ALLOWANCE RATE SCHEDULE
PARTICIPATING DENTAL PLAN
Adult Plan $34.95/monthly
Child Plan $29.95*/monthly     

 Procedure Categories

Premier Dental Plan Coverage 

 Patient
Responsibility

 Preventive    

 100%

 0%

 Restorative                    

 40%

 60%

 Crown and Bridge

 40%

 60%

 Endodontics

 40%

 60%

 Oral Surgery

 40%

 60%

 Prosthetics    

 40%

 60%

 Periodontics

 50%

 50%