Pizza Business Insurance

Dental Plan

Indemnity Benefits - See the dentist of your choice.
$1500 annual maximum
Low $50 deductible - waived for preventive services.
Set reimbursements for procedures - no surprises!
Cash paid directly to you or your provider†

ADA Code	Description	Reimbursement
0150	Comprehensive oral evaluation - new or established patient	$33.00
0274	X-Ray - bitewings - four films	$26.00
1110	Routine Prophylaxis - adult (once every six months)	$38.00
2331	Resin filling - two surfaces, anterior	$50.00
2750	Crown -porcelain fused to high noble metal*	$187.00
3330	Root Canal - Molar*	$196.00
4341	Periodontal scaling and root planning - per quadrant*	$48.00
7110	Single tooth (extraction)	$40.00

This illustration is a sample only. Please see the member certificate for all codes, exclusions, and limitations.

Click here for a full reimbursement schedule.

† Depending on your provider's billing practice.
†† Documentation consisting of the most recent prior invoice and summary of
benefits must be submitted the time of initial enrollment for waiver to be considered.
* 12 month wait for these services apply.