Using a Non-Network Dental Provider

Most insureds will visit the dentist for an exam, cleaning and bitewing x-rays to maintain their dental health, twice a year.

The following illustration will demonstrate your estimated out of pocket costs using a non-network Dentist.

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Procedure		Estimated Member Out of Pocket		Estimated Dentist Charge Without Ameritas
D0120 Periodic Oral Evaluation-Established Patient		$23.00		$37.00
D0272 Bitewings - Two Films		$22.00		$35.00
D1110 Prophylaxis - Adult		$39.00		$69.00
Total Per Visit		$84.00		$141.00
Two Visits Per Year		$168.00		$282.00
Annual Premium, including Section 125 savings of 20%		$85.00		$0.00
Your Estimated Cost For Treatment		$253.00		$282.00
You Save $29.00 With Ameritas!

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Illustration shows savings based on using a 90th U & C fee in ZIP code 33701. Costs include two evaluations (D0120), two Bitewing X-Rays (D0272) and two Adult Prohylaxis (D1110). Estimated out of pocket costs shown are based on a 90th U & C dentist, less the amount the plan pays.

Please note that the above illustration is only an estimate. Your actual savings will depend on the actual charges submitted by the provider you select.