|
DeltaCare USA |
In-Network |
Out-Of-Network |
Annual Maximum Benefit | Unlimited | Not Applicable |
Annual Deductible | None | Not Applicable |
Preventive Services | Office Visits $5 | Not Applicable |
Diagnostic Services | No Charge | Not Applicable |
Minor Services | Amalgam Restorations $25-$37 | Not Applicable |
Major Services | Crowns $125-$320 | Not Applicable |
Endodontics | Root Canal $190-$400 | Not Applicable |
Periodontics | Gingivectomy, per quadrant $640 | Not Applicable |
Prosthodontics | Dentures $450, Denture Reline $60-$150 | Not Applicable |
Orthodontics | Adults $2,400; Child $2,100 | Not Applicable |
Access To Providers | Network Providers Only | Not Applicable |