Solstice — S200 Plan

MORE INFORMATION ON YOUR NEW DENTAL & VISION

ADDITIONAL INFORMATION ABOUT YOUR MILLION DOLLOR SMILE!

typical cost for an adult	no coverage	s200 Plan
Two periodic exams	$72	$0
Four bitewing X-rays	$47	$0
Two quadrants of periodontal scaling and root planning	$290	$72*
Two routine cleanings	$140	$0
One resin/ Composite 1-Surface filing (anterior)	$115	$20
Anterior Root Canal (excluding final restoration)	$576	$100
Porcelain Crown	$912	$195*
Subtotal	$2,152	$387
You Would Save		$1,765

*This is just a typical case for detail information please review the Schedule of Benefits.
*Co-payments are not eligible for reimbursement under specialty plans
**When crown and/or bridgework exceeds six (6) consecutive units, an additional charge of $30.00 per unit applies

typical cost for a child	no coverage	s200 Plan
Two periodic Exams	$72	$0
Two Bitewing X-rays	$31	$0
Two Routine Cleanings	$100	$0
Two Fluoride Treatments	$148	$0
Single Extraction	$109	$25
Subtotal	$460	$25
You Would Save		$444

*This is just a typical case for detail information please review the Schedule of Benefits.

No Waiting Periods

No Deductibles

No Claim Forms to Submit

Most Diagnostic and Preventive care at No Charge

Cosmetic and Orthodontia treatment covered

Member co-payments listed in schedule of benefits are guaranteed to be between 25% and 60% discount, which are offered by a participating Solstice provider.

	Dental Benefit Description	S200
	20 Bi-weekly premiums
	Employee	$7.17
	Employee & Dependent	$13.02
	Employee & Family	$18.72
	24 Bi-weekly premium
	Employee	$5.98
	Employee & Dependent	$10.85
	Employee & Family	$15.60
	26 Bi-weekly premium
	Employee	$5.52
	Employee & Dependent	$10.02
	Employee & Family	$14.40