Willamette Dental ProCare

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Benefit Plan 1 Copayments Plan 2 Copayments
Annual Maximum No Annual Maximum No Annual Maximum
Deductable No Deductible No Deductible
Annual Child Out-of-Pocket Limit One Child Under Age 19 pays up to $350 Two or more Children under Age 19 pay up to $700 One Child Under Age 19 pays up to $350 Two or more Children under Age 19 pay up to $700
General Office Visit You pay a $35 Copay You pay a $20 Copay
Specialist Office Visit You pay a $35 Copay You pay a $30 Copay
Routine Exams and X-Rays You pay a $0 Copay You pay a $0 Copay
Teeth Cleaning You pay a $5 Copay You pay a $0 Copay
Fluoride Treatment You pay a $20 Copay You pay a $5 Copay
Sealants per Tooth You pay a $20 Copay You pay a $5 Copay
Filling – Amalgam You pay a $45 Copay You pay a $25 Copay
Porcelain/Metal Crown You pay a $500 Copay You pay a $400 Copay
Complete Upper or Lower Denture You pay a $600 Copay You pay a $500 Copay
Bridge (per tooth) You pay a $500 Copay You pay a $400 Copay
Root Canal Therapy (Anterior Tooth) You pay a $200 Copay You pay a $200 Copay
Root Canal Therapy (Bicuspid) You pay a $300 Copay You pay a $250 Copay
Root Canal Therapy (Molar) You pay a $400 Copay You pay a $300 Copay
Osseous Surgery (Per Quadrant) You pay a $300 Copay You pay a $200 Copay
Root Planning (Per Quadrant) You pay a $100 Copay You pay a $75 Copay
Routine Extraction (Per Tooth) You pay a $45 Copay You pay a $40 Copay
Surgical Extraction (Per Tooth) You pay a $190 Copay You pay a $150 Copay
Pre-Orthodontic Service You pay a $150 Copay You pay a $150 Copay
Comprehensive Orthodontia You pay a $3,000 Copay You pay a $2,800 Copay
Nitrous Oxide Per Visit You pay a $40 Copay You pay a $40 Copay

Rate Table

Members Plan 1 Plan 2
Per Enrolee Under Age 21 $30.40 $35.05
Member & Spouse/Partner $41.32 $47.22
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