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G. William Moore
Cal. Ins. Lic. # 0707682
Seal Beach, Calif.
562-431-5575 |
Dental Select HMO Plan
|
Dental Select HMO rates. |
To
Apply Online |
|
Covered
Benefits and Plan Highlights
Plan Summary |
These co-payments
apply only to services rendered by a Participating Dentist.
Specialty services provided by a Participating Specialty Dentist are
included on a separate schedule in your contract |
|
Dental Service |
Saver SelectHMO copays |
SelectHMO copays |
Premier SelectHMO copays |
| Office visit |
$ 5.00 |
$ 5.00 |
$ 5.00 |
Diagnostic Care
Oral Exams
X-rays |
No Charge
No Charge
|
No Charge
No Charge
|
No Charge
No Charge
|
Preventive Care
Prophylaxis - adult & child
Topical Fluoride - child |
No Charge
No Charge
|
No Charge
No Charge
|
No Charge
No Charge
|
Restorative Care
Filling - Permanent
1 surface amalgam
Filling - Permanent
2 surfaces amalgam
Filling - Permanent
3 surfaces amalgam
Filling - Permanent
4 or more surfaces amalgam |
$54
$64
$75
$89 |
No Charge**
No Charge**
No Charge**
No Charge** |
No Charge**
No Charge**
No Charge**
No Charge** |
Periodontal Care
Scaling/Root Planing
per quadrant |
$101 |
$101 |
No Charge** |
Orthodontic Care
Orthodontics - Child
Orthodontics - Adult
Retention |
$2,870
$3,045
$210 |
$2,870
$3,045
$210 |
$2,870
$3,045
$210 |
Prosthodontic Care
Denture (broken tooth repair) |
$57 |
$57 |
$57 |
Other Services
Office Visit After Hours
Local Anesthesia |
$56
$14 |
$56
$14 |
$56
$14 |
* First two treatments in 12
consecutive months. All additional treatments within a 12 month
period require copayments of $44 for adults and $35 for children.
** You must meet a six month waiting period before these benefits are
payable. |
Blue Cross Dental Select HMO Plans
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Comprehensive benefits - a broad range of preventive,
basic and major services
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Specialty services - orthodontic and cosmetic
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Affordable monthly rates - choice of payment options with
low $5 office visit fees for exams, cleanings and X-rays.
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Three HMO plans to choose from - Saver Select HMO, Select
HMO and Premier Select HMO
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Large Network of Dentists
Blue Cross invites you to put your best smile forward with on of
our three affordable plans. Please use this side-by-side comparison chart
to help you find the plan that works best for you. For additional details
please download the brochure.
To
Apply Online
Dental Select HMO rates.
Dental PPO Plan
4a
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