Dental Benefits at a Glance

Basic Services are Paid at 100%

These services include, but are not limited to:

• Exams, Fluoride, One Unit Of Polishing, 3 Units Of Scaling - These Services Are Covered Only Once Every 9 Months
• X-Rays: Periapical And Panoramic
• Bite Wing X-Rays - Once Every 18 Months
• Basic Fillings - Maximum of 5 surfaces in a 2-year period
• Habit Breaking Appliances
• Simple Extractions

Major Services are Paid at 90%

These services include, but are not limited to:

• Crowns/Inlays/Onlays/Veneers/Bridges/Dentures - Once Every 5 Years*
• Periodontal Treatment
• Oral Surgery/Complicated Extractions
• Endodontic Treatment

*Refer to your Benefit Booklet, Plan Portal or contact PBAS for further clarification.

BASIC & MAJOR SERVICES MAXIMUM:

$2,000 per family member per calendar year

Orthodontic Services are Paid at 60%

ORTHODONTIC SERVICES MAXIMUM:

$3,000 per family member per lifetime