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OPERATING ENGINEERS
TRUST FUNDS

Comparison of Dental Plan Benefits

The following examples help to show the difference between plans.

Your estimated cost if you select:
Description Average Charge Non-PPO Dentist* United Concordia Preferred* H&W PPO Dentist* Delta Care USA
Periodic Oral Exam (D0120) $55 $37 $0 $0 $0
Teeth cleaning (D1110) $100 $61 $0 $0 $0
X-Rays, complete series (D0210) $150 $74 $0 $0 $0
2-surface filling (D2150) $200 $144 $0 $0 $0
Porcelain/Metal Crown (D2750) $1,300 $900 $0 $0 $0
Extraction, erupted tooth (D7140) $200 $148 $0 $0 $0
Extraction, impacted tooth, completely bony (D7240) $525 $348 $0 $0 $0
Periodontal scaling/root planning, per quad (D4341) $300 $196 $0 $0 $0
Root Canal – 3 roots (D3330) $1,150 $750 $0 $0 $60
Full denture (D5110/5120) $2,000 $1,555 $0 $0 $65
Full cast partial denture (D5213/5214) $2,000 $1,422 $0 $0 $75
* After $25 deductible is satisfied. No Deductible

The sample table above is a small selection of common procedures. The average charges will vary based on the location of your dentist.

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