + 1 Dependent		$48.76
Employee + 2 Dependents		$75.29

¹ PCN Network - Dentists listed at www.smilecare.com
² PPO Network - Dentists listed at www.premierppo.com
³ OON - Any other dentist not listed on the above websites.

Rates are valid through Decemnber 30, 2007.