Dental Plans
You can choose between two dental options from Delta Dental.
Group Number: 10-0419
Member Service: (800) 521-2651
Website: www.deltadentalins.com
Dental health and oral hygiene are an integral part of good health. Proper dental care can help prevent tooth decay, gum disease, and even lower the risk of heart disease.
Your dental plan covers preventive cleanings twice per year for each covered family member. In addition to cleanings and preventive care, your plan covers most basic and restorative care including X-rays, fillings, root canals, periodontal work, and other procedures.
Look in the menu for additional plan information including detailed benefit summaries, summary plan descriptions, forms, documents, FAQ’s, and provider search directories.
Benefit Comparison
| High Plan | Low Plan | ||
|---|---|---|---|
| In-Network | Out-of-Network | In-Network | Out-of-Network |
| Deductible (Single / Family) | |||
| $50 | $50 | $50 | $50 |
| $150 | $150 | $150 | $150 |
| Annual Maximum | |||
| $2,500 | $2,500 | $1,250 | $1,250 |
| Preventive Care | |||
| Covered 100% | Covered 100% | Covered 100% | 30% |
| Basic Restorative Care | |||
| 20% after deductible | 20% after deductible | 20% after deductible | 60% after deductible |
| Major Restorative Care | |||
| 50% after deductible | 50% after deductible | 50% after deductible | 75% after deductible |
| Orthodontia | |||
| 50% | 50% | Not covered | Not covered |
| Orthodontia Dependent Coverage | |||
| Adult and Children | Adult and Children | Not covered | Not covered |
| Orthodontia Lifetime Maximum | |||
| $2,000 | $2,000 | Not covered | Not covered |
This is an overview of benefits. Please review the plan documents or call your provider for benefit details, limitations, exclusions, and verification of coverage.
Dental Plan Low
Group # 10-0419
Member Service: (800) 521-2651
Website: www.deltadentalins.com
Dental health and oral hygiene are an integral part of good health. Proper dental care can help prevent tooth decay, gum disease, and even lower the risk of heart disease.
Remember that when you access care through an In-Network provider, you will have lower out-of-pocket expenses and the providers cannot charge more than the carrier negotiated fees. If you use providers outside of the network, you may be subject to balance billing – paying the difference of what the provider charges in excess of what the plan covers.
Examples of Services
- Preventive – Cleanings, exams, sealants, space maintainers, x-rays
- Basic – Space maintainers, fillings, repairs, extractions, oral surgery, general anesthesia, endodontia, periodontia, etc
- Major – Inlays, onlays, crowns, bridges
Benefits Overview
| Dental Benefit Overview | In-Network | Out-of-Network |
|---|---|---|
| Deductible – Single | $50 | $50 |
| Deductible – Family | $150 | $150 |
| Annual Maximum | $1,250 | $1,250 |
| Preventive Care | Covered 100% | 30% |
| Basic Restorative Care | 20% after deductible | 60% after deductible |
| Major Restorative Care | 50% after deductible | 75% after deductible |
| Orthodontia | Not covered | Not covered |
| Orthodontia Dependent Coverage | Not covered | Not covered |
| Orthodontia Lifetime Maximum | Not covered | Not covered |
Dental Plan High
Group # 10-0419
Member Service: (800) 521-2651
Website: www.deltadentalins.com
Dental health and oral hygiene are an integral part of good health. Proper dental care can help prevent tooth decay, gum disease, and even lower the risk of heart disease.
Remember that when you access care through an In-Network provider, you will have lower out-of-pocket expenses and the providers cannot charge more than the carrier negotiated fees. If you use providers outside of the network, you may be subject to balance billing – paying the difference of what the provider charges in excess of what the plan covers.
Examples of Services
- Preventive – Cleanings, exams, sealants, space maintainers, x-rays
- Basic – Space maintainers, fillings, repairs, extractions, oral surgery, general anesthesia, endodontia, periodontia, etc
- Major – Inlays, onlays, crowns, bridges, implants
- Orthodontics – Adults and children; exams, x-rays, extraction and appliances
Benefits Overview
| Dental Benefit Overview | In-Network | Out-of-Network |
|---|---|---|
| Deductible – Single | $50 | $50 |
| Deductible – Family | $150 | $150 |
| Annual Maximum | $2,500 | $2,500 |
| Preventive Care | Covered 100% | Covered 100% |
| Basic Restorative Care | 20% after deductible | 20% after deductible |
| Major Restorative Care | 50% after deductible | 50% after deductible |
| Orthodontia | 50% | 50% |
| Orthodontia Dependent Coverage | Adult and Children | Adult and Children |
| Orthodontia Lifetime Maximum | $2,000 | $2,000 |
Your Guide to Dental Costs
** This table is to be used as a general guideline to illustrate the approximate cost of dental procedures. Costs will vary by region. Be an informed consumer and know what your dentist charges and what your insurance company will pay BEFORE you commit to dental work!
| General Dental Procedures | HIAA National Average |
| Periodic oral examination | $30 |
| Limited oral evaluation – problem focused | $48 |
| Comprehensive oral evaluation | $48 |
| Intraoral – complete series (including bitewings) | $95 |
| Intraoral – periapical – first film | $18 |
| Intraoral – periapical – each additional film | $16 |
| Intraoral – occlusal film | $24 |
| Extraoral – single film | $30 |
| Extraoral – each additional film | $26 |
| Bitewing – single film | $17 |
| Bitewing – two films | $28 |
| Bitewing – four films | $42 |
| Panoramic film | $76 |
| Pulp vitality tests | $32 |
| Diagnostic casts | $70 |
| Preventive Dental Care | National Average |
| Prophylaxis – adult | $64 |
| Prophylaxis – child | $44 |
| Topical application of fluoride (prophylaxis not included) -child |
$24 |
| Sealant – per tooth | $36 |
| Space maintainer-fixed- unilateral | $223 |
| Space maintainer-fixed- bilateral | $366 |
| Space maintainer – removable – unilateral | $353 |
| Restorative Dental Care | National Average |
| Amalgam – one surface, primary | $72 |
| Amalgam – two surfaces, primary | $91 |
| Amalgam – three surfaces, primary | $109 |
| Amalgam – one surface, permanent | $83 |
| Amalgam – two surfaces, permanent | $103 |
| Amalgam – three surfaces, permanent | $126 |
| Resin – one surface, anterior | $101 |
| Resin – two surfaces, anterior | $127 |
| Resin – three surfaces, anterior | $152 |
| Resin – one surface, posterior – primary | $90 |
| Resin – two surfaces, posterior – primary | $113 |
| Resin – three surfaces, posterior – primary | $131 |
| Resin – one surface, posterior – permanent | $109 |
| Resin – two surfaces, posterior – permanent | $146 |
| Resin – three surfaces, posterior – permanent | $179 |
| Crown – resin (laboratory) | $328 |
| Crown – porcelain fused to high noble metal | $821 |
| Crown – porcelain fused to predominantly base metal | $703 |
| Crown – porcelain fused to noble metal | $754 |
| Crown – full cast high noble metal | $776 |
| Crown – 3/4 cast metal | $830 |
| Recement crown | $64 |
| Prefabricated stainless steel crown – primary tooth | $175 |
| Prefabricated stainless steel crown – permanent tooth | $188 |
| Sedative filling | $66 |
| Pin retention – per tooth, in addition to restoration | $31 |
| Cast post and core in addition to crown | $277 |
| Prefabricated post and core in addition to crown | $228 |
| Temporary crown (fractured tooth) | $156 |
| Endodontics | National Average |
| Pulp cap – direct (excluding final restoration) | $38 |
| Pulp cap – indirect (excluding final restoration) | $33 |
| Therapeutic pulpotomy (excluding final restoration) | $91 |
| Anterior (excluding final restoration) | $417 |
| Bicuspid (excluding final restoration) | $498 |
| Molar (excluding final restoration) | $648 |
| Periodontics | National Average |
| Gingivectomy – per quadrant | $343 |
| Gingivectomy – per tooth | $110 |
| Mucogingival surgery – per quad | $482 |
| Osseous surgery (including flap entry and closure) – per quadrant |
$826 |
| Periodontal scaling and root planing – per quadrant | $167 |
| Periodontal maintenance procedures (following active therapy) | $102 |
| Dentures – Removable | National Average |
| Complete denture – maxillary | $899 |
| Complete denture – mandibular | $862 |
| Immediate denture – maxillary | $968 |
| Immediate denture – mandibular | $937 |
| Maxillary partial denture – resin base (including any conventional clasps, rests, and teeth) |
$617 |
| Mandibular partial denture – resin base (including any conventional clasps, rests, and teeth) |
$695 |
| Maxillary partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) |
$1,021 |
| Mandibular partial denture – cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) |
$1,015 |
| Adjust complete denture – maxillary | $50 |
| Adjust complete denture – mandibular | $48 |
| Adjust partial denture – maxillary | $53 |
| Adjust partial denture – mandibular | $50 |
| Oral Surgery | National Average |
| Single tooth | $94 |
| Each additional tooth | $85 |
| Root removal – exposed roots | $120 |
| Surgical removal of erupted tooth requiring elevation of flap and removal of bone/or section of tooth |
$179 |
| Removal of impacted tooth – soft tissue | $218 |
| Removal of impacted tooth – partially bony | $284 |
| Removal of impacted tooth – completely bony | $331 |
| Surgical removal of residual tooth roots (cutting procedure) | $185 |
| Surgical exposure of unerupted tooth with ortho attachments | $397 |
| Alveoplasty in conjunction with extractions – per quadrant | $156 |
| Orthodontics | National Average |
| Comprehensive orthodontic treatment – adolescents | $4,200 |
| Comprehensive orthodontic treatment – adults | $4,200 |
| Consultation | $0 |
| Diagnostic workup | $0 |
Dental Forms and Resources
VyStar Credit Union strives to provide you and your family with every resource possible to understand your benefits and have a positive experience every time you access care. This section provides you with important forms, documents, notifications, and resources.
In addition, we strongly encourage you to access your provider’s website and download their member services app. Your provider’s website will allow you to view your specific profile including claims, year-to-date deductible status, health and wellness tools, and helpful clinical resources for medical conditions.
