Urban Benefits Schedule for Washington D.C. (Zone 8)

(Click for the Washington D.C. Rural Fee Schedule)

Adjunctive General Services • Bleaching • Crowns • Diagnostic • Endodontics • Extractions • Fluoride Treatments • Oral Extractions • Orthodontics • Other • Other Restorative Services • Other Surgical • Periapical Services • Periodontics • Preventative • Prosthodontics-Fixed-Bridges • Prosthodontics-Removable • Radiographs • Restorative Amalgam • Restorative Composite • Savon Specific Codes • Special Maintainers • TMJ • Veneers

The fees listed on this schedule of benefits are as provided by a general dentist.

Please read the information at the bottom of this page

The fees listed on this schedule of benefits are as provided by a general dentist.

The Listing of any procedure on this schedule does not guarantee that all general dentists are qualified to perform all procedures.

Any procedure not listed shall be charged at 50% off the dentist’s own usual fee.

With unlisted procedures, lab fees are not discounted.

Any Orthodontic procedure not listed shall be charged at 25% off the dentist’s own usual fee.

SPECIALISTS ARE NOT BOUND TO THIS FEE SCHEDULE.

Any procedure done by a specialist will be reduced by 25% from the Specialist’s own fee.

Payment is due at the time of service.

Doctors may require a deposit prior to services.

Doctors will explain level of calcium/tartar deposits, (Periodontal problems)

The Rural fee schedule is in effect in any area with a population of less than 100,000 and at least 50 miles away from the center of an Urban area.  An Urban area is defined as any Metropolitan area with a population greater than 100,000.

Each dental office is independently owned and Savon assumes no responsibility for any dental services provided.

All Savon Dental Plan fee schedules are subject to change without notice to the members.

This fee schedule supersedes all other fee schedules.

This fee schedule is effective 04-01-2010