|
Monthly Rate Schedule
With Specialty Services at
CapDent Specialist Sites*
|
|
Low |
Medium |
High*** |
High
Enhanced*** |
| Employee only |
$16.90 |
$28.17 |
36.62 |
$40.85 |
| Employee and spouse |
27.46 |
48.94 |
64.08 |
72.54 |
| Employee and children |
27.46 |
48.94 |
64.08 |
72.54 |
| Full family |
38.02 |
69.71 |
91.54 |
104.23 |
Rates may
change at any time.
| Patient
Costs |
|
Per Visit Fee |
Copayment |
| High Enhanced |
$5.00 |
Per
Schedule** |
| High |
5.00 |
Per
Schedule** |
| Medium |
5.00 |
Per
Schedule** |
| Low |
0 |
Per
Schedule** |
| Patient
Copayment |
| Child |
$1,200.00 |
| Adult |
1,600.00 |
*When visiting a CapDent Specialist you
will receive a 25% discount off the Specialist's usual fee.
**The Copayment Schedule for services rendered by your CapDent
participating general dentist is included in your benefit brochure. The
copayments do not apply if services are rendered by CapDent or other
specialists.
*** Available to groups with three or more covered employees only.
For your convenience, premiums are automatically
deducted from your paycheck. No extra bills to write out!
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